Overall, the RANZCOG database identified 5409 eligible clinicians, all of whom received a standardised invitation email. This comprised of 2120 Fellows, 769 FRANZCOG trainees and 2520 Diplomates. A total of 545 valid responses were received and submitted for analysis (10.1%), less than the predicted response rate for medical personnel (32.8%) [12]. The response rate for O&G affiliates (12.9%) was consistent with gynaecologist rates from a similar risk perception study by Csajka et al (13%) [2]. The response rate for GP affiliates was 6.8%.
Demographics
Three hundred and seventy-three clinicians aligned with RANZCOG (68.4%) and 172 aligned with RACGP (31.6%). The demographic characteristics of the respondents are shown in table 1.Seventy-two percent of respondents were trained in Australian medical colleges with 60.9% having over 10 years’ experience in their area of speciality. Twenty-six percent of O&Gs and 12.3% of GPs respondents had not yet attained their fellowship. Ninety-eight percent of the clinicians saw pregnant women regularly in their clinical practice. Seventy-eight percent of O&Gs spent 11 hours or more per week caring for pregnant women compared to 18.7% of GPs.
Table 1 goes here
Interest
In general, respondents had no particular interest in perinatal mental health disorders (only 36.7%), however more GPs (46.7%) were interested than O&Gs (32.1%). The vast majority of clinicians (96.9%) had not conducted any perinatal mental health research in the last five years. Also, fewer than half (46.4%) of all clinicians had attended a conference or read a journal article where AD or AX medication use in pregnancy had been reviewed. In general, only a small percentage of clinicians (15.3%) were involved in the provision of education to trainees about psychotropic prescription during pregnancy.
Perception
Self-reported perception of concern around prescribing AD or AX medications was not significantly different between groups (p=0.38), with O&Gs (n=368) apportioning a mean score of 3.7 (SD 2.3) and GPs (n=169) a mean score of 3.9 (SD 2.4), indicating a relatively low level of concern on a 0 – 10 scale with 0 being no concerns. The perceived proportion of -patient non-compliance was also not significantly different (p=0.36) between groups with both estimating just over a third of patients on a 0 to 100 scale would be non-compliant with their AD or AX treatment: O&Gs (n=367) mean 34.8% (SD 18.7) and GPs (n=170) 36.4% (SD 19.3). When asked to share their perceptions, GPs (n=172) estimated their patients’ anxiety regarding AD and AX medication decision making in pregnancy as higher on a 0 to 100 scale: mean 73.7% (SD 21.3) compared with mean 63.1% (SD 24.1) for O&Gs (n=372), a mean difference of 10.6% (95% CI 6.4 – 14.8).
Practice
Only 10.5% of all clinicians (n=545) “very often” provided pregnant women with written information about the intended prescription AD or AX; 8.6% of O&Gs compared to 14.5% of GPs.
Sources of written information were varied and the overall numbers were small. For O&Gs, most sourced UpToDate (32.2%), followed by MIMS (26.8%) and MotherRisk (13.4%). For GPs, the most commonly used resource was MIMS (27.9%) followed by “other” (19.2%) and Drug Company leaflets (15.1%). Less than 10% of all clinicians had their own practice pamphlets or relied on the pharmacists as their main source of written information. Thirty-two percent of O&Gs provided no written information compared with 16.3% of GPs (p<0.001).
If seeing a pregnant patient with mental health illness for the first time, the time spent discussing potential maternal and foetal side effects of AD or AX treatment differed between clinician group (p<0.001, n=541). More than half of GPs (52.6%, n=171) reported spending 15 minutes discussing potential maternal and foetal side effects of AD or AX treatment compared with 48.6% of 370 O&Gs spending less than 5 minutes.
There was a statistically and clinically significant difference (p<0.001) in prescription practice where AD or AX initiation was surveyed: 84.8% of 171 GPs initiated these medications compared to 52.2% of 372 O&Gs.
The GPs ranked “prior response to the medicine” as being an influential reason (60.5%) for prescribing a particular AD or AX. O&Gs (n=372) on the other hand, were more influenced by a medication “a mental health practitioner has previously prescribed” (50.5%). This preponderance for O&Gs to rank a specialist mental health clinicians’ opinion highly was also demonstrated later in the questionnaire, where 55.7% of 357 O&Gs would rely on the original prescriber’s management plan whereas only 11.7% of 162 GPs would (p<0.001).
Responses to the question relating to discontinuation of fluoxetine in a hypothetical pregnant patient signified varying practices between clinician groups. Fifty-nine percent of GPs indicated they would initiate a patient consultation compared with only 18.0% O&Gs. Furthermore, 48.8% of O&Gs suggested that they would seek referral to a mental health specialist compared to 5.3% of 171 GPs.
Confidence
The questionnaire revealed that, overall, clinicians’ main concerns regarding AD and AX medication prescription to women of reproductive age are, in order of perceived influence medical safety profile including teratogenicity (86.9%, n=543), medical efficacy (75.2%, n=537), neonatal adaption syndrome (70.0%, n=543), and medication addiction potential (48.6%, n=537). Of note, 57.4% of 169 GPs were concerned about maternal side effects compared to 47.3% of 368 O&Gs (p=0.029).
There were differences in levels of reported confidence in being up-to-date with medication recommendations and safety profile with 57.6% of GPs feeling confident compared to 44.2% of O&Gs (p=0.004). Figure 1 shows that in general, GPs consider themselves to be more confident in their knowledge (mean difference 0.9 (95% CI 0.5 – 1.3) and ability to prescribe (mean difference 2.2 (95% CI 1.7 – 2.6) and manage (mean difference 2.1 (95% CI 1.7 – 2.6) AD and AX medications than O&Gs.
Figure 1 goes here
Knowledge
Respondents were tested on their knowledge of five well-known AD and AX medications and their potential teratogenicity. As demonstrated in table 2, GPs knowledge were generally similar to that of O&Gs, with the majority of respondents recognising that these medications had no significant proven teratogenicity. However, up to 22.3% respondents in both clinician groups incorrectly ascribed recognised teratogenicity to a commonly used AD or AX. Around 13% of 118 trainees were incorrect for sertraline, venlafaxine and diazepam while 28.2% of 117 were incorrect for amitriptyline and 21.2% of 118 for mirtazapine. Twelve percent of O&Gs considered “Sertraline” teratogenic compared to 3.5% of GPs (p=0.001).
Table 2 goes here
Training adequacy
GPs were more likely to agree that training and education had been adequate for them to feel confident in prescribing AD and AX to pregnant women (56.1%) compared to only a third of O&Gs (29.0%), p<0.001. When asked what would be more useful to daily practice of caring for pregnant patients, 71.0% of all 541 respondents chose increased clinician education and training (71.1% O&Gs versus 70.8% GPs) over increased technological supports such as apps for smart phones. Interestingly, 67.4% of 543 clinicians overall agreed that completion of the study questionnaire had increased their interest in pursuing more information regarding AD and AX use in pregnancy.