The results of this online survey revealed that pregnant or postpartum women have identifiable preferences regarding their participation and role in the depression treatment decision making process. Comparable to other women's health samples, most women preferred an active and collaborative role in treatment decision making, amenable to shared decision making and decision support interventions [28
]. With respect to decision making tasks, respondents in this sample preferred to defer control of the problem solving tasks, which require evidence-based information about depression treatment, to the physician and preferred to share or keep control of decision making tasks. This finding is consistent with previous studies of women facing decisions about contraception; fertility and breast cancer treatment [35
]. These data as well as open-ended question data demonstrated a desire to be involved in decision making, the importance of communicating evidence-based information, and the need for patient-specific decision support tools and guides to assist women in healthcare decision making with their providers.
Contrary to our hypothesis, we found combination treatment to be the preferred treatment among women in our sample. Other studies showed that most participants preferred treatment with psychotherapy alone, although other studies did not include combination treatment as an option [13
]. There may be several reasons for this. Preference for combination may also be a reflection of our sample, 60% of whom had already made a treatment decision about their treatment and presumably discussed concerns about medications and a risk-benefit discussion with their healthcare providers. Further, respondents were predominantly postpartum and the reticence for medications is often greater during pregnancy; however, being pregnant or postpartum did not influence treatment preference in this sample. Treatment preference results should be rendered tentative due to our sample size; however, they merit consideration as identifiable patient-level factors to be aware of and address during the treatment decision making process. Several studies have found that discussing treatment preferences facilitates treatment negotiation and better uptake of recommendations [45
]. Thus it is reasonable to hypothesize that providers who engage pregnant or postpartum women in the risk-benefit discussion will likewise facilitate treatment alliance and uptake if they not only provide evidence-based information and offer their treatment recommendation but also discuss patients’ treatment preferences [49
Notably, in our sample approximately one-third of women who accessed and used perinatal mood disorders websites and reported receiving a diagnosis of MDD from their healthcare professional had not made a treatment decision about their depression. Overall, respondents in this sample had low decisional conflict compared to other samples of women facing health decisions [38
]. Several small pilot studies have found a considerable portion of their respondents expressed uncertainty about what to choose (% uncertain ranging from 52% [41
] to 69% [38
]. In our sample, those who already made a decision had lower decisional conflict relative to those who had not. We believe this is due a biased sample of well-educated, highly motivated and recruited though perinatal mood disorders websites to which their providers referred them. Decisional conflict was greater among the younger women in this sample, which identifies them as a group at risk for decisional delay. Subscale analyses revealed that younger women report feeling less informed as compared to older women in this sample. Increasing patient knowledge of treatment options is a modifiable factor that providers can address using decision support during the treatment decision making process, especially with young pregnant or postpartum women experiencing depression.
To our knowledge, this is the first quantitative study to examine depressed women's perspectives and preferences for the treatment decision making process during pregnancy and after birth. Unlike previous studies assessing treatment preferences, we examined preferences for participation in decision making, surveyed treatment decisions and uncertainty surrounding this decision as well as needs and services to facilitate patient-physician communication about treatment decisions for depression during the perinatal period. However, our study should be rendered tentative given several limitations which constrain their generalizability to depressed perinatal women in the general population. First, we were limited to a small convenience sample of predominantly white well-educated depressed women who self-report a diagnosis of depression. We were also unable to include in our analyses data on 20% of our sample that was excluded because they were more than 52 weeks postpartum (20%). Second, we examined preferences for decision making among a sample in which more than half of the participants had already made a decision regarding their treatment with their provider. We did not collect information on treatment history or current treatment. This limited our ability to fully examine demographic, treatment (i.e. preference and status) and clinical variables and their influence on decision making preferences. Third, our sample is likely biased by the likely exclusion of women who do not use a web resource for perinatal depression and women who do not use a computer or have access to one. Lastly, we were limited by quantitative measurement of decision making preferences at one single point in time. Preferences could change with passage of time, remission of depression, education about treatment options, cost of treatments, access to care, therapeutic discussion with a clinician, and actual treatment experience. Future research will need to assess a larger and more representative sample using qualitative and quantitative methods to allow for comparisons of preference patterns, enrich our understanding of preferences for treatment decision-making and explore factors that influence them. In addition, it will be important to capture women at different stages of their help seeking to understand how preferences vary and determine appropriate timing for a shared decision making intervention. Future studies will address these issues as well as other influences on treatment decision making during the perinatal period.
Pregnancy and the postpartum period are developmental and situational transitions for women that sets up a cascade of decisions that may directly or indirectly affect the health of women and their families. For many of these decisions there is no right or wrong answer and women need to carefully deliberate on the best option for them. Supporting women and families through these decisions can start with asking them about their preferences for the approach to decision making with the physician. Exploring the patient's expectations for the physician's as well as her own will improve communication and congruence between patient and provider beliefs about participation and thereby enhance outcomes to treatment and satisfaction with care [51
], top priorities for both parties.