Overall, the RANZCOG database identified 5409 eligible clinicians, all of whom received a standardised invitation by 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 were affiliated 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. Majority of the clinicians (98%) saw pregnant women in their clinical practice on a regular basis. Seventy-eight percent of O&Gs spent 11 hours or more per week caring for pregnant women compared to 18.7% of GPs.
Interest
In general, respondents had no particular interest in perinatal mental health disorders (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 the 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). This indicated 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 the groups. Both of these estimated that 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. (6% of O&Gs compared to 14.5% of GPs). Sources of written information were varied and the overall numbers were small. Most of the O&Gs sourced UpToDate (32.2%), followed by MIMS (26.8%) and Mother Risk (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 O&Gs (48.6%, n= 370) 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% O&Gs (n=357) would rely on the original prescriber’s management plan whereas only 11.7% of GPs (n=162) (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 that 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 GPs.
Confidence
The questionnaire revealed that overall, clinicians’ main concerns regarding AD and AX medication prescription to women of reproductive age in order of perceived influence are: 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 GPs (n=169) were concerned about maternal side effects compared to 47.3% of O&Gs (n=368) (p=0.029) (figure 1).
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). 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.
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% (n=118) trainees were incorrect for sertraline, venlafaxine and diazepam while 28.2% (n=117) were incorrect for amitriptyline and 21.2% (n=118) for mirtazapine. Twelve percent of O&Gs considered “Sertraline” teratogenic compared to 3.5% of GPs (p=0.001).
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) in preference to increased technological supports such as apps for smart phones. Interestingly, 67.4% of a total of 543 clinicians agreed that completion of the study questionnaire had increased their interest in pursuing more information regarding AD and AX use in pregnancy.