Unmet needs in mental healthcare for women with clinically significant symptoms of perinatal depression and/or anxiety during the COVID-19 pandemic

ORIGINAL ARTICLE Unmet needs in mental healthcare for women with clinically significant symptoms of perinatal depression and/or anxiety during the COVID-19 pandemic Raquel Costa 1,2,3 | Ana Mesquita 4,5 | Emma Motrico 6 | Sara Domínguez-Salas 7 | Pelin Dikmen-Yildiz 8 | Sandra Saldivia 9 | Eleni Vousoura 10 | Ana Osorio 11 | Claire A. Wilson 12,13 | Rena Bina 14 | Drorit Levy 14 | Andri Christoforou 15 | Maria Fernanda Gonz alez 16 | Camelia Hancheva 17 | Ethel Felice 18 | Tiago Miguel Pinto 3 1 EPIUnit - Instituto de Saúde Pública, Universidade do Porto, Porto, Portugal 2 Laborat orio para a Investigaç˜ ao Integrativa e Translacional em Saúde Populacional (ITR), Universidade do Porto, Porto, Portugal 3 Hei-Lab: Digital Human-Environment Interaction Lab, Faculty of Psychology, Education and Sports, Lus ofona University, Porto, Portugal 4 School of Psychology, University of Minho, Braga, Portugal 5 ProChild CoLab Against Poverty and Social Exclusion –Association (ProChild CoLAB) Campus de Couros R, Guimar˜ aes 6 Department of Psychology, Universidad Loyola Andalucia, Spain 7 Departamento de Psicología Experimental, Universidad de Sevilla, Sevilla, Spain 8 Department of Psychology, Kirklareli University, Kirklareli, Turkey 9 Department of Psychiatry and Mental Health, Faculty of Medicine. Universidad de Concepci on, Chile 10 Department of Psychology, School of Philosophy, National & Kapodistrian University of Athens, Greece 11 Graduate Program on Developmental Disorders and Mackenzie Center for Research in Childhood and Adolescence, Center for Biological and Health Sciences, Mackenzie Presbyterian University, S˜ ao Paulo, SP, Brazil 12 Institute of Psychiatry, Psychology and Neuroscience, King's College London, UK 13 South London and Maudsley NHS Foundation Trust, UK 14 The Louis and Gabi Weisfeld School of Social Work, Bar-Ilan University, Israel 15 Department of Social and Behavioral Sciences, European University Cyprus, Cyprus 16 Health Sciences Faculty, National University of Entre Rios, Argentina 17 Sofia University “St. Kliment Ohridski”, Bulgaria 18 University of Malta, Msida, Malta Correspondence Raquel Costa, EPIUnit, Instituto de Saúde Pública, Universidade do Porto, Rua das Taipas, 135, 4050-600 Porto, Portugal. Email: [email protected] Funding information National Institute for Health and Care Research; Fundaç˜ ao para a Ciência e a Tecnologia, Grant/Award Numbers: Abstract Objective/Background: Unmet needs in perinatal mental healthcare are an important public health issue particularly in the context of a stressful life event such as the COVID-19 pandemic but data on the extent of this problem are needed. Aim: The aim of this study is to determine the (1) proportion of women with clinically significant symptoms of perinatal depression, anxiety or comorbid Received: 9 April 2023 Revised: 2 January 2024 Accepted: 9 January 2024 DOI: 10.1111/acps.13664 This is an open access article under the terms of the Creative Commons Attribution License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited. © 2024 The Authors. Acta Psychiatrica Scandinavica published by John Wiley & Sons Ltd. 474 Acta Psychiatr Scand. 2024;150:474–491. wileyonlinelibrary.com/journal/acps UIDB/04750/2020, LA/P/0064/2020, UIDB/05380/2020, SFRH/BPD/117597/ 2016; CAPES/Proex, Grant/Award Number: 88887.310343/2018-00; European Social Fund; COST (European Cooperation in Science and Technology); ProChild CoLAB, Grant/Award Numbers: NORTE59-2018-41, NORTE-06-3559-FSE- 000044; Regional Operational Programme of the North 2020; European Social Fund (ESF); Mission Interface Program from theResilience and Recuperation Plan, Grant/Award Number: 01/C05-i02 /2022; Psychology Research Centre—CIPsi, Grant/Award Number: PSI/01662; Foundation forScience and Technology (FCT), Grant/Award Number: UIDB/PSI/ 01662/2020 symptoms of depression and anxiety, receiving mental healthcare overall and by country and (2) factors associated with receiving mental healthcare. Method: Women in the perinatal period (pregnancy or up to 6 months postpartum) participating in the Riseup-PPD-COVID-19 cross-sectional study, reported on sociodemographic, social support health-related factors, and COVID-19 related factors, and on symptoms of depression (Edinburgh Postnatal Depression Scale [EPDS]) and anxiety (Generalised Anxiety Disorder [GAD-7]) using self-report questionnaires. Clinically significant symptoms were defined as EPDS ≥13 for depression and GAD-7 ≥10 for anxiety. Mental healthcare was defined as self-reported current mental health treatment. Results: Of the 11 809 participants from 12 countries included in the analysis, 4 379 (37.1%) reported clinically significant symptoms of depression (n = 1 228; 10.4%; EPDS ≥13 and GAD-7 h10), anxiety (n = 848; 7.2%; GAD-7 ≥10 and EPDS h13) or comorbid symptoms of depression and anxiety (n = 2 303; 19.5%; EPDS ≥13 and GAD-7 ≥10). Most women with clinically significant symptoms of depression, anxiety, or comorbid symptoms of depression and anxiety were not receiving mental healthcare (89.0%). Variation in the proportion of women with clinically significant symptoms of depression and/or anxiety reporting mental healthcare was high (4.7% in Turkey to 21.6% in Brazil). Women in the postpartum (vs. pregnancy) were less likely (OR 0.72; 95% CI 0.59-0.88), whereas women with previous mental health problems (vs. no previous mental health problems) (OR 5.56; 95% CI 4.41-7.01), were more likely to receive mental healthcare. Conclusion: There are high unmet needs in mental healthcare for women with clinically significant symptoms of perinatal depression and/or anxiety across countries during the COVID-19 pandemic. Studies beyond the COVID-19 pandemic and covering the whole range of mental health problems in the perinatal period are warranted to understand the gaps in perinatal mental healthcare. KEYWORDS anxiety, depression, EPDS, postpartum, pregnancy 1|INTRODUCTION Womenintheperinatalperiodareespeciallyvulnerable to mental health problems, particularly to depression and anxiety, the prevalence of which has increased during the COVID-19 pandemic. 1,2 The estimates of major depressive episode in the perinatal period ranged from 6.5% to 12.9% and the combined period prevalence was 19.2% for the first 3 months postpartum. 3 The estimates of a recent systematic review and of a study conducted in Brazil, Chile, Cyprus, Greece, Israel, Portugal, Spain, Turkey, and the United Kingdom, indicated that clinically significant symptoms of depression (EPDS≥13) reached 26% during pregnancy and the postpartum in the pre-pandemic vs 50% during pregnancy and 55% in the postpartum in the COVID-19 pandemic. 2,4 The estimates of clinically significant symptoms of anxiety (GAD-7 ≥10) reaches 30% during pregnancy and 20% in the postpartum in the pre-pandemic vs 36% during pregnancy and 42% in the postpartum in the COVID-19 pandemic in studies conducted in Albania, Brazil, Bulgaria, Chile, Cyprus, Greece, Israel, Malta, Portugal, Spain, Turkey, and the United Kingdom. 2,5 The estimates of recent systematic reviews and of a study conducted in Brazil, Chile, Cyprus, Greece, Israel, Portugal, Spain, Turkey, and the United Kingdom, indicated that clinically significant symptoms of depression and anxiety is around 6.3% during pregnancy and 5.7% postpartum, in COSTA ET AL.475 16000447, 2024, 5, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/acps.13664 by Readcube (Labtiva Inc.), Wiley Online Library on [03/12/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License the pre-pandemic period vs 15% during pregnancy and 20% in the postpartum in the COVID-19 pandemic. 2,6,7 Despite the high rates of perinatal mental health problems, especially in countries with lower inequality-adjusted human development index 5 during the COVID-19 pandemic, more than 60% of antenatal or postnatal mental healthcare services of 130 countries were disrupted. 8 During the pre-pandemic period, it was estimated that about 1 in 2 pregnant women with a major depressive episode received mental health treatment in the United States of America, 9 1in 4 women with clinically significant symptoms of depression or anxiety in the postpartum period had consulted a health professional, and 37% had unmet needs in mental healthcare in Canada. 10 During the COVID-19 pandemic, a simulation of patient accessibility and affordability of perinatal mental healthcare in 15 mental health clinics in the United States of America showed that only about 1 in 2 women seeking care without a prior referral are successful, and in these cases, the initial appointment may be scheduled foraslongas2months. 11 When women are screened for depression in the perinatal period, the uptake referral rate can be as high as 51.8%. 12 A recent metaanalysis reported that 43% (pooled rate from studies conducted in Australia, China, Iceland, Israel, NewZealand,Singapore,SouthAfrica,USA,Turkey; 95% CI 35%–50%) of women screened positive for depression attended mental health department/clinic to undergo further assessment/treatment or received on-site assessment/treatment. 13 Still, detailed information by country on he the proportion of women screened for depression in maternal and neonatal healthcare services and on the proportion of those with perinatal mental health problems receiving treatment is largely unknown. For major depressive disorders in general (not exclusively in the perinatal period), the World Mental Health (WMH) surveys of the World Health Organisation (WHO) provided information on treatment for 21 countries. About 1 in 5 people in high-income (Argentina [17.9%], Belgium [29.5%], France [23.0%], Germany [31.6%], Israel [15.8%], Italy [16.7%], Japan [22.2%], Netherlands [33.1%], Portugal [18.8%], Spain [27.2%], USA [26.6%]) and 1 in 27 in low/middle-income countries (Brazil [14.9%], Bulgaria [6.7%], Colombia [9.0%], Iraq [2.5%], Lebanon [7.0%], Mexico [6.4%], Nigeria [0.0%], Peoples Republic of China [not possibletoestimateduetolow responses], Peru [0.9%], Romania [13.5%]) with 12-month diagnosis of major depressive disorder received minimally adequate treatment. 14 This is an important public health issue, and the COVID-19 pandemic might have worsened care provision, and intensified inequities in access to care. 15 Several aspects may be associated with the perpetuation of unmet needs in perinatal mental healthcare including individual (women or healthcare provider, e.g., substandard mental health literacy), socio-cultural (e.g. language, stereotypes, stigma), healthcare facilityrelated (e.g., lack of resources, healthcare professionals overload or lack of training or reluctance to meet patients' emotional needs, lack of clear referrals), or structural (e.g., policies or resources) factors; these may be important barriers for help seeking behaviours and care policy and provision. 16–22 Findings from a recent systematic review suggests increased mental healthcare use among pregnant and postpartum women, when in addition to screening, the healthcare systems implement interventions that target barriers related to patient, perinatal care provider and practice. 23 Untreated perinatal depression and anxiety have a negative impact on women's health and well-being as well as on child outcomes. 24–26 Therefore, providing timely and adequate mental healthcare in the perinatal period is extremely important to improve women's mental health and quality of life and to minimise its negative impact on the child. Few studies have assessed perinatal depression and/or anxiety and explored unmet needs in mental healthcare in women with clinically significant symptoms, and the existing ones are context-restricted and conducted before the Significant Outcomes •High variations between countries in the provision of mental healthcare for women with clinically significant symptoms of depression and/ or anxiety. •Overall, about one in ten women with clinically significant symptoms of depression, anxiety or comorbid symptoms were receiving mental healthcare. •Individual and health-related factors were associated with receiving mental healthcare. Limitations •Underrepresentation of women in disadvantaged socio demographic groups. •Other symptoms than those of depression and anxiety were not considered in the analysis of the proportion of women receiving mental healthcare. 476 COSTA ET AL. 16000447, 2024, 5, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/acps.13664 by Readcube (Labtiva Inc.), Wiley Online Library on [03/12/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License COVID-19 pandemic (e.g., 10 ). Data on unmet needs in mental healthcare combined with data on the factors associated with receiving mental healthcare among women with clinically significant symptoms, can provide important information to develop cost-effective strategies to improve perinatal mental healthcare. This study aimed to determine the proportion of women with clinically significant symptoms of perinatal depression (EPDS ≥13 and GAD-7 < 10), anxiety (GAD-7 ≥10 and EPDS <13) or comorbid symptoms of depression and anxiety (EPDS ≥13 and GAD-7 ≥10) receiving mental healthcare overall and by country. Additionally, it also aimed to analyse the factors (socio-demographic, perinatal, health-related, social support and COVID-19 related) associated with receiving mental healthcare among women with clinically significant symptoms of perinatal depression, anxiety, or comorbid symptoms of depression and anxiety. 2|MATERIAL AND METHODS 2.1 |Study design This is a cross-sectional study reported according to STROBE guidelines 27 (Supporting Information Table S1). Data comes from the Riseup-PPD-COVID-19 cross-sectional observational study (ClinicalTrials.gov: NCT04595123) conducted from 8th June 2020 to 4th April 2021 in 13 countries: Albania, Argentina, Brazil, Bulgaria, Chile, Cyprus, Greece, Israel, Malta, Portugal, Spain, Turkey, and the United Kingdom. The methodology of the project is described in detail elsewhere. 28 Pregnant women or mothers in the postpartum period (with a biological infant up to 6 months of age) and aged 18 years or more were eligible to participate in the study. Invitations to participate in the study were sent directly by message or email, or through social media, networks of organisations, policymakers, local organisations, and other stakeholders, as well as networks of the research team. A link to an online surveythatfirstpresentedadetailedinformedconsent with an overview of the research objectives, procedures, data management and other ethical considerations was provided. Only participants who gave their consent, were able to proceed to the online survey. 2.2 |Study population Our sample includes women in the antenatal or the postnatal period from 12 RISEUP-PPD countries (Albania not included in the analyses due to small sample size). Between the study period 23,866 women accessed the questionnaire link and signed the informed consent form. Of these 3030 (12.7%) were excluded due to non-eligibility (e.g., date of birth indicates a child with more than 6 months), 127 (0.5%) were excluded due to suspected duplicates (e.g., verified by checking the answers with the same personnel contacts), 2852 (12.0%) due to extremely incomplete questionnaires, and 110 were from Albanian participants and were excluded due to small eligible sample size in this country (n=63; see Figure 1). Data from 17,747 participants were considered valid. In this analysis, missing data was not imputed, we only included women who completed the Edinburgh Postnatal Depression Scale (EPDS) and the Generalised Anxiety Disorder Questionnaire-7 (GAD-7) questionnaires and information on current mental health treatment (N=11,809; see Figure 1). 2.3 |Data collection Data were collected using a standardised self-report questionnaire initially developed in English and translated into the participating countries' languages using back translation, as described in detail elsewhere. 28 2.3.1 | Social and demographic factors Information included age, country of birth, country of residence, educational level (secondary education or lower vs. high school vs. higher education), professional status (employed vs. unemployed/student/housewife), and marital status (married/cohabiting vs. single/separated/divorced/widow). 2.3.2 | Perinatal factors Information included first pregnancy (yes vs. no), high risk pregnancy (no vs. yes if women self-reported gestational diabetes or hypertension or short cervix or other— including anaemia or placental abruption), and perinatal period (prenatal vs. postnatal). 2.3.3 | Health-related factors Information included self-reported history of previous mental health problems (no vs. yes if at least one of the following: At any time in your past have you received treatment for any of the following? (Check all that apply) a. mental health, b. substance abuse (including problems with prescription drugs, illegal drugs or alcohol), c. I have had mental health problems but have not been treated, d. I have had substance abuse problems but have not been treated), perceived support by the primary COSTA ET AL.477 16000447, 2024, 5, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/acps.13664 by Readcube (Labtiva Inc.), Wiley Online Library on [03/12/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License maternity care provider (“How well are you currently being supported by your primary maternity care provider?”3-point Likert-type scale: 1. not very well supported, 2. somewhat well supported, 3. very well supported). 2.3.4 | Social support Information included perceived support from the social network (“Currently, how supported do you feel by your social network?”7-point Likert-type scale from 1 [not supported] to 7 [very supported]). 2.3.5 | COVID-19 related factors Information included exposure to COVID-19 (no vs. yes if exposed to at least one of the following: history of COVID-19 diagnosis, COVID-19 related symptoms, direct physical contact with an infected person, or death of a relative with COVID-19), perceived level of distress about own COVID-19 related symptoms or potential illness (7-point Likert-type scale from 1 [no distress] to 7 [highly distressed]), perceived overall level of impact to daily life due to the COVID-19 outbreak (7-point Likert-type scale from 1 [nothing] to 7 [extreme]), perceived level of stress related to the COVID-19 outbreak (7-point Likert-type scale from 1 [nothing] to 7 [extreme]), perceived level of distress experienced with disruptions to social support due to the COVID-19 outbreak (7-point Likert-type scale from 1 [no distress] to 7 [highly distressed]), and perceived importance of access to a mental health provider during the COVID-19 outbreak (3-point Likert-type scale: 1. not important at all, 2. somewhat important, and 3. very important). 2.3.6 | Mental healthcare Information on current mental health treatment was selfreported, using the following question: “Are you FIGURE 1 Participation flowchart. EPDS, Edinburgh Postnatal Depression Scale; GAD-7, Generalised Anxiety Disorder Questionnaire. 478 COSTA ET AL. 16000447, 2024, 5, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/acps.13664 by Readcube (Labtiva Inc.), Wiley Online Library on [03/12/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License currently receiving mental health treatment (for example for depression, anxiety, stress, attention deficit hyperactivity disorder, bipolar disorder, eating disorder, or posttraumatic stress disorder)?”(yes vs. no). 2.3.7 | Symptoms of depression The EPDS 29 was used to assess the severity of depressive symptoms. This is a 10-item self-report questionnaire in a 4-point Likert-type scale. Total score ranges from 0 to 30. Higher scores indicate greater symptom severity. The threshold of 13 or more was used to indicate clinically significant symptoms of depression, as recommended for a cutoff with higher specificity in the perinatal period regardless the country human development index, based on data from several countries including seven of the countries in our analysis (Brazil, Chile, Greece, Malta, Portugal, Spain, Turkey, and the UK 30 ). In the remaining countries included in our analysis, the EPDS is validated in Argentina, Cyprus, and Israel, 31–33 and, in Bulgaria, even though it is used in research, there is no official validation paper as far as we are aware. The overall reliability (Cronbach's alpha) in our sample was 0.73 (Argentina =0.75; Bulgaria =0.76; Brazil =0.76; Chile =0.78; Cyprus =0.64; Greece =0.74; Israel =0.52; Malta =0.68; Portugal =0.79; Spain =0.75; Turkey =0.54; UK =0.75). 2.3.8 | Symptoms of anxiety The GAD-7 34 was used to assess the severity of anxiety symptoms. This is a self-reported questionnaire with 7 items in a 4-point Likert-type scale. Total score ranges from 0 to 28. Higher scores indicate greater symptom severity. We used the threshold of 10 or more to indicate clinically significant anxiety symptoms, 34 based on the original validation study and in studies with perinatal population (e.g., 2,35–39 ). The GAD-7 is validated in Argentina, Cyprus, Portugal, Spain, Turkey, and the UK, 34,39–43 and even though it is used in research in the remaining countries, there is no official validation paper as far as we are aware. The overall reliability (Cronbach's alpha) in our sample was 0.83 (Argentina =0.87; Bulgaria =0.89; Brazil =0.86; Chile =0.80; Cyprus =0.86; Greece =0.64; Israel =0.79; Malta =0.83; Portugal =0.85; Spain =0.80; Turkey =0.87; UK =0.87). 2.3.9 | Current mental health status Attending to the scores on EPDS and GAD-7, women were classified in four categories: (1) without clinically significant symptoms of depression or anxiety (EPDS <13 & GAD-7 < 10), (2) with clinically significant symptoms of depression and without clinically significant symptoms of anxiety (EPDS ≥13 & GAD-7 < 10); (3) with clinically significant symptoms of anxiety and without clinically significant symptoms of depression (GAD-7 ≥10 & EPDS <13); and (4) with clinically significant comorbid symptoms of depression and anxiety (EPDS ≥13 & GAD-7 ≥10). 2.4 |Ethics Ethical principles according to the Declaration of Helsinki were followed in this study. Ethical approvals were issued by the following Ethic Committees: Bedër University College, Albania (Ethics protocol: 145); Sofia University “St. Kliment Ohridski”, National University of Entre Ríos, Argentina (Ethics Protocol: CD 610/09); Mackenzie Presbyterian University, Brazil (Ethics Protocol: 31155120.7.0000.0084); Universidad de Concepcion, Chile (Ethics Protocol: CEC 13/2020 and CEBB 704–2020); Cyprus National Bioethics Committee (Ethics protocol: EEBK ΕΠ 2020.01.126); American College of Greece (Ethics protocol: #202005207); Bar Ilan University School of Social Work, Israel (Ethics approval 062001); University of Malta (Ethics protocol: FRECMDS_1920_179); University of Minho, Portugal (Ethics Protocol: CEICVS 045/2020); Andalusian Ministry of Health, Spain (Ethics Protocol: 1257- N-20); Kırklareli University, Turkey (Ethics protocol: 35523585–199-E.8606); King's College London, the United Kingdom (Ethics protocol: ID 19747). Participants gave their informed consent online, and protection of personal data was ensured by adherence to guidelines and regulations in each country. One link was shared to all potential participants. Data were collected anonymously; participants gave their informed consent and were informed that confidentiality of all data is secured according to European legislation detailed at Regulation (EU) 2019/679 of the European Parliament and the Council of 27 April 2016 on the protection of persons concerning the processing and transfer of personal data. 3|STATISTICAL ANALYSIS We first described the socio-demographic and clinical characteristics of participants. Then, we report the proportion of women receiving mental healthcare services by women classified in four groups: no clinically significant symptoms of depression or anxiety (EPDS <13 and GAD- 7 < 10); clinically significant symptoms of depression (EPDS ≥13 and GAD-7 < 10); clinically significant symptoms of anxiety (GAD-7 ≥10 and EPDS <13); clinically COSTA ET AL.479 16000447, 2024, 5, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/acps.13664 by Readcube (Labtiva Inc.), Wiley Online Library on [03/12/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License significant comorbid symptoms of depression and anxiety (EPDS ≥13 and GAD-7 ≥10). We reported mental healthcare use by country, and by perinatal period (prenatal vs. postnatal). We then investigated factors associated with receiving mental healthcare among the combined groups of women with either clinically significant symptoms of depression (EPDS≥13 and GAD-7 < 10); clinically significant symptoms of anxiety (GAD-7 ≥10 and EPDS<13); or clinically significant comorbid symptoms of depression and anxiety (EPDS≥13 and GAD-7 ≥10). Mixed effects logistic regressions adjusting for country as a random effect (Model 1) and adjusting for country as a random effect and for symptom severity (EPDS and GAD-7 total scores) as fixed effects (Model 2) were performed to obtain the odds ratio (OR) and 95% confidence interval (CI) of receiving mental healthcare among women with clinically significant symptoms of depression, anxiety or comorbid symptoms of depression and anxiety. All analyses were carried out using SPSS 26.0 (SPSS Inc., USA). 4|RESULTS 4.1 |Sample description and description of mental health status Participants' characteristics overall are depicted in Table 1, and by country in Supporting Information Table S2. Most participants were aged between 25 and 35 years (68.5%), born in the country where they gave birth (94.5%), with higher education (76.8%), employed (69.1%) and married (95.5%). About half were pregnant (45.5%). Of the 11,809 participants included in the analysis, 62.9% (n=7430) reported non clinically significant symptoms, and 4379 (37.1%) reported clinically significant symptoms of depression (n=1228; 10.4%), anxiety (n=848; 7.2%) or comorbid symptoms of depression and anxiety (n=2303; 19.5%). Mean scores for EPDS and GAD-7 by mental health status are depicted in Table 1, indicated greater depression and anxiety symptom severity for women with clinically significant comorbid symptoms of depression and anxiety. Cyprus was the country with the highest proportion of women reporting noclinically significant symptoms of depression or anxiety (73.3%), whereas Brazil was the country with the lowest proportion of women reporting noclinically significant symptoms of depression or anxiety (47.9%). Clinically significant comorbid symptoms of depression and anxiety were the highest in Brazil (30.8%) and Chile (28.0%) and the lowest in Cyprus (11.0%) and Israel (11.2%). 4.2 |Self-reported mental healthcare overall, by country, and by perinatal period Overall, about one in 10 women with clinically significant symptoms (EPDS ≥13, or GAD-7 ≥10 or EPDS ≥13 & GAD-7 ≥10) were receiving mental healthcare (11.0%). These proportions were slightly higher for women with clinically significant comorbid symptoms of depression and anxiety (13.6%), and lower for women with clinically significant symptoms of depression (8.6%) or anxiety (7.4%) (see Table 2; Supplementary Figure 1A–D). The proportion of women with clinically significant symptoms of depression receiving mental healthcare varied from 3.8% in Cyprus to 16.7% in Argentina and Brazil, whereas the proportion of women with clinically significant symptoms of anxiety receiving mental healthcare varied from 0% in Malta and Bulgaria to 17.9% in Israel. Variation in the provision of mental healthcare for women with clinically significant comorbid symptoms of depression and anxiety was also high between countries, with the lowest provision of care in Turkey (4.7%) and the highest (21.6%) in Brazil. The proportion of women with clinically significant symptoms of depression, anxiety or comorbid symptoms of depression and anxiety receiving mental healthcare in the prenatal period was 12.0% and in the postnatal period was 10.3%, with higher proportions in the prenatal period in all countries except Greece. The proportion of women with clinically significant comorbid symptoms of depression and anxiety receiving mental healthcare was 14.9% in the prenatal period and 12.8% in the postnatal period, with higher proportions in the prenatal period in most countries except Bulgaria, Greece, Israel, and UK (see Figure 2;Supporting Information Table S3). 4.3 |Factors associated with self-reported mental healthcare Women with clinically significant symptoms of depression or anxiety or comorbid symptoms of depression and anxiety in the postnatal period (OR =0.72; 95% CI 0.59–0.88) were less likely to receive mental healthcare compared to women in the prenatal period, whereas women with previous mental health problems (OR 5.56; 95% CI 4.41–7.01), with clinically significant comorbid symptoms of depression and anxiety (OR 1.57; 95% CI 1.23–1.99), exposed to COVID-19 (OR 1.30; 95% CI 1.05–1.60), or perceiving access to mental healthcare as very important (OR 4.47; 95% CI 2.33–8.59) were more likely to receive mental 480 COSTA ET AL. 16000447, 2024, 5, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/acps.13664 by Readcube (Labtiva Inc.), Wiley Online Library on [03/12/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License TABLE 1 Characteristics of the participants included in the study overall and by mental health status. Total N=11,809 No clinically significant symptoms of depression or anxiety (EPDS < 13 & GAD-7 < 10) n=7430 Clinically significant symptoms of depression (EPDS ≥13 & GAD-7 < 10) n=1228 Clinically significant symptoms of anxiety (GAD-7 ≥10 & EPDS < 13) n=848 Clinically significant comorbid symptoms of depression and anxiety (EPDS ≥13 & GAD-7 ≥10 n=2303) n%n%n%n%n% Sociodemographic factors Age (years) ≤24 731 6.5 372 5.2 104 8.9 50 6.2 206 9.3 25–35 7751 68.5 4918 69.1 787 67.4 545 67.2 1501 67.6 ≥36 2836 25.1 1832 25.7 276 23.7 216 26.6 512 23.1 Missing 490 4.1 308 4.1 61 5.0 37 4.4 84 3.6 Mean (SD) 32.18 4.83 32.40 4.70 31.66 5.20 32.29 4.89 31.71 5.00 Country of birth Country-born 10,433 94.5 6642 94.5 1070 94.4 738 94.9 1983 94.1 Foreign-born 613 5.5 384 5.5 64 5.6 40 5.1 125 5.9 Missing 763 6.5 404 5.4 94 7.7 70 8.3 195 8.5 Education Secondary education or lower 175 1.5 95 1.3 29 2.5 8 1.0 43 1.9 High school 2474 21.7 1390 19.3 297 25.1 162 19.9 625 28.1 Higher education 8778 76.8 5722 79.4 857 72.4 644 79.1 1555 70.0 Missing 382 3.2 223 3.0 45 3.7 34 4.0 80 3.5 Professional status Employed 7731 69.1 4993 71.3 720 63.7 595 71.8 1423 64.0 Unemployed/student/ housewife 3451 30.9 2006 28.7 410 36.3 234 28.2 801 36.0 Missing 627 5.3 431 5.8 98 8.0 19 2.2 79 3.4 Marital status Married/cohabiting 11,119 95.5 7085 96.5 1156 95.6 782 94.4 2096 92.4 Other situation 1 529 4.5 257 3.5 53 4.4 46 5.6 173 7.6 Missing 161 1.4 88 1.2 19 1.5 20 2.4 34 1.5 Argentina 425 3.6 267 62.8 36 8.5 38 8.9 84 19.8 Country Brazil 915 7.7 438 47.9 120 13.1 75 8.2 282 30.8 Bulgaria 293 2.5 206 70.3 26 8.9 16 5.5 45 15.4 Chile 1196 10.1 633 52.9 91 7.6 137 11.5 335 28.0 Cyprus 484 4.1 355 73.3 52 10.7 24 5.0 53 11.0 Greece 994 8.4 690 69.4 82 8.2 77 7.7 145 14.6 (Continues) COSTA ET AL.481 16000447, 2024, 5, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/acps.13664 by Readcube (Labtiva Inc.), Wiley Online Library on [03/12/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License TABLE 1 (Continued) Total N=11,809 No clinically significant symptoms of depression or anxiety (EPDS < 13 & GAD-7 < 10) n=7430 Clinically significant symptoms of depression (EPDS ≥13 & GAD-7 < 10) n=1228 Clinically significant symptoms of anxiety (GAD-7 ≥10 & EPDS < 13) n=848 Clinically significant comorbid symptoms of depression and anxiety (EPDS ≥13 & GAD-7 ≥10 n=2303) n%n%n%n%n% Israel 554 4.7 385 69.5 90 16.2 17 3.1 62 11.2 Malta 264 2.2 168 63.6 34 12.9 11 4.2 51 19.3 Portugal 1463 12.4 1013 69.2 143 9.8 70 4.8 237 16.2 Spain 3189 27.0 1929 60.5 218 6.8 339 10.6 703 22.0 Turkey 1393 11.8 945 67.8 251 18.0 25 1.8 172 12.3 UK 639 5.4 401 62.8 85 13.3 19 3.0 134 21.0 Missing 0 0.0 0 0.0 0 0.0 0 0.0 0 0.0 Perinatal factors First pregnancy Yes 7026 59.5 4456 60.0 705 57.5 507 59.8 1358 59.0 No 4779 40.5 2972 40.0 521 42.5 341 40.2 945 41.0 Missing 4 0.0 2 0.0 2 0.0 0 0.0 0 0.0 Risk pregnancy Yes 3564 32.0 2047 29 415 36.3 291 36.1 811 38.1 No 7582 68.0 5021 71 727 63.7 514 63.9 1320 61.9 Missing 663 5.6 362 4.9 86 7.0 43 5.1 172 7.5 Perinatal period Prenatal 5377 45.5 3562 47.9 555 45.2 351 41.4 909 39.5 Postnatal 6432 54.5 3868 52.1 673 54.8 497 58.6 1394 60.5 Missing 0 0.0 0 0.0 0 0.0 0 0.0 0 0.0 Health-related factors Previous mental health problems Yes 2 3258 27.9 1544 21 387 32.0 292 34.7 1035 45.3 No 8438 72.1 5813 79 824 68.0 550 65.3 1251 54.7 Missing 113 1.0 73 1.0 17 1.4 6 0.7 17 0.7 Support from the healthcare provider Not very well supported 1243 10.5 591 8.0 165 13.4 113 13.3 374 16.2 Somewhat well supported 3876 32.8 2284 30.8 421 34.4 287 33.8 884 38.4 Very well supported 6687 56.6 4552 61.3 642 52.3 448 52.8 1045 45.4 Missing 3 0.0 3 0.0 0 0.0 0 0.0 0 0.0 482 COSTA ET AL. 16000447, 2024, 5, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/acps.13664 by Readcube (Labtiva Inc.), Wiley Online Library on [03/12/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License the legal regime in force, approved by Decree Law no. 63/2019, of May 16th, as well as in its 1st review on “Technology and Innovation Centres—CTI”and “Collaborative Laboratories—CoLABs,”approved by Decree-Law no. 126-B/2021, of December 31st. The Psychology Research Centre—CIPsi (PSI/01662), School of Psychology, University of Minho, was supported by the Foundation for Science and Technology (FCT) through the Portuguese State Budget (Ref.: UIDB/PSI/01662/2020) CONFLICT OF INTEREST STATEMENT All authors declare no support from any organisation for the submitted work other than those described above; no financial relationships with any organisations that might have an interest in the submitted work in the previous 3 years; no other relationships or activities that could appear to have influenced the submitted work. PEER REVIEW The peer review history for this article is available at https://www.webofscience.com/api/gateway/wos/peerreview/10.1111/acps.13664. DATA AVAILABILITY STATEMENT The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions. 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BJPsych International. 2020;17(1):1-2. doi:10.1192/ bji.2019.32 SUPPORTING INFORMATION Additional supporting information can be found online in the Supporting Information section at the end of this article. How to cite this article: Costa R, Mesquita A, Motrico E, et al. Unmet needs in mental healthcare for women with clinically significant symptoms of perinatal depression and/or anxiety during the COVID-19 pandemic. Acta Psychiatr Scand. 2024; 150(5):474‐491. doi:10.1111/acps.13664 COSTA ET AL.491 16000447, 2024, 5, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/acps.13664 by Readcube (Labtiva Inc.), Wiley Online Library on [03/12/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License