Table 2 Individual, social, and clinician factors

Individual Capability

 Low recognition of treatment need

I felt depressed during all three pregnancies…. This time… I have acknowledged the severity of it. —Black patient

[For many women with perinatal depression] they were so overwhelmed they didn’t even know what was going on. [By the time they seek treatment], they have a major depression, it’s recurrent, it’s pretty deep, and it’s harder to treat. —Mental health clinician

I just was in such denial…. I was in such a state that was so normal to me that I didn’t really know that it was postpartum depression. —White patient

 Low understanding of how treatment works

I am pretty sure I got [information about depression] in the packet when we left the hospital [after giving birth], but when you get home… you don’t really have time to think about, “oh there are all those resources I can use.” —White patient

[Patients need to know] that group [treatment] is effective and not just [the healthcare system’s strategy] to limit how much mental healthcare they can have. —Mental health clinician

[When I was depressed] it was just four weeks of torture, of just, “When can I be seen? When can I be seen?” because I couldn’t figure out who I was supposed to call and how to even get a referral [for depression treatment]. —White patient

There’s not great advertising about [the facility’s postpartum depression group]. Unless someone tells them about it, they really don’t know. —OBGYN physician

Individual Motivation

 Attitudes towards antidepressant medication

[During my pregnancy] I ended up needing a low dose of [an antidepressant medication]. My new provider felt that my anxiety was just really, really bad, and it would be more harmful to the pregnancy than the medication. —Asian patient

I always offer [antidepressant medication] to them, and very few [women with perinatal depression] will take it. —OBGYN physician

I am extremely open to going on medication [after I give birth], because I would love to do anything that I can in order not to have postpartum depression again…. For now, I’d seek therapy out to avoid the medication. —Latina patient

There’s this idea that [depression] is not a real illness…. [I] tell them, “If… you had to take this medication to bring down your blood pressure to help the pregnancy, I don’t think you would feel as resistant as you do right now.” —OBGYN physician

 Attitudes towards group therapy

Being able to attend a support group and meet other moms who are experiencing the same thing, it was really helpful knowing that I wasn’t alone. —Asian patient

I think most patients, regardless of presenting issue, have some reluctance about group… [but] some women are going to have even more reluctance to being in group and it’s not just because of group. It’s because of culture reasons. —Mental health clinician

I wanted everything to be perfect in my world, and I didn't want anybody to know…. I didn’t want to go in front of a [depression therapy] group and say that [I had difficulties]. —Black patient

Social Environment

 Culturally based stigma

“You have to stay strong,” [people say]…. Whatever emotions you have, you push them away because you don’t want to seem weak. And just pray about it. —Black patient

[There are barriers to treatment engagement] related to stigma, shame, and so on. And also, related to their community’s judgment about them if they seek mental health services. —Primary care physician

If you go to the psychologist or something, it’s not well seen. It’s like you’re, oh, like a crazy person. —Latina patient

The kind of social media… perfect mommy scenario where you feel like it’s normal to get everything done…. And to admit that it does not come as easily, there’s a little bit of shame in society. —White patient

 Fear of discrimination

I wasn’t comfortable with accepting medication because I didn’t want it to be in my medical record…. I didn’t know if it can affect if I want to increase my life insurance or employment factors or my [professional] licensure. —Black patient

I have had a couple of patients where they thought they were being [racially] profiled [during behavioral health screening]. —OBGYN physician

I wasn’t sure if [discussing your depression with a doctor would] affect your visa or your stay here [in the U.S.]. And I didn’t want to mess that up… so I didn’t know what to do. —Latina patient

For our African-American patients, there’s so much history [of discrimination] that makes all of this deeply complicated for them to get care and trust in the system. —OBGYN physician

 Family attitudes towards treatment

My daughter’s grandmother [would say], “Oh, you need to just pull up your bootstraps and, you know, get through it.” —Asian patient

A lot of times, the women themselves are very onboard [for treatment] but they’re very afraid of what their mom, mother-in-law, husband, whatever, is going to think of it. —OBGYN physician

My mom… was pretty adamant about the fact that I should go and see [a therapist]. —Black patient

 Low social support & trauma history

I got to the point in my pregnancy that I left [my child’s] dad… because we got into it so bad that I honestly thought I was going to have a miscarriage…. And I thought, "Hmm, me and the baby or it’s you. —Black patient

There’s times where I think [about a patient], “This woman is really struggling with poverty. Her partner vanished. She is on WIC. She has next to no family support, and she has had addiction issues in the past. —Mental health clinician

You know, I came [to the U.S.] and my [partner] was really abusive. Then when I had my baby … I find out he was cheating…. And now that I have my baby boy, I think it reminded me of all that. —Latina patient

 Time and resources

We want to feel better, too, but… if it’s going to cause too much trouble in our lives to get that seven-month-old a babysitter… you have to choose what’s best for your baby. And if that means you miss that [depression treatment] appointment, then that means you miss the appointment. —White patient

Young Hispanic or African-American women were often in jobs where taking time off [for depression treatment] would have been a significant issue. —Primary care physician

Clinical Encounter

 OBGYN physician’s approach

[My OBGYN provider] was focused on my medical complications more, but I didn’t feel supported with my depression with her at all. —Black patient

I feel confident about using [antidepressant] medications and talking with [patients] about that. But, I probably didn’t coming right out of residency…. When I went to residency, I don’t think we even talked about postpartum depression. —OBGYN physician

My first OBGYN treated me like a statistic, a number…. “Here, take this [antidepressant] medication and go away…." But my second OB has been so great. She listens, she is very understanding, and she makes me feel the communication is open. –Latina patient

 Mental health clinician’s approach

I really, really like who I see [OBGYN behavioral health provider]. I feel like she can relate to what I’m going through and stuff. —Asian patient

There are a couple [mental health providers who] are really passionate about [perinatal depression] and a couple that are possibly not as confident. —OBGYN physician

[The mental health provider] mansplained things to me, and he just assumed it was extremely bad PMS all the time…. I never went back to him after that. —Latina patient

 Cultural (mis)under-standings

[My therapist] was a child of immigrant parents, and I really felt connected with her because of that…. She wasn’t necessarily my same cultural background, but just being the child of immigrant parents made a huge difference because I felt like she understood where I was straddling both worlds all the time. —Latina patient

In some [cultural] backgrounds, it’s just not okay to be depressed. So, I try to use different language, particularly with my Latina patients. They don’t really talk about depression as much as they talk about feeling anxious or feeling down or feeling sad. That tends to work better. —OBGYN physician

 Language barriers

When you have a different language, I think you feel more comfortable when you have somebody who can speak your language. —Latina patient

It’s awkward when the interpreter [telephone service] comes on. Unfortunately, when it’s a man, I find that [patients] tend to shut down and not want to talk about some of their other problems. —OBGYN physician