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Abstract
Introduction Reproductive hormone transitions (menstrual cycle, post partum and menopause) can trigger mental disorders in a subset of women. Gynaecological diseases, such as endometriosis and polycystic ovary syndrome, can also elevate the risk of mental illness. The link between psychiatrists and obstetricians is already well established in the peripartum period; however, the link between gynaecology and psychiatry is less so. This mixed-methods systematic review aims to synthesise the existing evidence for integrated mental healthcare for gynaecological illnesses or reproductive hormone transitions outside the perinatal period.
Methods and analysis A systematic search of the MEDLINE, Embase, Scopus, PsycInfo, CINAHL and Web of Science databases will be conducted. All study types will be considered, both quantitative and qualitative. Opinion and expert consensus statements, as well as government and professional body documents, will also be included, but separately analysed and reported. Studies examining the unmet clinical needs and experiences of women experiencing mental disorders related to reproductive hormone transitions (menarche, menstrual, menopause, but not pregnancy or breast feeding) or gynaecological illness will be included. Studies related to the experience or training of professionals caring for them will be included, specifically on the concept of integrated or interdisciplinary work with colleagues outside their specialty. Abstracts of the identified papers will be screened independently by two reviewers. Full texts will be assessed by two reviewers, and data will be extracted using predetermined data extraction tools. Quantitative studies will be synthesised in narrative format. A thematic synthesis of qualitative studies will be conducted and an integrated narrative synthesis will be described.
Ethics and dissemination Ethical approval is not required for this systematic review, as no primary data will be collected. The results will be disseminated via a peer-reviewed publication in a relevant scientific journal.
PROSPERO registration number CRD42024523590.
- delivery of health care, integrated
- psychiatry
- gynaecology
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Strengths and limitations of this study
This is the first systematic review examining integrated mental healthcare in gynaecology settings and in non-pregnancy-related reproductive transitions.
The synthesis of quantitative and qualitative evidence will provide a comprehensive picture of what is currently known about this topic.
The selection, appraisal and synthesis of studies will be conducted by two reviewers.
This systematic review protocol is prepared in line with the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols statement and is prospectively registered.
The restriction to English-language publications will limit the generalisability of the findings.
Introduction
Rationale
The WHO has stated that ‘the focus on hospital-based, disease-based and self-contained ‘silo’ curative care models undermines the ability of health systems to provide universal, equitable, high-quality and financially sustainable care’.1 In Ireland, the Sláintecare and Sharing the Vision reports have incorporated this view and promote greater integration of care between physical and mental healthcare.2 3
Women are seeking greater cooperation between gynaecologists and mental health professionals and improved understanding of the impact of hormonal transitions and gynaecological symptoms on their mental health, particularly in relation to premenstrual dysphoric disorder, menopause, and endometriosis.4
There are high rates of comorbidity between gynaecological and female reproductive system disorders.5 Many common gynaecological conditions are associated with psychological or psychiatric disturbances and impaired quality of life, including endometriosis,6–18 polycystic ovarian syndrome,19–32 adenomyosis,33 and chronic pelvic pain.34–38 There is a well-established link between depression and pain.39
Normal reproductive events also predispose women to psychiatric symptoms, with an increased rate of depression during perimenopause.40–44 Premenstrual disorders are a particular area where closer collaboration is needed between gynaecologists and psychiatry (or mental health professionals more widely), given that the assessment and treatment span both specialties. Premenstrual dysphoric disorder was incorporated into the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) in 2013,45 46 and has a prevalence of at least 5% among women of reproductive age.47 Treatments include selective serotonin reuptake inhibitors, drospirenone-containing combined oral contraceptives, and in severe cases, the use of gonadotropin hormone-releasing hormone analogues and bilateral salpingo-oophorectomy with hysterectomy.48 It can be difficult to differentiate premenstrual dysphoric disorder from premenstrual exacerbations of pre-existing mental illnesses.49 There is also an association between premenstrual dysphoric symptoms and suicidal thoughts and behaviours independent of psychiatric comorbidity.50–52 Interdisciplinary work between the two specialties is essential to ensure accurate diagnosis and appropriate management of complex cases.
The impact of maternal mental illness during pregnancy on both mothers and infants has been established.53–55 This is reflected in the recent development of perinatal mental health services in the UK56 and Ireland,57 and there are robust calls for improved access to these services in Australia, New Zealand,58 the USA59 and Canada.60 While this is an emerging area of healthcare delivery, integration of mental healthcare into obstetric settings appears to be effective,61 62 though further work is needed to determine the most effective service model.63 Given the expanse of active research on mental health in the perinatal period, this review will only consider non-pregnancy-related reproductive transitions and gynaecological illnesses.
Objectives
The objective of this mixed-methods systematic review is to synthesise the current evidence base for integrated working between mental health professionals and gynaecologists to inform clinical practice, service delivery and public policy. Given the multifaceted nature of the available evidence, a synthesis of both qualitative and quantitative evidence is necessary.
What is the evidence for the clinical need and effectiveness of integrated mental healthcare in non-pregnancy-related reproductive hormone transitions and gynaecological illness, and how has this been implemented? (Quantitative component).
What are the experiences, attitudes and perceptions of patients and professionals regarding the assessment and treatment of mental health conditions associated with non-pregnancy-related reproductive hormone transitions and gynaecological illnesses? What are the barriers and facilitators of this? (Qualitative component)
Methods and analysis
Design
The Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols (PRISMA-P) were used in the preparation of this protocol64 (see online supplemental appendix 1) and will be reported in accordance with the PRISMA-2020 statement,65 the Enhancing Transparency in Reporting the Synthesis of Qualitative Research (ENTREQ) statement66 and the guideline for Synthesis Without Meta-analysis (SWiM) items.67 This protocol is informed by the Joanna Briggs Institute (JBI) guidance for mixed-methods systematic reviews.68
Supplemental material
The protocol was registered with the International Prospective Register of Systematic Reviews (PROSPERO) on 23 March 2024 (CRD42024523590).69
Eligibility criteria
Population
This review will consider studies that relate to women or those assigned female at birth experiencing mental illness associated with gynaecological disorders or reproductive transitions of menarche, menstruation and menopause, but not pregnancy-related reproductive transitions. Women’s mental health outside of these circumstances will be out of the scope of this review. Healthcare professionals in the field of mental health or gynaecology working with these patient groups will also be included.
Concept of interest
The design and delivery of integrated healthcare, interdisciplinary collaboration between mental health professionals of any kind and gynaecologists and cross-disciplinary training will be examined in this review. Papers describing the impact of a lack of integration will also be included.
Outcomes
The quantitative component of this review will consider studies that include the following outcome measures: quality of care, access to diagnosis and treatment, diagnostic delay, or misdiagnosis.
Views, perceptions, opinions and experiences of patients/service users, carers, or any healthcare professionals regarding the diagnosis and treatment of these conditions will be explored through the qualitative component.
Context
Any physical or mental healthcare setting, including gynaecology and primary care women’s health services, as well as postgraduate or specialty medical training. Studies in mixed obstetric and gynaecological populations will be included only if gynaecological outcomes are reported separately.
Study design
As the literature on this topic is limited, all study types (quantitative, qualitative or mixed methods) will be considered for inclusion. Reviews, opinion papers, editorials, expert consensus, government reports and clinical guidelines will also be included. Only papers published in English or with an English translation will be included. No time limits will apply to allow in order to report on the evolution of clinical practice and theories on the relationship between mental health and the female reproductive system over time.
Information sources
The following electronic databases will be searched: MEDLINE, CINAHL, Embase, Scopus, PsycInfo and Web of Science. The search strategy was developed with the assistance of a medical librarian using medical subject heading terms and keywords identified through an initial exploratory search. The search strategy for MEDLINE is included in online supplemental appendix 2. This will be adapted for each database. The reference lists of the included articles will be hand searched for additional studies.
Supplemental material
Hand searches of the websites of relevant professional, government and non-government organisations in English-speaking countries for grey literature will be completed, including the Royal College of Obstetricians & Gynaecologists, the American College of Obstetricians & Gynecologists, the Royal Australian & New Zealand College of Obstetricians & Gynaecologists, The Society of Obstetricians and Gynaecologists of Canada, the Royal College of Psychiatrists, American Psychiatric Association, the Royal Australian and New Zealand College of Psychiatrists, the Canadian Psychiatric Association, the International Association for Premenstrual Disorders, the International Society for Psychosomatic Obstetrics & Gynaecology, and the International Menopause Society.
Study records
Data management
References will be imported into Endnote software,70 and duplicates will be removed. This list will then be uploaded to the Covidence web application71 for study selection process.
Selection process
Title and abstract screening will be completed independently by two reviewers (YH and RC-T), and full texts will be retrieved for these papers. The full texts will be assessed against the inclusion and exclusion criteria by the same two reviewers independently, with a third reviewer resolving disagreements. The selection process will be documented in a PRISMA flow diagram. The reasons for the exclusion of full texts will be reported.
Data extraction
Quantitative and qualitative data will be independently extracted by two reviewers (YH and RC-T) and input into Microsoft Excel. This process will be validated by a third reviewer.
A data extraction form will be used to collect the following data from quantitative studies:
Title, author, year of publication and journal
Research aim
Setting
Methodology
Participant characteristics
Intervention: the Template for Intervention Description and Replication (TIDieR) checklist will be used for any intervention characteristics.72
Assessment tools used
Results
Conclusions
Strengths and limitations
The JBI ‘QARI Qualitative data extraction tool’ will be used to extract data from qualitative studies.73 Data from the results and discussion sections of qualitative studies or qualitative components of mixed-methods studies will be imported into NVivo74 for analysis. The JBI ‘Textual data extraction form for text and opinion publications’ will be used to extract data from opinion papers.75
Quality appraisal
Quality appraisal will be conducted independently by two reviewers (YH and RC-T), and a third reviewer will resolve disagreements. The appraisal tools used will depend on the study design in question. Observational studies will be assessed using the ‘Risk Of Bias In Non-randomised Studies-of Exposures’ (ROBINS-E) tool.76 It is not anticipated that there will be any randomised controlled trials, but if any are found, they will be assessed using the Cochrane risk of bias tool for randomised trials (RoB-2).77
Qualitative studies will be subjected to both the Critical Appraisal Skills Programme (CASP) checklist for qualitative studies78 and the JBI ‘Critical Appraisal Checklist for Qualitative Research’.73 There is the lack of consensus on a preferred tool for appraising qualitative studies, or even consensus on whether qualitative studies can be critically appraised. Using two differing tools will allow different aspects of included studies to be examined. The JBI ‘Critical Appraisal Checklist for Text and Opinion Papers’75 will be used for opinion articles and grey literature will be appraised using the ‘Authority, Accuracy, Coverage, Objectivity, Date, Significance’ checklist.79 The results of the quality appraisal will be reported in narrative and tabular format in the final manuscript.
Data synthesis
The data synthesis will follow a convergent segregated design in line with the JBI methodology,68 where quantitative and qualitative data are synthesised separately before being integrated.
Synthesis of quantitative data
Based on an exploratory search of the literature, the heterogeneity of quantitative studies is anticipated to be high and will likely preclude meta-analysis. If included papers allow for meta-analysis, a random effects model will be used with evaluation of heterogeneity and publication bias via I2, funnel plots and Egger test. The data will be presented in tabular form, and a narrative synthesis will be employed to provide a descriptive summary of the quantitative studies. The SWiM guidance will be used where a meta-analysis is not possible.67
Synthesis of qualitative data
Qualitative data will be synthesised using inductive thematic analysis using the methodology described by Thomas and Harden.80 This was selected as a flexible synthesis strategy that is appropriate to healthcare research. A critical realist epistemological stance will be adopted in this study. The data from the results and discussions of the included qualitative studies will be imported in entirety into NVivo software. These data will be coded line-by-line by two reviewers (YH and RC-T). A coding structure will be agreed on by the two reviewers, compared across studies, and added to as needed. Codes will be grouped into a thematic tree structure. The coding and thematic analysis will be reviewed by two other members of the review team (AMD and RD). Analytical themes will be generated from this independently by YH and RC-T to answer our review objectives before a final analysis is agreed.
Integration of evidence
In this mixed-methods synthesis, qualitative findings contextualise and complement the quantitative results. The findings of the quantitative and qualitative syntheses will be compared and contrasted. Depending on the outcome, the results will be presented as configured analysis or narrative analysis. The integration of opinion and grey literature will be separately reported. The Grading of Recommendations Assessment, Development, and Evaluation will be used to assess evidence quality where appropriate.81
Terminology relating to sex and gender will be reported as per the original paper. The results paper will adhere to the Sex and Gender Equity in Research (SAGER) guidelines.82
Discussion
The mixed-methods systematic review protocol described here aims to synthesise what is currently known about integrating mental healthcare in the treatment of gynaecological illness or during reproductive hormone transitions outside the perinatal period. The incorporation of both quantitative and qualitative research will demonstrate the wider service-level clinical need for integrated care and the human impact of these gaps. The main limitations of this review will likely lie in the limited number and heterogeneity of studies on this topic; hence, it will be unlikely to be possible to conduct a meta-analysis of the included articles. Only studies in English will be included due to limited resources, so some relevant studies may be excluded. The inclusion of opinion and grey literature will supplement the available empirical data, but will be separately reported. The data synthesis will be guided by validated guidelines to achieve methodological rigour: PRISMA, SWiM and ENTREQ. The use of two independent reviewers in the screening, selection, data extraction, quality appraisal and synthesis processes will strengthen the validity of our results. This review aims to guide current service delivery in women’s mental health and inform future service and policy development to better meet the needs of this patient cohort.
Patient and public involvement
There will be no patient or public involvement in the current study.
Ethics and dissemination
Ethical approval is not required for this systematic review, as no primary data will be collected. The results will be disseminated via a peer-reviewed publication in a relevant scientific journal, through oral or poster presentations at national or international academic conferences, at presentations to national policymakers such as the Women’s Health Taskforce in the Republic of Ireland, and to other interested groups via social media. This review will also form part of a doctoral thesis by the author YH. The dataset generated from this synthesis will be made available by the study authors on request.
Ethics statements
Patient consent for publication
References
Supplementary materials
Supplementary Data
This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.
Footnotes
RD and AMD are joint senior authors.
X @annedohertypsy
Contributors YH: conceptualisation, methodology, writing - original draft. RC-T: methodology, writing - review and editing. RD: methodology, supervision, writing - review and editing. AMD: methodology, supervision, resources, writing - review and editing. All authors have read and approved the final manuscript. The corresponding author guarantees the paper and that the authorship statement is correct.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests RD works as a consultant psychiatrist in perinatal mental health and sits on the National Oversight Implementation Group for the Specialist Perinatal Mental Health Services in Ireland. The other authors have no conflicts of interest to declare.
Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting or dissemination plans of this research.
Provenance and peer review Not commissioned; externally peer reviewed.
Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.