TRIPPD: A Practice-Based Network Effectiveness Study of Postpartum Depression Screening and Management

Abstract

PURPOSE Postpartum depression is common but inadequately recognized and undertreated. Continuing depressive symptoms are associated with adverse outcomes for the woman, her infant, and family. We wanted to determine the effect of a practice-based training program for screening, diagnosis, and management of depression in postpartum mothers. METHODSIn this practice-based effectiveness study, 28 practices were randomized to usual care (n = 14) or intervention (n = 14), and 2,343 women were enrolled between 5 and 12 weeks' postpartum. The intervention sites received education and tools for postpartum depression screening, diagnosis, initiation of therapy, and follow-up within their practices. Usual-care practices received a 30-minute presentation about postpartum depression. Screening information for the usual care was obtained from baseline surveys sent directly to the central site but was not available for patient care. Outcomes were based on patient-reported outcomes (level of depressive symptoms) from surveys at 6 and 12 months, plus medical record review (diagnosis and therapy initiation). RESULTSAmong the 2,343 women enrolled, 1,897 (80.1%) provided outcome information, and were included in the analysis. Overall, 654 (34.5% of 1,897) women had elevated screening scores indicative of depression, with comparable rates in the intervention and usual-care groups. Among the 654 women with elevated postpartum depression screening scores, those in the intervention practices were more likely to receive a diagnosis (P = .0006) and therapy for postpartum depression (P = .002). They also had lower depressive symptom levels at 6 (P = .07) and 12 months' (P = .001) postpartum.CONCLUSIONS Primary care-based screening, diagnosis, and management improved mother's depression outcomes at 12 months. This practical approach could be implemented widely with modest resources.

Beyond screening: a review of pediatric primary care models to address maternal depression

“…Several studies describe models for managing depression in maternal health care settings (42)(43)(44)(45)50,51). Miller et al, working with a largely Hispanic clientele in an urban community health center, trained providers in screening, assessment, and treatment engagement strategies, with care provided by onsite general providers and referral to a psychiatrist for only the most complicated cases (45).…”

“…They provide a practical training model for primary providers that could be adapted to a pediatric setting without need for additional mother-specific providers. Yawn et al 's Translating Research into Practice for Postpartum Depression study was carried out in family medicine practices (50). Intervention sites received education and tools for postpartum depression screening and therapy initiation, including plans for follow-up visits, prescription support tools, and education about cognitive behavioral therapy and nursing follow-up calls to monitor medication initiation, adherence and side effects.…”

“…Intervention sites received education and tools for postpartum depression screening and therapy initiation, including plans for follow-up visits, prescription support tools, and education about cognitive behavioral therapy and nursing follow-up calls to monitor medication initiation, adherence and side effects. Women in the intervention group were more likely to receive a diagnosis and therapy for postpartum depression, and tended to have lower depressive symptom levels at 6 and 12 mo postpartum (50). Leung et al (51) conducted a randomized controlled trial of structured screening using the Edinburgh Postnatal Depression Scale in Maternal and Child Health Centers in Hong Kong (which provide preventive care to mothers and children up to age 5 y), with control mothers receiving general clinical assessment (usual care).…”

“…These clinics vary in the types of providers they employ, from obstetricians to mother-only general practitioners to maternal-child clinics but all differ from the pediatric models in that the providers are already the women's providers (as opposed to her children's). Nevertheless, these models contain elements that may be useful in pediatric practices.Several studies describe models for managing depression in maternal health care settings (42)(43)(44)(45)50,51). Miller et al, working with a largely Hispanic clientele in an urban community health center, trained providers in screening, assessment, and treatment engagement strategies, with care provided by onsite general providers and referral to a psychiatrist for only the most complicated cases (45).…”

Why should we screen for perinatal depression? Ten reasons to do it

“…A recent cluster randomized trial [81], which included family medicine practice sites from around the US, compared a condition that included a regimen of screening, further assessment, medication management or referral, and follow-up to a usual care condition for women who scored at least 10 on the EPDS and later at least 10 on the Patient Health Questionnaire-9 [82]. More than 2000 women were enrolled between 5 and 12 weeks postpartum.…”