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.

Methods: In 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).

Results: Among 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.

Figure 1

Postpartum depression assessment and follow-up. EPDS = Edinburgh Postnatal Depression Scale; MD = physician; PHQ-9 = 9-item Patient Health Questionnaire; Q = question; R = prescription medication; SI = suicidal ideation. Notes: EPDS is scored on a range from 0 to 30, in which higher scores indicate possible depression. PHQ-9 is scored on a range from 0 to 27, in which higher scores indicate more depressive symptoms. SI defined as EDPS score >19 and reply to question 10 (self-harm) was “sometimes” or “yes”; and PHQ-9 score ≥19 and question 9 (better off dead) reply was more than “not at all.” White: women without suggestion of postpartum depression (normal EPDS). Light gray: women at with high risk of postpartum depression and then with diagnosed postpartum depression. Dark gray: women requiring assessment for suicidal ideation.

Figure 2

TRIPPD Consort diagram.