For the first time, a large U.S. study of screening and follow-up care for postpartum depression has shown improved maternal outcomes at 12 months. The study results are good news for family physicians, says lead researcher Barbara Yawn, M.D., because the study took place in "real-world family medicine practices."
The Translating Research into Practice for Postpartum Depression (TRIPPD) study(annfammed.org), reported in the July/August 2012 Annals of Family Medicine, is important for family medicine because "we kept most of the care in the practice," says Yawn, a family physician and research director at Olmsted Medical Center in Rochester, Minn.
"In most other studies, women were referred out if they screened positive for postpartum depression," says Yawn. "But most won't go when they're referred for mental health care. Women have reported a desire not to leave their usual practice for mental health services, and our study results support those findings.
"This study says to us that postpartum depression -- a condition that adversely affects the entire family, not just the mother -- can be managed in a family medicine practice."
- Maternal outcomes improved in this large study of the effectiveness of screening and follow-up care for postpartum depression.
- The study took place in real-world family medicine practices, with most care kept in the practices instead of referred out.
- The study toolkit has been posted online to help other FPs begin to screen for and treat postpartum depression in their practices.
Twenty-eight family medicine practices in 21 states, most of them in the Academy's National Research Network, participated in the TRIPPD study between March 2006 and August 2010. The practices were randomized to usual care and intervention groups, with 14 in each group.
The usual-care practices received a 30-minute presentation about postpartum depression and then continued to provide the same postpartum and mental health care or referral they had provided before the study.
The intervention practices received education and a toolkit to help them with screening, diagnosis, treatment and follow-up for postpartum depression within the practice.
New mothers age 18 and older were enrolled in the study. The Edinburgh Postnatal Depression Scale (EPDS) and the nine-item Patient Health Questionnaire (PHQ-9) were used to screen for and diagnose postpartum depression. Enrolled women were asked to mail the completed questionnaires directly to the study's central site.
At six and 12 months postpartum, the women were asked again to complete the questionnaires and return them to the central site.
The TRIPPD toolkit and related educational slides contain materials to facilitate diagnosis, follow-up and management of postpartum depression in the family medicine practice. The kit includes
- a format for follow-up calls by nurses or medical assistants after therapy is initiated,
- a content outline for postpartum depression follow-up visits,
- information on common side effects and usual dosage range for medications that could be prescribed,
- an explanation of cognitive behavioral therapy, and
- self-help sheets for patients and family members.
Intervention practices learned their patients' EPDS and PHQ-9 screening scores, but usual-care practices did not. If a patient reported suicidal ideation to the central site, however, her practice was notified even if it was in the usual-care group.
Outcomes were based on the level of depressive symptoms the women reported on the surveys at six and 12 months, plus review of the women's medical records to determine whether postpartum depression had been diagnosed and treatment initiated.
The study analysis included 1,897 women from the usual-care and intervention practices who returned one or more of the screening questionnaires to the study central site.
Overall, about 35 percent of the women had screening scores that indicated depression. The intervention and usual-care groups had rates that were comparable.
Women in the intervention practices were significantly more likely to be diagnosed with postpartum depression and to receive therapy than women in the usual-care practices, and they also had lower depressive symptom levels at six and 12 months.
The study report notes that "the independent statistical significance of both receiving a diagnosis and being part of the intervention group highlights the importance of programs that go beyond just universal postpartum depression screening and initial diagnosis."
Halfway through the study, usual-care practices were "crossed over" to the intervention.
Yawn says she's pleased that many women in the intervention practices improved even though the practices struggled to follow the study design, which called for more follow-up phone calls and visits after therapy initiation than the practices were able to provide.
"Even with the limited amount of time and effort available, the intervention practices did make a difference," she says. "If the practices had been able to follow the study design fully, I believe even more women would have improved."
Is it time to recommend that family medicine practices screen for postpartum depression? "I think so," says Yawn, as long as they have resources available to follow up with patients who screen positive.
"To that end, we've posted the TRIPPD toolkit online so that family physicians can access the tools and materials we used in the study," says Yawn. "We also posted a set of educational slides about postpartum depression, how to use the toolkit and how to follow up with diagnosed patients.
"We hope this will make it possible for Academy members to make this change in their practices, using our materials to guide their efforts."
If health care reform brings payment for care coordination, it will be easier for nurses or medical assistants to commit the time needed to do follow-up phone calls and make sure that women don't fall between the cracks, adds Yawn. "This is a place where health care reform and care coordination payments could be very helpful."
Funding from the Agency for Healthcare Research and Quality supported the TRIPPD study.