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

Amidst considerable controversy concerning the lack of evidence for perinatal depression screening, the TRIPPD study makes a significant contribution. Admirable effort was made (with success) to assess the impact of depression screening among perinatal women in real life settings and, importantly, to comparatively assess how these women fared compared to those in non-screening practices. This research effort involved in recruiting 28 practices each with their own IRB! Two promising outcomes were realized: 1) initiation of treatment was significantly higher among women in the intervention practices and 2) women from practices that implemented the screening had significantly lower depressive symptoms at 12 months.

Although positive outcomes were realized, careful reading of the implementation procedures reveals important caveats. The implementation of perinatal depression screening in the intervention practices of this study closely aligned with the recommendations of the U.S. Preventative Services Task Force for adults in the general population--"screen adults for depression when staff-assisted depression-care supports are in place to assure accurate diagnosis, effective treatment, and follow-up". In the TRIPPD study, 87% of women with elevated depression scores RECEIVED AT LEAST ONE FOLLOW-UP SUPPORT CALL FROM A NURSE. It is not clear that "typical" community or primary care based perinatal depression screening programs have included this follow-up component. Indeed it is our sense that many screening programs involve simply having women complete a screening instrument and then, for those with elevatated scores, providing them with a referral. Thus while the TRIPPD study provides evidence in favor of perinatal depression screening, it does not provide support for screening programs that do not implement all of the follow-up elements. We know, as a group, that barriers to mental health care are significant and thus it is clear that this follow-up feature is important.

Congratulations to this research team for their significant contribution.

Competing interests:   None declared

Thank you to Dr. O'Mahen for your thoughtful comments. We agree completely that screening without follow up is poor care if not unethical. We also agree that both system factors and individual issues for the woman and her family must be addressed. The work by Flynn et al is very helpful in beginning the discussion of individual level support. In our training session for discussing the results of the PPD screening we suggested that the physician or other clinician ask the woman what she thinks about the screening results. However, Dr. O'Mahen's description is even more useful. Indeed woman do report feeling stigmatized and several of our clinical sites worried that women would not want to complete the screening due to that concern. However, by simply changing the name used to describe the screening tool to the "Women's Feelings" resulted in women expressing their thanks that someone was talking to them about how they felt. We like the idea of one-ended discussion about feelings and not labeling it postpartum depression until it has been discussed. Thank you. We will add this as a reference to the PPD screening and follow up tool kit that is on the AAFP website at http://www.aafp.org/online/en/home/clinical/research/natnet/studies/alpha- studies/trippd-study/ppdtoolkit.html and linked to the Annals of Family Medicine website.

During the TRIPPD study many of our clinics did attempt to find sites for cognitive behavioral therapy but few opportunities were available at that time. As Dr. O'Mahen comments, now opportunities for distance CBT or interpersonal therapy are more readily available and more family physicians are including such skills into their practices either personally or using collaborative care with mental health professionals. We hope to study this advance in available resources in future work on PPD. And finally, we were also convinced that future screening work for PPD should include assessment of parenting stress with attention to treating high levels of stress as were seen to co-exist with PPD in many women. We do hope future work in this area will identify programs to address maternal stress that can become part of care within the community and the family medicine practice. Maybe such a program exists already?

Barbara P. Yawn, MD MSc For the authors

Competing interests: None declared

I was pleased to read this important study by Dr. Yawn and colleagues. As Dr. Buist points out in her commentary, the burden of perinatal depression is high. Despite this, there has been mounting evidence that universal screening for postpartum depression (PPD) alone is not enough to enact meaningful change in outcomes for women. There are both systemic and individual level factors contributing to these results, and as Dr. Yawn's study demonstrates, at the level of the health care system, appropriate follow-through with screening is critical and when implemented can impact change in women's depression outcomes.

A growing body of research also suggests that individual level changes are important to enact as well. Women with PPD talk about their concerns about stigma, and this impacts on their willingness to pursue treatment. Understanding how women feel about depression will help providers in collaborative care models know how to successfully initiate and discuss mood symptoms with women. For example, in one study we conducted about how women wanted health care providers to speak to them about depression (Flynn, Henshaw, O'Mahen, Forman, 2010), women reported that they first wanted providers to talk to them about their problems in an open-ended fashion without labelling the problem, and once establishing that there was a problem, discuss whether the problem was in fact depression or not. This approach helped to ease women's concerns around stigma about depression and enhanced their willingness to discuss treatment options. Such communication approaches may further improve collaborative care approaches.

It is notable that in Dr. Yawn and colleagues study the treatment most commonly offered was antidepressants. It is unclear why psychosocial therapies were only offered when activity was impaired in this study? Often, there can be barriers to accessing empirically supported treatments, including the lack of available treatments (especially for low income women with limited insurance). However, given that perinatal women often express a preference for psychosocial therapies, it is important to also highlight the need to think about cost-effective ways to improve women's treatment choices (e.g., online treatments supported by "low- intensity" or primary care health providers).

Lastly, the thoughtful inclusion of both dyadic conflict and parenting stress measures in this study is commendable. The fact that parenting stress did not significantly change and that high parenting stress predicted poorer response to the intervention underscores the need to think carefully about ways to intervene both with women's mood and with their parenting concerns.

With thanks to Dr. Yawn and colleagues for this is timely and commendable study.

Competing interests:   None declared

We appreciate the interest and support of Dr. Kozhimannil in her letter. The "modest resources" include: Time for the practice to educate themselves about postpartum depression, the available screening tools, to refresh clinicians knowledge of available types of therapy including anti-depressant initiation and dosing, development of a plan for dealing with suicidal ideation and developing collaboration to refer the limited number of women with complex mental health problems. Of course this may also requires changing the attitude of some clinicians and nursing staff who would prefer to ignore the issue and avoid having to talk to women about feellings and moods.

All of the education can be supported by the tools in the appendix of our article and the eductional slides (both long--about 4 hours and condensed versions---about 1 hour) that are available on the AAFP's National Research Network website at www.AAFP.org/NRN.

The most difficult resource to find was as always time. The nursing staff found it difficult to find time to make phone calls,especially to women who returned to work and needed after hours calls. Perhaps health care reform will pay for this type of care coordination and facilitate our ability to employ nursing personnel or medical assistants that can deal with care coordination calls.

The final change is to the begin treating PPD as a chronic disease. PPD requires follow up care as do all chronic diseases. This means that the women with postpartum depression will need to make PPD management appointments during the first year. As Dr. Kozhimannil pointed out, this can work well for family physicians who can use the same appointment to provide well child care and follow up for PPD.

In residency programs, the additional committment was for repeated education since new residents join the practice each year. The refresher was potentially useful for all staff. Several clinics added a 5-minute overview of the TRIPPD intervention to the orientation of all new support staff, adding more indepth information appropriate to the new staff member's position.

Competing interests:   None declared

After many efforts to address the urgent and compelling issue of postpartum depression have met with disappointing results, it is heartening to read the findings that Dr. Yawn and her colleagues document in their important contribution to this literature. They have demonstrated success in improving detection and treatment by treating women within primary care settings. However, as the authors acknowledge, retaining maternal mental health care within family practice (vs. specialty mental health care) increases the effort required by clinicians operating under an already-high burden of care within primary care practices.

The abstract mentions that the results obtained in the TRIPPD intervention may be implemented with "modest resources." From a policy perspective and to support broader implementation, it would be useful to have more information on the required resources for implementation and how these may differ across practice settings (residency status, patient populations, geographic location, etc.). In the coming years, aspects of health reform such as Accountable Care Organizations or Patient-Centered Medical Home models may provide the foundational structures that could shift resources to support the provision of more comprehensive services within primary care settings.

Family physicians who care for both maternal and pediatric populations are particularly well-situated to improve recognition and treatment of postpartum depression. This analysis provides a helpful buildling block for practice-based efforts to address maternal mental health. As this model is diffused, future analyses in non-RCT settings should include both process and outcome measures (as Dr. Yawn and her colleagues have done in this paper) in order to understand whether and how similar results may be achieved across different practice settings.

Competing interests:   None declared

We agree with Dr. Bennett that the potential for success will differ by practice type and probably patient populaiton. We appreciate the question since manuscript length often limits what can be presented.

The practices were all either family medicine or FQHCs based. The residencies were all family medicine residencies. We agree that the screening and follow up care system would be more difficult to implement in pediatric practices where there may not be anyone to provide care to the mothers. A similar problem may exist for many OB/GYN practices. However, multi-specialty practices that include pediatrics, family medicine and OB/GYN should be able to develop a system for care that keeps the patients within the same practice and is collabortive between the specialities.

The average income level for the women receiving postpartum care in our enrolled practices was low with over 55% receiving Medicaid during pregnancy. Therefore, we believe that the results are generalizable to many types of practices that include family medicine physicians and other clinicians.

Dr. Bennett's comments regarding the low rate of completion for outside referrals to mental health professionals was one of the factors that drove our design of trying to keep care within the practice whenever possible. In addition to the low income women who do not complete the outside referrals, a recent study in Minnesota based in moderate income pediatric and family medicine practices demonstrated that the failure to attend those referral visits is not limited to low income women.1

1. Gjerdingen D, McGovern P, Center B. Problems with a diagnostic depression interview in a postpartum depression trial. J Am Board Fam Med. 2011;24(2):187-93.

Competing interests:   None declared

I also want to congratulate Dr. Yawn and her team for addressing this important and understudied area. The delivery of care for women with perinatal depression (pregnancy and postpartum) is critical to supporting the healthy development of children as well as providing care to the women suffering from this common and serious disorder. I am very curious as to the care system/context in which the practices that were included in this study work. There was not much information regarding whether the practices were specialty (family medicine or pediatrics) and/or multidisciplinary as you might find in an FQHC. These differences clearly make a major difference as to whether a health services intervention will work to improve outcomes. For example family physicians or physicians working in multidisciplinary sites may be much more successful than those in pediatric sites in engaging directly with the mother for her care. There are also large disparities based on the care model that our group have shown based on insurance or other health system factors. It appears that for low income women at least providing referrals (one of the outcomes in the current study) rarely result in mental health specialty care - for both health system and patient related factors. More information on these system issues would be helpful for understanding the relevance of the current study to a range of care settings serving postpartum women.

Competing interests:   None declared

We thank Dr Anne Buist for her assessment that our work should prompt review by groups that have been reluctant to recomend screening for PPD. While one study is never enough to change policy, I think that our work can guide design of future studies. In particular our findings that it is important to keep screening, assessment and most care within the primary care setting saving referral for complex and unresponsive cases.

We are aware of the important work in Australia and the difficulties that occur when trying to change practice across an entire country. Some of the tools that are provided in the online appendix to our article might make that very ambitious task easier.

We look forward to suggestions from others of how to help make an impact on care for women with PPD.

Barbara P. Yawn, MD MSc for the authors

Competing interests:   None declared