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

Barbara P. Yawn; Allen J. Dietrich; Peter Wollan; Susan Bertram; Debbie Graham; Jessica Huff; Margary Kurland; Suzanne Madison; Wilson D. Pace; In collaboration with the TRIPPD practices

doi:10.1370/afm.1418

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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.
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Figure 2
TRIPPD Consort diagram.

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Table 1

Demographic Information of Enrolled Practices, n = 28

Clinician Type	Physicians	Residents	Nonphysician Clinicians
Practice clinicians, mean (range), No.	4 (2–10)	15 (12–24)	0.5 (0–4)
Mean age, y (range)	46 (28–69)	31 (27 to 47)	35 (24–57)
Years in practice (including residency), No. (range)	21 (1–41)	2 (1–3)	8 (1–6)
Women, %	34	56	80

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Table 2

Demographic Characteristics of Enrolled Women

Characteristic	All Usual-Care Women (n = 990)	All Intervention Women (n = 1,353)	Usual-Care Women With Elevated Depression Score^a (n = 255)	Intervention Women With Elevated Depression Score^a (n = 399)
Age, mean y (SD)	26.7 (5.6)	26.1 (5.4)	26.8 (5.7)	25.6 (5.2)
Married, %	60	50	49	37
Living with partner, %	78	74	72	67
At least one other adult in household, %	90	87	86	81
Race: black, %	18	18	21	21
Ethnicity: Hispanic, %	14	18	13	19
Employed outside of home, %	45	48	42	43
Education >high school, %	56	49	50	43
Income >$50,000, %	40	35	33	24
Primiparous, %	37	38	34	38
History of depression, %	32	29	56	46
Uninsured at 1st postpartum visit, %	8	5	9	4
Uninsured at 2 months postpartum, %	42	33	35	23

EPDS = Edinburgh Postnatal Depression Scale; PHQ-9 = 9-item Patient Health Questionnaire.
↵a Elevated depression score: EPDS ≥10 on a scale ranging from 0 to 30; or PHQ-9 of ≥10 on a scale ranging from 0 to 27.

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Table 3

Characteristics of Women With Elevated Edinburgh Postnatal Depression Scale (EPDS) Scores (≥10)

Characteristic	Usual Care (n = 233) No. (%)	Intervention (n = 322) No. (%)	P Value
Received postpartum depression diagnosis^a	78 (41)	194 (66)	.0001
Elevated parenting stress (PSI score >74)^a
Baseline	196 (89)	187 (81)	.38
12 Months’ postpartum^b	117 (74)	128 (72)	.82
Low partner satisfaction (DAS-6 score in bottom 10%)
Baseline	3 (2)	3 (2)	.71
12 Months’ postpartum	6(5)	2 (2)	.30
Treatment of women with postpartum depression diagnosis
Medication	67 (35)	169 (56)	<.0001
Counseling	20 (11)	54 (20)	.02
Medication plus counseling	70 (37)	176 (60)	<.0001

DAS-6 = Dyad Adult Satisfaction short form; PHQ-9 = 9-item Patient Health Questionnaire; PSI = Parenting Stress Inventory.
↵a According to PHQ-9 scores and clinician assessment.
↵b Based on questionnaire returned at 12 months’ postpartum.

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Table 4

Characteristics That Predict Improved Outcomes (≥5-point Drop in PHQ-9 Score) at 12 Months, Odds Ratios From Logistic Regression (GLME)

	Improved PHQ-9 Score in Women With Initial Elevated Depression Scores

Characteristic	Usual Care No. (%)	Intervention No. (%)	Unadjusted OR (95% CI)	Adjusted^a OR (95% CI)
Total	60 (35)	98 (45)	1.82 (1.14–2.91)^b	1.74 (1.05–2.86)^b
Postpartum depression diagnosed
Yes	25 (44)	51 (48)	1.67 (1.08–2.59)	2.05 (1.25–3.34)
No	24 (27)	37 (41)
History of depression
Yes	33 (33)	40 (41)	0.69 (0.46–1.04)	0.79 (0.51–1.23)
No	27 (38)	58 (48)
Married
Yes	33 (37)	44 (50)	1.33 (0.86–2.05)	1.38 (0.82–2.31)
No	27 (33)	54 (29)
Income >$50,000
Yes	26 (37)	24 (40)	0.89 (0.56–1.40)	0.71 (0.40–1.23)
No	33 (35)	70 (46)
Age >25 years
Yes	38 (36)	49 (42)	0.92 (0.61–1.39)	0.91 (0.57–1.47)
No	22 (33)	49 (48)
Elevated PSI score^c
Yes	41 (33)	58 (39)	0.51 (0.33–0.80)^c	0.52 (0.33–0.84)^c
No	19 (40)	40 (61)
Education more than high school
Yes	32 (37)	48 (48)	1.23 (0.81–1.87)	1.03 (0.63–1.69)
No	28 (33)	50 (42)

GLME = generalized linear mixed effects; OR = odds ratio; PHQ-9 = 9-item Patient Health Questionnaire; PSI=Parenting Stress Inventory.
↵a OR is calculated adjusting for all other variables in the table.
↵b Significant effect for intervention.
↵c Significant negative effect of high PSI score.

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Table 5

Characteristics of Women Initially Positive for Postpartum Depression Who Returned and Did Not Return Questionnaires at 12 Months’ Postpartum

	Usual Care, %		Intervention, %^a

Characteristic	Returned Questionnaires (n = 173)	Did Not Return Questionnaires (n = 82)	Returned Questionnaires (n = 235)	Did Not Return Questionnaires (n = 166)
Not married	48	58	60	72
History of depression	58	52	43	53
Income <$50,000	57^b	89^b	72	84
Uninsured at 2 months’ postpartum	29^b	49^b	22	24

↵a No statistically significant differences between women who did and did not return questionnaires at 12 months’ postpartum.
↵b Statistically significant differences, P <.01.

Additional Files

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Supplemental Appendix & Table

Supplemental Appendix 1. Tools to Facilitate Diagnosis, Follow-Up, and Management of Postpartum Depression; Supplemental Table 1. Power Estimate Simulations

Files in this Data Supplement:

Supplemental data: Appendix - PDF file, 11 pages, 14.4 MB
Supplemental data: Table - PDF file, 1 page, 70 KB
The Article in Brief

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

Barbara P. Yawn , and colleagues

Background Postpartum depression is common but often unrecognized. This study reports on the effectiveness of a program of screening, evaluation, and management of postpartum depression in family medicine offices, with referral outside the practice for complicated or unresponsive cases.

What This Study Found Primary care physicians given screening tools and education are more likely to diagnose and treat postpartum depression, and their patients have lower depressive symptoms at 6 and 12 months of follow-up. In a study of 28 practices that received either education and tools for postpartum depression screening or usual care, rates of diagnosis, treatment initiation, and referral for psychiatric evaluation were higher in the intervention group, indicating the program effectively raised awareness. Specifically, of the 1,897 patients in the analysis, 654 had elevated screening scores indicating 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 and therapy for postpartum depression. They also had lower depressive symptom levels at 6 and 12 months' postpartum.

Implications

The authors call for dissemination efforts and continued evaluation of similar practical primary care-based programs that have minimal requirements for referrals to outside mental health services.