Variation in Implementation of Universal Screening for Perinatal Mental Disorders and Suicide Risk: Role of Clinic Factors

Context: Common perinatal mental disorders (depression and anxiety) are the leading health abnormalities of pregnancy and the year postpartum and death by suicide is the most common modifiable cause of maternal mortality. Despite this and evidence based recommendations for screening there are low rates of their detection in primary care settings providing maternal-child health care.

Objective: Identify clinic site level factors associated with variation in perinatal screening for common mental disorders and risk of suicide.

Study Design: Mixed quantitative and qualitative methods.

Setting or Dataset: Four multi-disciplinary primary care health centers in the University of Washington Neighborhood Clinics network.

Population studied: Maternal-child health clinical teams engaged with implementing enhanced care for common perinatal mental disorders in pregnancy and the year postpartum.

Intervention/Instrument: A multifaceted intervention to support team care for perinatal mental health was supported at all sites with training, external facilitation, and audit-feedback data on screening and clinical care (provided as monthly reports).

Outcome Measures: Depression and suicide risk screening with the PHQ-9 or Edinburgh Postnatal Depression Scale (EPDS); both validated for the perinatal population.

Results: pre-intervention screening varied among the sites from 38%-72% for pregnancy and 1%-51% in pediatric care. Over the course of a 12-month implementation process one site achieved the target screening rate of 80% for both populations and two others had variable improvements from baseline for an overall population of more than 500 women. A range of factors potentially influencing this variation based on the Consolidated Framework for Implementation Research (CFIR) is under analysis. These include differences in leadership/champions, provider interest/commitment in the intervention, competing priorities, and effectiveness of the QI audit/feedback process.

Conclusions: There was a high level of variation in the implementation of universal screening for perinatal common mental disorders in four primary care sites participating in a quality improvement effort with substantial resources including on site practice facilitation and audit-feedback. We are currently exploring possible explanations for this variation using mixed methods data framed by the Consolidated Framework for Implementation Research.