Primary Care Management Effective for Postpartum Depression

July 16, 2012 — Primary care physicians can effectively screen, diagnose, and manage postpartum depression when given the right tools and education, new research shows.

Postpartum depression is common but is not adequately recognized and is undertreated, with adverse outcomes for the mother, baby, and family, lead author Barbara P. Yawn, MD, from Olmsted Medical Center, Rochester, Minnesota, toldMedscape Medical News.

Dr. Yawn said she was prompted to undertake the current study after she realized that she had cared for over 2000 postpartum women, several of whom were having problems that were likely related to postpartum depression, which she had not diagnosed.

"I also know that the postpartum visit is a very busy visit and that without a tool and help from the whole team, women would not be screened, and we could not diagnose just by looking or informally assessing," she said. "In doing a study of fetal and infant mortality in southeast Minnesota several years ago, we identified 3 of the 8 preventable deaths as due to maternal postpartum depression. This was a real wake-up call."

The study is published in the July/August issue of the Annals of Family Medicine.

Multicenter Study

In the Translating Research into Practice for Postpartum Depression (TRIPPD) study, Dr. Yawn and her team sought to assess the effectiveness of a program that trained healthcare providers in family practices in how to screen, diagnose, and manage depression in postpartum mothers.

The study was conducted in 28 family medicine research network practices in 21 states between March 2006 and August 2010. Fourteen practices were randomly assigned to usual care, and 14 practices were randomly assigned to the TRIPPD program.

Practitioners in the TRIPPD program received education and tools to screen for and diagnose postpartum depression, as well as to initiate therapy and follow-up within their practices.

The practitioners randomly assigned to usual care received a 30-minute presentation about postpartum depression, and they continued to provide the same postpartum and mental healthcare or referral that they did before the start of the study.

Tools used to screen and diagnose postpartum depression in the TRIPPD program included the Edinburgh Postnatal Depression Scale (EPDS) and the 9-item Patient Health Questionnaire (PHQ-9). A PHQ-9 score of 10 or greater was deemed consistent with postpartum depression in the absence of other causes for depressive symptoms.

Practice sites randomly assigned to the intervention had access to patients’ EPDS and PHQ-9 screening scores, but the usual-care sites did not.

Providing the Basics

Of the 1897 patients included in the study analysis, 654 (34.5%) had elevated screening scores that indicated depression, with comparable rates in the intervention and usual-care groups.

The study found that women in the intervention practices were significantly more likely to be diagnosed with postpartum depression (P = .0006) and to receive therapy (P = .002) than women in the usual-care practices. They were also more likely to be referred for psychiatric care for postpartum depression, although this was uncommon.

The study also showed that the educational intervention had a positive effect on the patients’ depressive symptoms. At 12 months, women in the intervention practices were more likely to have a 5-point drop in their PHQ-9 score from baseline (odds ratio, 1.8; 95% confidence interval [CI], 1.1 – 2.9; P = .001) than women in the usual-care practices.

Dr. Yawn stressed that the TRIPPD program is specifically designed for family physicians and that it is important to include all of the components of the program.

"This program was not designed for psychiatrists’ offices. It is for family physicians and is designed to provide the basic tools that could be implemented in any family medicine practice. It is important that the program include all of the components. Screening without diagnosis and follow-up is not helpful," she said.

Barrier to Care

Postpartum depression is an important issue that can and should be dealt with in family medicine practices, Dr. Yawn emphasized.

"The difference between this program and others that have not shown improved outcomes is that it is contained in the practice itself. Women are not sent out from the practice for evaluation and initiation of therapy, unless they are complicated cases, which in this study accounted for about 6% of cases.

"Other programs have done the screening in the family medicine or primary care practice and then sent the women to another site or person for further evaluation, and the women do not go. Therefore, the work ends with the abnormal screening results, which is not helpful to the women or their families."

"I hope that many practices will consider trying this program and that future studies of postpartum depression screening will improve upon our results by adding other components. But keep the screening, diagnosis, and management based in the medical home or family medicine practice," she added.

"This large, well-designed multicenter trial demonstrates that educating family physicians about postpartum depression screening and treatment significantly improves detection and patient outcome," Shari Lusskin, MD, from Mt. Sinai Medical Center in New York City, told Medscape Medical News. "Lack of education among providers is a barrier to care that can, and should, be removed."

The study was sponsored by the Agency for HealthCare Research and Quality. Dr. Yawn and Dr. Lusskin have disclosed no relevant financial relationships.

Ann Fam Med. 2012;10:320-329. Full article