Table 1

SiteNew Haven Healthy Start Program [22] ( ,336)Minneapolis and St. Paul, MN, screening at well child programs [21] ( )Australia, universal PPD screening [28, 3032] ( unknown)US family medicine practices [27] ( ,263)Olmsted County, MN universal PPD screening program [23] ( )New Hampshire, screening at all well child visits in pediatric practices [20, 33] ( ,398)New Jersey State wide initiative [29] (30,955 analyzed)Hong Kong Program [26] ( )

Enrollment criteriaLow-income women within 6 months of delivery
(i) self-referred
(ii) referred by outreach worker
Women bringing children to 0-1 month to well child visits at family medicine or pediatric clinicsAll postpartum women in all practices in the countryAll women between 4 and 12 weeks PP coming for PP or well child visit to 28 enrolled practicesAll women between 4 and 9 wks PP coming for PP visit to OB or FM to Olmsted County, MN providerAll women bringing children 0–18 years for well child visits for 6 month time period in three enrolled pediatric practicesAll women with Medicaid insurance for during pregnancy and 1st yr PP were used in analyses, all women in state delivering an infant during time of interest were in programAll women visiting maternal and child health centers for 2 month well child check. Exclude if already receiving mental health care
(English or Spanish)(English only)(English only)(English or Spanish)(English only)(English only)(Unknown)(Mandarin only)

Site characteristicsNew Haven Healthy Start initiative—a community-based program not within any clinicSeven family clinics, 4 urban family medicine, and 3 suburban pediatric clinicsAll clinics providing postpartum care in the country28 US FM practices including rural, urban, and residency practicesAll OB and FM postpartum care providers in the communityRural Peds practices, all pediatric providers (pediatricians and nurse practitioners)All maternity and well child practices in New JerseyOne maternal and child health clinic in Hong Kong, nurse run and staffed. Support from local psychiatrists
Screening by staffScreening by staffScreening by staffScreening by clinic staff and physician reviewScreening by staff, review by physicianScreening by staff, review by cliniciansScreeners unknownScreening by nurses

Screening toolsPHQ-9 (cutoff for followup 10), PTSD screener, anxiety and alcohol screenerPHQ-2 and then PHQ-9EPDSEPDS follow by PHQ-9 for all scores greater than 10 versus usual care with no formal screeningEPDS, score >9 considered high risk for PPDPHQ-2, (scored 0–6) with cut point of 3 or more for positive screenLeft to the practice following an educational program to introduce screening and PPD management to physicians and other cliniciansEPDS, score >9 considered elevated compared to usual clinical assessment by nurse

Diagnostic methodsTelephone interview by master’s level clinical social workerReferral for SCID to mental health clinicUnknown, primarily screening programPHQ-9 and physician assessmentPhysician or other clinician choiceClinician discussed and offered referral resourcesPhysician or other clinician choice. Education covered both PPD care and referralOnsite counseling by nurse trained with short program. Could go for additional referral

Followup programReferral for therapy and calls by social worker at 1, 3, and 6 months for further referral suggestions Community educationAs per mental health care professional to whom the patient is referredUnknownDetailed followup program and tools to support care, medication, and counseling use and schedule nurse callsNone provided As per mental health professional to whom the patient is referredFollowup as determined by care providersFollowup was single session by trained nurse with optional additional counseling

OutcomesRates of therapy, levels of symptoms monthly after referralRates of screening completion including SCIDRates of screeningRates of screening, diagnosis, therapy initiation, levels of depressive symptoms at 6 and 12 months PPRates of PPD diagnosis and rates of PPD therapy initiatedRates of screening completed and screen positive status, and rates of women willing to take action plus rates of pediatrician support offeredRates of depression care initiation and continuation of care after 90 and 120 daysLevels of depressive symptoms at 6 and 18 months PP

ResultsNo change with program (before and after assessments)Less than 33% completed screening and assessment with SCIDRates of screening <40% in several regionsIncreased rates of PPD diagnosis, therapy initiation, and lower levels of depressive symptoms at 12 months PPIncreased rates of PPD diagnosis and increased rates of PPD therapy initiatedScreening completed at 67% to 74% of well child visits. 6% of women had scores ≥3
Among screen + mothers: 47% thought might be depressed and willing to take action. 28% thought stressed, not PPD. Clinician action in 62%
No change in rates of care initiation or continuation (before and after the onset of the statewide program assessment)Risk ratio of EPDS <10 was 0.50 for intervention versus usual care and NNS was 25 to prevent one EPDS of >10 at 12 months

Study designPre- and post-“open label”RCTCohortRCTPre- and post-cohortCohortPre- and post-study of Medicaid subset of populationRCT

Depression monitoring metricsPHQ-9 scoreUnknownNonePHQ-9 scoreNoneN/ANoneNone

Support systems
and tools
Social worker phone calls, weekly drop in programs for behavioral health or pharmacological services, provided at no costNoneNoneIAP, medication table, nurse call scripts, self help tools, father’s pamphlet, and monitoring scheduleNoneN/AEducation attended by 38% of obstetrical care physicians and other clinicians and 16% of pediatricians and 12% of family physicians in New JerseyNurses doing counseling had 12 hours of training and could refer to psychiatrist if desired

Reported barriers
to success
Adding mental health people into practice without integration may have decreased physician role as screener and evaluator, low SES populationNeed to refer offsite for SCIDUnable to get EPDS screening integrated into many practices.
A national program without incentives
Time barriers for clinic nurses to make calls, loss of insurance at 6 to 8 weeks PP for many of the women, failure to address PPD as chronic conditionNo followup program includedPediatrician role limited to screening, discussing impact on child, referral and short-term followupLess than one-third of clinical care providers participated in the educational programMore than half of the women attending the clinic were ineligible including several who had already undergone PND screening