Low-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 clinics
All postpartum women in all practices in the country
All women between 4 and 12 weeks PP coming for PP or well child visit to 28 enrolled practices
All women between 4 and 9 wks PP coming for PP visit to OB or FM to Olmsted County, MN provider
All women bringing children 0–18 years for well child visits for 6 month time period in three enrolled pediatric practices
All 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 program
All 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 characteristics
New Haven Healthy Start initiative—a community-based program not within any clinic
Seven family clinics, 4 urban family medicine, and 3 suburban pediatric clinics
All clinics providing postpartum care in the country
28 US FM practices including rural, urban, and residency practices
All OB and FM postpartum care providers in the community
Rural Peds practices, all pediatric providers (pediatricians and nurse practitioners)
All maternity and well child practices in New Jersey
One maternal and child health clinic in Hong Kong, nurse run and staffed. Support from local psychiatrists
Screening by staff
Screening by staff
Screening by staff
Screening by clinic staff and physician review
Screening by staff, review by physician
Screening by staff, review by clinicians
Screeners unknown
Screening by nurses
Screening tools
PHQ-9 (cutoff for followup 10), PTSD screener, anxiety and alcohol screener
PHQ-2 and then PHQ-9
EPDS
EPDS follow by PHQ-9 for all scores greater than 10 versus usual care with no formal screening
EPDS, score >9 considered high risk for PPD
PHQ-2, (scored 0–6) with cut point of 3 or more for positive screen
Left to the practice following an educational program to introduce screening and PPD management to physicians and other clinicians
EPDS, score >9 considered elevated compared to usual clinical assessment by nurse
Diagnostic methods
Telephone interview by master’s level clinical social worker
Referral for SCID to mental health clinic
Unknown, primarily screening program
PHQ-9 and physician assessment
Physician or other clinician choice
Clinician discussed and offered referral resources
Physician or other clinician choice. Education covered both PPD care and referral
Onsite counseling by nurse trained with short program. Could go for additional referral
Followup program
Referral for therapy and calls by social worker at 1, 3, and 6 months for further referral suggestions Community education
As per mental health care professional to whom the patient is referred
Unknown
Detailed followup program and tools to support care, medication, and counseling use and schedule nurse calls
None provided
As per mental health professional to whom the patient is referred
Followup as determined by care providers
Followup was single session by trained nurse with optional additional counseling
Outcomes
Rates of therapy, levels of symptoms monthly after referral
Rates of screening completion including SCID
Rates of screening
Rates of screening, diagnosis, therapy initiation, levels of depressive symptoms at 6 and 12 months PP
Rates of PPD diagnosis and rates of PPD therapy initiated
Rates of screening completed and screen positive status, and rates of women willing to take action plus rates of pediatrician support offered
Rates of depression care initiation and continuation of care after 90 and 120 days
Levels of depressive symptoms at 6 and 18 months PP
Results
No change with program (before and after assessments)
Less than 33% completed screening and assessment with SCID
Rates of screening <40% in several regions
Increased rates of PPD diagnosis, therapy initiation, and lower levels of depressive symptoms at 12 months PP
Increased rates of PPD diagnosis and increased rates of PPD therapy initiated
Screening 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 design
Pre- and post-“open label”
RCT
Cohort
RCT
Pre- and post-cohort
Cohort
Pre- and post-study of Medicaid subset of population
RCT
Depression monitoring metrics
PHQ-9 score
Unknown
None
PHQ-9 score
None
N/A
None
None
Support systems and tools
Social worker phone calls, weekly drop in programs for behavioral health or pharmacological services, provided at no cost
None
None
IAP, medication table, nurse call scripts, self help tools, father’s pamphlet, and monitoring schedule
None
N/A
Education attended by 38% of obstetrical care physicians and other clinicians and 16% of pediatricians and 12% of family physicians in New Jersey
Nurses 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 population
Need to refer offsite for SCID
Unable 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 condition
No followup program included
Pediatrician role limited to screening, discussing impact on child, referral and short-term followup
Less than one-third of clinical care providers participated in the educational program
More than half of the women attending the clinic were ineligible including several who had already undergone PND screening