Stepped Care Treatment of Postpartum Depression: Impact on Treatment, Health, and Work Outcomes
===============================================================================================

* Dwenda Gjerdingen
* Scott Crow
* Patricia McGovern
* Michael Miner
* Bruce Center

## Abstract

*Purpose:* The purpose of this study was to pilot a stepped collaborative care intervention for women with postpartum depression and evaluate health differences between self-diagnosed depressed and nondepressed women.

*Methods:* Five hundred six mothers of infants from 7 clinics completed surveys at 0 to 1, 2, 4, 6, and 9 months postpartum and a Structured Clinical Interview for DSM-IV (SCID). SCID-positive depressed women were randomized to stepped collaborative care or usual care. Nine-month treatment, health, and work outcomes were evaluated for stepped care women (n = 19) versus control depressed women (n = 20), and self-diagnosed depressed women (n = 122) versus nondepressed women (n = 344).

*Results:* Forty-five women had SCID-positive depression whereas 122 had self-diagnosed depression. For SCID-positive depressed women, the stepped care intervention increased mothers’ awareness of their depression diagnosis (100% vs 61%; *P* = .008) and their receipt of treatment (94% vs 56%; *P* = .019). Self-diagnosed depressed women (vs nondepressed women) had more depressive symptoms and acute care visits, worse general and mental health, and greater impact of health problems on regular activities.

*Conclusions:* The stepped care intervention improved women's knowledge of their postpartum depression diagnosis and their receipt of treatment. However, our formal diagnostic procedures missed many women whose depressed mood interfered with their health and function.

Postpartum depression (PPD), the most prevalent serious complication of pregnancy, affects up to 22% of women who have recently given birth.1 Given that fewer than half of postpartum women are screened for depression,2–5 it follows that only a minority of cases are probably treated.

In studies of nonpostpartum depression, collaborative treatment of depression has been acclaimed as superior to traditional treatment methods (eg, antidepressants and/or psychotherapy). Collaborative care consists of a team-based approach to care that, when applied to mental disorders, involves a primary care provider, mental health specialist (psychiatrist and/or psychologist or social worker), care manager,6–11 and other allied health professionals, as needed. The team usually offers enhanced provider/patient education about major depression, treatment with antidepressant medication and/or psychotherapy, and regular monitoring by the care manager (often by telephone) of depressed patients’ symptoms and treatment adherence.7 A recent meta-analysis of 37 collaborative care studies documented that collaborative care, compared with usual depression care, improves depression treatment adherence and outcomes, with long-term benefits of at least 5 years.12

Collaborative care treatment programs can improve not only depressive symptoms6,7,10,13,14 but also depressed patients’ function,7,14,15 quality of life,7 pain,14 work performance and productivity,16,17 marital adjustment,18 and physical health, including chronic health conditions such as arthritis.14

A special type of collaborative care—stepped care treatment—delivers care in a step-wise manner, beginning with screening, diagnosis, and initial treatment in a primary care setting and adding follow-up and support, decision support, mental health consultation, or referral by a care manager as needed for patients with persistent depressive symptoms.19 Although it would seem that collaborative care would also improve PPD outcomes, neither collaborative or stepped care have ever been experimentally tested in a postpartum population. Such evaluation would be important given that postpartum women often possess unique barriers to treatment, such as the need for childcare during mental health visits,20 concerns about medication effects on nursing infants,21 and fear of judgment or referral to child protection.22

The purpose of this study was to pilot a stepped collaborative care treatment program for women with PPD to begin to test the impact of such a program on women's mental and physical health outcomes and to evaluate differences in health outcomes between women with and without PPD.

## Methods

### General Procedures

Before its initiation the study was approved by the University of Minnesota's Institutional Review Board. Patients were recruited for the study from October 1, 2005, through September 30, 2006, during well-child visits, and surveys were administered from October, 2005, through June, 2007. Mothers registering their infants for an initial (0 to 1 month) well-child visit at one of 7 participating clinics were given an enrollment packet by the receptionist. The packet consisted of a brief description of the study, an enrollment form (indicating their willingness to participate), a consent form, and an initial survey. Enrollees were given follow-up surveys at subsequent 2-, 4-, and 6-month well-child visits (or, alternatively, they completed telephone or mailed surveys), and were mailed a final survey at 9 months postpartum. Mothers were also asked to complete the depression module of the Structured Clinical Interview for DSM-IV (SCID)23 within 2 weeks of the 0- to 1-month survey, and subsequently if a previously nondepressed woman developed either a positive 2-question depression screen or 9-item Patient Health Questionnaire (PHQ-9) at a later interval.

### Study Participants and Practices

Participants were recruited from 7 Minneapolis/St. Paul metropolitan area clinics: 4 were urban university-affiliated family medicine residency clinics and 3 were suburban, private pediatric clinics (staffed by approximately 130 and 11 physicians, respectively). Inclusion criteria included being a mother of a 0- to 1-month-old infant who was registered at one of the participating clinics, being English literate, and being ≥12 years old.

### Provider Training

Providers from the participating practices were offered a 1-hour training session and printed educational materials about PPD and study procedures before the study's initiation. The training session covered the following topics: PPD background, risk factors, diagnosis, study protocol and methods, scoring of 2 depression screens (2-question screen and PHQ-9), and management, including components of stepped collaborative care, the role of the primary care provider, the use of antidepressants and psychotherapy, the selection of antidepressants for breastfeeding mothers, antidepressant side effects, the duration of treatment, the importance of social support, and indications for mental health referral.

### Measures

Survey measures included (1) demographic information (initial survey), which indicated the mother's age, level of education, race/ethnicity, total family income, health insurance, marital status, number of children, and delivery date; (2) depression screening measures (all surveys), including a 2-question screen which asks about problems with mood or pleasure during the past month (positive if either question is answered “yes”) and the PHQ-9 (positive if the score >10)5; (3) receipt of treatment (9-month survey), which included the mother's self-report about being depressed or receiving a depression diagnosis after delivery, the mother's report of treatment in general and of antidepressant treatment and/or counseling in particular; (4) duration of treatment (9-month survey), including the number of weeks treated, treatment for ≥12 weeks, and the number of counseling and psychiatry visits; (5) health outcomes (0- to 1-month and 9-month surveys), including the PHQ-9,5 the mental health scale (5 items, from SF-36),24 general health (single item from Short Form-36), the number of mother's and infant's days of illness during 2 weeks, and the number of mother's and infant's acute care visits to clinic/urgent care/emergency department during 2 weeks; (6) work outcomes (9-month survey), including the length of maternity leave, the number of hours missed at work during the previous 7 days, the number of hours worked during the previous 7 days, and the impact of health problems on activities unrelated to their job (work-related questions taken from the Work Productivity and Impairment Questionnaire)25; and (7) satisfaction with depression treatment (9-month survey).

### Depression Diagnosis

All participants were expected to complete the depression module of the SCID interview23 by telephone within 2 weeks of completing their 0- to 1-month survey, and again later if a previously nondepressed woman was screen-positive on a follow-up survey. The SCID interview, our reference standard for the diagnosis of major depressive disorder, was conducted by 3 trained psychology doctoral students whose training consisted of observing SCID training tapes and completing 5 practice tapes under the supervision of an experienced doctoral-level clinical psychologist, followed by weekly quality assurance assessment conferences throughout the study. Sixty-eight (13.4%) of the women could not be reached for the initial SCID and an additional 9 women could not be reached for a follow-up SCID interview.

SCID-positive depressed participants were informed of the depression diagnosis, and these women were advised to see their primary care provider within 1 week. Providers were informed about their patients’ depression diagnoses, the nature of the study, and their patients’ participation in it. Although 31 of the randomized patients were each seen by a different provider, the remaining 8 patients shared providers: 3 providers had one patient in each of the 2 treatment groups, and one provider had 2 patients in the control group. Participants were also given the opportunity to self-diagnose depression through a 9-month survey question with a yes/no answer: “Since your baby was born, have you been depressed or diagnosed with depression?”

### Randomization

Women who became SCID-positive at 0 to 6 months postpartum were randomized to stepped or usual care using computer-generated block randomization schedules (block size, 10), which were stratified by clinic. This was done to ensure an approximately equal split of patients in each clinic. Providers were not blinded to their patients’ group assignment.

### Intervention

The stepped care intervention included (1) referral to the primary care provider for initial treatment (we recommended an antidepressant and/or psychotherapy referral, both found to be effective in previous research21); (2) regular telephone follow-up with a care manager (see details below); (3) decision support for primary care providers (eg, advice regarding specific antidepressants, additional treatment, or mental health referral); (4) consultation or referral to a mental health specialist for complex cases (eg, psychiatrists conducted psychiatric evaluations and adjusted medications and therapists provided psychotherapy using cognitive behavioral therapy, interpersonal therapy, or other therapies depending on the needs of the patient); and (5) patient education provided through the primary physician, care manager, and a mailed PPD brochure. Stepped care treatment was continued until either the patient was in remission, using Dietrich et al's8 definition of remission as a PHQ-9 score of <5, or the patient had passed the 9-month follow-up period. After this point, depression care continued according to the provider's standard.

The care manager was a registered nurse with mental health experience. She was trained in telephone call procedures by the principle investigator (DG), and training included PHQ-9 administration, depression diagnosis and treatment, patient education and social support, the use of the telephone protocol form, and triage of women with suicidal ideation.

Women in the stepped care group received an average of 4.1 calls from the care manager. These calls, which usually lasted 20 to 30 minutes, were attempted every 2 weeks until symptom remission and addressed depressive symptoms (using PHQ-9), mental health visits, treatment adherence and side effects, social support, suicidal ideation/plans, and lifestyle issues including nutrition, exercise, and rest. The content of each call was documented on a form and a copy was faxed to the woman's primary provider. If a participant's symptoms were not resolving as expected, this was specifically communicated.

If a call or survey revealed suicidal ideation (for any participant), the principle investigator was informed and contacted the participant to determine the severity of her symptoms. For cases in which there was potential risk for injury or suicide (5 stepped care women, 1 control woman, and 1 SCID-negative woman), a plan of action was developed and executed that included informing the woman's provider and recommending an urgent visit to the primary care and/or mental health provider or emergency department. Also, if warranted and if the mother agreed, the principle investigator communicated with an adult friend or relative the need for 24-hour supervision of the mother until she was determined to be safe by a health professional. Providers were responsive to our communication about urgent problems and worked with the principle investigator in developing and implementing a plan of action. Control group women were also informed of their depression diagnosis and referred to their primary care provider, who managed the depression according to the provider's usual practice.

### Statistical Analysis

To control for experiment-wide error rate on multiple dependent variables, 4 separate multivariate analyses of variance (MANOVAs) were performed to assess the impact of treatment on receipt of treatment, duration of treatment, health outcomes, and work outcomes (see “Measures,” above, for a listing of variables included within each of these 4 categories). Independent variables were treatment group and specialty (family medicine versus pediatric clinic). If a given MANOVA was significant, individual ANOVAs were examined, looking at dependent variables within the group.

To determine the impact of the intervention on specific 9-month health, work, and duration of treatment outcomes, we performed one-way ANOVA (or χ2 tests) on randomized women with treatment group as the independent variable, and the following as dependent variables: PHQ-9 score, mental health score, general health score, mother's and infant's days of illness and number of acute care visits, length of maternity leave, hours spent at work during the previous week, hours of missed work during the previous week, the impact of health problems on work productivity and on regular activities (not related to work), the duration of treatment, treatment duration of >12 weeks, and the number of counseling and psychiatry visits.

A post hoc analysis was performed to compare 9-month health outcomes between women with self-diagnosed depression (both treated and untreated) versus women with no depression. To compare these 3 groups while controlling the experiment-wise error rate, we initially performed a multivariate analysis of covariance (MANCOVA) with the 3 “as-treated” groups and specialty as independent variables; the baseline (0 to 1 month) measure of the dependent variable as the covariate; and PHQ-9 score, mental health score, general health score, mother's and infant's days of illness, mother's and infant's health care visits, and activities not related to work as dependent variables. Given that the MANCOVA result was significant, we then performed univariate ANCOVAs on the above-listed dependent variables. Group comparisons on job-related outcomes could not be effectively evaluated because of the small number of depressed women who were at work at 9 months. A descriptive analysis was performed to identify reasons that self-diagnosed depressed women did not receive treatment.

*T* tests and χ2 tests were used to compare stepped care and control patients on baseline demographic and health characteristics and to compare drop-outs (women who did not complete the final survey) with those who completed the study on selected variables.

## Results

### Participants’ Characteristics

A total of 506 women participated in the study, which represented approximately 33% of the estimated 1556 eligible (English literate) women. Figure 1 illustrates the progress of women through the phases of the study.

![Figure 1.](http://www.jabfm.org/https://www.jabfm.org/content/jabfp/22/5/473/F1.medium.gif)

[Figure 1.](http://www.jabfm.org/content/22/5/473/F1)

Figure 1. 
Flow diagram of participants’ progress through phases of the study. PPD, postpartum depression.

Sixty-seven percent of participants were white, 18% were black, and 7% were Asian; 27% had annual family incomes of <$20,000 whereas 37% had incomes of ≥$80,000. Sixteen percent had less than a high school diploma and 52% had a 4-year degree or more education; 55% had private health insurance whereas 31% had medical assistance. The mean age of the mothers was 29.1 years (SD, 6.2; range, 16–46); 65% of mothers were married, 64% were employed, and 42% had only one child. One hundred sixty-seven (33%) participants were recruited from family medicine clinics and 339 (67%) from pediatric clinics. More detail about demographic characteristics was provided in a previous publication.26

Only 34 (6.7%) of the 506 participants did not complete the final survey and were therefore considered dropouts. When dropouts were compared with those who completed the study, dropouts were found to be younger (26 vs 29 years old), less educated (32% vs 73% had more than a high school education), were less likely to be married (27% vs 68%), had more children (2.5 vs 1.9), had lower family incomes (64% vs 25% had annual income <$20,000), and had more depressive symptoms (21% vs 6% had a positive PHQ-9 score).26

### SCID-Positive Depression

Forty-five women (8.9%) had SCID-positive depression: 19 women were randomized to stepped care (the intervention group), 20 women were randomized to usual care (the control group), and 6 women were diagnosed at the 9-month interval and therefore could not be randomized. Thirty-four of the 39 randomized women completed the final survey. Baseline demographic and health characteristics of this group indicate that a majority had low education and income levels and most were not white and were receiving medical assistance. No significant baseline differences were seen between the 2 treatment groups, indicating that the randomization procedure was effective (Table 1).

View this table:
[Table 1.](http://www.jabfm.org/content/22/5/473/T1)

Table 1. 
**Baseline Comparisons between Stepped Care and Control Subjects on Demographic and Health Characteristics**

Women in both the stepped care and control groups were generally satisfied with their treatment, with a mean (SD) satisfaction score of 4.4 (1.6) for the stepped care group, and 5.5 (1.2) for the control group (satisfaction scale: 1 = very dissatisfied, 4 = somewhat satisfied, 7 = very satisfied; *P* = .091). Women in the stepped care group were receptive to follow-up calls by the care manager and they each received an average of 4.1 calls (range, 0–11). Only one stepped care participant could not be reached for follow-up calls.

### Impact of Intervention on Outcomes

MANOVA results (with treatment group and specialty as independent variables) showed that the stepped care intervention had a significant positive impact on the receipt of treatment (λ = 0.738; F = 3.305; *P* = .035). Results from one-way ANOVAs on these individual outcomes are shown on Table 2 and indicate that the intervention improved mothers’ awareness of their depression diagnosis and their receipt of treatment, particularly antidepressant medication. For the remaining 3 MANOVAs (duration of treatment, health outcomes, and work outcomes), treatment group effects were not significant. Group comparisons on specific health, work, and treatment duration outcomes are given on Table 3; with one exception (length of maternity leave), there were no significant group differences.

View this table:
[Table 2.](http://www.jabfm.org/content/22/5/473/T2)

Table 2. 
**The Impact of Stepped Care on Structured Clinical Interview for DSM-IV–Positive Depressed Patients’ Self-Report of Depression and Receipt of Treatment**

View this table:
[Table 3.](http://www.jabfm.org/content/22/5/473/T3)

Table 3. 
**Impact of Stepped Care Treatment for Postpartum Disorder on 9-Month Health, Work, and Duration of Treatment Outcomes**

Specialty effects approached statistical significance in 2 MANOVAs: receipt of treatment (λ = 0.771; F = 2.769; *P* = .060) and health outcomes (λ = 0.594; F = 2.346; *P* = .056). In both cases, mothers whose infants attended pediatric clinics had better outcomes than those who attended family medicine clinics. There were no significant group by specialty interactions.

### Self-Diagnosed Depression

When patients were asked if they had been depressed or diagnosed with depression since delivery, 122 (24.1%) answered “yes,” with 76 (62%) reporting treatment and 46 (38%) no treatment. Three-fourths of women (344) said they had not been depressed.

MANCOVA results showed that these 3 self-diagnosis groups were significantly different in their health outcomes (λ = .726; F = 11.139; *P* = .000). Follow-up ANCOVAs found that depressed women (both treated and untreated) compared with nondepressed women had more depressive symptoms (PHQ-9), worse general health and mental health, and greater impact of health problems on regular activities. Treated depressed women, versus the other 2 groups, had more acute care visits (Table 4). Specialty effects and specialty/group interactions were also significant (λ = 0.929 and 0.891; F = 4.9 and 3.8; *P* = .000 and .000, respectively); mothers from family medicine clinics, particularly those with treated self-diagnosed depression, had worse outcomes. Women's reasons for not taking depression treatment are shown in Table 5.

View this table:
[Table 4.](http://www.jabfm.org/content/22/5/473/T4)

Table 4. 
**Significant Differences in 9-Month Health Outcomes between the Treated Depressed Women, Untreated Depressed Women, and Nondepressed Women Self-Report Groups**

View this table:
[Table 5.](http://www.jabfm.org/content/22/5/473/T5)

Table 5. 
**Mothers’ Reasons for Not Taking Depression Treatment***

## Discussion

Our stepped care intervention improved mothers’ awareness of their depression diagnosis and their likelihood of being treated—both important clinical outcomes. The stepped care intervention did not, however, seem to significantly impact treatment duration, health, or work outcomes. One explanation for the absence of observed impact on these outcomes is the relatively small number of women available for these analyses: 18 for duration of treatment, 34 for health outcomes, and 10 for work outcomes. Other factors that may have contributed to nonsignificant group differences are the relatively brief period of follow-up and the inclusion of women with chronic depression and other associated severe mental health conditions (eg, bipolar disease), who may have been less responsive to this treatment program. In addition, the larger number of presumably higher-risk medical assistance patients in the stepped care group (15 vs 9; *P* = .075) may have blunted intervention effects.

It is interesting that women's self-reported diagnosis of depression produced nearly 3 times the number of depressed cases as the SCID-based diagnoses (122 vs 45, respectively). This large discrepancy between self-reported and SCID-based diagnoses is probably caused by the nature of our measures, at least in part. For example, the SCID is designed to diagnose major depression whereas the self-report question may have also identified women with transient or subthreshold depressive symptoms. We may have also missed cases because of noncompletion of a survey or SCID interview or discordance in survey timing with depressive symptoms. We are not aware of other studies comparing mothers’ self-reported depression to criterion-based depression, and the term “self-reported depression” in other PPD studies usually refers to positive depression surveys.27–30 This unexpected finding should be pursued in future studies.

As anticipated, our analysis comparing women from the 3 self-report groups (depressed/treated, depressed/untreated, and nondepressed) revealed that depressed mothers have worse mental and physical health outcomes and that depressed women's health problems have a significantly greater impact on activities not related to their jobs. Because caring for one's infant is usually a large component of a mother's “regular” activities, it follows that depression probably impacts a mother's care of her newborn. Prior research has also shown a relationship between mothers’ and fathers’ depressive symptoms.31–33 Therefore, it is important that depressed women be effectively treated, both for their own sake and the sake of other family members.

Importantly, 46 (38%) of the self-diagnosed depressed women said they had not received treatment. Although the most common reason for not receiving treatment was that women thought they could handle their depression themselves, postpartum-specific concerns were also raised, including medication effects on nursing infants, lack of childcare during depression visits, no time for visits, or fear that the infant might be taken away. Interventions that address these treatment barriers (eg, nurse phone calls exploring reasons for not receiving treatment, patient and physician education about treatment risks and benefits, or cultural liaisons for women of diverse cultural/ethnic backgrounds) should be explored in future studies.

Observed specialty effects—worse outcomes for women from family medicine (vs pediatric) sites—were confounded by other factors. The family medicine clinics were all urban residency training sites whereas the pediatric clinics were suburban community-based clinics. Therefore, our specialty-based differences could be based on socioeconomic factors.

Strengths of the study included case finding during well-child visits in pediatric and family medicine clinics; a low drop-out rate; depression diagnoses based on a reference standard (SCID interview); quantitative comparison of SCID-based depression diagnosis to self-diagnosis; the use of randomized controlled trial design with a practical, stepped, collaborative care intervention; and our finding that the intervention positively impacted depressed mothers’ knowledge of their diagnosis and their treatment. Weaknesses included our lower-than-expected participation rate, specialty effects being intertwined with residency training and socioeconomic characteristics, the modest number of SCID-diagnosed women, and, as a result, the apparent absence of treatment effect on health outcomes. Future studies exploring this intervention with larger numbers of depressed women would be useful.

## Conclusion

This study found that the stepped care intervention increased mothers’ recognition of their depression diagnosis and improved rates of treatment. In addition, formal diagnostic procedures (eg, SCID interviews) missed many women whose depressed mood interfered with their psychological health and daily functioning.

## Notes

*   This article was externally peer reviewed.
    
    *Funding:* This study was funded by the National Institute of Mental Health.
    
    *Conflict of interest:* none declared.
    
    See Related Commentary on Page [471](http://www.jabfm.org/lookup/volpage/22/471).

*   Received for publication September 11, 2008.
*   Revision received December 13, 2008.
*   Accepted for publication December 26, 2008.

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