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| IMPLEMENTATION STORIES
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Implementing PPD Screening and Follow Up: The TRIPPD Protocol
Over the past 4 years, 28 family medicine practices have introduced and implemented a plan to increase recognition of postpartum depression. They provide services to women identified as being at high risk of depression as part of the TRIPPD study (Translating Research into Practice for Postpartum Depresssion). TRIPPD was inspired by the Three Component Model. TRIPPD uses many of the same tools and the same systematic approach but focused on postpartum depression. Also, TRIPPD uses the resources of participating practices alone. Of note, a recent study from Germany using an approach similar to TRIPPD applied to MDD and found improved depression outcomes.1
TRIPPD is based on routine screening of all postpartum women at their postpartum visit or their infant’s well baby visit. Screening was done with the EPDS (Edinburgh Postnatal Depression Scale) and PHQ-9.
Assuring all women were screened requires the combined efforts of the reception and nursing staffs to identify the visit as a postpartum or a well-infant visit and then to make sure the women are given the screening instruments. Some practices find the receptionist best able to identify screening candidates and give the tools to the women; others find their nursing staff is better able to do this.
Feedback from women suggests that the tools should not be labeled as a depression assessment, but rather as a ‘mother’s feelings tool’ since all mothers have feelings, but not all are comfortable saying they are agreeable to depression screening. Initially, staff were concerned that women would not like to receive screening regarding their feelings, however many women relayed just the opposite message.
“Keep sending them, I'll keep doing them. Thanks! God bless you all!” (Patient wrote on the back of survey.)
"To whom it may concern: Thank you all for caring (worrying) about the health of pregnant women for me and my family. At this time I have been more depressed than normal now that two years have passed since my daughter died shortly after birth . . . and the economic situation is very difficult in my home, but I know we will make it. Many thanks for giving me the opportunity to participate in your surveys. God bless you." (Note written on a paper sent with 12-month packet translated from Spanish.)
"Thank you for letting me be part of this survey/study." (Note from a patient.)
“Thank you for doing this study. Being a mom is so hard and lonely at times. So adding depression into that picture is REALLY HARD.” (Note from a patient.)
“Also I would like to thank Dr. C. She was very understanding with me and always listened to what I had to say. I'm thankful for that. If I ever had a problem or a question, she would always help. Thank you. Keep doing what you do.” (A patient commented on her last survey.)
Practices worried that women might report suicidal ideation that would require excessive time and attention. The TRIPPD study developed a simple tool for guiding evaluation and action for suicidal ideation called the IAP (Immediate Action Protocol available on request). This protocol is a one-page tool that includes questions to guide evaluation, as well as a list of local resource emergency numbers if immediate action is required.
“The main change is the IAP is at every phone, so all nurses know what to do with that sort of phone call and can apply it to all forms of suicidal ideation. The nurses have something to refer to, and nurses are now very comfortable with what to do.” (Clinic nurse coordinator)
An important part of the program is the follow up of women diagnosed with depression. While return visits to the physician’s office were an integral part of the follow up, nurse follow-up telephone calls were also very strongly recommended. Though many nurses were initially reluctant to do these calls, they came to value the increased contact with depressed patients.
“The nurse calls have also helped to have a sense of team work in patient care.” “Patients seem to appreciate the calls.” (Clinic coordinator)
“Patients appreciate that we really care, that we take the time to call, and that it does not cost them anything.” (Clinic nurse coordinator)
“Dr. V is also making more follow-up calls for non-PPD issues.” (Clinic nurse coordinator)
To simplify the process, the TRIPPD program provided two tools to facilitate the nurses’ calls. The calls were designed to assess therapy adherence and address new problems, such as medication side effects and issues with keeping counseling appointments, not to provide therapy. The nurse’s call form allowed nursing staff to have a simple format for the calls, and the one-page management of common antidepressant side effects form supported practical advice to decrease side effects commonly experienced with the initiation of antidepressants. Family physicians commented on the benefits provided by a structured universal postpartum screening program with recommended follow up.
“(I was) surprised about who is screening positive.” (Physician interview)
“I was not really screening in any systematic way. I of course thought I was doing a good job, and I think I picked up most of the really very depressed women but missed the borderline ones.
This forces me to talk about the issues and work through them with the women.” (Physician interview)
“The nurses’ follow-up calls were the most important thing. It is a key part. . . just like chronic disease management for all kinds of chronic diseases.” (Physician interview)
“The phone follow up has done pretty well and positive changes have been seen. It really seems to have made a difference.” (Physician interview)
The study will be complete in late 2010, and further information will be available at that time.
Tools available on request from:
Barbara P. Yawn, MD MSc
Olmsted Medical Center
Director of Research
210 Ninth St SE
Rochester, MN 55904
507-287-2758
byawn@olmmed.org
1. Gensichen J, von Korff M, Peitz M, Muth C, Beyer M, Guthlin C, et al. Case management for depression by health care assistants in small primary care practices. A cluster randomized trial.
Ann Intern Med. 2009;151:369-78 |
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