Briefly describe a specific question, or set of related questions, about a health care test or treatment that this program should consider.

• For women in the postpartum period, what is the effectiveness and safety of screening and treatment for depression?

Please use the USPSTF framework, which considers not only screening but followup treatment and management. The treatment question may be considered separately, but should be linked back to screening.

Postpartum = 1 year after delivery of a viable pregnancy (includes IUFD, preterm and term infants).

Depression does not include “baby blues” or postpartum psychosis.

Does your question include a comparison of different health care approaches? (If no, your topic will still be considered.)

yes

If yes, explain the specific technologies, devices, drugs, or interventions you would like to see compared:

Differing approaches to screening, treatment and management for postpartum depression.

Screening approaches may include: 1) different access points (e.g., pediatrician, ob-gyn, other primary care provider; non-traditional community-based setting [e.g., family planning clinics]; other). 2) different screening tools (e.g., the Edinburgh is widely thought to be the best, but for which populations does it work?—populations categories may include Medicaid and CHIP enrollees, mothers of child Medicaid and CHIP enrollees, racially/ ethnically/ socioeconomically diverse populations, mothers with prenatal or preconception depression (v. not), women whose children were born prematurely or with developmental disorders, age groups, and others that may be identified.

Treatment approaches may include anti-depressant medications, cognitive therapy, individual or group psychotherapy, hormonal therapy.

What patients or group(s) of patients does your question apply to? (Please include specific details such as age range, gender, coexisting diagnoses, and indications for therapy.)

All postpartum women (including women who did not deliver a live birth).

Are there subgroups of patients that your question might apply to? (For example, an ethnic group, stage or severity of a disease.)

As in Item 2 above:

-Insurance status, especially Medicaid and CHIP enrollees, mothers of child Medicaid and CHIP enrollees -racially/ ethnically/ socioeconomically diverse populations -mothers with prenatal or preconception depression (v. not) -women with high-risk pregnancies and pregnancy outcomes such as prematurity, NICU status, IUFD -breastfeeding

Describe the health-related benefits you are interested in. (For example, improvements in patient symptoms or problems from treatment or diagnosis.)

• Improvements in patient depressive symptoms
• Improvements in parenting skills
• Improvements in quality of life, including marital and other social relationships

Describe any health-related risks, side effects, or harms that you are concerned about.

• Screening without having treatment and followup services available is a concern among Medicaid programs and pediatricians.
• Ineffective treatments may worsen PPD problems
• Prescription drug treatments may have side effects or harms.
• Hormonal treatment may have side effects or harms.

Appropriateness for EHC Program

Does your question include a health care drug, intervention, device, or technology available (or likely to be available) in the U.S.?

yes

Which priority area(s) and population(s) does this topic apply to? (check all that apply)

EHC Priority Conditions (updated in 2008)

• Depression and other mental health disorders
• Pregnancy, including preterm birth

AHRQ Priority Populations

• Low income groups
• Women
• Children
• Individuals with special health care needs, including individuals with disabilities or who need chronic care or end-of-life health care

Federal Health Care Program

• Medicaid
• State Children's Health Insurance Program (SCHIP)
• Other

Importance

Describe why this topic is important.

Over 11% of women experience major or minor postnatal depression six weeks postnatally. (Paulden, BMJ online, citing AHRQ Review 2005), although estimates vary by time at which PPD is screened for and population subcategories (e.g., Chaudron et al., 2010). Considerable evidence shows “that postpartum depression has a substantial impact on the mother and her partner, the family, mother-baby interactions, and the longer term emotional an dcognitive development of the baby, especially when depression occurs in the first year of life.” (Paulden, BMJ online) However, primary care providers fail to recognize half of all cases of PPD (Yawn, 2006, cited in AHRQ Research Activities). Medicaid program directors and pediatricians who see Medicaid-enrolled infants and their postpartum mothers have reported avoiding screening for postpartum depression due to concerns about liability should mothers not be able to access treatment (due to lapse in Medicaid benefits for the moms soon after the child’s birth). The ACA is likely to ameliorate this concern as more mothers remain eligible and covered longer after delivery. Thus, it is important to know whether and which postpartum depression screening (and followup) approaches are effective and safe for women covered by Medicaid and CHIP.

What specifically motivated you to ask this question? (For example, you are developing a clinical guideline, working with a policy with large uncertainty about the appropriate approach, costly intervention, new research you have read, items in the media you may have seen, a clinical practice dilemma you know of, etc.)

AHRQ is leading the improvement, enhancement, and development of core healthcare quality measures for Medicaid and CHIPRA for children and for perinatal services affecting child health. (www.ahrq.gov/chipra) Postpartum depression screening was not selected as a core measure for the initial recommended set due to a paucity of evidence and the aforementioned concerns about liability. Knowing the evidence base for postpartum screening and treatment for depression will help the AHRQ Pediatric Quality Measure Program awardees enhance and improve existing measures (e.g., NCQA) or develop new measures for use by the Medicaid and CHIP programs, and other private and public programs, as required by CHIPRA.

Does your question represent uncertainty for clinicians and/or policy-makers? (For example, variations in clinical care, controversy in what constitutes appropriate clinical care, or a policy decision.)

yes

If yes, please explain:

Numerous approaches to screening and treatment for PPD are recommended. The following summaries are based on quick reviews of pubmed searches.

Screening: A previous AHRQ SER (2005) could not recommend specific screening tools, noted that screening tools could not distinguish between major and minor depression, and suggested that future studies have larger samples, including disparities populations. Subsequent studies: NICE recommends use of the two-three “Whooley questions” at primary care visits (Paulden) as a quicker and cheaper way to assess PPD than the more traditional Edinburgh postnatal depression scale (EPDS) (see attached pubmed searches for screening for PPD). Paulden’s cost-effectiveness analysis using a hypothetical sample concluded that the NICE recommendation was appropriate, and questioned the need for more formal screening methods. However, an educational intervention with pediatricians did not find that a “two-question” approach to screening sufficiently identified PPD (Mishina, 2009). Stating that PPD is a multifactorial disorder, Podolska et al. suggest incorporating the NEO Five-Factor Inventory to assess personality disorders. Also available (and studied to some extent) are the PDSS-SF (Zubaran, 2010), the PHQ-9 (Yawn, 2009); PRIME-MD-9 (Reuland). A Health Technology Assessment (Hewitt et al., 2009) proposed a research agenda. Additional questions include the timing of PPD screening: is once enough? (Sheeder, et al., 2009). Priority populations: Focusing on adolescent mothers, Logsdon and Myers (2010) compared the EPDS and the CES-D; also see Logsdon et al., 2009). Focusing on low-income urban mothers, Chaudron et al. compared the EPDS with the BDI II and the PDSS; they found all to be accurate, but suggested changes in cutoff points for the population they studied. Given the high birth rate among Hispanic women, accuracy of Spanish- and other language translations is important (Reuland, et al., 2009; Gibson, et al., 2009). Other variations

Potential Impact

How will an answer to your research question be used or help inform decisions for you or your group?

CHIPRA measures are required to be evidence-based, according to the law. Thus, the availability of knowledledge about the evidence base will help guide further development of measures of the quality of postpartum depression care.

Perhaps more importantly, a knowledge base will help providers and policymakers decide whether and how to screen and whether and how to cover PPD services.

Describe the timeframe in which an answer to your question is needed.

Within a year from this submission would be ideal. (i.e., October 2011). The PQMP begins in late December 2010.

Describe any health disparities, inequities, or impact on vulnerable populations your question applies to.

While reports of depression in general are low among African-American and Hispanic populations, these groups have birth rates higher than Non-Hispanic White women, and other reasons to be at more risk (e.g., low income, discrimination, lack of access). In addition, they are likely to be low-income and unable to afford out of pocket costs for mental health treatment. Hispanic women are more likely to be uninsured.

Nominator Information

Other Information About You: (optional)

Please choose a description that best describes your role or perspective: (you may select more than one category if appropriate)

CHIPRA measures are required to be evidence-based, according to the law. Thus, the availability of knowledledge about the evidence base will help guide further development of measures of the quality of postpartum depression care.

Perhaps more importantly, a knowledge base will help providers and policymakers decide whether and how to screen and whether and how to cover PPD services.

Are you making a suggestion as an individual or on behalf of an organization?

Organization

Please tell us how you heard about the Effective Health Care Program

I work at AHRQ.