This study found no evidence to support independent depression screening and referral among perinatal women in publicly funded clinics. In the first set of analyses, we examined whether a program that included provider education, community awareness, and direct systematic depression screening by an individual who was not the health care provider diminished the rates of depressive symptoms among pregnant and postpartum women. In contrast to our expectations, the rates of depression diminished significantly less after, than before, the program was initiated. Although this difference was significant, the differential of .23 point on the BHQ between the two groups is not likely of clinical significance. More-over, outcomes for the group in greatest need, those with a BHQ score of at least 10, did not differ significantly. In the second set of analyses, we examined whether actual participation in the NHHS program led to decreased depressive symptoms. Neither overall participants in the NHHS program nor those who were most symptomatic and enrolled in NHHS had significantly greater improvement in depressive symptoms compared with women who were not enrolled in NHHS.
Our third set of analyses showed that detection and clinician referral to specialty mental health care was lower after than before initiation of the NHHS program. Although the NHHS depression initiative sought to strengthen the therapeutic role of the obstetrical provider in intervening on depression, the addition of NHHS workers on site may have been viewed by health care providers as replacing their need to detect symptoms and refer women. This may have resulted in a more fragmented system in which busy providers felt that detection and treatment referral for mental health issues was addressed by support staff. This theory is congruent with work demonstrating that the addition of mental health workers on site may reduce detection, referral, and treatment by primary care providers because of providers’ abdication of these responsibilities to the mental health specialists (25
). The fragmented process of detection and care may be why our results differ markedly from those of Georgiopoulos and colleagues (10
), who found benefits for screening postpartum women. In their study, many women were treated for depressive symptoms on site by an obstetrical provider. Nearly one-half were prescribed an antidepressant, which may be more acceptable among postpartum women than pregnant women.
Our results are in accord with the meta-analysis by Gilbody and colleagues (8
), who found that depression screening changed neither levels of depressive symptoms nor the use of depression treatment in unselected populations. Our intervention had additional components that included general education of the community and practitioners and a system in place to offer care to those who screened positive for depressive symptoms. The U.S. Preventive Services Task Force (9
) suggested that screening is more likely to diminish the burden of depression if there are procedures in place to care for patients with depressive symptoms. Even the availability of treatment resources did not enhance the effectiveness of depression screening. However, we did not have the kind of rigorous on-site depression treatment that has promoted successful treatment of depression in other primary care settings (27
Our inability to show that the NHHS program improved depression may have been hampered by issues unique to our patient cohort. First, providers may be reluctant to initiate—and pregnant patients may be less likely to accept—treatment on site because this usually indicates pharmacological treatment. Referrals to specialty mental health care meant that patients needed additional motivation to schedule and follow up with appointments or attend appointments off-site during drop-in hours.
Second, there were substantial differences in the groups at baseline. Although propensity score adjustment should have equalized possible confounding factors, there may have been residual confounding or other differences related to improvement in depressive symptoms for which there was not adequate adjustment.
Third, the lack of effect of the NHHS initiative also may have been due to a relatively low rate of treatment need. A score of 10–15 points on the BHQ indicates only a mild degree of depression and was found in 13%–18% of women in these groups. In this cohort of underprivileged women, we may have identified women who were in distress because of a host of psychosocial issues, including unstable housing, scarcity of food, and concerns about neighborhood violence and crime. A more clinically meaningful score of >15 was endorsed by 5%–6% of women in each group, but some of those women were already in treatment. Thus, even though our cohort was large, the actual small numbers of women who needed treatment may have limited power of the analyses to detect differences.
Other investigators have found that despite thoughtful procedures and enthusiastic community interest, community-based interventions frequently do not show demonstrable clinical benefits (30
). Reasons for this include failure to measure behavioral change for a sufficient period, weak interventions, or difficulties in providing the intervention to those who need it the most (30
). The NHHS depression initiative provided robust treatment resources (flexible appointment times and multiple referrals). However, a stronger focus on treatment engagement or on-site treatment resources may have been needed.
Finally, it may be that women in the greatest need of treatment had already been identified. This is not likely, however, because our previous work has shown that only about one-quarter of women with a mood or anxiety disorder, including 12% with suicidal ideation, were detected by a prenatal care provider in these publicly funded prenatal care settings (3