Effect of Immediate Referral vs a Brief Problem-solving Intervention for Screen-Detected Peripartum Depression: A Randomized Clinical Trial

Key Points Question Is an immediate, activated referral to care or a brief problem-solving intervention more effective for the initial management of screen-detected depression in pregnant and postpartum persons? Findings In this randomized clinical trial of 230 pregnant and postpartum participants followed up for 12 months, there were no significant differences in the rate of depressive or anxiety symptom episodes between groups; however, the evidence suggested improved symptom trajectory following immediate referral. Meaning Further work is necessary to guide approaches to ensuring adequate follow-up care following a positive depression screen result among peripartum persons. This randomized clinical trial compares the effectiveness of immediate referral strategy with short-term management of symptoms among pregnant and peripartum persons with screen-detected depression. Importance The US Preventive Services Task Force recommends screening adults for depression in settings with programs in place to ensure receipt of appropriate care. Best practices regarding how to ensure such care are unknown, particularly for pregnant and postpartum persons. Objective To compare the effectiveness of 2 strategies for the initial management of screen-detected peripartum depressive symptoms. Design, Setting, and Participants This randomized comparative effectiveness trial was performed from February 1, 2018, to June 30, 2020, at the prenatal clinic, postpartum unit, and pediatric clinic within an urban safety-net hospital. Participants included peripartum persons with positive depression screen results. Data were analyzed from July 6, 2020, to September 21, 2022, based on intention to treat. Interventions Engagement-focused care coordination (EFCC), which used shared decision-making and motivational techniques to refer patients to outside mental health services, and problem-solving education (PSE), a brief cognitive-behavioral program delivered at the screening site. Main Outcomes and Measures The primary outcome consisted of severity of depressive symptoms; secondary outcomes included severity of anxiety symptoms and engagement with care, each measured bimonthly over 12 months. Rates of symptom elevations were modeled using negative binomial regression; rates of symptom trajectories were modeled using treatment x time interactions. Results Among the 230 participants (mean [SD] age, 29.8 [5.8] years), 125 (54.3%) were Black and 101 (43.9%) were Hispanic or Latina. At baseline, 117 participants (50.9%) reported at least moderately severe depressive symptoms (Quick Inventory of Depressive Symptomatology score >= 11), and 56 (24.3%) reported clinically significant anxiety symptoms (Beck Anxiety Inventory score >= 21). Across 6 assessment time points, the mean (SD) number of moderately severe depressive symptom episodes in EFCC was 2.2 (2.2), compared with 2.2 (2.1) in PSE, for an adjusted rate ratio (aRR) of 0.95 (95% CI, 0.77-1.17). The mean (SD) number of anxiety symptom elevations in EFCC was 1.1 (1.8), compared to 1.1 (1.6) in PSE, for an aRR of 0.98 (95% CI, 0.69-1.39). There were significant treatment x time interactions relative to mean depressive symptom scores (-0.34 [95% CI, -0.60 to -0.08]; P=.009 for interaction term), favoring EFCC. There were no differences in engagement with care. Conclusions and Relevance In this randomized comparative effectiveness trial, there were no differences in depressive or anxiety symptom burden across comparators; however, the evidence suggested improved depressive symptom trajectory with immediate referral. Further work is necessary to guide approaches to management following depression screening for peripartum persons. Trial RegistrationClinicalTrials.gov Identifier: NCT03221556