After having a baby, some women develop a condition called postpartum depression, or PPD, which can cause sadness, anxiety, and difficulty bonding with their newborn. Right now, most women aren't screened for PPD until about 6 to 8 weeks after giving birth, but this study wants to find out if checking earlier could help identify signs sooner. To test this, researchers will work with 428 women who deliver at an MGH hospital clinic and have no history of depression. Each woman will be randomly placed into one of two groups: one group will fill out a short depression questionnaire online at 2 to 3 weeks after delivery, while the other group will follow the usual process and complete the same questionnaire at their regular 6-week visit. The results will go to each woman's doctor, who will decide if any follow-up care is needed, just like they normally would. The study will follow each participant for 6 months after delivery to see whether earlier screening makes a difference.
This is a pragmatic clinical trial comparing early EPDS screening (2 weeks postpartum) with standard care (6 weeks postpartum) in 428 patients without a history of depression and delivering and receiving obstetric care at an MGH-affiliated clinic. Patients will be stratified as high-risk or low-risk for PPD using a validated prediction model and then randomized (1:1) to one of two arms: early screening (intervention group) or routine care (control group). Patients and clinical team members will be blinded to risk assignment. The early EPDS screening group will be sent an electronic EPDS (PROMS) at 2-3 weeks postpartum by the MGH Obstetric Clinic Staff; results will be directed to the patient's primary obstetric provider, mirroring the clinical process for the routine 6-week postpartum EPDS screen. The routine care group will continue to receive standard postpartum care, which includes a visit around 6 to 8 weeks postpartum and administration of the EPDS survey. Clinic staff will review and manage screening results according to local clinic protocols (e.g., arranging virtual or in-person visits, social work referrals, etc.); this includes managing reports of self-harm, which is a component of the scale. The research team will not be responsible for sending or reviewing EPDS results in real-time. The study will be conducted until 214 high- and 214 low-risk patients have been randomized and followed through 6 months postpartum. This study is a pilot project designed to generate preliminary data for a larger definitive trial. In the retrospective data, 10.1% of patients in the high-risk group and 2.0% of patients in the low-risk group had an EPDS score\>12 at 6 weeks postpartum (non-responders were considered not to have a positive screen). Assuming the same rates in this prospective cohort, 107 individuals in each risk grouping would provide 80% power at alpha=0.05 to detect the same effect (one-sided Z-test). The study will enroll 107 individuals in the control arm in each risk grouping. The study will employ an intent-to-treat approach, analyzing all randomized participants in their assigned groups, with a secondary per-protocol analysis limited to participants who completed their assigned screening protocol. The primary endpoint, EPDS-positive screen (EPDS \>12 vs ≤12), will be compared using chi-square tests within the standard screening group between the high- and low-risk groups. EPDS score at 2 weeks postpartum in the early screening group will be compared between high-risk and low-risk participants using Mann-Whitney U tests for median scores or t-tests for mean scores, if normally distributed. Secondary EPDS score endpoints at 6 weeks postpartum will be analyzed using the same methods. The binary endpoints of PPD incidence and mental health referral/treatment at 6 months (defined as the presence of a mood/depressive disorder diagnosis code, psychiatric medication prescription, or EPDS \>12) will be compared between groups using chi-square tests. Feasibility endpoints, including EPDS completion rates at 2 and 6 weeks and positive screen rates (EPDS \>10 and \>12), will be analyzed using chi-square tests. Time to mental health referral or treatment initiation will be evaluated using Kaplan-Meier survival curves with log-rank tests for between-group comparisons. Model validation will be assessed through AUROC analysis for discrimination between those who develop PPD and those who do not, along with calibration plots comparing predicted versus observed PPD rates. Using an intention-to-treat analytic plan, the primary analysis will compare rates of positive EPDS screening among the high- and low-risk groups in the control arm; non-responders to the EPDS screen will be considered "screen negative" to mirror the approach used for our sample size calculation. For other analyses, a complete-case approach will be used as the primary comparison method. Regression will adjust for patient characteristics, such as race (White vs. non-White), language (English vs. non-English), age (\< vs ≥35 years), and mode of delivery (vaginal vs. cesarean delivery), to examine effect modification across various subgroups.
Study Type
INTERVENTIONAL
Allocation
RANDOMIZED
Purpose
SCREENING
Masking
DOUBLE
Enrollment
428
Edinburgh Perinatal Depression Scale (EPDS) administered at approximately 2 weeks postpartum
Proportion of positive Edinburgh Postnatal Depression Scale (EPDS) screens at 6 weeks in the routine care group by postpartum depression (PPD) risk status
To compare rates of positive EPDS screens (EPDS \>12) at 6 weeks (in the routine care group) by PPD risk status (high vs. low)
Time frame: 6 weeks postpartum is defined as a period between 28-56 days after the day of delivery
Edinburgh Peripartum Depression Scale (EPDS) scores at 2 weeks postpartum in the early screening group by PPD risk status
To compare EPDS scores at 2 weeks postpartum by PPD risk status (high vs. low) in the early screening group. EPDS score: range 0-30; higher scores are more strongly associated with PPD
Time frame: 2 weeks postpartum is defined as a period between 8-24 days after the day of delivery
Edinburgh Postnatal Depression Scale (EPDS) score at 6 weeks in the routine screening group by PPD risk status (high vs. low).
To compare EPDS scores at 6 weeks postpartum among women at high and low risk in the standard screening group. EPDS score: range 0-30; higher scores are more strongly associated with PPD
Time frame: 6 weeks postpartum is defined as a period between 28-56 days after the day of delivery
Proportion of individuals with PPD at 6 months postpartum in the routine care group by PPD risk status
To compare the incidence of PPD (as defined by the presence of a diagnosis code for a mood or depressive disorder, a psychiatric medication prescription, or EPDS results \>12) at 6 months postpartum by PPD risk status (high vs. low) in the routine care group
Time frame: 6 months postpartum is defined as a period between the day of delivery and 180 days after delivery
Proportion of individuals with PPD at 6 months postpartum in the early screening group by PPD risk status
To compare the incidence of PPD (as defined by the presence of a diagnosis code for a mood or depressive disorder, a psychiatric medication prescription, or EPDS results \>12) at 6 months postpartum by PPD risk status (high vs. low) in the early screening group
Time frame: 6 months postpartum is defined as a period between the day of delivery and 180 days after delivery
Proportion of individuals with PPD (excluding EPDS diagnositic criteria) at 6 months postpartum in the routine care group by PPD risk status
To compare the incidence of PPD (as defined by the presence of a diagnosis code for a mood or depressive disorder, or a psychiatric medication prescription, but not an EPDS results \>12) at 6 months postpartum by PPD risk status (high vs. low) in the routine care group
Time frame: 6 months postpartum is defined as a period between the day of delivery and 180 days after delivery
Proportion of individuals with PPD (excluding EPDS diagnostic criteria) at 6 months postpartum in the early screening group by PPD risk status
To compare the incidence of PPD (as defined by the presence of a diagnosis code for a mood or depressive disorder, or a psychiatric medication prescription, but not an EPDS results \>12) at 6 months postpartum by PPD risk status (high vs. low) in the early screening group
Time frame: 6 months postpartum is defined as a period between the day of delivery and 180 days after delivery
Edinburgh Postnatal Depression Scale (EPDS) completion rates at 2 weeks postpartum in the early screening group by PPD risk status
To evaluate the feasibility of electronic-based EPDS screening at 2 weeks postpartum in the early screening group, as measured by screening completion rates
Time frame: 2 weeks postpartum is defined as a period between 8-24 days after the day of delivery
Edinburgh Postnatal Depression Scale (EPDS) completion rates at 6 weeks postpartum in the routine care group by PPD risk status
To examine EPDS completion rates at 6 weeks by PPD risk status (high vs. low) in the routine care group
Time frame: 6 weeks postpartum is defined as a period between 28-56 days after the day of delivery
Proportion of positive Edinburgh Postnatal Depression Scale (EPDS) screens at 2 weeks in the early screening group by PPD risk status
To compare rates of positive EPDS screens (EPDS \>10 and \>12) at 2 weeks (early screening group) by PPD risk status (high vs. low)
Time frame: 2 weeks postpartum is defined as a period between 8-24 days after the day of delivery
Proportion of positive Edinburgh Postnatal Depression Scale (EPDS) screens at 6 weeks in the early screening group by PPD risk status
To compare rates of positive EPDS screens (EPDS \>10 and \>12) at 6 weeks postpartum (early screening group) by PPD risk status (high vs. low)
Time frame: 6 weeks postpartum is defined as a period between 28-56 days after the day of delivery
Proportion of participants with mental health referrals (social work, therapy, psychology, psychiatry) and treatment (psychotherapy, medication prescription) within 6 months postpartum in the routine care group by PPD risk status
To compare mental health referrals and treatment within 6 months postpartum by PPD risk status (high vs. low) in the routine care group
Time frame: 6 months postpartum is defined as a period between the day of delivery and 180 days after delivery
Proportion of participants with mental health referrals (social work, therapy, psychology, psychiatry) and treatment (psychotherapy, medication prescription) within 6 months postpartum in the early screening group by PPD risk status
To compare mental health referrals and treatment within 6 months postpartum by PPD risk status (high vs. low) in the early screening group
Time frame: 6 months postpartum is defined as a period between the day of delivery and 180 days after delivery
Days between delivery and first diagnosis of a postpartum mood disorder within 6 months postpartum by PPD risk status
To compare days between delivery and first diagnosis of a postpartum mood disorder (based on diagnosis code and/or documentation with a clinical note) within 6 months postpartum by PPD risk status (high vs. low)
Time frame: 6 months postpartum is defined as a period between the day of delivery and 180 days after delivery
Days between delivery and first mental health referral or treatment within 6 months postpartum in the routine care group by PPD risk status
To compare time to mental health referral and treatment within 6 months postpartum by PPD risk status (high vs. low) in the routine care group
Time frame: 6 months postpartum is defined as a period between the day of delivery and 180 days after delivery
Days between delivery and first mental health referral or treatment within 6 months postpartum in the early screening group by PPD risk status
To compare time to mental health referral and treatment within 6 months postpartum by PPD risk status (high vs. low) in the early screening group
Time frame: 6 months postpartum is defined as a period between the day of delivery and 180 days after delivery
Change in Edinburgh Postnatal Depression Scale (EPDS) score between 2 and 6 weeks postpartum in the early screening group by PPD risk status
To compare the change in EPDS score between 2 and 6 weeks postpartum by PPD risk status (high vs. low) in the early screening group. EPDS score: range 0-30; higher scores are more strongly associated with PPD.
Time frame: 2 weeks postpartum is defined as a period between 8-24 days after the day of delivery; 6 weeks postpartum is defined as a period between 28-56 days after the day of delivery
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