PURPOSE Postpartum depression is common but inadequately recognized and undertreated. Continuing depressive symptoms are associated with adverse outcomes for the woman, her infant, and family. We wanted to determine the effect of a practice-based training program for screening, diagnosis, and management of depression in postpartum mothers. METHODSIn this practice-based effectiveness study, 28 practices were randomized to usual care (n = 14) or intervention (n = 14), and 2,343 women were enrolled between 5 and 12 weeks' postpartum. The intervention sites received education and tools for postpartum depression screening, diagnosis, initiation of therapy, and follow-up within their practices. Usual-care practices received a 30-minute presentation about postpartum depression. Screening information for the usual care was obtained from baseline surveys sent directly to the central site but was not available for patient care. Outcomes were based on patient-reported outcomes (level of depressive symptoms) from surveys at 6 and 12 months, plus medical record review (diagnosis and therapy initiation). RESULTSAmong the 2,343 women enrolled, 1,897 (80.1%) provided outcome information, and were included in the analysis. Overall, 654 (34.5% of 1,897) women had elevated screening scores indicative of depression, with comparable rates in the intervention and usual-care groups. Among the 654 women with elevated postpartum depression screening scores, those in the intervention practices were more likely to receive a diagnosis (P = .0006) and therapy for postpartum depression (P = .002). They also had lower depressive symptom levels at 6 (P = .07) and 12 months' (P = .001) postpartum.CONCLUSIONS Primary care-based screening, diagnosis, and management improved mother's depression outcomes at 12 months. This practical approach could be implemented widely with modest resources.

Hypothesized that maternal perceptions would be more significant predictors of emotional adjustment than medical severity. Mothers of 99 children, between the ages 4-10 years, completed the Child Behavior Checklist, Parenting Stress Index, Parental Locus of Control Scale, and a measure of perception of medical severity. Assessed medical severity by number of hospitalizations, operations, catheterizations, hospital days, outpatient visits, and a cardiologist's rating of illness severity. Maternal perceptions were potent predictors of emotional adjustment. Approximately 33% of the variability in adjustment was accounted for by maternal perceptions, while the medical severity accounted for less than 3% of the variability. Severity of illness appears less critical to successful adaptation than the quality of the mother-child relationship.

English as a Second Language programs serve large foreign-born populations in the US with elevated risks of tuberculosis (TB), yet little is known about TB perceptions in these settings. Using a community-based participatory research approach, we elicited perceptions about TB among immigrant and refugee learners and staff at a diverse adult education center. Community partners were trained in focus groups moderation. Ten focus groups were conducted with 83 learners and staff. Multi-level, team-based qualitative analysis was conducted to develop themes that informed a model of TB perceptions among participants. Multiple challenges with TB control and prevention were identified. There were a variety of mis-perceptions about transmission of TB, and a lack of knowledge about latent TB. Feelings and perceptions related to TB included secrecy, shame, fear, and isolation. Barriers to TB testing include low awareness, lack of knowledge about latent TB, and the practical considerations of transportation, cost, and work schedule conflicts. Barriers to medication use include suspicion of generic medications and perceived side effects. We posit adult education centers with large immigrant and refugee populations as excellent venues for TB prevention, and propose several recommendations for conducting these programs. Content should dispel the most compelling misperceptions about TB transmission while clarifying the difference between active and latent disease. Learners should be educated about TB in the US and that it is curable. Finally, TB programs that include learners and staff in their design and implementation provide greater opportunity for overcoming previously unrecognized barriers.

Objectives:To compare the Edinburgh Postnatal Depression Scale (EPDS) and Patient Health Questionnaire (PHQ-9) as screening tools for postpartum depression.Methods: This study population included the first 500 women to enroll and return their packets during an ongoing study of postpartum depression.Results: The primary outcome of this study was to find rates of concordance and discordance in the EPDS and PHQ-9 categories of "normal" and "increased risk for major depressive disorder." Overall, 97% of eligible women enrolled and 70% returned the packets that included the EPDS and PHQ-9. Four hundred eighty-one of the first 500 packets had complete data, with elevated EPDS or PHQ-9 scores in 138 and 132 women, respectively. Concordance of the EPDS and PHQ-9 were present in 399 women (83%): 326 (67.8%) had "normal" score on both, and 73 (15.2%) had elevated scores for both. Discordant scores in 82 women included 17 with elevated PHQ-9 scores but normal EPDS scores and 65 with elevated EPDS scores and PHQ-9 scores <10. In multivariate logistic regression modeling, only age >30 and low education level were predictive of discordant scores, using EPDS and PHQ-9 scores of >10 as elevated (odds ratio, 1.9 and P ‫؍‬ .02; and odds ratio, 2.3 and P ‫؍‬ .01, respectively). PHQ-9 scores of 5 to 9 have been referred to as consistent with "mild depressive symptoms" and appropriate for "watchful waiting" and repeat PHQ-9 at follow-up. Using this follow-up approach would require reevaluation of 120 (25%) of the women screened.Conclusions: Postpartum depression screening is feasible in primary care practices, and for most women the EPDS and PHQ-9 scores were concordant. Further work is required to identify reasons for the 17% discordant scores as well as to provide definitive recommendations for PHQ-9 scores of 5 to 9.

The value and appropriateness of universal postpartum depression (PPD) screening remains controversial in the United States. To date, several PPD screening programs have been introduced and a few have been evaluated. Among those programs that have been evaluated, most report screening rates, diagnosis rates, or treatment initiation rates. Only four studies included patient outcomes such as the level of depressive symptoms at 6 to 12 months postpartum, and only two reported success in improving outcomes. Program characteristics that appear to result in low rates of diagnosis and followup after PPD screening include requirements for a formal psychiatric evaluation, the need to refer women to another site for therapy, and failure to integrate the PPD screening into the care provided at the woman's or her child's medical home. The two programs that reported improved outcomes were both self-contained within primary care and included specific followup, management, and therapy procedures. Both resulted in the need for outside referrals in less than 10% of women diagnosed with postpartum depression. Future studies should be based on the successful programs and their identified facilitators while avoiding identified barriers. To affect policies, the future program must report maternal outcomes going beyond the often reported process outcomes of screening, referral, and therapy initiation rates.