screening for postpartum depression among low-income mothers using an interactive voice response...
TRANSCRIPT
Screening for Postpartum Depression Among Low-IncomeMothers Using an Interactive Voice Response System
Helen G. Kim • Joni Geppert • Tu Quan •
Yiscah Bracha • Virginia Lupo • Diana B. Cutts
Published online: 17 May 2011
� Springer Science+Business Media, LLC 2011
Abstract This study tested the feasibility of using an
interactive voice response (IVR) phone system to screen for
postpartum depression among low-income, English- and
Spanish-speaking mothers. Newly delivered mothers were
interviewed in the hospital. Consenting subjects completed a
background questionnaire and were asked to call an auto-
mated phone system 7 days postpartum to complete an IVR
version of the Edinburgh Postnatal Depression Screen
(EPDS). During the phone screen, subjects were branched to
different closing narratives based on their depression scores
which were later posted to a password protected website.
Logistic regression was used to assess relationships between
demographic and psychosocial factors, IVR participation,
and depression scores. Among 838 ethnically diverse, low
income, postpartum mothers, 324 (39%) called into the
automated phone screening system. Those who called were
more likely to have at least a high school education
(OR = 1.63, 95%CI: 1.23, 2.16), be employed (OR = 1.48,
95%CI: 1.08, 2.03) and have food secure households
(OR = 1.50, 95%CI: 1.06, 2.13). There was no statistically
significant difference between callers and non-callers in
terms of marital status, race/ethnicity, parity, or self-reported
history of depression. Postpartum depression symptoms
were present in 17% (n = 55) and were associated with
being single (AOR = 2.41, 95% CI: 1.29, 4.50), first time
mother status (AOR = 2.43, 95% CI: 1.34, 4.40), temporary
housing (AOR = 2.35, 95% CI: 1.30, 4.26), history of
anxiety (AOR = 2.79, 95% CI: 1.69, 6.67), and history of
self-harm (AOR = 2.66, 95% C: 1.01, 6.99). Automated
phone screening for postpartum depression is feasible
among disadvantaged mothers but those with the highest
psychosocial risk factors may not choose or be able to access
it. IVR could be used to supplement office- and home visit-
based screening protocols and to educate patients about
mental health resources.
Keywords Postpartum depression � Interactive voice
response � Mental health screening � Underserved women
Introduction
Postpartum depression affects 7–25% of all women during the
first year after delivery and is particularly common in low
income and minority populations [1–3]. Postpartum depres-
sion leads to maternal disability, impaired mother–child
attachment, and infant social and cognitive developmental
problems [4, 5]. Low income and minority women are at
particularly high risk for unrecognized and untreated post-
partum depression [6, 7]. This higher prevalence of postpartum
depression among disadvantaged populations leads to health
disparities in children of affected mothers [8]. Treatment of
postpartum depression thus represents an urgent public health
issue, particularly among disadvantaged populations [9].
H. G. Kim (&)
Department of Psychiatry, Hennepin Women’s Mental Health
Program, Hennepin County Medical Center, Minneapolis,
MN 55404, USA
e-mail: [email protected]
J. Geppert � T. Quan � D. B. Cutts
Department of Pediatrics, Hennepin County Medical Center,
Minneapolis, MN, USA
Y. Bracha
Center for Urban Health, Hennepin County Medical Center,
Minneapolis, MN, USA
V. Lupo
Department of Obstetrics/Gynecology, Hennepin County
Medical Center, Minneapolis, MN, USA
123
Matern Child Health J (2012) 16:921–928
DOI 10.1007/s10995-011-0817-6
Despite its high prevalence and negative impact,
postpartum depression frequently goes undetected, espe-
cially in high risk populations [3]. Many disadvantaged
mothers fail to follow-up for routine postpartum care due
to childcare and transportation issues [10, 11]. An addi-
tional barrier to detection involves using conventional
paper–pencil questionnaires to screen for depression since
an estimated 90 million Americans have low literacy
skills and difficulty using printed materials in daily life
[12, 13]. In one study of health literacy in two public
hospitals, one-third of English-speaking patients could not
read and understand basic health-related materials, 26%
could not understand information on an appointment
slip, and 60% could not understand a standard consent
form [14].
Interactive health information technology (health IT)
engages patients as consumers of health services and
active participants in their own health management.
Interactive technologies such as phone- or web-based
questionnaires provide health information and tools that
integrate individual needs and preferences into clinical
information systems. By giving patients access to relevant
health information that is delivered in an accessible way,
interactive health IT can empower patients to monitor,
manage and choose interventions most suitable for them-
selves. A report by the Agency for Healthcare Research
and Quality (AHRQ) emphasized that as health IT inter-
ventions increase, it will be important to assess the
accessibility, use, and benefit to specific target groups such
as those with chronic conditions and underserved popula-
tions [15].
Interactive voice response (IVR) is an example of a
health IT application that could facilitate mental health
monitoring and screening [16]. With this technology,
participants self-enter data directly into an electronically
maintained database using a touch-tone telephone. IVR
has been used for home monitoring of depression in
patients with chronic medical illness [17–19] and to
facilitate telephone peer support among older adults with
heart failure [20]. IVR has also been used to assess
psychosocial status [21, 22] and to improve access to
depression screens in non-English speaking patients [23].
Furthermore, studies have assessed different IVR versions
of depression instruments [24–27], and shown consistency
between IVR- and clinician-administered depression
questionnaires [28, 29].
We hypothesized that an automated phone system using
IVR would be a promising way of screening for postpartum
depression in disadvantaged mothers as it could accom-
modate low literacy patients and allow new mothers to
access the screen at a time that is both convenient and
private. In an earlier study we found that low income
pregnant women had no difficulty completing an IVR
depression screen that they accessed by a phone stationed
in their prenatal clinic [30]. The purpose of this current
study was to test the feasibility of using an automated
phone screen for postpartum depression that low income
mothers access remotely outside their clinic visits.
Methods
Study Population
The study population was drawn from newly delivered
mothers at Hennepin County Medical Center (HCMC), a
university-affiliated public hospital in Minneapolis, Min-
nesota. Trained research assistants approached eligible
subjects on postpartum day 1 or 2 while they were still
inpatients. In order to be eligible to participate in the study,
subjects had to be English- or Spanish-speaking. The
HCMC Institutional Review Board approved the study
which was conducted from February 2006 to February
2008. During this study period, 1,591 patients were
approached for the study and 1,013 (63.7%) consented to
participate and completed the baseline demographic ques-
tionnaire. For our final sample, we excluded 70 who were
native-born Africans because we had not assessed their
English literacy skills. We also excluded 105 because they
had private insurance and represented a less at-risk group.
We limited our final analysis to the remaining 838 patients
on Medical Assistance or with no insurance to focus on the
most at-risk mothers.
Study Protocol
While still in the hospital after giving birth, eligible
mothers completed a demographic questionnaire and a
validated survey about household food insecurity (HFI)
because of the high prevalence of HFI in the target popu-
lation and the known association between maternal
depression and HFI [31]. Subjects were offered small gifts
for completing the initial interview, the automated phone
screen for depression after delivery, and the 3-month fol-
low-up survey. Research assistants then taught subjects
how to call the IVR system from home in order to complete
the Edinburgh Postnatal Depression Scale (EPDS) [32].
The EPDS is a 10-item self-rating scale that has been
validated in Spanish and English and is widely recom-
mended as a first-stage screening instrument for postpartum
depression [33, 34]. Subjects were asked to call the IVR
system 7–10 days postpartum to complete the EPDS.
Consenting subjects were given a refrigerator magnet with
a toll free phone number for the IVR system, instructions
on calling, the dates during which they should make their
first call, their individual identification number to input
922 Matern Child Health J (2012) 16:921–928
123
when calling the IVR system, and a phone number to call
with questions about using the system.
Automated Phone Screen for Postpartum Depression
When participants called into the IVR system, they heard a
recorded voice introducing and then administering the IVR
version of the EPDS [30]. An automated voice recited each
of the 10 EPDS questions along with instructions to press
different numbers on the phone to respond. After com-
pleting the EPDS, the patient would remain on the phone
and then hear different follow-up narratives depending
on their EPDS score. Patients who scored in the ‘‘not
depressed range’’ (i.e. EPDS \ 10) were branched to a
closing message inviting to them to call the study team for
questions or information about postpartum depression.
Those scoring in the ‘‘depressed’’ range (EPDS C 10) were
told that their answers indicated that they may have
symptoms of depression. They were invited to participate
in a support group at HCMC and also encouraged to call
for information and assistance. Patients who responded
affirmatively to question 10 on the EPDS indicating
thoughts of self-harm also heard instructions for calling
911, a crisis hotline, or going to the nearest emergency
room. After completing the IVR phone session, a patient’s
IVR results were posted to a password protected website
that was monitored by our research staff. Patients who
responded affirmatively to the self-harm question were
called by the study psychiatrist.
Quantitative outcomes included percent and character-
istics of participants who called into the IVR system,
predictors of calling into the IVR system, rates of post-
partum depression based on the EPDS, and characteristics
of those with depressive symptoms.
Data Analysis
All data analyses were performed using SPSS version 16.0
(SPSS, Inc., Chicago IL). Dependent variables included IVR
participation and postpartum depression as determined by
two different cutoff scores on the EPDS (i.e. EPDS C 10 and
EPDS C 12). Using the Chi Square test, bivariate analyses
were used to determine unadjusted associations between
sociodemographic and mental health characteristics and the
dependent variables. Multivariate logistic regression analy-
sis was used to identify covariates. Variables from the
bivariate analyses with a p value \ 0.05, were evaluated for
significance using multiple iterations of the enter procedure
in addition to variables with theoretical importance to the
model based on the published literature. The variable of high
school diploma or GED was identified as a covariate for IVR
participation. African American race and Hispanic ethnicity
were identified as covariates for the EPDS C 10 group. Due
to small sample size, multivariate analyses were not per-
formed for the EPDS C 12 group.
Results
Among patients included in the final analysis (N-838), 96%
were on public insurance and 4% reported having no
insurance. The group was racially and ethnically diverse
with 26% African American, 51% Latina, 15% Caucasian,
and 8% other. Eighty-five percent of patients were over the
age of 20, 64% were married, 50% had a high school
diploma or GED, and 38% percent of participants were first
time mothers. The sample was predominately low-income
with 74% being unemployed, 22% living in food insecure
households, and 33% residing in a temporary living situa-
tion. When asked about their mental health history, 16%
reported a history of depression, 10% a history of anxiety
and 6% a history of self-harm.
Callers into the Automated Postpartum Depression
Phone Screen
Among the 838 study subjects, 324 (39%) called into the
automated postpartum depression screening system
(Table 1). Half of the callers (N = 162) called into the
Spanish-speaking phone line. In the unadjusted, bivariate
analysis (Table 1), compared to non-callers, those who
called were more likely to have at least a high school
education, be employed, and have food secure households.
After adjusting for maternal education in multivariate
analyses, employment and food insecurity were not sig-
nificant at the p \ 0.05 level. There was also no statisti-
cally significant difference between callers and non-callers
in terms of race/ethnicity, marital status, parity, and self-
reported history of depression, anxiety or self-harm.
Postpartum Depression Rates
Table 2 shows the rates of postpartum depression obtained
through the automated phone administration of the EPDS.
Table 3 shows the proportion of those with postpartum
depression symptoms as indicated by an EPDS C 10
adjusted and unadjusted for covariates. After adjusting for
African American race and Hispanic ethnicity, postpartum
depression symptoms were significantly associated with
being single, first time mother status, temporary living
situation, history of anxiety, and history of self-harm.
Follow-Up Survey
Among the 838 study subjects, only 61 people (7%)
completed the 3-month follow-up phone survey and 53 of
Matern Child Health J (2012) 16:921–928 923
123
Table 1 Description of sample
according to IVR participation
unadjusted and adjusted for
covariates (N = 838)
NA not applicable, CIconfidence intervala Adjusted for maternal high
school diploma/GED
* p \ 0.05
** p B 0.001
Unadjusted for covariates Adjusted for
covariatesa
Non IVR callers
(N = 514) %
IVR callers
(N = 324)
%
Odds ratio
(95% CI)
Odds ratio
(95% CI)
All 61.3 38.7
Maternal variables
Age
\20 16.5 13.0 1.32 (0.89, 1.97) 1.17 (0.78, 1.76)
C20 83.5 87.0 1.00 1.00
Race
African American 26.3 25.3 0.86 (0.55, 1.35) 0.87 (0.53, 1.33)
Hispanic or Latina 51.8 50.0 0.87 (0.58. 1.30) 1.06 (0.69, 1.6)
White or Caucasian 14.4 16.1 1.00 1.00
Other 7.8 8.3 0.90 (0.53, 1.76) 0.942 (0.51,
1.73)
US-born
Yes 46.2 51.6 1.23 (0.93, 1.62) 1.09 (0.81, 1.46)
No 53.8 48.4 1.00 1.00
Marital status
Married/dual headed 63.9 62.5 1.06 (0.79, 1.41) 1.04 (0.78, 1.39)
Single/separated 36.1 37.5 1.00 1.00
Education NA
No high school diploma or GED 54.6 42.4 1.00
High school diploma or GED 45.4 57.6 1.63 (1.23, 2.16)**
Insurance
No insurance 4.5 3.4 1.00 1.00
Public insurance 95.5 96.6 1.33 (0.64, 2.76) 1.31 (0.63, 2.74)
Employment
Yes 23.0 30.7 1.48 (1.08, 2.03)* 1.31 (0.95, 1.81)
No 77.0 69.3 1.00 1.00
First time mother
Yes 37.4 39.0 1.00 1.00
No 62.6 61.0 1.07 (0.81, 1.43) 1.07 (0.80, 1.43)
Psychosocial variables
Household food security
Food insecure 24.6 17.8 1.00 1.00
Food secure 75.4 82.2 1.50 (1.06, 2.13)* 1.39 (0.97, 1.98)
Temporary living situation
Yes 66.3 68.8 1.00 1.00
No 33.7 31.2 1.12 (0.83, 1.51) 1.10 (0.82, 1.50)
History of depression
Yes 16.1 14.9 1.03 (0.70, 1.53) 0.97 (0.66, 1.44)
No 83.9 85.1 1.00 1.00
History of anxiety
Yes 10.5 8.0 1.00 1.00
No 89.5 92.0 1.34 (0.82, 2.18) 1.33 (0.81, 2.18)
History of self harm
Yes 5.8 6.5 1.13 (0.64, 2.01) 1.13 (0.63, 2.01)
No 94.2 93.5 1.00 1.00
924 Matern Child Health J (2012) 16:921–928
123
61 said they had called the IVR system. We made three
attempts to contact subjects by phone and then mailed them
the survey. Many patients had disconnected phones or had
moved with no forwarding address. Feedback was very
positive among IVR participants. Most said that it was easy
to use and helpful. The following comments reflect the
majority of the feedback: ‘‘simple, straight to the point,’’
‘‘easy process for a new mom,’’ ‘‘appreciated follow-up
that didn’t involve going in for an appointment.’’ All
answered ‘‘no’’ to calling the research staff for additional
questions. Specific patient suggestions for the IVR system
included: having more parenting advice at the end of the
depression questionnaire, organizing a meeting with new
moms and those who had overcome postpartum depression,
and explaining that postpartum depression can still occur
after 3 months postpartum.
Discussion
In a large group of low income, high risk, ethnically
diverse new mothers, nearly 40% called into an automated
phone system for postpartum depression screening. This is
similar to the participation rate in another study of a like-
wise high risk postpartum population [3], however, with
some notable differences. In this previous study, 285 of
443 (64%) new mothers returned for their scheduled
postpartum visit and 121 out of this group of 285 (42%)
participated in the postpartum depression screen. Unfor-
tunately this means that 36% of eligible new mothers never
attended their postpartum visit to even learn about the
screening study. Requiring patients to attend clinic visits to
complete depression screens precludes participation by
many at-risk new mothers. The relatively high participation
rate in our IVR study suggests that we could supplement
clinic-based and home visit-based postpartum depression
screening protocols with an automated phone option that
would allow mothers to complete the screen regardless of
whether or not they can attend a clinic visit or be available
to receive a nurse home visitor.
In our study, educational status was the primary pre-
dictor of participating in the IVR screen. New mothers with
at least a high school education were 1.6 times more likely
to call into the IVR system than those who did not com-
plete high school. After adjusting for education, IVR
participation was not associated with race, ethnicity, age,
parity, or previous history of depression. This suggests that
IVR seems accessible to many low income mothers,
however, those with lower educational levels may need
additional assistance in accessing the IVR system or may
need to be screened directly in clinic or during a home
visit.
Although this current study demonstrates that an auto-
mated IVR system is a promising way of connecting with
high risk mothers, some of our findings raised important
limitations to this technology. For instance, the rates for
depressive symptoms in our study were lower than previ-
ous studies of postpartum depression in similarly at-risk
women [2, 35]. In an ethnically diverse, low income group,
Yonkers et al. used an EPDS cutoff of C12 and found a
prevalence of postpartum depression of 16% compared to
11% in our study. Since our study was mainly a feasibility
study of using IVR to screen for postpartum depression, we
did not validate the IVR version of the EPDS to see if
results obtained are comparable to those obtained through
the paper–pencil version of the EPDS. It is possible that the
IVR version of the EPDS is less sensitive than the paper
pencil version, or alternatively, that many depressed
women opted not to call into the system. Of note, we did
find similar predictors of postpartum depression as previ-
ous studies which suggests we are capturing a group of
depressed mothers, though clearly not the whole group. For
instance we found that single and first time mothers and
those in temporary housing were 2–2.4 times more likely to
screen at risk for postpartum depression. This is similar to
previous studies which have shown that socioeconomically
disadvantaged mothers were twice as likely to report
depressive symptoms (OR 2.7, 95% CI:1.64, 4.4) at
4 weeks postpartum compared to socioeconomically
advantaged women [36]. Future studies are needed to
confirm the validity of the IVR version of the EPDS before
instituting wide scale screening using this technology.
Another important finding from our study includes the
high rates of participation in depression screening coupled
with low rates of follow-up beyond screening. Among the
324 mothers who called into the IVR system, only one
called for more information. Everyone who participated in
the study was encouraged during the consenting process to
call staff for more information about depression or for
additional resources. In addition, anyone who called into
the IVR system was reminded to call our research staff for
information about resources while the women scoring in
the depressed range were also told they may have symp-
toms of postpartum depression and could call for assis-
tance. Some mothers may have followed up with their own
healthcare providers rather than call our staff. However,
despite our frequent prompts, few mothers contacted us for
additional assistance. This finding is consistent with other
Table 2 Proportion of women with elevated EPDS scores
EPDS scores (N = 324) %
C10 55 17.0
C12 36 11.1
Suicidal ideation 24 7.4
Matern Child Health J (2012) 16:921–928 925
123
Table 3 Description of postpartum depression sample among IVR callers, unadjusted and adjusted for covariates (n = 324)
Unadjusted for covariates Adjusted for covariatesa
EPDS \ 10
(n = 269) %
EPDS C 10
(n = 55) %
Odds ratio
(95% CI)
EPDS C 10 odds ratio
(95% CI)
All 83.0 17.0
Maternal variables
Age
C20 87.0 87.3 1.03 (0.43, 2.45) 1.13 (0.41, 3.12)
\20 13.0 12.7 1.00 1.00
Race
African American 24.2 30.9 2.05 (0.75, 5.59) –
Hispanic or Latina 49.8 50.9 1.64 (0.64, 4.20) –
White or Caucasian 17.5 10.9 1.00 –
Other 8.6 7.3 1.36 (0.35, 5.31) –
US-born
Yes 50.7 52.7 1.08 (0.61, 1.9) 1.32 (0.51, 3.38)
No 49.3 47.3 1.00 1.00
Marital status
Married/dual headed 65.8 47.3 1.00 1.00
Single/separated 34.2 52.7 2.15 (1.19, 3.86)* 2.41 (1.29, 4.50)*
Education
No high school diploma or GED 58.7 52.7 1.28 (0.71, 2.29) 1.26 (0.46. 1.30)
High school diploma or GED 41.3 47.3 1.00 1.00
Employment
Yes 29.0 38.2 1.00 1.00
No 71.0 61.8 1.51 (0.83, 2.77) 1.54 (0.82, 2.90)
First time mother
Yes 35.3 56.4 2.37 (1.31, 4.26)* 2.43 (1.34, 4.40)*
No 64.7 43.6 1.00 1.00
Psychosocial variables
Household food security
Low/very low 18.0 16.4 1.13 (0.52, 2.45) 1.18 (0.53, 2.60)
Mild/high 82.0 83.6 1.00 1.00
Temporary living situation
Yes 27.5 47.3 2.36 (1.31, 4.28)* 2.35 (1.30, 4.26)*
No 72.5 52.7 1.00 1.00
History of depression
Yes 13.8 21.8 4.37 (2.22, 8.59)** 1.77 (0.84, 3.72)
No 86.2 78.2 1.00 1.00
History of anxiety
Yes 6.3 16.4 2.90 (1.22, 6.90)* 2.79 (1.69, 6.67)*
No 93.7 83.6 1.00 1.00
History of self harm
Yes 5.2 12.7 2.64 (1.01, 6.87)* 2.66 (1.01, 6.99)*
No 94.8 87.3 1.00 1.00
Percents not adding up to 100 are due to rounding
NA not applicable, CI confidence intervala Adjusted for African American race and Hispanic ethnicity
* p \ 0.05
** p B 0.001
926 Matern Child Health J (2012) 16:921–928
123
studies that have shown that depression screening does not
necessarily improve patient outcomes [3, 37]. Furthermore,
pregnant and postpartum patients may accept depression
screening, however, often fail to follow-up for treatment.
For instance, in a randomized trial of cognitive therapy,
among 400 pregnant women, 93% agreed to be screened
for depression, while only 15 of 49 who screened positive
(EPDS [ 12) agreed to be contacted, and only 7 of 15
attended a follow-up interview [38]. Another study found
among pregnant and postpartum women diagnosed with
depression, 38% attended at least one mental health visit
while only 6% remained in treatment during the 6 month
follow-up period [39]. Future studies are needed to
understand how to help depressed mothers engage in
treatment and to explore alternatives to current treatment
models.
IVR or Other Health IT Solutions for Low Income
Patients
From this study we conclude that automated phone
screening for postpartum depression has great promise for
disadvantaged mothers. By removing the need for a clinic
visit, accommodating low literacy patients, and offering
flexibility and privacy, an IVR option for postpartum
depression screening could supplement office-based and
home visit-based screening protocols. One positive aspect
of our IVR system was that it assessed patients’ current
depression symptoms, gave immediate interpretation and
feedback to patients of the results, and suggested a follow-
up call. The high rates of calling into the system coupled
with the low rates of follow-up calls at 3 months’ post-
partum suggest that we could add more information to the
initial phone call rather than count on patients to make a
second call or come to a follow-up visit. We could also
have incorporated a voicemail capability into the IVR
system where patients could leave a message with a phone
number to be called back at their convenience.
Interactive health IT can empower patients with infor-
mation to make informed decisions about their health.
While IVR and other health IT applications are no sub-
stitute for a caring personal relationship with a health care
provider, they can provide another avenue for connecting
patients with information and resources until they are able
and willing to have a face-to-face meeting with a health-
care professional.
Important questions remain regarding the use of IVR in
disadvantaged pregnant and postpartum women. Our find-
ings suggest that an IVR screening system may miss the
most depressed or vulnerable patients, however, low
income mothers with low to moderate depressive symp-
toms and with at least a high school education may benefit
from the availability of an IVR system. It remains to be
seen whether this same technology can facilitate ongoing
monitoring of depressive symptoms and assist in helping
patients engage in treatment interventions. Patients’ per-
ception of benefit, convenience and usability will all con-
tribute to adoption of new ways of accessing health care. In
addition, adoption of IVR-based screening raises questions
of reimbursement for clinics or hospitals that implement an
IVR postpartum depression screening system.
Acknowledgments This research was supported by a grant from the
Minnesota Medical Research Foundation and the Department of
Psychiatry, Hennepin County Medical Center. The authors wish to
thank Dr. Michael K. Popkin for his ongoing support of the Hennepin
Women’s Mental Health Program, and the participants and staff who
contributed to the project.
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