Perinatal Identification, Referral, and Integrated Management for Improving Depression: Development, Feasibility and Pilot Randomised Controlled Trial of the PIRIMID System.

Background/Objectives: Postnatal depression imposes a substantial burden on wellbeing as well as costs estimated to exceed $7 billion for every one-year cohort of births in Australia. Despite this, most cases go untreated, a major barrier being the poor rate of treatment uptake. We developed and pilot tested an integrated screening and clinical decision support system (PIRIMID) to assist maternal and child health nurses (MCHNs) to create individualised management plans, with specific referral pathways, for women depressed postnatally. We assessed the feasibility of PIRIMID by examining acceptability for both nurses and women, ease of implementation, and referral rates, and we monitored treatment uptake and depression. Methods: An extensive co-design and consultation process was used to develop PIRIMID. A pilot cluster randomised controlled trial (RCT) was conducted comparing PIRIMID to Routine care, with partial crossover (PIRIMID followed by crossover to Routine care and Routine care followed by continued Routine care). A state-wide survey of MCHNs in Victoria, Australia, explored perceived benefits and barriers of PIRIMID from a consumer perspective. Results: Twelve MCHNs (PIRIMID: n = 6; Routine care: n = 6) and 229 women (conditions: PIRIMID, n = 52; Crossover Routine care, n = 42; Routine care, n = 57; Continued Routine care, n = 78) were recruited to the RCT. Median scores for depression, anxiety and stress symptoms were low and similar at all timepoints and conditions. PIRIMID was acceptable and helpful to MCHNs and women, and most MCHNs rated integration into their existing clinical systems as easy. There were trends in favour of higher referral rates by PIRIMID MCHNs (18%, 95% CI: 5-40) compared with other conditions (10-15%, 95% CIs: 6-29, 2-27, 6-26), but treatment uptake appeared similar across conditions. The statewide survey (n = 292) revealed that 84% of MCHNs would use PIRIMID, and the main potential barriers to use would be time constraints and technical issues. Conclusions: This pilot work indicates that PIRIMID shows promise as a feasible and acceptable tool to assist MCHNs to develop management plans for women depressed postnatally. Further research with adequate statistical power is needed to explore effects on treatment uptake with larger samples of postnatally depressed women.