Mayo Clinic Proceedings Home

Depressive Symptoms and Access to Mental Health Care in Women Screened for Postpartum Depression Who Lose Health Insurance Coverage After Delivery: Findings From the Translating Research Into Practice for Postpartum Depression (TRIPPD) Effectiveness Study



      To determine the impact of losing health insurance coverage on perceived need for and access to mental health care in women screened for postpartum depression (PPD) in primary care settings.

      Patients and Methods

      The study sample included 2343 women enrolled in a 12-month, multisite, randomized trial that compared clinical outcomes of a comprehensive PPD screening and management program with usual care (March 1, 2006, through August 31, 2010). Screening for PPD occurred at the first postpartum visit (5-12 weeks) using the Edinburgh Postnatal Depression Scale followed by the 9-item Patient Health Questionnaire. Insurance status during the prenatal period, at delivery, and during the first postpartum year and perceived need for and access to mental health care during the first postpartum year were assessed via questionnaires completed by individual patients and participating practices.


      Rates of uninsured increased from 3.8% during pregnancy and delivery (n=87 of 2317) to 10.8% at the first postpartum visit (n=253 of 2343) and 13.7% at any subsequent visit to the practice after 2 months post partum (n=226 of 1646) (P<.001, both comparisons vs baseline). For patients with data on insurance type during follow-up, insurance loss occurred primarily in Medicaid beneficiaries. Nine-item Patient Health Questionnaire scores and self-reported need for mental health care did not differ significantly between patients who remained insured and those who lost insurance during the first postpartum year. However, of patients who reported the need for mental health care, 61.1% of the uninsured (n=66 of 108) vs 27.1% of the insured (n=49 of 181) reported an inability to obtain mental health care (P<.001).


      Loss of insurance during the first postpartum year did not significantly affect depressive symptoms or perceived need for mental health care but did adversely affect self-reported ability to obtain mental health care.

      Abbreviations and Acronyms:

      EPDS (Edinburgh Postnatal Depression Scale), IOM (Institute of Medicine), OR (odds ratio), PHQ-9 (9-item Patient Health Questionnaire), PPD (postpartum depression), TRIPPD (Translating Research Into Practice for Postpartum Depression study), TRIPPD-UP (Translating Research Into Practice for Postpartum Depression for Underinsured/Uninsured Patients)
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Mayo Clinic Proceedings
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Cohen L.S.
        • Wang B.
        • Nonacs R.
        • Viguera A.C.
        • Lemon E.L.
        • Freeman M.P.
        Treatment of mood disorders during pregnancy and postpartum.
        Psychiatr Clin North Am. 2010; 33: 273-293
        • O'Hara M.W.
        • Swain A.M.
        Rates and risk of postpartum depression: a meta-analysis.
        Int Rev Psychiatry. 1996; 8: 37-53
        • Kingston D.
        • Tough S.
        • Whitfield H.
        Prenatal and postpartum maternal psychological distress and infant development: a systematic review.
        Child Psychiatry Hum Dev. 2012; 43: 683-714
        • Murray L.
        • Cooper P.
        Effects of postnatal depression on infant development.
        Arch Dis Child. 1997; 77: 99-101
        • Civic D.
        • Holt V.L.
        Maternal depressive symptoms and child behavior problems in a nationally representative normal birthweight sample.
        Matern Child Health J. 2000; 4: 215-221
        • Grace S.L.
        • Evindar A.
        • Stewart D.E.
        The effect of postpartum depression on child cognitive development and behavior: a review and critical analysis of the literature.
        Arch Womens Ment Health. 2003; 6: 263-274
        • Yawn B.P.
        • Olson A.L.
        • Bertram S.
        • Pace W.
        • Wollan P.
        • Dietrich A.J.
        Postpartum depression: screening, diagnosis, and management programs 2000 through 2010.
        Depress Res Treat. 2012; 2012: 363964
        • Sockol L.E.
        • Epperson C.N.
        • Barber J.P.
        A meta-analysis of treatments for perinatal depression.
        Clin Psychol Rev. 2011; 31: 839-849
        • Craig M.
        • Howard L.
        Postnatal depression.
        Clin Evid (Online). 2009; 2009
        • Noonan K.
        • Carroll A.
        • Reichman N.E.
        • Corman H.
        Mental illness as a risk factor for uninsurance among mothers of infants.
        Matern Child Health J. 2010; 14: 36-46
        • Dietz P.M.
        • Williams S.B.
        • Callaghan W.M.
        • Bachman D.J.
        • Whitlock E.P.
        • Hornbrook M.C.
        Clinically identified maternal depression before, during, and after pregnancies ending in live births.
        Am J Psychiatry. 2007; 164: 1515-1520
        • Gavin N.I.
        • Gaynes B.N.
        • Lohr K.N.
        • Meltzer-Brody S.
        • Gartlehner G.
        • Swinson T.
        Perinatal depression: a systematic review of prevalence and incidence.
        Obstet Gynecol. 2005; 106: 1071-1083
        • Baicker K.
        • Taubman S.L.
        • Allen H.L.
        • et al.
        The Oregon experiment: effects of Medicaid on clinical outcomes.
        N Engl J Med. 2013; 368: 1713-1722
        • Machnicki G.
        • Dillon C.
        • Allegri R.F.
        Insurance status and demographic and clinical factors associated with pharmacologic treatment of depression: associations in a cohort in Buenos Aires.
        Value Health. 2011; 14: S13-S15
        • Tian D.
        • Qu Z.
        • Wang X.
        • et al.
        The role of basic health insurance on depression: an epidemiological cohort study of a randomized community sample in northwest China.
        BMC Psychiatry. 2012; 12: 151
        • Lo Sasso A.T.
        • Lindrooth R.C.
        • Lurie I.Z.
        • Lyons J.S.
        Expanded mental health benefits and outpatient depression treatment intensity.
        Med Care. 2006; 44: 366-372
        • Yawn B.P.
        • Dietrich A.J.
        • Wollan P.
        • et al.
        TRIPPD: a practice-based network effectiveness study of postpartum depression screening and management.
        Ann Fam Med. 2012; 10: 320-329
        • Cox J.L.
        • Holden J.M.
        • Sagovsky R.
        Detection of postnatal depression: development of the 10-item Edinburgh Postnatal Depression Scale.
        Br J Psychiatry. 1987; 150: 782-786
        • Kroenke K.
        • Spitzer R.L.
        • Williams J.B.
        The PHQ-9: validity of a brief depression severity measure.
        J Gen Intern Med. 2001; 16: 606-613
        • Yawn B.P.
        • Pace W.
        • Wollan P.C.
        • et al.
        Concordance of Edinburgh Postnatal Depression Scale (EPDS) and Patient Health Questionnaire (PHQ-9) to assess increased risk of depression among postpartum women.
        J Am Board Fam Med. 2009; 22: 483-491
        • Finkelstein A.
        • Taubman S.
        • Wright B.
        • et al.
        The Oregon Health Insurance Experiment: evidence from the first year.
        Q J Econ. 2012; 127: 1057-1106
        • Institute of Medicine
        Depression in Parents, Parenting, and Children.
        National Academies Press, Washington, DC2009
        • Cooper P.J.
        • Campbell E.A.
        • Day A.
        • Kennerley H.
        • Bond A.
        Non-psychotic psychiatric disorder after childbirth: a prospective study of prevalence, incidence, course and nature.
        Br J Psychiatry. 1988; 152: 799-806
        • Nylen K.J.
        • O'Hara M.W.
        • Brock R.
        • Moel J.
        • Gorman L.
        • Stuart S.
        Predictors of the longitudinal course of postpartum depression following interpersonal psychotherapy.
        J Consult Clin Psychol. 2010; 78: 757-763
        • Harman J.S.
        • Hall A.G.
        • Zhang J.
        Changes in health care use and costs after a break in Medicaid coverage among persons with depression.
        Psychiatr Serv. 2007; 58: 49-54
        • Simon G.E.
        • VonKorff M.
        • Barlow W.
        Health care costs of primary care patients with recognized depression.
        Arch Gen Psychiatry. 1995; 52: 850-856
        • Dagher R.K.
        • McGovern P.M.
        • Dowd B.E.
        • Gjerdingen D.K.
        Postpartum depression and health services expenditures among employed women.
        J Occup Environ Med. 2012; 54: 210-215
        • Fisher J.
        • Wynter K.
        • Hammarberg K.
        • et al.
        Age, mode of conception, health service use and pregnancy health: a prospective cohort study of Australian women.
        BMC Pregnancy Childbirth. 2013; 13: 88
        • Simon G.E.
        • Fleck M.
        • Lucas R.
        • Bushnell D.M.
        Prevalence and predictors of depression treatment in an international primary care study.
        Am J Psychiatry. 2004; 161: 1626-1634
        • Myers E.R.
        • Aubuchon-Endsley N.
        • Bastian L.A.
        • et al.
        Efficacy and Safety of Screening for Postpartum Depression: Comparative Effectiveness Review 106.
        Agency for Healthcare Research and Quality, Rockville, MD2013 (AHRQ Publication No. 13-EHC064-EF)
        • Cuijpers P.
        • Brannmark J.G.
        • van Straten S.A.
        Psychological treatment of postpartum depression: a meta-analysis.
        J Clin Psychol. 2008; 64: 103-118
        • Harris K.M.
        • Carpenter C.
        • Bao Y.
        The effects of state parity laws on the use of mental health care.
        Med Care. 2006; 44: 499-505
        • Friedman S.H.
        • Resnick P.J.
        Postpartum depression: an update.
        Womens Health (Lond Engl). 2009; 5: 287-295
        • Sobey W.S.
        Barriers to postpartum depression prevention and treatment: a policy analysis.
        J Midwifery Womens Health. 2002; 47: 331-336
        • Eisenberg J.M.
        • Power E.J.
        Transforming insurance coverage into quality health care: voltage drops from potential to delivered quality.
        JAMA. 2000; 284: 2100-2107