A systematic review of studies validating the Edinburgh Postnatal Depression Scale in antepartum and postpartum women

Objective: The Edinburgh Postnatal Depression Scale (EPDS) is the most widely used screening tool for postpartum depression (PPD). We systematically reviewed the published evidence on its validity in detecting PPD and antepartum depression (APD) up to July 2008. Method: Systematic review of validation studies of the EPDS included 1987–2008. Cut‐off points of 9/10 for possible PPD, 12/13 for probable PPD and 14/15 for APD were used. Results: Thirty‐seven studies met the inclusion criteria. Sensitivity and specificity of cut‐off points showed marked heterogeneity between different studies. Sensitivity results ranged from 34 to 100% and specificity from 44 to 100%. Positive likelihood ratios ranged from 1.61 to 78. Conclusion: Heterogeneity among study findings may be due to differences in study methodology, language and diagnostic interview/criteria used. Therefore, the results of different studies may not be directly comparable and the EPDS may not be an equally valid screening tool across all settings and contexts.     

Validation of the Thai Edinburgh Postnatal Depression Scale for screening postpartum depression

This study aimed to validate and determine an appropriate cut-off score on the Thai Edinburgh Postnatal Depression Scale (EPDS) as a screen for postpartum depression. A prospective cohort of postpartum women at 6-8 weeks were tested using the EPDS and clinically interviewed by psychiatrists to establish a DSM-IV diagnosis of major or minor depressions in a university hospital in Southern Thailand. Of 351 postpartum women interviewed, 38 postpartum women met the criteria for depressive disorders, major depression in four women (1%) and minor depressive disorder in 34 women (10%). The area under the curve was 0.84 (95% confidence interval 0.76-0.91). Using an EPDS cut-off sum score of 6/7, major and/or minor depression was detected with a sensitivity of 74%, specificity of 74%, positive predictive value of 26% and negative predictive value of 95%. When the cut-off score was higher, the sensitivity was lower but the specificity was higher. The Thai version of the EPDS is a valid self-report instrument and is useful in Thailand where no other screening instrument for postpartum depression is available.     

Validation of the Turkish version of the Edinburgh Postnatal Depression Scale among women within their first postpartum year

BACKGROUND: The aim of the study was to find out the validity and reliability of the Turkish version of the Edinburgh Postnatal Depression Scale (EPDS) and to determine the optimum cut-off value for postnatal depression. METHOD: Validation of the Turkish version of the EPDS was conducted on a sample of 341 women who were within their first postpartum year. Structured Diagnostic Interview for DSM-IV Axis I Disorders was used as the gold standard test, and receiver operating characteristic analysis was used to evaluate test performance of the EPDS. RESULTS: The study of sensitivity, specificity and predictive values versus SCID-I indicated a cut-off score of 12.5 as the best (sensitivity: 75.5, specificity: 71.5). Positive predictive value was 30.3% and negative predictive value was 94.5%. Cronbach's alpha value was calculated as 0.72. CONCLUSIONS: It was concluded that: (1) values for the validity were respectable, but not excellent; (2) the scale needs to be improved for use in the Turkish population; and (3) the high prevalence of postnatal depression found in this study may be a function of the low validity of the test.     

The validity of the Arabic Edinburgh Postnatal Depression Scale

For the purpose of this study, a consecutive sample of 95 postpartum women were assessed at 1 week postpartum with the (EPDS) and at 8±2 weeks postpartum using the Present State Examination (PSE). A moderate correlation between PSE total score and EPDS score was found (r=0.57). A moderate agreement between EPDS and Catego diagnosis of depression was also found (Kappa=0.52). Using a cut-off score of 12 on EPDS and Catego diagnosis as a criterion variable, the sensitivity and specificity of the scale were 73% and 90%, respectively. However, using a cut-off score of 10, the sensitivity of the scalerose to 91% without much fall in its specificity (84). The internal reliability of the scale was 0.84 ( Cronbach). We conclude that the Arabic version of the EPDS is a reliable and valid screening tool for depression in postpartum women.     

Detecting women at risk for postnatal depression using the Edinburgh Postnatal Depression Scale at 2 to 3 days postpartum.

OBJECTIVE: This study evaluates the capacity of the Edinburgh Postnatal Depression Scale (EPDS) implemented in the first days postpartum to detect women who will suffer from postnatal depression. METHOD: A sample of 1154 women completed the EPDS at 2 to 3 days postpartum and again at 4 to 6 weeks postpartum. RESULTS: There was a highly significant positive correlation between EPDS scores on both occasions (Spearman rank correlation: r = 0.59, P < 0.0001). The cut-off scores of 10 and 11 for EPDS administered at 2 to 3 days obtained good specificity, sensitivity, and positive predictive values for the cut off scores proposed for the diagnosis of postnatal depression at 4 to 6 weeks postpartum. CONCLUSION: The EPDS completed at 2 to 3 days postpartum is a useful means of detecting women at risk of postnatal depression.     

The performance of the Edinburgh Postnatal Depression Scale in English speaking and non-English speaking populations in Australia

Background The Edinburgh Postnatal Depression Scale (EPDS) has been widely used to assess maternal depression following childbirth in a range of English speaking countries, and increasingly also in translation in non-English speaking ones. It has performed satisfactorily in most validation studies, has proved easy to administer, is acceptable to women, and rates of depression in the range of 10–20% have been consistently found. Methods The performance of the EPDS was compared across different population samples in Australia: (i) Women born in Australia or in another English speaking country who completed the EPDS in English as part of the 1994 postal Survey of Recent Mothers (SRM) 6–7 months after birth (n = 1166); (ii) Women born in non-English speaking countries who also completed the EPDS in English in the same survey (n = 142); and (iii) Women born in Vietnam (n = 103), Turkey (n = 104) and the Philippines (n = 106) who completed the EPDS 6–9 months after birth in translation in the Mothers in a New Country Study (MINC) study (total n = 313). The pattern of item responses on the EPDS was assessed in various ways across the samples and internal reliability co-efficients were calculated. Exploratory factor analyses were also conducted to assess the similarity in the factor solutions across the samples. Results The EPDS had good construct validity and item endorsement by women was similar across the samples. Internal reliability of the scale was also very satisfactory with Cronbach’s alpha for each sample being ≥8. Between 39 and 46% of the variance in each of the three main samples was accounted for by one principal factor ‘depression’ (6–7 items loading), with two supplementary factors ‘loss of enjoyment’ (2 items loading) and ‘despair/self-harm’ (2–3 items loading) accounting for a further 20–25% of the variance. Alternative one and two factor solutions also showed a great deal of consistency between the samples. Conclusions The good item consistency of the EPDS and the relative stability of the factor patterns across the samples are indicative that the scale is understood and completed in similar ways by women in these different English speaking and non-English speaking population groups. With the proviso that careful translation processes and extensive piloting of translations are always needed, these findings lend further support to the use of the EPDS in cross-cultural research on depression following childbirth.     

Validity of the Hospital Anxiety and Depression Scale and Patient Health Questionnaire-9 to screen for depression in patients with coronary artery disease

OBJECTIVE: Depression is common but frequently undetected in patients with coronary artery disease (CAD). Self-report screening instruments for assessing depression such as the Hospital Anxiety and Depression Scale (HADS) and the Patient Health Questionnaire-9 (PHQ-9) are available but their validity is typically determined in depressed patients without comorbid somatic illness. We investigated the validity of these instruments relative to a referent diagnostic standard in recently hospitalized patients with CAD. METHOD: Three months post-discharge for a cardiac admission, 193 CAD patients completed the HADS and PHQ-9. The Mini International Neuropsychiatric Interview (MINI) was the criterion standard. Scale reliability was calculated using Cronbach's alpha. Convergent validity was computed using Pearson's intercorrelations. Sensitivity and specificity for various cut-off scores for both measures and for the PHQ-9 categorical algorithm were calculated using receiver operating characteristics (ROC). For analyses, participants were assigned to two groups, 'major depressive disorder' or 'any depressive disorder'. RESULTS: For all calculations, alpha was 0.05 and tests were two-tailed. Internal consistencies for the two measures were excellent. Criterion validity for the PHQ-9 and HADS was good. We found no statistical differences between the PHQ-9 and HADS for detecting either group; however, the categorical algorithm of the PHQ-9 for diagnosing major depression had a superior LR+ when compared with the summed HADS or PHQ-9. The operating characteristics of the screening instruments for 'any depressive disorder' were slightly lower than for 'major depressive disorder'. Some optimum cut-off scores were lower than the generally recommended cut-off scores, particularly when screening for major depression (e.g., > or = 5/6 vs. > or = 10 and > or = 8 for PHQ-9 and HADS, respectively). Lowering the cut off scores substantially improved the sensitivity of these instruments while retaining specificity, thereby improving their usefulness to screen for CAD patients with depression. CONCLUSIONS: Both instruments have acceptable properties for detecting depression in recently hospitalized cardiac patients, and neither scale is statistically superior when summed scores are used. The categorical algorithm of the PHQ-9 for diagnosing major depression has a superior LR+ compared to the summed PHQ-9 and HADS scores. Use of the generally recommended cut-off scores should be cautious. In light of the aversive outcomes associated with depression in CAD, screening for depression is a clinical priority.     

Review of validation studies of the Edinburgh Postnatal Depression Scale.

OBJECTIVE: To review validation studies of the Edinburgh Postnatal Depression Scale (EPDS). METHOD: A systematic search was performed in Medline and the Science Citation Index Expanded (ISI) from the period 1987-2000. For sensitivity and specificity of the EPDS presented in each study, 95% confidence intervals were estimated. Positive and negative predictive values were estimated assuming prevalences of postpartum depression ranging from 5% to 20%. RESULTS: Eighteen validation studies were identified. The study design varied between studies. The sensitivity and specificity estimates also varied: 65-100% and 49-100%, respectively. The confidence intervals were estimated to be wide. Our estimates suggest a lower positive predictive value in a normal population than in the validation study samples. CONCLUSION: Most studies show a high sensitivity of the EPDS. Because of the differences in study design and large confidence intervals, uncertainty remains regarding the comparability between the sensitivity and specificity estimates of the different EPDS versions.     

Affective (depressive) morbidity in puerperal Nigerian women: validation of the Edinburgh Postnatal Depression Scale

OBJECTIVE: To determine the rate of depression in a group of postpartum Nigerian women and to validate the Edinburgh Postnatal Depression Scale (EPDS) in this group. METHOD: Between April and August 2000, all postpartum women who remained in the maternity ward for up to 7 days, and those who attended the postnatal clinics of Nnamdi Azikiwe University Teaching Hospital were recruited. Translated local language versions of the EPDS and the Zung Self-Rating Depression Scale were used to screen the subjects. A structured interview schedule was adapted from the depression section of the Composite International Diagnostic Interview and affective module of the ICD-10 Symptom Check List to assess screened subjects. RESULTS: The total rejection rate was 23%, with 225 women participating in the study. Twenty-four subjects (10.7%) had depression. At the optimal cut-off score of 9, the EPDS had a sensitivity of 0.75, and specificity of 0.97. CONCLUSION: The EPDS clearly distinguished between depressed and non-depressed postpartum mothers (t = 7.63, P < 0.001, df = 222). Because of its brevity and acceptability, it is recommended that the EPDS be used in routine postnatal screening.     

Screening postpartum depression with the Taiwanese version of the Edinburgh Postnatal Depression scale

This study is intended to develop the Taiwanese version of the Edinburgh Postnatal Depression Scale (EPDS-T), to evaluate its validity, and to estimate the prevalence of postpartum depressive disorders (PPD) among Taiwanese women. A prospective cohort of 203 subjects who completed the EPDS-T, the Beck Depression Inventory (BDI-II), and postpartum questionnaire at 6 weeks after giving birth were assessed with the Mini-International Neuropsychiatric Interview (MINI) and DSM-IV to establish their psychiatric diagnoses. We tested the validity of EPDS-T against the clinical diagnoses and compared its applicability with BDI-II. We found that the Taiwanese version of EPDS-T had satisfactory sensitivity and better specificity than BDI-II, that the 12/13 cutoff point was the best for screening PPD, and that 10.3% of the study population suffered from depressive disorders at 6 weeks postpartum. Based on the findings of this study, we suggest that PPD prevalence among Taiwanese women is not lower than that among most Western populations and that the validated EPDS-T can be used for early detection and management of postpartum depression in Taiwan.     

Clinical utility of Patient Health Questionnaire-9 (PHQ-9) in memory clinics

Background. Both dementia and depression may produce complaints of memory impairment. Differential diagnosis may be difficult, but has practical implications regarding choice of appropriate treatment. Aim. To assess the clinical utility of the Patient Health Questionnaire-9 (PHQ-9), a validated instrument for measurement of depression severity, in differentiating patients with and without dementia, referred with complaints of memory impairment to dedicated memory clinics. Methods. Pragmatic prospective study of consecutive referrals (n=113) to two dementia clinics, diagnosed using standard clinical diagnostic criteria for dementia (DSM-IV) and also administered the PHQ-9. Results. PHQ-9 proved acceptable to patients, and was quick and easy to use. Using traditional parameters of diagnostic utility (sensitivity, specificity, positive predictive value, likelihood ratios), PHQ-9 performance was modest for the diagnosis of dementia. However, pragmatically PHQ-9 scores proved helpful in deciding which patients, both with and without dementia, required a trial of antidepressant medication. Conclusions. PHQ-9 proved useful as a brief screen for depression in patients attending dementia clinics with a complaint of memory impairment.     

A study of the Edinburgh Postnatal Depression Scale (EPDS) on 859 mothers: detection of mothers at risk for postpartum depression

The postpartum is a high-risk period for the occurrence of anxious and depressive episodes. Indeed, during the first few days after delivery, mothers can present postpartum blues symptomatology: fatigue, anxiety, disordered sleeping and a changing mood. Postpartum depression is characterised by a changing mood, anxiety, irritability, depression, panic and obsessional phenomena. It occurs in approximately 10 to 20% mothers. The exact prevalence depending on the criteria used for detection. The first symptoms usually appear between the fourth and sixth week postpartum. However, postpartum depression can start from the moment of birth, or may result from depression evolving continuously since pregnancy. We can add that the intensity of postpartum blues is a risk factor that can perturb maternal development. So it is important for health professionals to dispose of predictive tools. This study is a validation of the French version of the EPDS. The aims of the study were to evaluate the postpartum depression predictive value at 3 days postpartum and to determine a cut-off score for major depression. Subjects participating in this study were met in 3 obstetrical clinics in, or in the vicinity of, Toulouse. Mothers with psychological problems, under treatment for psychological problems or mothers whose babies present serious health problems were excluded from the study. The EPDS was presented to 859 mothers (mean age=30.3; SD=4.5) met at one of the clinics at 3 days postpartum (period 1). They had an EPDS mean score of 6.4 (SD=4.6); 258 (30%) mothers had an EPDS score 9. 82.6% of these mothers experienced a natural childbirth and 17.3% a caesarean section; 51.5% gave birth to their first child, 36.2% to their second child and 12.3% to their third or more. All subjects were given a second EPDS with written instructions to complete the scale during the period 4 to 6 weeks postpartum and return it for analysis (period 2). Between the 4 to 6 weeks postpartum period, 722 mothers replied again to the EPDS. 131 mothers had an EPDS score 11 (mean age=30.3; SD=4.8). They had an EPDS mean score of 13.6 (SD=3.3). Mothers with probable depression were interviewed and assessed, using the Mini (Mini Neuropsychiatric Interview, Lecrubier et al. 1997), the SIGH-D (Structured Interview Guide for the Hamilton Depression Scale) and the BDI (Beck Depression Inventory) in order to diagnose a major depressive episode. They had a HDRS mean score of 13.7 (SD=5.1) and a BDI mean score of 13.6 (SD=5). At 3 days postpartum, we observed that 258 mothers (30%) had an EPDS scores 9 and 164 mothers (19%) had an EPDS scores 11. Between 4 and 6 weeks postpartum, we observed 18.1% of postpartum depression (EPDS 11) and 16.8% (EPDS 12) of major postpartum depression. The analysis of the sensitivity and the specificity at 3 days postpartum provides a cut-off score of 9 (Sensibility: 0.88) (Specificity: 0.50) as predictive of postpartum depression, for this cut-off score, the type I error is low (5.8%) but the type II error is more higher (18.9%). The analysis of the sensitivity and the specificity between 4 and 6 weeks postpartum provides a cut-off score of 12 (Sensibility: 0.91) (Sensibility: 0.74) for the detection of major postpartum depression. Factor analysis shows at 3 days postpartum that the internal structure of the scale is composed of two subscales. The first factor F1 "anxiety" accounts 28% of the variance and the second factor F2 "depression" accounts 20% of the variance. Between 4 and 6 weeks postpartum, factor analysis suggests an unidimensional model in the evaluation of postpartum depression which is better than a two factor model. This factor accounts 40% of the variance. The scale has a good predictive value, and we can observe a significant correlation with the EPDS periods 1 and 2 (r=0.56; p<0.05). This result shows that the depressive mothers mood intensity predicts a future depressive risk. Furthermore, correlations between EPDS and BDI (r=0.68; p<0.05) and EPDS and HDRS (r=0.67; p<0.05) show a good convergent validity. The reliability study confirms the good internal consistency of the EPDS, at 3 days postpartum and in the postpartum depression -symptomatology evaluation (Cronbach's Alpha>0.80). In conclusion, this scale demonstrates good validity and is fast and easy use in obstetrical services, allowing early detection of women who risk to develop postpartum depression and, in the first week of postpartum, of mothers who suffer from a major postpartum depression. The use of the EPDS for an early screening of the risk of postnatal depression which is essential considering the consequences that postnatal depression can have on the development of the infant, on the quality of the relationship within the couple and on other social relationships. Mothers at risk for postnatal depression should be controlled and surveyed by the health professionals in obstetrical clinics.     

Validation of the Patient Health Questionnaire-9 for depression screening among Chinese Americans

OBJECTIVE: The objective of this study was to validate the Chinese Bilingual version of the Patient Health Questionnaire (CB-PHQ-9) for screening for depression among Chinese Americans in primary care. METHOD: Chinese-American patients attending a primary care clinic were screened for major depressive disorder (MDD) using the CB-PHQ-9. All patients who scored 15 or higher on the CB-PHQ-9 were interviewed using the Chinese-bilingual Structured Clinical Interview for the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, patient version. Eight percent of patients who scored less than 15 on the CB-PHQ-9 were randomly selected and interviewed with the depression module of the Chinese-bilingual Structured Clinical Interview for the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, patient version. RESULTS: During the study, 1940 unduplicated patients completed the CB-PHQ-9. The CB-PHQ-9 had high internal consistency (alpha = 0.91), and the scores of each of its 9 items had moderate to moderately high correlations (0.52-0.85) with the total scores. The sensitivity and specificity of the CB-PHQ-9 for recognizing MDD were found to be 81% and 98%, respectively, and the area under the receiver operating characteristic curve was estimated to be 0.97 (SE, 0.01). CONCLUSION: The CB-PHQ-9 is a valid and useful instrument for screening for MDD among Chinese Americans in primary care.     

Comparative Efficacy of the Generalized Anxiety Disorder 7-Item Scale and the Edinburgh Postnatal Depression Scale as Screening Tools for Generalized Anxiety Disorder in Pregnancy and the Postpartum Period

Objective:

About 24.1% of pregnant women suffer from at least 1 anxiety disorder, 8.5% of whom suffer specifically from generalized anxiety disorder (GAD). GAD is often associated with major depressive disorder (MDD). During the perinatal period, the presence of physical and somatic symptoms often makes differentiation between depression and anxiety more challenging. To date, no screening tools have been developed to detect GAD in the perinatal population. We investigated the psychometric properties of the GAD 7-item Scale (GAD-7) as a screening tool for GAD in pregnant and postpartum women.

Methods:

Two hundred and forty perinatal women (n = 155 pregnant and n = 85 postpartum) referred for psychiatric consultation were enrolled. On the day of initial assessment, all women completed the GAD-7 and the Edinburgh Postnatal Depression Scale (EPDS). Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition–based diagnoses were made by experienced psychiatrists. Scores from the GAD-7 and EPDS were compared with the clinical diagnoses to evaluate the psychometric properties of the GAD-7 and EPDS when used as a screening tool for GAD.

Results:

The GAD-7 yielded a sensitivity of 61.3% and specificity of 72.7% at an optimal cut-off score of 13. Compared with the EPDS and the EPDS-3A subscale, the GAD-7 displayed greater accuracy and specificity over a greater range of cut-off scores and more accurately identified GAD in patients with comorbid MDD.

Conclusion:

Our findings suggest that the GAD-7 represents a clinically useful scale for the detection of GAD in perinatal women.     

Validation of the Edinburgh Postnatal Depression Scale against both DSM-5 and ICD-10 diagnostic criteria for depression

Background

The Edinburgh Postnatal Depression Scale (EPDS) is widely used in many countries to screen women for depression in the perinatal period. However, across studies the psychometric properties and cutoff scores of the EPDS have varied considerably; potentially due to different depression criteria and diagnostic systems being used. Therefore, we validated the Danish EPDS against a depression diagnosis according to both DSM-5 and ICD-10. Furthermore, we examined whether the Danish EPDS is multidimensional, as it has previously been suggested.

Methods

Women (N?=?324) were recruited after routine screenings with the EPDS between 2 and 10?months postpartum (T1). At a subsequent home visit (T2), the EPDS and the Structured Clinical Interview for DSM-5 were administered. Diagnostic interviews were audio recorded to enable subsequent coding for ICD-10 diagnoses and inter-rater reliability analysis. A two-phase stratified sampling strategy with three sampling categories (EPDS-score at T1) was used. Using the distribution of 4931?T1 EPDS-scores from the same population from which we sampled the participants, we used sampling weighing to reweight the sample. The calculation of weights was based upon the mother’s sampling category at T1 (i.e. the probability of being sampled) and the weights were applied when assessing the receiver operation characteristics (ROCs) of the EPDS. Sensitivity, specificity, positive predictive value, negative predictive value and area under the ROC curve were computed from the reweighted data for all relevant cutoff values. CIs were computed by embedding the calculations in a weighted logistic regression. Exploratory factor analysis was done using oblique rotation. Parallel analysis was used to assess the number of factors.

Results

A score of 11 or more was found to be the optimal cutoff for depression according to both DSM-5 and ICD-10 criteria. Factor analysis suggested that the Danish EPDS consists of three factors, including an ‘anxiety factor’.

Conclusions

The Danish EPDS has reasonable sensitivity and specificity at a cutoff score of 11 or more. There are no notable differences with respect to using ICD-10 or DSM-5 criteria for depression in terms of optimal cutoff. The variation in cutoff scores is likely to be due to cultural variations in the expression of depressive symptoms.

     

The Patient Health Questionnaire-9 for measuring depressive symptoms among the general population in Hong Kong

ObjectivesThe Patient Health Questionnaire-9 (PHQ-9) assesses depressive symptoms by self-report, is brief, and was developed to correspond to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, criteria for major depression. This article presents information regarding its reliability and validity and the distribution of scores in a Chinese community sample in Hong Kong.MethodsA total of 6028 participants 15 years or older were recruited using random household sampling. They completed the Chinese version of the PHQ-9, the Happiness Scale, the Chinese Health Questionnaire, and the Short-Form 12-Item Health Survey (SF-12). Information was also gathered on health and health service use.ResultsExploratory factor analysis and confirmatory factor analysis supported a single factor with strong loadings for all 9 items. Multiple-group analyses demonstrated that the structure can be generalized across sex and age groups (ie, adolescents, adults, and individuals 65 years or older). The internal consistency of the PHQ-9 was 0.82. The test-retest reliability over a 2-week interval was 0.76. As expected, the total score of the PHQ-9 was significantly associated with the Chinese Health Questionnaire (r = 0.49) and the Happiness Scale (r = ?0.41). In addition, as expected, the relationship with the physical component subscale of the SF-12 was significantly weaker (r = ?0.27) than for the mental component subscale of the SF-12 (r = ?0.60). Participants with higher scores on the PHQ-9 were more likely to report having been diagnosed with depression by a physician, having chronic illness, using medicine, and using inpatient and outpatient health services. Almost 40% of participants did not report any depressive symptoms (score, 0). Self-reported symptoms at a level that would qualify for a diagnosis of major depressive disorder were provided by 1.7% of the participants.ConclusionsOur data support the reliability and validity of the PHQ-9 in assessing depressive symptoms among the general population in Hong Kong. Its validity against diagnostic interview for major depressive disorder and its sensitivity and specificity should be determined in future studies.