A Simplified Predictive Index for the Detection of Women at Risk for Postnatal Depression

Background: Many women who suffer from postnatal depression are never diagnosed or treated. The objective of this study was to develop an index for use in maternity settings that identifies women who may be at risk for postnatal depression. Methods: Women (n = 1762) attending the ‘‘booking‐in’’ clinic were screened for antenatal risk factors for postnatal depression. On the third postnatal day eligible women were screened for postnatal risk factors. The Edinburgh Postnatal Depression Scale was mailed to participants16 weeks after the birth. A predictive index was developed, based on the mean Edinburgh Postnatal Depression Scale scores for each risk factor. The sensitivity, specificity, positive predictive value, and negative predictive value were used to assess the diagnostic value of the index. Results: Seven hundred and twenty‐three (50.1%) of the eligible women completed all phases of the study. Of this group, 93 (12.2%) women scored higher than 12 on the Edinburgh Postnatal Depression Scale. At a cutoff of 6, the index had positive predictive value of 39.8 percent for postnatal depression, a threefold improvement over the base rate. Conclusion: The Brisbane Postnatal Depression Index provides a clinically useful method for identifying women at risk for developing postnatal depression. It has applications for early intervention or to identify high‐risk groups for research purposes. (BIRTH 30:2 June 2003)     

Improving antenatal recognition of women at risk for postnatal depression

The purpose of this study was to assess the effectiveness of a practical antenatal screen used at the Royal Women's Hospital, Brisbane, to identify women at risk for postnatal depression. It was a prospective, hospital-based, cohort study of 901 women (600 with and 301 without prenatal risk factors for postnatal depression). Depression was measured 16 weeks after the birth using the Edinburgh Postnatal Depression Scale. More of the women with a prenatal risk factor for depression (25.9%) scored above 12 on the Edinburgh Postnatal Depression Scale than those without any risk (10.9%) (p < or = 0.001). Low social support (p < or = 0.001), a personal history of mood disorder (p < or = 0.001) and a past history of postnatal depression ( p = 0.002) were all strongly associated with postnatal depression in this sample. Results indicate that an objective, psychosocial assessment during pregnancy improves recognition of women at risk for postnatal depression.     

IDentify, Educate and Alert (IDEA) trial: an intervention to reduce postnatal depression

Objective To test the effectiveness of a prenatal intervention in reducing the incidence of postnatal depression.
Design A randomized controlled trial.
Setting A large metropolitan obstetric hospital.
Population or sample Pregnant women with risk factors for postnatal depression.
Methods Women attending their first prenatal visit at the Royal Women's Hospital, Brisbane, were screened for risk factors for postnatal depression ( ID entify). Positively screened women were randomly allocated to the intervention group or the control group. The intervention consisted of a booklet about postnatal depression, which included contact numbers; prenatal screening using the Edinburgh Postnatal Depression Scale; a discussion with the woman about her risk of developing postnatal depression ( E ducate); and a letter to the woman's referring general practitioner and local Child Health Nurse, alerting them of the woman's risk for postnatal depression ( A lert).
Main outcome measure Edinburgh Postnatal Depression Scale Score> 12 at 16 weeks postpartum.
Results Of the 509 women who were sent a follow up questionnaire, 371 (72.9%) responded. The proportion of women who reported an Edinburgh Postnatal Depression Scale score of>12 was 26%. There were no significant differences between intervention (46/192, 24%) and control groups (50/177, 28.2%) on this primary outcome measure (OR 0.80; 95% CI 0.50–1.28).
Conclusion Over one-quarter of women with risk factors will develop postnatal depression. It is a treatable disorder but under-diagnosis is common. Efforts to reduce postnatal depression by implementing interventions in the prenatal period have been unsuccessful.     

Predicting Postnatal Depression Among Pregnant Women

ABSTRACT: Background : Depression after the birth of a baby is a common cause of maternal morbidity, and its prevalence in Australia is 10 to 15 percent at 6 to 9 months postpartum. This study assesses the prediction of postnatal depression at 6 weeks postpartum, Method : Women at 24 weeks' gestation or less were invited to complete a Modified Antenatal Screening Questionnaire (MASQ) that identified women more vulnerable to becoming depressed after childbirth. Of these 249 women, 144 (58%) screened more vulnerable, and were randomly allocated to receive either a supportive intervention to reduce postnatal depression or to receive no intervention. At 6 weeks postpartum the women completed the Edinburgh Postnatal Depression Scale (EPDS) to assess their mood after the birth. Results : No difference occurred at 6 weeks postpartum between the MASQ vulneruble group (return rate 64/68) and the MASQ less vulnerable group (return rate 44/51) in the frequency of those who screened as potential candidates for major depression using the EPDS. For major depression the MASQ's sensitivity was 73 percent, specificity 43 percent, positive predictive value 17 percent, and negative predictive value 91 percent; for minor depression its sensitivity was 81, 48, 34, and 89 percent, respectively. The MASQ was able to predict minor depression. More women in the vulnerable group scored at increased risk of minor depression on the EPDS at 6 weeks postpartum. Conclusion : Further studies are needed to extend this work and develop a screening test with higher specificity and greater positive predictive value.     

Postnatal Quality of Life Assessment: Introducing the Mother‐Generated Index

Background: The extent of postnatal morbidity has become increasingly apparent over the last 15 years, but currently no tool is available that measures postnatal quality of life. This pilot study introduces a subjective tool, the Mother‐Generated Index, which assesses the woman's quality of life and identifies those aspects that are of most concern to her. Methods: The Mother‐Generated Index was administered by structured interview to 60 participants at 6 to 8 weeks and to 43 participants at 8 months postpartum. Validation was sought through concurrent use of the Edinburgh Postnatal Depression Scale, the SF12, and two indexes related to maternal and neonatal physical morbidity. The Mother‐Generated Index gives a primary index (quality of life) score, which is reported here, and a secondary index, which identifies the areas considered most important by the mother. Results: The primary index was more sensitive at 8 months. The highest and lowest quartile scores were compared. Statistically significant differences in were found in the mothers' Edinburgh Postnatal Depression scores at 6 to 8 weeks, and in their Edinburgh Postnatal Depression and SF12 mental component scores and their physical morbidity index at 8 months. Although physical problems were only a small feature at 8 months, social and psychological issues were prominent in both groups. Age, parity, and mode of delivery had no significant effect on the women's scores or the areas they identified as most important. Conclusion: Quality of life of is a complex and personal area, affected by many different aspects of health and well‐being. From this pilot study the primary index appears to be a useful step in assessing a mother's quality of life. It identifies which areas of her life are most important to her, and allows her to indicate where she would like to see improvements. (BIRTH 29:1 March 2002)     

Diagnosing postpartum depression: can we do better?

OBJECTIVE: The purpose of this study was to evaluate the efficacy of the Edinburgh Postnatal Depression Scale versus routine clinical evaluation to detect postpartum depression among a low-income inner-city population and to evaluate risk factors associated with a positive score on the Edinburgh Postnatal Depression Scale. STUDY DESIGN: On the basis of the day of the month, all English-speaking patients who were seen for their postpartum visit were assigned either to routine clinical evaluation for postpartum depression or routine clinical evaluation plus the use of the 10-question Edinburgh Postnatal Depression Scale. RESULTS: During the 7-week study period, 72 women participated in the study: 35 women in the routine evaluation group and 37 women in the Edinburgh Postnatal Depression Scale group. Women who completed the Edinburgh Postnatal Depression Scale were significantly more likely than those in the routine evaluation group to be identified as being at risk for depression: 11 of 37 women (30%) versus 0 of 35 women (P <.001). A failed attempt at breast-feeding was associated with an increased risk of a score of > or =10 on the Edinburgh Postnatal Depression Scale (relative risk, 3.78; 95% CI, 1.03-13.89). CONCLUSION: The Edinburgh Postnatal Depression Scale appears to be a valuable and efficient tool for the identification of patients who are at risk for postpartum depression.     

Impact of Postnatal Depression on Breastfeeding Duration

Abstract: Background: Postnatal depression can cause adverse effects on both mother and infant, but its impact on breastfeeding duration is poorly understood. The aim of this study was to investigate the relationship between maternal postnatal depression and breastfeeding duration. Methods: A cohort of 1745 women was recruited on the postnatal wards of two large Australian obstetric hospitals. Self‐report questionnaires were completed at recruitment, and at 2, 6, and 12 months postpartum. Breastfeeding status was determined at each follow‐up, and the Edinburgh Postnatal Depression Scale was used to screen for symptoms of depression. Diagnostic psychological interviews were conducted on a subsample of women at each interval. Results: Breastfeeding was initiated by 96 percent of the participants; at 2 months 79 percent were still breastfeeding, 57 percent at 6 months, and 22 percent at 12 months. Of the 18 percent of participants diagnosed with postnatal depression, the onset occurred before 2 months in 63 percent of cases. Median duration of breastfeeding was 26 weeks for women with early‐onset depression, 28 weeks for women with late‐onset depression, and 39 weeks for women without depression. After adjustment for confounding factors, early cessation of breastfeeding was found to be significantly associated with postnatal depression (adjusted hazard ratio 1.25, 95% CI 1.03–1.52). Onset of postnatal depression occurred before cessation of breastfeeding in most cases. Conclusions: Postnatal depression has a significant negative impact on breastfeeding duration. Assistance with breastfeeding issues should be included in the management of postnatal depression. (BIRTH 30:3 September 2003)     

The psychometric properties of the Icelandic version of the Edinburgh Postnatal Depression Scale (EPDS) when used prenatal

ObjectiveTo evaluate the psychometric properties of the Icelandic version of the Edinburgh Postnatal Depression Scale (EPDS) when used prenatal, explore the dimensionality of the scale and describe its effectiveness in identifying depression.DesignA sample of Icelandic women filled in the EPDS at week 16 gestation, week 24 and week 36. If screened positive in week 16 they were asked to attend a psychiatric diagnostic interview 2–4 weeks later. Every 10th woman screened negative was also asked to attend an interview.SettingAntenatal clinics at primary health care centres in Iceland.ParticipantsIn total, 2512 women receiving prenatal care participated in the study. At week 16 gestation, 2397 women filled in the Edinburgh Postnatal Depression Scale, 2025 at week 25, and 1756 at week 36. 474 women attended diagnostic interview two to four weeks after screening.Measurements and findingsInternal reliability, convergent validity and test-retest correlation of the Icelandic version of the Edinburgh Postnatal Depression Scale appeared acceptable. An exploratory factor analysis supported a one-factor structure of the Edinburgh Postnatal Depression Scale that was confirmed by confirmatory factor analysis showing best fit for one general factor with two group factors. A cut-off score of 11 or higher had specificity of 0.89, sensitivity of 0.80 and positive predictive value of 0.44.Key conclusions and implications for practiceThe Icelandic version of the Edinburgh Postnatal Depression Scale is a valid and reliable one-dimensional instrument suitable to screen for depression prenatally. We recommend using score 11 or higher as a cut-off. If women score 11, they should be re-assessed two weeks later, but if they score 12 or higher, they should be referred directly for a further assessment. A time gap of two to four weeks does weaken the scale's ability to discriminate between those suffering from Major Depression and those who screen negative.     

Prevalence of antenatal depression in women enrolled in an outreach program in Canada

OBJECTIVE: To determine the prevalence of depression and its correlates in pregnancy and to establish the appropriateness of using the Edinburgh Postnatal Depression Scale with inner-city, high-risk pregnant women. DESIGN: Convenience sample of women enrolled in a prenatal outreach program. Women were recruited and the Edinburgh Postnatal Depression Scale was administered during home visits. PARTICIPANTS: 39 women, most of whom were Aboriginal, participating in a prenatal outreach program. MAIN OUTCOME MEASURE: Edinburgh Postnatal Depression Scale score of >or=10 suggests minor depressive symptoms and >or=13 suggests probable major depression. RESULTS: 27% of women reported symptoms consistent with major depression. The Aboriginal women had higher levels of depressive symptoms than the non-Aboriginal women. Women who had stopped using tobacco or alcohol during pregnancy had more depressive symptoms than those who had quit before pregnancy. Acceptability of the Edinburgh Postnatal Depression Scale for use with high-risk, Aboriginal, and non-Aboriginal pregnant women was supported. CONCLUSIONS: The prevalence of depressive symptoms and concurrent substance use within this population is a major public health problem. Nurses can incorporate the Edinburgh Postnatal Depression Scale into routine prenatal visits to identify women at risk for depression.     

Postnatal depression and sexual health after childbirth

OBJECTIVE: To investigate the sexual health experiences of depressed and nondepressed postnatal women within a 6-month postnatal period. METHODS: This cross-sectional study used obstetric records and postal survey 6 months after delivery from a cohort of primiparous women (n = 796) delivering a live-born infant at St. George's NHS Trust, London. Women self-reported sexual problems and sexual behaviors and completed the Edinburgh Postnatal Depression Scale. RESULTS: Of the 796 parturients, 484 responded (61%), and 468 completed the survey questions on depression and sexual health (97%). Of the latter, 57 (12%) fit the Edinburgh Postnatal Depression Scale criteria. Comparing the depressed with nondepressed women, resumption of sexual activity occurred with 77% versus 90% (P =.003), and the median number of specific sexual problems reported was two versus one, respectively (P =.009). CONCLUSION: Sexual health problems were common after childbirth in both depressed and nondepressed women; however, depressed women were less likely to have resumed intercourse at 6 months and more likely to report sexual health problems. Given the frequency of sexual health problems, postnatal sexual morbidity cannot be assumed to be simply a product of the depressed mental state.     

Health, sociodemographic data, and pregnancy outcome in women with antepartum depressive symptoms

OBJECTIVE: To study whether women with antepartum depression have an increased risk for adverse perinatal outcome. METHODS: From a sample of 1,489 women, an index group (n = 259) of all women with depressive symptoms on the Edinburgh Postnatal Depression Scale in gestational week 35-36 was selected. Two hundred fifty-nine women with no depressive symptoms on the Edinburgh Postnatal Depression Scale antepartum or postpartum were randomly chosen as the reference group. Medical, gynecologic, and obstetric history, socioeconomic status, pregnancy, and perinatal data were collected from standardized medical records for all women. RESULTS: Women with antepartum depressive symptoms were more often multiparas with a history of earlier obstetric complications. Complications during the present pregnancy were more frequent in the antepartum-depressed group of women. There were no differences concerning outcome of delivery, puerperium, and neonatal health between the index and reference groups. Forty-six percent of the women with antepartum depressive symptoms had depressive symptoms at 6-8 weeks or 6 months postpartum or both. CONCLUSION: Women depressed during pregnancy constitute a group without an increased risk for adverse obstetric or neonatal outcome but with a high risk for postpartum depressive symptoms.     

A stress-coping transactional model of low mood following childbirth

The present study was designed to assess whether or not a transactional model of stress could predict low mood following childbirth in a sample of primiparous women. The research used a two-wave longitudinal design--data were collected during the last trimester of pregnancy (n = 306) and at approximately 6 weeks postpartum (n = 223). Depression vulnerability, social support, appraisal and coping style were assessed at Time 1, and concurrent levels of social support, stress and appraisal were assessed at Time 2. The proposed model was generally upheld: High Edinburgh Postnatal Depression scores were predicted by women's predisposition to depression, negative appraisals of an anticipated childcare stressor, perceptions of low antenatal support and a high use of avoidance coping. In addition, a high number of daily hassles reported since the beginning of pregnancy, stressful childcare events, perceptions of low postnatal social support and negative postnatal appraisals contributed to the onset of low postnatal mood. This model extends the utility of the diathesis-stress account of Postnatal Depression (PND) and has important implications for how PND is treated.     

Are Pregnant and Postpartum Women Moodier? Understanding Perinatal Mood Instability

ObjectiveTo better understand mood changes in pregnancy and postpartum, we studied mood instability in a group of perinatal women and in a group of normally menstruating non-pregnant women.MethodsPerinatal women (n = 45) completed the Edinburgh Postnatal Depression Scale at 16 weeks’ and 30 weeks’ gestation and again at four weeks postpartum. Immediately after completing the Edinburgh Postnatal Depression Scale, participants also completed mood diaries with separate visual analogue scales for depressed, irritable, anxious, and euphoric/activated moods. This was done twice daily for one week. A comparison group of 31 non-perinatal women without depression or premenstrual symptoms completed identical mood diaries for seven consecutive weeks. Mood instability was represented by the mean square successive difference statistic.ResultsPerinatal women showed higher mean levels of depressed, irritable, anxious, and high mood instability than the non-perinatal women. The findings held when pregnant women who were depressed were removed from the comparison, except that the difference in depressed mood instability was no longer significant.ConclusionsWider fluctuation in mood in pregnant and postnatal women is consistent with the common belief that perinatal women are moodier than non-perinatal women.     

The clinical utility of maternal self-reported personal and familial psychiatric history in identifying women at risk for postpartum depression

BACKGROUND: To determine whether maternal self-reported data on personal and family psychiatric history would significantly predict postpartum depressive symptomatology at 8 weeks postpartum and to examine which of these variables were the most predictive for inclusion in an obstetrical clinical assessment aimed at early identification of postpartum depression. METHODS: As part of a longitudinal study, a population-based sample of 622 women completed mailed questionnaires at 1 and 8 weeks postpartum. RESULTS: At 8 weeks postpartum, mothers who indicated that they had any personal psychiatric history were almost four times more likely to exhibit depressive symptomatology (Edinburgh Postnatal Depression Scale score > 9) than those with no previous mental health difficulties (odds ratio [OR] 3.65, 95% CI 2.30-5.82). Any family psychiatric history was not a significant risk factor. Variables most predictive of depressive symptomatology at 8 weeks, explaining 42% of the variance, included: maternal antenatal depression (OR 3.77, p=0.03), maternal history of postpartum depression (OR 2.21, p=0.02), and Edinburgh Postnatal Depression Scale score >9 at 1 week postpartum (OR 18.23, p<0.001). CONCLUSIONS: The results suggest that maternal variables, particularly those related to the index and past pregnancies, not family psychiatric history, are the best predictors of postpartum depressive symptoms. These findings highlight the importance of assessing symptoms of depression and anxiety during pregnancy and the early postpartum period, in order to facilitate timely identification of women at risk for developing postpartum depression.     

Evaluation of Antenatal and Postnatal Support to Overcome Postnatal Depression: A Randomized,Controlled Trial

ABSTRACT: This randomized, controlled trial tested the hypothesis that women identified as more vulnerable to developing postnatal depression who attended two specific antenatal groups and one postnatal group have a reduced frequency of postnatal depression from 37 to 15 percent at 6 weeks, 12 weeks, and 6 months postpartum. A modified antenatal screening questionnaire was completed, and women identified as more vulnerable to postnatal depression were stratified by parity and randomly allocated to receive extra support groups or to a control group. The Edinburgh Postnatal Depression Scale (EPDS) was used to detect postnatal depression. Attendance at the support groups was low, 31 percent overall. At six weeks, in the intervention group, 8 (13%) of 64 women scored high (>12) on the EPDS, compared with 11 (17%) controls. Similarly, at 12 weeks 7 (11%) of 63 versus 10 (15%) of 65 women scored higher than 12, and at 6 months, 9 (15%) of 60 versus 6 (10%) of 64 women scored higher than 12, indicating that the intervention did not reduce postnatal depression. It is possible that the method of applying the intervention, using groups separate from the standard antenatal classes, may have affected attendance. More research is required into ways of reaching and supporting women who may become depressed.     

Postnatal depression or perinatal dysphoria? Findings from a longitudinal community-based study using the Edinburgh Postnatal Depression Scale

Abstract

Postnatal depression is a label which will quickly be applied to any unhappywoman who has recently had a baby. However, both of these terms: postnatal and depression, place constraints on the ways that we think about and research this phenomenon that may not, in fact, be helpful. The term postnatal, for example, implies that we are considering a phenomenon that develops after the birth. As a result the majority of studies have only recruited subjects postnatally, and have therefore reinforced this assumption by failing to observe that some women were already unhappy before delivery. However, studies have shown that rates of depression in pregnancy are at least as high as those typically reported afterwards. Depression is a concept that forces us into dichotomies, whereas women who are not clinically depressed span a continuum from the euphoric to the very miserable. Pre- and postnatal scores on the Edinburgh Postnatal Depression Scale (EPDS) are presented from 1272 women. These show, firstly, that valuable data is wasted by dichotomizing on the basis of EPDS scores and, secondly, that the EPDS, while not a direct measure of depression, has face validity as a continuous measure of emotional well-being both antenatally and postnatally.     

Prevalence of depressive symptoms in late pregnancy and postpartum

BACKGROUND: Postnatal depression refers to a non-psychotic depressive episode that begins in or extends into the postpartum period. The aims of this study were to examine the prevalence of depressive symptoms in a pregnant and later postnatal population, to determine the natural course of these symptoms and whether there is an association between antenatal and postnatal depressive symptomatology. METHODS: A longitudinal study with a total population of 1,558 consecutively registered pregnant women in the southeast region of Sweden. Presence of depressive symptoms was measured with the Edinburgh Postnatal Depression Scale on four occasions namely in gestational week 35-36, in the maternity ward, 6-8 weeks and 6 months postpartum. RESULTS: The prevalence of depressive symptoms during late pregnancy was 17%; in the maternity ward 18%; 6-8 weeks postnatally 13%; and 6 months postnatally, 13%. A correlation between antenatal and postnatal depressive symptoms was found (r=0.50, p<0.0001). CONCLUSION: Detection of women at risk for developing postnatal depressive symptoms can be done during late pregnancy. Antenatal care clinics constitute a natural and useful environment for recognition of women with depressive symptoms.     

Intergenerational transmission of postpartum depression

Objective: This study aimed to explore the hypothesis of an intergenerational transmission of postpartum depression. Mother’s postpartum depressive symptomatology was linked to former depression, postpartum depression of her mother as well as the quality of the mother–daughter relationship. Method: A sample of 65 women and their mothers completed questionnaires one month after delivery: the Edinburgh Postnatal Depression Scale (EPDS), dimension A of the International Mini Neuropsychiatric Interview (MINI) assessing a former depressive episode, the Mother and Adult Daughter Questionnaire (MAD) as well as the Inventory of Peer and Relative Attachment (IPPA). Their mothers completed the Bromley Postnatal Depression Scale (BPDS) in order to retrospectively diagnose a postpartum depression. Results: Women whose mother had suffered from a postnatal depression had significantly higher scores on the EPDS. Former depression symptoms and grandmother’s former postnatal depression were significant predictors of postpartum depression symptoms intensity. Conclusion: this study confirms the hypothesis of an intergenerational transmission of postpartum depression and highlights the need to provide an in‐depth examination of these issues.     

Postnatal Depression: Its Nature,Effects, and Identification Using the Edinburgh Postnatal Depression Scale

ABSTRACT: Postnatal depression, or clinical depression in mothers during the months after childbirth, occurs at a time when heavy demands are placed on these women's resources, and when infant learning and development are taking place. Identification and treatment are facilitated when health professionals and services are in close contact with the family and can provide beneficial intervention. Two studies examined whether women with nonpsychotic postnatal depression could be recognized and treated within existing services, using the Edinburgh Postnatal Depression Scale and a randomized, controlled trial of counseling intervention with health visitors.     

The factor structure of the Chinese version of the Edinburgh Postnatal Depression Scale (EPDS)

The psychometric properties of the Chinese version of the Edinburgh Postnatal Depression Scale (EPDS) were evaluated at the six‐week postnatal period. A shorter version, the EPDS‐6, was found to offer an optimal fit to our data and provides a sound psychometric basis for the development of an abbreviated version of the tool which may offer enhanced screening and predictive utility.