Review of screening instruments for postpartum depression

Summary This paper presents a review and discussion of eight self-report measures used to assess for depressive symptoms in the postpartum period. Because postpartum depression is a significant mental health problem, there is a need for reliable and valid screening instruments. Published psychometric data (e.g., reliability, sensitivity, specificity, positive predictive value, concurrent validity) of each self-report instrument are presented and critiqued. Results suggest that the Edinburgh Postnatal Depression Scale is the most extensively studied measure with postpartum women with moderate psychometric soundness. This review illustrates the need for more research in this area. Issues involved in the selection of measures are considered. Implications for clinical practice, research, culture and language are discussed.     

Measurement issues in postpartum depression part 1: Anxiety as a feature of postpartum depression

Summary We investigated the contribution of anxiety symptoms to scores on the Edinburgh Postnatal Depression Scale (EPDS) between 36 weeks gestation and 16 weeks postpartum in 150 women. The 3-item anxiety subscale of the EPDS accounted for 47% of the total score in late pregnancy, and 38% of the total score in the postpartum period. Two categories of anxiety were common in the perinatal period: subsyndromal, situational anxiety (in particular during the last weeks of pregnancy); and clinically significant comorbid anxiety, which was experienced by nearly 50% of clinically depressed pregnant and postpartum women. The close relationship between anxiety and depression raises questions about whether symptoms of anxiety might be more common in the perinatal period than in other depressions. A strong role for anxiety symptoms in postpartum depression, and implications for its etiology and treatment, are discussed. Received June 26, 2002; accepted November 12, 2002 Published online January 17, 2003 Acknowledgements The authors wish to thank the women and their families who participated in this research. This work was funded in part by the Natural Sciences and Engineering Research Council of Canada, the Canadian Institutes of Health Research, the Women's College Hospital Foundation, the Ontario Women's Health Council, and the North American Society for Psychosocial Obstetrics and Gynecology. Dr. L.E. Ross is now Research Fellow, Department of Psychiatry and Behavioural Neuroscience, McMaster University, Hamilton, Ontario; and Research Scientist, Women's Mental Health and Addiction Research Section, Centre for Addiction and Mental Health, Toronto, Ontario. Correspondence: Lori E. Ross, Ph.D., Women's Health Concerns Clinic, St. Joseph's Healthcare, Fontbonne Building, 6^th Floor, 50 Charlton Ave. E., Hamilton, Ontario, Canada L8N 4A6. e-mail: l.ross@utoronto.ca     

Temperament and character in women with postpartum depression

Summary Objective: To investigate whether women with postpartum depression differ in personality traits from healthy postpartum women, healthy controls from the normal Swedish population and non-postpartum women with major depression. Methods: Forty-five women with postpartum depression were compared with 62 healthy postpartum women, 62 age-matched, healthy, non-postpartum women from a normal sample and 74 non-postpartum women with major depression from a clinical sample. The edinburgh postnatal depression scale was used in order to screen for postpartum depression. A clinical diagnostic interview was done including a rating with the Montgomery-Asberg depression rating scale. Personality i.e. temperament and character was measured by the temperament and character inventory. Results: Harm avoidance (HA) was higher (p < 0.001) and self-directedness (SD) scored lower (p < 0.001) in women with postpartum depression compared to healthy postpartum women. These differences were the most important differences between these two groups. Women with postpartum depression scored lower (p = 0.001) in cooperativeness (CO) and higher (p = 0.019) in self-transcendence (ST) compared to healthy postpartum women. Women with postpartum depression scored overall similar to women with major depression. Conclusion: High HA and low SD can be seen as vulnerability factors for developing a depression and especially in a stressful situation as childbirth.     

Prevalence and psychosocial correlates of depressed mood during pregnancy and after childbirth in a Moroccan sample

Summary The objective of the current study was to determine the prevalence of depression among 100 women followed from the first trimester of pregnancy to 9 months after delivery. Mini International Neuropsychiatric Interview, Edinburgh Postnatal Depression Scale and Paykel Life Events Inventory were used. Seventeen per cent of the subjects experienced depression during postpartum, 19.2% started their episode during pregnancy. Psychosocial variables were positively correlated to depression during pregnancy.     

Tricyclics vs SSRIs for postpartum depression

Summary Background: We investigated whether differential responsivity to tricyclics (TCA) compared to serotonin specific reuptake inhibitors (SSRI) occurred in our clinical population of women with postpartum depression. Method: Sequential records (N = 35) of women with non-psychotic, non-bipolar, postpartum-onset major depression were reviewed to determine drug response. Response was defined as 50% reduction in the initial depression score by week 8 of treatment. Results: The response rate was 67% for TCA was 79% for SSRI. The five nonresponders to TCA were treated with an SSRI, and four (80%) were effectively treated. Discussion: This naturalistic data obtained from our clinic supports that SSRI are superior to TCA for the treatment of postpartum major depression. The difference in percent response (12%) is similar to that of other studies in which TCA were compared to SSRI for treatment depression in women.     

Morning light therapy for postpartum depression

Summary Postpartum depression (PPD) is a frequent complication of childbirth, but many women refuse pharmacological treatment. Little data exists on bright light therapy for PPD. Fifteen outpatient women with PPD were randomly assigned to bright light (10,000 lux, n = 10) or dim red light (600 lux, n = 5) and completed a 6-week trial and weekly assessments using self-report depression scales and clinician ratings of symptom course. Both groups showed significant improvement over time on all measures, with no significant difference between conditions.     

Prevalence of generalized anxiety at eight weeks postpartum

Summary Objective: This study investigated the prevalence and nature of generalized anxiety symptoms in women who were eight weeks postpartum. Method: A community-based sample of 68 postpartum women completed an interview assessing generalized anxiety disorder and depression and a self-report measure of worry associated with concerns relevant to postpartum women. Results: Three women (4.4%) met DSM-IV criteria for generalized anxiety disorder, and an additional 19 women (27.9%) endorsed subsyndromal difficulties with generalized anxiety. Approximately one third of these women endorsed symptoms of depression. In contrast, only two woman met criteria for major depressive disorder. Conclusion: Postpartum generalized anxiety has a higher prevalence than postpartum depression. Received February 26, 2002; accepted November 11, 2002 Published online January 31, 2003 Acknowledgement This work was supported by a New Faculty Scholar Award and a Graduate Research Fellowship from the University of North Dakota. The authors would like to express their appreciation to Jennifer Brendle, Peter Schmutzer, Talia Tweten, and Chad Lystad for their assistance with this research. Correspondence: Amy Wenzel, Ph.D., Department of Psychology, University of North Dakota, Grand Forks, ND 58202-8380, U.S.A.; e-mail: amy_wenzel@und.nodak.edu     

A history of personal violence and postpartum depression: is there a link?

Summary Background: A link between violence and depression has been shown, but not a link between violence and postpartum depression. This study sought to determine if there is an association between a history of abuse (physical, sexual, emotional as a child or adult) and postpartum depression (PPD). Method: 200 postpartum women were recruited from 6 hospitals. At 8–10 weeks postpartum, a telephone interviewer asked women about physical, emotional or sexual abuse as an adult or child and sociodemographic, obstetrical and personal medical history. PPD was assessed using the Edinburgh Postnatal Depression Scale (EPDS, score of ≥12). Abuse was determined by the Conflict Tactics Scale or the Abuse Assessment Screen. Chi-square and logistic regression were used to determine the relationship between violence and PPD. Results: 11% of women had EPDS scores of ≥12. Rates of childhood (6.5%), or adult (6.5%) physical abuse; and childhood (13%) or adult (14%) sexual abuse were reported by respondents. Emotional abuse in the current relationship (29.6%) exceeded that of childhood abuse (3.5%). Overall 43.2% of respondents had at least one form of abuse. Having a history of depression (OR = 3.3 (95% CI, 1.3–8.7)), panic attack during pregnancy (OR = 5.4 (1.6–19.0)), maternal complications (OR = 5.0 (1.7–15.1)), low social support (OR = 3.3 (1.3–8.7)) and emotional abuse (OR = 2.8 (1.1–7.4) were associated with PPD. Conclusion: Emotional abuse but not physical or sexual abuse was found to be associated with PPD. A possible explanation for this relationship may be that being in an abusive situation puts one at risk for depression and in turn, postpartum depression.     

Prenatal calcium supplementation and postpartum depression: an ancillary study to a randomized trial of calcium for prevention of preeclampsia

Summary Nulliparous women, between 11 and 21 weeks gestation, were randomized to receive either placebo or 2,000 mg elemental calcium per day as subjects in the NIH-sponsored Calcium for Preeclampsia Prevention (CPEP) trial. Six weeks following delivery, a demographic and medical history questionnaire, and the Edinburgh Postnatal Depression Scale (EPDS), was mailed to subjects in two CPEP sites, Portland, OR and Albuquerque, NM. Subjects in the Portland site were reassessed at 12 weeks following birth. There were no statistically significant differences between treatment and placebo groups with respect to maternal demographics, history of prior depressive illness, impact of life stressors, utilization of breast-feeding, nor infant characteristics. Utilizing a standardized definition of depression (EPDS ≥ 14), chi square analysis of 293 women at 6 weeks postpartum indicated a trend (p = 0.07) toward less depression in calcium-supplemented women. Among the 247 women evaluated at 12 weeks postpartum, calcium-treated subjects had significantly less depression (p = 0.014).     

Patient choice of treatment for postpartum depression: a pilot study

Summary Objective: The lack of systematic efficacy research makes the selection of optimal treatment for postpartum depression (PPD) difficult. Moreover, the treatment decisions for women with PPD who are breastfeeding are heavily influenced by their concerns about infant exposure to antidepressant medication. The objective of this pilot trial was to examine the clinical characteristics of women with PPD associated with treatment selection. Method: This open pilot trial offered 23 women with PPD one of 3 treatment options: sertraline, interpersonal psychotherapy (IPT), or their combination administered in an outpatient mental health setting over 12 weeks. Baseline and treatment outcome measures included the Hamilton Rating Scale for Depression (HRSD), the Beck Depression Inventory (BDI) and the Edinburgh Postnatal Depression Scale (EPDS). Results: Completers across all 3 treatment groups (n = 18) experienced significant clinical improvement with each of the 3 treatment modalities on the HRSD (p < 0.001), BDI (p < 0.001) and EPDS (p < 0.001). There were trends for women with a prior depression to more frequently choose sertraline as a treatment (alone or with IPT, p = 0.07), and for women who were breastfeeding to choose sertraline (alone or with IPT, p = 0.10) less frequently. Conclusion: In this small sample of women with PPD, most women chose IPT with or without sertraline. A larger randomized study could further confirm the suggested predictors of treatment selection identified in this study: previous depression and breastfeeding status.     

Prevalence of anxiety and depression during pregnancy in a private setting sample

Summary Objectives: To estimate the prevalence and risk factors for antenatal anxiety (AA) and antenatal depression (AD). Methods: We performed a cross sectional study of 432 women attending a private clinic in the city of Osasco, S?o Paulo, from 5/27/1998 to 5/13/2002. The following instruments were used: Spielberger state-trait anxiety inventory (STAI), Beck depression inventory (BDI), and a questionnaire for socio-demographic and obstetric data. Inclusion criteria were: pregnant women with no past or present history of depression, psychiatric treatment, alcohol or drug abuse and no clinical and obstetric complications. The prevalence of AA, according to STAI, and AD, according to Beck Inventory, were estimated with 95% confidence intervals (95% CI). Odds ratios and 95% CI were used to examine the association between AA and AD and exposures variables. Results: The prevalence of AA, state and trait were 59.5 (95 CI%: 54.8:64.1%) and 45.3% (95% CI: 40.6:50.0), respectively. The prevalence of AD was 19.6 (95% CI:15.9:23.4). In the multivariate analysis, AA-trait (OR: 5.26; 95% CI 2.17:12.5, p < 0.001), AA-state (OR: 2.27; 95% CI 1.08:4.76, p = 0.02) and AD (OR: 2.43; 95% CI 1.40:4.34, p = 0.002) were associated with lower women’s educational level. AA-trait (OR: 3.43; 95% CI 1.68:7.00, p = 0.001), AA-state (OR: 2.22; CI 95% 1.09:4.53, p = 0.02) and AD (OR: 2.82; CI 95% 1.35:5.97, p = 0.005) were also associated with not being married. AA-trait was associated with lower women’s income (OR: 2.22; 95% CI 0.98:5.26, p = 0.05) and not being white (OR: 1.7; 95% CI 1.00:2.91, p = 0.04), while AD was associated with lower couple’s income (OR: 2.43; 95% CI 1.40:4.34, p = 0.001) and greater number of previous abortions (OR: 2.21; 95% CI 1.23:3.97, p = 0.009). Conclusions: Prevalence of AA and AD were high in this sample of women attending a private care setting, particularly AA state and trace. AA and AD were associated with similar socio-demographic and socio-economic risk factors, suggesting some common environmental stressors may be involved.     

Screening women for postpartum depression at well baby visits: resistance encountered and recommendations

Summary Objective: Postpartum major depression afflicts 10–15% of childbearing women and can have serious consequences. Unrecognized and therefore untreated episodes of postpartum major depression can predispose women to future depressive episodes, especially those related to other reproductive events. In the United States, women typically have one visit at six weeks postpartum with their obstetrican which is focused on physical recovery from delivery. Pediatricians typically see new mothers 4–6 times per year at well baby visits. Therefore, our objective is to test the utility of screening women for postpartum depression at each well baby visit over the course of the first postpartum year as compared with controls derived from clinical practice and chart review. Method: Subjects for this prospective study were recruited at their first well baby visit at the UCSD Primary Care Pediatric Clinic and interviewed by telephone. Subjects then were asked to complete the Edinburgh Postnatal Depression Scale (EPDS) and the Beck Depression Inventory (BDI) at intervals consistent with the timing of well baby visits. If scores on the EPDS or the BDI exceeded the thresholds (EPDS ≥ 12 and BDI ≥ 10) then subjects were assessed further with the Structured Clinical Interview for the Diagnostic and Statistical Manual of Mental Disorder, Fourth Edition (SCID-DSM IV). If diagnosed with postpartum major depression, subjects were referred for appropriate treatment. Results: Out of 160 study packets distributed, only 7 women volunteered for the study, despite endorsement and presentation of the study by their pediatricians. Of those participants, five scored above threshold values at some point in the interval studied. Discussion: The difficulty in recruitment in this study highlights some of the problems encountered in clinical practice in terms of identifying and referring women with postpartum mental illnesses. We recommend further study be focused on how to attract potentially affected women while simultaneously addressing their fears of stigma. Since resistance also was encountered in other physicians, we recommend that educational efforts be aimed at increasing knowledge and awareness of postpartum mental illnesses in both the lay and professional spheres. Accepted July 26, 2002; Published online October 7, 2002 Acknowledgement This project was supported by a grant for the Eli Lilly Center for Women's Health. Correspondence: Leslie Westlund Tam, M.D., 591 Camino de la Reina, #821, San Diego, CA 92116, U.S.A. e-mail: ltam@ucsd.edu     

The effect of postpartum depression on child cognitive development and behavior: A review and critical analysis of the literature

Summary ¶The incidence of postpartum depression (PPD) in Western societies is approximately 10–15% and its cause multi-faceted. Because mothers largely constitute infants social environment and mediate their experience of the external world, it is imperative to investigate the effects of PPD on child growth and development. PsycInfo, Medline, Embase, CINAHL, ProQuest, and Health Star databases were searched with key terms for English language abstracts from 1990 onwards, and key contents were searched. There are small effects of PPD on cognitive development such as language and IQ, seen particularly among boys. Behavioral effects are variably supported, but may persist up to 5 years postpartum and beyond. However, chronic or recurrent maternal depression, rather than postpartum depression per se is likely related to later effects on the child. These adverse effects of PPD based on sex of infant are discussed.Received February 7, 2003; accepted June 15, 2003 Published online August 12, 2003     

Prevalence of depression in menopause: a pilot study

Summary Objective: The objective of this study was to determine whether women in peri-menopause are more likely to have a major mood disorder than those in pre- or postmenopause. Methods: We studied 100 women between the ages of 45 and 65 years old who were seen at four different women's health centers. Using menstrual and when available, laboratory criteria, each subject was determined to be pre-, peri- or postmenopausal. Each subject completed a Beck Depression Inventory (BDI) and provided psychiatric and medical history in a telephone interview. All patients with a BDI score greater than or equal to 10 were invited to have a psychiatric assessment, including a Structured Clinical Interview for DSM-IV Diagnoses (SCID-DSM IV). Results: The women in the perimenopausal group (n = 38) had statistically significant higher BDI scores than those women in the pre-menopausal (n = 17) and postmenopausal (n = 45) groups (p < 0.0001). Of those in the perimenopausal group who scored ≥ 10 and completed the SCID and met criteria for any psychiatric diagnosis, 11 out of 22 met criteria for Major Depressive Disorder, Recurrent. Conclusions: These data suggest that perimenopause may be a associated with recurrence of pre-existing depressive illness. The findings underscore the clinical importance of screening for and treating major depressive illness in women during the menopausal years.     

Development and validation of a scale to assess social support in the postpartum period

Summary The development, reliability, and validity of a new instrument designed to assess aspects of social support specifically relevant to the postpartum period, the Postpartum Social Support Questionnaire (PSSQ), is described. The PSSQ was administered to 126 women at 2, 4, 6, and 12 months postpartum. Results indicate that it has high test–retest reliability and internal consistency. Factor analyses suggest that the scale consists of four factors: partner support, parent support, in-law support, and extended-family and friends support. In addition, the PSSQ scores of depressed and nondepressed women were compared at 2, 4, 6, and 12 months postpartum. Women who met diagnostic criteria for depression at 2 months postpartum reported less partner support than the nondepressed women at each assessment. The instrument appears to be a valid and reliable measure that should be useful in studies examining the role of social support in postpartum adaptation. Correspondence: Joyce Hopkins, Institute of Psychology, Illinois Institute of Technology, Chicago, IL 60106, U.S.A.     

A depressive symptoms responsiveness model for differentiating fatigue from depression in the postpartum period

Summary Fatigue is both a symptom and a predictor of depression in women after childbirth. At the same time, postpartum fatigue is experienced by most non-depressed women. Health care providers experientially know that not all women who experience postpartum fatigue will manifest depression. However, while researchers agree that fatigue and depression are distinct concepts, they have not yet identified a means for describing or measuring this distinctness. A new model proposing how fatigue may be differentiated from depression after childbirth is presented. The Depressive Symptoms Responsiveness Model proposes that depression-related postpartum fatigue may potentially be differentiated from non-depression-related postpartum fatigue on the basis of whether depressive symptoms abate when fatigue is relieved. The ability to differentiate between fatigue and depression in postpartum women has the potential to improve women’s health through improvements in practice and resource utilization. Furthermore, differentiation may lead to a better understanding of the role of fatigue in postpartum depression. Correspondence: Jennifer J. Runquist, PhD, RN, Assistant Professor, College of Nursing, University of Wisconsin-Milwaukee, PO Box 413, Milwaukee, WI 53201, U.S.A.     

Multicentre prospective study of perinatal depression in Japan: incidence and correlates of antenatal and postnatal depression

Summary A multicentre study on the epidemiology of perinatal depression was conducted among Japanese women expecting the first baby (N = 290). The incidence rate of the onset of the DSM-III-R Major Depressive Episode during pregnancy (antenatal depression) and within 3 months after delivery (postnatal depression) were 5.6% and 5.0%, respectively. Women with antenatal depression were characterised by young age and negative attitude towards the current pregnancy, whereas women with postnatal depression were characterised by poor accommodation, dissatisfaction with sex of the newborn baby and with the emotional undermining. Antenatal depression was a major risk factor for postnatal depression.     

Social support and online postpartum depression discussion groups: a content analysis

Objective

Social support has a positive influence on women's childbearing experience and is shown to be a preventive factor in postpartum depression. This study examined the perceived value and types of social supports that characterize the discussions of women who participate in postpartum depression online discussion groups.

Methods

A directed content analysis was used to examine 512 messages posted on a postpartum depression online support group over six months.

Results

The majority of the women's postings illustrated emotional support followed by informational and instrumental support.

Conclusions

Online support groups provide women experiencing postpartum depression a safe place to connect with others and receive information, encouragement and hope.

Practice implications

Education strategies are needed to address the many questions regarding PPD medical treatment. Recommending vetted links to PPD online support groups will create opportunities for women to share their experiences and obtain support.