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)     

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.     

Prospective Testing of the Brisbane Postnatal Depression Index

Abstract: Background: Over 50 percent of women have one or more risk factors for postnatal depression during pregnancy or in the perinatal period, but only 10 to 15 percent become clinically depressed. The objective of this study was to prospectively test the Brisbane Postnatal Depression Index (referred to here as Index), to validate a theoretical index that was developed earlier, and to establish whether the index could be introduced as a clinically useful method to detect women who may be at risk for developing postnatal depression. Methods: Antenatally, women were asked about social support and about personal and family history of mental illness, including postnatal depression. Responses were scored according to predefined ratings on the Index. In the postnatal wards, 353 women were recruited and their scores for “blues,” social support, feelings about the baby, and satisfaction with the birth process were added. Sixteen weeks after hospital discharge, women were asked to complete the Edinburgh Postnatal Depression Scale. The Brisbane Index was validated by the number of women scoring more than 12 on the Edinburgh Postnatal Depression Scale at 16 weeks postpartum who were correctly predicted by a score of more than 6 on the Index. Sensitivity, specificity, positive predictive value, and negative predictive value for the Index, using >6 as a cutoff point, were calculated. “Ease of use” was assessed informally with participants and staff responsible for administration and scoring the instrument. Results: Compared with results from the derivation study, prospective testing of the index showed an improvement in sensitivity from 36.3 to 47.5 percent and a small decrease in specificity, but no improvement on the positive predictive value from 39.8 to 39.6 percent. Conclusion: The Brisbane Postnatal Depression Index was validated in a prospective sample, but its sensitivity and specificity require improvement before introduction as a measure of prediction. (BIRTH 33:1 March 2006)     

Further development of the Postpartum Depression Predictors Inventory-Revised

OBJECTIVES: To describe the newly developed item coding and computation of the total score for the Postpartum Depression Predictors Inventory-Revised along with recommended cutoff points. DESIGN: Methodologic research. SETTING: Obstetrician and gynecologist offices in the Pacific Northwest. PARTICIPANTS: This longitudinal study included 139 women; the study began in the participant's third trimester of pregnancy and ended at 8 months after childbirth. METHODS: The participants completed the Postpartum Depression Predictors Inventory-Revised in their third trimester of pregnancy and again at 2 and 6 months after childbirth. Postpartum depression symptoms were measured by the Edinburgh Postnatal Depression Scale and psychiatric nurse practitioner interview at 2 and 6 months after childbirth. MAIN OUTCOME MEASURES: Sensitivity and specificity of the Postpartum Depression Predictors Inventory-Revised at three points: prenatal and 2 and 6 months after childbirth. RESULTS: The receiver operating characteristic curve analysis indicated that the Prenatal Postpartum Depression Predictors Inventory-Revised performed well and explained 67% of the variance of postpartum depressive symptomatology as measured by Edinburgh Postnatal Depression Scale scores. The Prenatal Postpartum Depression Predictors Inventory-Revised yielded a sensitivity of .76 and a specificity of .54 at a cutoff score of 10.5. CONCLUSIONS: A cutoff score of 10.5 is recommended when using the Postpartum Depression Predictors Inventory-Revised during pregnancy. Further research needs to be conducted on recommended cutoff scores for use of the Postpartum Depression Predictors Inventory-Revised during the postpartum period.     

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.     

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.     

Effectiveness of an Exercise Support Program in Reducing the Severity of Postnatal Depression in Taiwanese Women

ABSTRACT: Background: Depression during the perinatal period should be identified as early as possible to avoid negative effects on the new family. The purpose of this study was to examine the effectiveness of an exercise support program on reducing psychological morbidity after childbirth. Methods: A controlled trial was conducted in a regional hospital in Taipei, Taiwan. Eighty primiparas with an Edinburgh Postnatal Depression Scale (EPDS) score above 10 at 4 weeks postpartum agreed to participate. They were allocated alternately to an intervention (to receive exercise support) and control group (to receive standard care) at 6 weeks postpartum. The exercise support consisted of 1 hour per week at the hospital and two sessions at home for 3 months. Sixty‐three primiparas finished the exercise support program. The main outcome measure was the EPDS score at 5 months postpartum. Results: Women who received the exercise support program were less likely to have high depression scores after childbirth when compared with the control group. Conclusions: The exercise support program given to postpartum women appeared to benefit their psychological well‐being. This promising finding should be tested in a well‐designed randomized controlled trial. (BIRTH 35:1 March 2008)     

Assessment and relationship of sleep quality to depression in early pregnancy

Sleep quality is integral to optimal physical functioning and mental health during pregnancy. There has, however, been little work conducted to determine the most appropriate measure of sleep quality in this clinical group, a surprising observation given the complex and dynamic psychobiology of pregnancy. The Pittsburgh Sleep Quality Index (PSQI) was evaluated to determine the usefulness of this measure in early pregnancy. The psychometric properties of the PSQI were evaluated in women at 14 weeks of pregnancy and revealed the instrument to have good internal consistency and convergent and divergent reliability properties. Confirmatory factor analysis suggested that the removal of the PSQI sleeping medications sub‐scale from the global sleep quality total score calculation would improve the utility of this measure in early pregnancy. Women classified as depressed on the basis of Edinburgh Postnatal Depression Scale (EPDS) scores were found to have significantly poorer sleep quality scores on the majority of PSQI sub‐scales. The relationship between sleep quality and depression was found to be statistically significant and clinically relevant during early pregnancy and the PSQI would appear to be an appropriate measure to assess sleep quality in this group.     

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.     

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.     

Early mother–infant interaction: associations with the close relationships and mental health of the mother

The present study examined the association between a woman's close relationships and mental health and the quality of her maternal behaviour in early mother–infant interaction. A total of 131 mothers and their infants participated in the study. The quality of the mother's childhood relationship with her own mother and her marital relationship were investigated in a semi‐structured interview and, as a part of the interview, the Structured Clinical Interview for DSM‐IV (SCID) was used to assess her mental health. Mother–infant interaction was videotaped at 8–11 weeks of the infant's age, and scored using the Global Rating Scale for Mother–Infant Interaction. The mother's childhood relationship with her mother was significantly related to her own interactive and affective behaviour with her infant. A poor, disengaged marital relationship was also associated with poorer interactive behaviour but only among mothers with mental health problems. Thus the mother's close relationships had an effect on maternal behaviour; however, maternal perinatal psychopathology per se was not related to maternal behaviour at 2 months of the infant's age.     

Postpartum depression: a comparison of screening and routine clinical evaluation

OBJECTIVE: This study compared the efficacy of routine clinical evaluation with that of screening with the Edinburgh Postnatal Depression Scale for the detection of postpartum depression in a residency training program practice.Study Design: Three hundred ninety-one patients during a period of 1 year were assigned according to delivery date to screening for postpartum depression with the Edinburgh Postnatal Depression Scale or to a control group who had only spontaneous detection during routine clinical evaluation. The incidences of postpartum depression detection and demographic characteristics were compared between 79 patients in the Edinburgh Postnatal Depression Scale group and 96 patients in the clinical evaluation group by means of chi(2) analyses. RESULTS: The incidence of postpartum depression detection with the Edinburgh Postnatal Depression Scale was significantly higher than the incidence of spontaneous detection during routine clinical evaluation (35.4% and 6.3%, respectively; P =.001). CONCLUSIONS: The Edinburgh Postnatal Depression Scale is an effective adjunct to clinical interview for diagnosis of postpartum depression and should be considered in residency training.     

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.     

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)     

Teenage mother's predictions of their support levels before and actual support levels after having a child

OBJECTIVES: To evaluate to what extent teenage mothers are able to predict their postnatal support networks in the antenatal period, and the extent to which support correlates with depressive symptomatology and social class. DESIGN: A prospective cohort study. SETTING: Teenage antenatal clinic. PARTICIPANTS: Teenage mothers (n=124) aged less than 18 years. INTERVENTION: Women were surveyed in the antenatal period and again 6 months postpartum about their anticipated and actual levels of support using the Maternal Social Support Index. The questionnaire covered key issues involved in discharge planning such as the availability of help with household tasks, emergency respite, and communication. Subjects also completed social class data and the Edinburgh Postnatal Depression Scale. MAIN OUTCOME MEASURE: Ability of pregnant teenagers to predict postnatal support and correlation of support with social class and depressive symptomatology. RESULTS: The key finding was that teenage mothers significantly overestimated their support networks in the antenatal period compared to the reality experienced 6 months postpartum (P=0.0001). Dissatisfaction was most marked in the communication and daily activity support subscales. The level of support at 6 months postpartum correlated significantly with the Edinburgh Postnatal Depression score (P=0.0001) and with social class (P=0.017). CONCLUSION: Services for teenage mothers that provide assistance with communication and daily support activities are required to help overcome the discrepancies between idealization and reality. Poor support correlates with depressive symptomatology and social class.     

Maternal representations,depression and interactive behaviour in the postnatal period: a brief report

The association between pre/postnatal change in the content of maternal representations and maternal interactive capacity/number of depressive symptoms at 6 months postpartum was investigated among 12 substance‐addicted mothers in residential treatment. The measures used were semantic differentials of the Interview of Maternal Representations (IRMAG), maternal variables of the Parent‐Child Early Relational Assessment (ERA) and the Edinburgh Postnatal Depression Scale (EPDS). Change towards a more negative view of the child was associated with having more problem areas in maternal interaction, and more depressive symptoms at 6 months postpartum. Change towards a more negative view of the child's father and own mother‐as‐mother was associated with having more interaction problems, and towards a more negative view of self was related to depression postnatally.     

Maternal quality of life assessment: the feasibility of antenatal–postnatal follow‐up using the Mother‐Generated Index

Introduction. The Mother‐Generated Index (MGI) is a quantitative/qualitative postnatal quality‐of‐life tool. This study examined the feasibility of assessing changes in quality of life from late pregnancy to the postnatal period. Design. Attempted 6‐week postnatal follow‐up of 35 women who had completed the MGI and General Health Questionnaire antenatally. Quality of life comments were assessed thematically. Quantitative data were analysed in Excel and SPSS. Stepwise regression assessed the feasibility of identifying factors predictive of postnatal MGI score. Findings. Nineteen participants responded postnatally (56%). Quality of life scores rose for some and fell for others. Whereas 38% of comments antenatally had been positive, this rose to 51% postnatally. During pregnancy, ‘Tiredness’, ‘Looking forward to baby’, ‘Aches and pains’ and ‘Work’ predominated; postnatally, this changed to ‘Feelings about baby’, ‘Sense of self’, ‘Relationship with partner’, and ‘Adaptation to new role’. The regression analysis suggested that antenatal MGI, parity and degree of perineal trauma may be predictive of postnatal MGI score. Conclusions . This small exploratory study suggests that postnatal follow‐up using the MGI is feasible. This approach contributes towards a more holistic understanding of the pregnant woman/mother and her unique and evolving situation.     

Pilot study: quality of life assessment of postnatal fatigue and other physical morbidity

Postnatal morbidity is increasingly recognized, but standard assessments may not capture what is most important to the woman with such morbidity in terms of her quality of life. The Mother-Generated Index (MGI) is a proposed postnatal quality-of-life instrument which allows the mother to determine both content and scoring. In this pilot study we found that although a degree of psychological and physical morbidity (including tiredness) is common, and may be very significant, for most women these factors are low-grade, and other aspects of their lives are more important. A quality-of-life approach allows the mother to determine her own postnatal assessment, and encourages practitioners to view her more holistically.     

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.     

Factors associated with depressive symptoms among postnatal women in Nepal

BACKGROUND: Depression after childbirth affects both the mother and her infant. In South-Asia, maternal depression might also contribute to poor infant growth. Knowledge of risk factors could improve the health workers' recognition of depression. AIM: To examine possible risk factors for depression in the postnatal period among women in one clinical, one urban and one rural population in Lalitpur district, Nepal. METHOD: A total of 426 postnatal women were included in a cross-sectional structured interview study, 5-10 weeks after delivery. Depressive symptoms were measured by the Edinburgh Postnatal Depression Scale [EPDS]. RESULTS: Multivariate analysis showed that depression (EPDS>12) was strongly associated with husband's alcoholism, polygamy and previous depression. Other significant factors were stressful life events, multiparity, smoking and depression during pregnancy. There was a non-significant trend of lower depressive scores among women living in arranged marriages, and among women practicing the tradition of staying in their maternal home after delivery. CONCLUSIONS: In addition to previously documented risk factors, traditional family structures may influence the risk of depression among postnatal women in Nepal.