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Detecting Women at Risk for Postnatal Depression Using the Edinburgh
Postnatal Depression Scale at 2 to 3 Days Postpartum
Article in Canadian journal of psychiatry. Revue canadienne de psychiatrie · February 2004
DOI: 10.1177/070674370404900108 · Source: PubMed
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Detecting Women at Risk for Postnatal Depression Using the Edinburgh Postnatal Depression Scale at 2 to 3 Days Postpartum
Original Research
Detecting Women at Risk for Postnatal Depression
Using the Edinburgh Postnatal Depression Scale at 2 to
3 Days Postpartum
Frédérique Teissèdre, PhD1, Henri Chabrol, MD, PhD2
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.
(Can J Psychiatry 2004;49....)
Information on funding and support and author affiliations appears at the end of the
article.
Clinical Implications
· In this study we found a high correlation between Edinburgh Postnatal Depression Scale
(EPDS) scores at 2 to 3 days and at 4 to 6 weeks postpartum.
· The cut-off scores of 10 and 11 for the EPDS implemented at 2 to 3 days postpartum obtained
good specificity, sensitivity, and positive predictive values for the EPDS cut-off scores proposed for diagnosing postnatal depression.
· The EPDS implemented at 2 to 3 days postpartum, while mothers are still in hospital, effectively identifies mothers at risk for postnatal depression.
Limitations
· We lacked information on socioeconomic status required to assess the influence of this variable on detecting women at risk for postnatal depression.
· In Canada, mothers are typically discharged within 48 hours postpartum. Thus, the Edinburgh
Postnatal Depression Scale (EPDS) should be administered even earlier.
· The benefits of early identification may not be realized everywhere because of different hospital policies.
Key Words: postnatal depression, Edinburgh Postnatal Depression Scale, early detection
he Edinburgh Postnatal Depression Scare (EPDS) is a
self-report questionnaire originally designed by Cox and
colleagues to screen for postnatal depression (1). Large
community surveys have shown the EPDS to have strong va-
T
Can J Psychiatry, Vol 49, No 1, January 2004 W
lidity and reliability. A review analysis identified 18 validation studies of both the original English version of the EPDS
and its translations into numerous languages (2). The cut-off
scores for detecting major depression varied from 9 or 10 to 12
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The Canadian Journal of Psychiatry—Original Research
or 13. The sensitivity and specificity estimates also varied
(from 65% to 100% and from 49% to 100%, respectively). A
further validation study yields similar results (3).
The EPDS may be used to screen women at risk for postnatal
depression in the first days postpartum. The higher incidence
of postpartum blues among women who later suffer from
postnatal depression has long been noted (for example, 4).
Empirical studies have confirmed this relation (5,6). Hannah
and colleagues used the EPDS to rate 217 women at 5 days and
again at 6 weeks postpartum (7). A highly significant positive
correlation was noted between EPDS scores at 5 days and at 6
weeks postpartum (Spearman rank correlation: r = 0.60, P <
0.0001), together with similar symptom profiles. Of the 25
women who suffered from postnatal depression (6-week
EPDS score $13), 17 (68%) had similar symptoms 5 days
postpartum (EPDS score > 10). A threshold of 10 was found to
be predictive of postnatal depression.
This study evaluates the capacity of the EPDS, when implemented earlier than by Hannah and colleagues, to detect
women who will suffer from postnatal depression. In the
study by Hannah and colleagues, participants completed the
EPDS at 5 days postpartum—when symptoms of postpartum
blues have been shown to be more intense (8,9). However,
mothers generally stay no longer than 3 days at the obstetrics
clinic. We tested the predictive power of the EPDS implemented at 2 or 3 days postpartum, so that women could be routinely screened while still in hospital; women at risk might
benefit from preventive intervention.
Method
Participants
The participants were 1309 women (mean age 30.2 years, SD
4.5 years, range 18 to 44 years) consecutively admitted to 3
obstetrics clinics in Toulouse, France: 86% had a normal
delivery, and 14% had a cesarean section; 51% were
primiparous; 97% were married or cohabiting. Being fully
covered under the social health care system, the clinics do not
discriminate on the basis of income and admit patients of
diverse socioeconomic levels.
Instrument
The EPDS is a 10-item self-report questionnaire. Items 1 and 2
assess anhedonia; item 3, self-blame; item 4, anxiety; item 5,
fear or panic; item 6, inability to cope; item 7, difficulty sleeping; item 8, sadness; item 9, tearfulness; and item 10,
self-harm ideas. Responses are scored 0, 1, 2, and 3, increasing according to the severity of the symptom. The total score is
calculated by adding the scores for each of the 10 items. The
score can range from 0 to 30. The validity of the EPDS has
been widely documented (2). The internal consistency of the
EPDS has previously been found to be satisfactory (1). In this
770
study, the Cronbach’s alpha was 0.79 for the EPDS administered at 2 to 3 days postpartum and 0.82 at 4 to 6 weeks
postpartum.
Procedure
Participants were asked to complete the French version of the
EPDS (10) on the second or third day postpartum while
staying at the clinics. The EPDS was completed on the second
day postpartum by 8% of participants and on the third day by
92%. We adapted the EPDS procedure, as it evaluates only the
period of the preceding week, by asking the participants to
assess how they had been feeling since delivery. A stamped,
addressed envelope was provided for return of the second
EPDS, which was to be completed between 4 to 6 weeks
postpartum. Written informed consent was obtained from
all participants.
Data Analyses
Because EPDS scores have nonnormal distribution, the links
between EPDS scores at 2 to 3 days and 4 to 6 weeks were
assessed with Spearman’s rank-order correlation coefficient.
We performed a multiple regression analysis to study the
influence of age and parity on the relation between EPDS
scores at 2 to 3 days and at 4 to 6 weeks.
According to the cut-off points used by Hannah and colleagues, scores were classified into 4 categories (0; 1 to 9; 10
to 12; $ 13). The correlation of these categories between 2 to 3
days and 4 to 6 weeks was assessed using Kendall’s
rank-correlation coefficient.
Specificity, sensitivity, and positive predictive values for different thresholds on the 4-to-6 week scores were calculated
for different thresholds on the 2-to-3 day scores.
Results
Comparison of EPDS Mean Scores
The mean score of the first EPDS was significantly higher
than the mean score of the second EPDS (mean 6.54, SD 4.64
vs mean 6.03, SD 4.36; t1153, P < 0.0001).
Links Between EPDS Scores
Of the 1309 participants, 1154 (88.1%) returned the second
EPDS. There was a highly significant positive correlation
between EPDS scores at 2 to 3 days postpartum and those at 4
to 6 weeks postpartum (Spearman D = 0.59, P < 0.0001, n =
1154). In a multiple regression analysis predicting EPDS
scores at 4 to 6 weeks, we entered 2-to 3-day EPDS scores,
age, parity, and type of delivery. This model accounted for
34.6% of the variance of EPDS scores at 4 to 6 weeks (F4 1149 =
152.4, P < 0.0001) and showed that the only significant predictor was EPDS scores at 2 to 3 days ($ = 0.59, t = 24.51, P <
0.0001). Age, parity, and type of delivery were not significant
W Can J Psychiatry, Vol 49, No 1, January 2004
Detecting Women at Risk for Postnatal Depression Using the Edinburgh Postnatal Depression Scale at 2 to 3 Days Postpartum
Table 1 Frequencies of Edinburgh Postnatal Depression Scale (EPDS) scores at 4 to 6 weeks as a
function of scores at 2 to 3 days
EPDS scores at 4 to 6 weeks
³ 13
10 to 12
1 to 9
0
% (n)
% (n)
% (n)
% (n)
³ 13 (n = 135)
33.3 (45)
29.6 (40)
37.0% (50)
0.0 (0)
10 to 12 (n = 159)
17.6 (28)
29.5 (47)
52.0% (83)
0.6 (1)
1 to 9 (n = 768)
3.5 (27)
6.5 (50)
84.0% (646)
5.9 (45)
0 (n = 92)
2.2 (2)
8.7 (8)
43.5% (40)
45.6 (42)
EPDS scores at 2 to 3 days
Table 2 Frequencies of EPDS scores at 2 to 3 days as a function of scores at 4 to 6 weeks
EDPS scores at 2 to 3 days
³ 13
EPDS scores at 4 to 6 weeks
10 to 12
1 to 9
0
% (n)
% (n)
% (n)
% (n)
³ 13 (n = 102)
44.0 (45)
27.5 (28)
26.5 (22)
2.0 (2)
10 to 12 (n = 145)
27.6 (40)
32.4 (47)
34.5 (50)
5.5 (8)
1 to 9 (n = 819)
6.0 (50)
10.0 (83)
79.0 (646)
5.0 (40)
0 (n = 88)
0.0 (0)
1.1 (1)
51.0 (45)
47.7 (42)
predictors ($ = 0.02, t = 0.63, P = 0.52; $ = 0.03, t = 0.96, P =
0.33; and $ = 0.04, t = 1.57, P = 0.11, respectively).
The correlation between the 4 score categories (0; 1 to 9; 10 to
12; and $ 13) on both assessment occasions was highly significant (Kendall J = 0.47, z = 23.9, P < 0.001), showing that participants tended to score within the same range at 2 to 3 days
and 4 to 6 weeks.
Severe dysphoria (EPDS score $ 13) was more common at 2
to 3 days than at 4 to 6 weeks (11.3% vs 8.8%, P = 0.04). Moderate dysphoria (EPDS score 10 to 12) was almost equally frequent at 2 to 3 days and at 4 to 6 weeks (13.4% vs 12.6%, P =
0.55). EPDS scores from 1 to 9 were slightly less common at 2
to 3 days than at 4 to 6 weeks (66.4% vs 70.9%, P < 0.05).
Scores of 0 were almost equally frequent at 2 to 3 days and at 4
to 6 weeks (8.8% vs 7.6%, P = 0.28). Table 1 gives the distribution of EPDS scores at 4 to 6 weeks as a function of those at
2 to 3 days. Table 2 gives the distribution of scores at 2 to 3
days as a function of those at 4 to 6 weeks.
Sensibility, Specificity, and Predictive Positive Value
Table 3 gives a range of 2- to 3-day EPDS score thresholds
and the corresponding sensitivity, specificity, and predictive
positive values for different 4-to 6-week cut-off scores for the
diagnosis of postnatal depression.
Discussion
The high response rate (88.1%) for the EPDS at 4 to 6 weeks
confirms that postnatal women are accepting of the EPDS.
Can J Psychiatry, Vol 49, No 1, January 2004 W
Comparison of EPDS Scores
The intensity of depressive symptomatology tends to be
higher in early postpartum than at 4 to 6 weeks. The depressive component of postpartum blues tends to be more intense
than the subsequent postnatal depressive symptomatology.
Relation Between EPDS Scores
The high correlation between EPDS scores at 2 to 3 days and 4
to 6 weeks (r = 0.59) compares with the correlation reported
by Hannah and colleagues between 5-day and 6-week EPDS
scores (r = 0.60). This result suggests that 2-to 3-day EPDS
scores are as predictive of subsequent depressive
symptomatology as 5-day EPDS scores.
The 4 categories of scores (0; 1–9; 10–12; $13) were significantly correlated, showing that participants tend to respond
within the same category at 2 to 3 days as at 4 to 6 weeks. This
result confirms that the severity of the depressive
symptomatology of postpartum blues is predictive of subsequent postnatal depression.
We examined various thresholds for EPDS scores at 2 to 3
days and their corresponding sensitivity, specificity, and predictive positive value for different cut-off scores at 4 to 6
weeks for diagnosing postnatal depression. We determined
that the EPDS is a satisfactory instrument for screening early
postpartum mothers for a risk of subsequent postnatal depression. The cut-off scores of 10 and 11 obtained good specificity, sensitivity, and positive predictive values for the cut-off
scores of 12 and 13 that are proposed for diagnosing postnatal
depression. This result is consistent with the threshold of 10 at
771
The Canadian Journal of Psychiatry—Original Research
Table 3 Thresholds for EPDS at 2 to 3 days related to EPDS cut-off scores at 4 to 6 weeks for postnatal depression
Specificity (%)
4- to 6-week EPDS scores
Sensitivity (%)
Predictive positive value (%)
10.0
11.0
12.0
13.0
10.0
11.0
12.0
13.0
10.0
11.0
12.0
13.0
8
0.71
0.69
0.66
0.65
0.78
0.78
0.79
0.78
42.8
33.0
24.9
17.8
9
0.80
0.77
0.75
0.73
0.72
0.73
0.76
0.76
49.7
39.4
29.8
21.8
10
0.85
0.83
0.81
0.79
0.64
0.68
0.72
0.71
54.4
45.0
34.7
24.8
11
0.89
0.87
0.86
0.84
0.54
0.60
0.64
0.64
58.0
49.5
39.2
28.4
12
0.92
0.91
0.90
0.88
0.43
0.49
0.54
0.55
60.0
53.7
43.0
31.6
13
0.94
0.94
0.92
0.91
0.34
0.39
0.43
0.44
63.0
56.3
45.2
33.3
2- to 3-day EPDS thresholds
5 days, which Hannah and colleagues found to be predictive of
postnatal depression (7).
Study Limitations
We conducted the study in an obstetrics clinic that admits
women from various socioeconomic backgrounds. Thus, our
results are likely generalizable. However, the lack of more
precise information on socioeconomic status prevents us from
assessing the influence of this variable on the detection of
women at risk of postnatal depression. Another limitation of
the study is the absence of a clinical interview of subjects at 4
to 6 weeks postpartum; thus we could not directly compare
2-to-3 day EPDS scores with the clinical diagnosis of major
depression.
Conclusion
Our findings confirm the results of Hannah and colleagues,
who found that the EPDS completed at 5 days postpartum is a
useful means of detecting women at risk for postnatal depression. Our results suggest that implementing the EPDS earlier,
at 2 to 3 days postpartum, is similarly effective in detecting
women vulnerable to postnatal depression. The EPDS could
be used routinely while mothers are still in the maternity ward
to identify women at risk for postnatal depression both
quickly and cheaply.
References
1. Cox JL, Holden JM, Sagovsky R. Development of the 10-item Edinburgh
Postnatal Depression Scale. Br J Psychiatry 1987;150:782–6.
2. Eberhard-Gran M, Eskild A, Tambs K, Opjordsmoen S, Samuelsen SO. Review
of validation studies of the Edinburgh Postnatal Depression Scale. Acta Psychiatr
Scand 2001;104:243–9.
3. Leverton TJ, Elliot SA. Is the EPDS a magic wand?: a comparison of the Edinburgh Postnatal Depression Scale and Health Visitor Report as predictors of diagnosis on the Present State Examination. J Reprod Infant Psychol
2000;4:279–96.
4. Pitt B. Atypical depression following childbirth. Br J Psychiatry
1968;114:1325–35.
5. Cox JL, Connor Y, Kendell RE. Prospective study of psychiatric disorders of
childbirth. Br J Psychiatry 1982;140:111–7.
6. O’Hara MW, Schechte JA, Lewis DA, Wright EJ. Prospective study of
postpartum blues: biologic and psychosocial factors. Arch Gen Psychiatry
1991;48:801–6.
7. Hannah P, Adams D, Lee A, Glover V, Sandler M. Links between early
post-partum mood and postnatal depression. Br J Psychiatry 1992;154:777–80.
8. Kendell R, McGuire R, Connor Y, Cox J. Mood changes in first 3 weeks after
childbirth. J Affect Disord 1981;3:317–326.
9. Kennerley H, Gath D. Maternity blues: I. Detection and measurement by questionnaire. Br J Psychiatry 1989;155:356–73.
10. Guedeney N, Fermanian J. Validation of the French version of the Edinburgh
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Manuscript received April 2003, revised, and accepted October 2003.
1
Junior Lecturer, Université de Toulouse-Le Mirail, Toulouse, France.
2
Professor of Psychology, Université de Toulouse-Le Mirail, Toulouse,
France.
Address for correspondence: Dr H Chabrol, 21 rue des Cèdres, 31400
Toulouse, France
e-mail: chabrol@univ-tlse2.fr
Résumé : In translation
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