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Guest Editorial
Psychiatry, Technology, and the Corn Fields of Iowa
Harry Karlinsky
(PDF)

In Review
The Internet’s Impact on the Practice of Psychiatry
Rima Styra
(PDF)

Clinical and Educational Telepsychiatry Applications: A Review
Donald M Hilty, Shayna L Marks, Doug Urness, Peter M Yellowlees, Thomas S Nesbitt
(PDF)

Portable Computing in Psychiatry
John Luo
(PDF)

Original Research
Assessing and Monitoring Antipsychotic-Induced Movement Disorders in Hospitalized Patients: A Cautionary Study
Leonardo Cortese, Mandar Jog, T Jeffrey McAuley, V Kotteda, Giuseppe Costa
(PDF)

Sociodemographic Factors Associated With Comorbid Major Depressive Episodes and Alcohol Dependence in the General Population
JianLi Wang, Nady El-Guebaly
(PDF)

Delineating the Population Served by a Mobile Crisis Team: Organizing Diversity
Janet Landeen, Julie Pawlick, Steven Rolfe, Ian Cottee, Melanie Holmes
(PDF)

Detecting Women at Risk for Postnatal Depression Using the Edinburgh Postnatal Depression Scale at 2 to 3 Days Postpartum
Frédérique Teissèdre, Henri Chabrol
(PDF)

Review Paper
Ethics in Psychiatric Research: Study Design Issues
Gordon DuVal
(PDF)

Brief Communication
The Prevalence of Psychological Morbidity in West Bank Palestinian Children
Tanya L Zakrison, Amira Shahen, Shaban Mortaja, Paul A Hamel
(PDF)

Book Reviews
(PDF)

Beyond Technique in Solution Focused Therapy.
Reviewed by
Llewellyn W Joseph, MD, FRCPC

The Epidemiology of Schizophrenia.
Reviewed by
Mary V Seeman, MD

The Private Self.
Reviewed by
Paul Ian Steinberg, MD, FRCPC

Treatment Planning in Psychotherapy: Taking the Guesswork Out of Clinical Care.
Reviewed by
Gilbert Pinard, MD, FRCPC

Pharmacogenetics of Psychotropic Drugs.
Reviewed by
Gustavo Turecki MD PhD

Psychotherapy and Counselling in Practice. A Narrative Framework.
Reviewed by
Paul KB Dagg

Oedipus and Beyond: A Clinical Theory.
Reviewed by
Paul Ian Steinberg, MD, FRCPC

Letters to the Editor
(PDF)

Modafinil Treatment of Excessive Sedation Associated With Divalproex Sodium

Ziprasidone in Parkinson’s Disease Psychosis

Combined Oral Venlafaxine and Intravenous Clomipramine-A: Successful Temporary Response in a Patient With Extremely Refractory Depression

Doxepin Increases Serum Cholesterol Levels

Re: Suicide: The Persisting Challenge

Reply: Suicide: The Persisting Challenge

Depression and a History of Alcoholism

Gains in Speeded Information Processing Following Clozapine Treatment of Schizophrenia

Problems With Crystallizing Phenomenology and Nosology in Adolescent Psychiatry

Serotonin Syndrome With Prolonged Dysphagia

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

The Edinburgh Postnatal Depression Scale (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 validity 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 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 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 π = 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 (F_{4, 1149} = 152.4, P < 0.0001) and showed that the only significant predictor was EPDS scores at 2 to 3 days (ß = 0.59, t = 24.51, P < 0.0001). Age, parity, and type of delivery were not significant predictors (ß = 0.02, t = 0.63, P = 0.52; ß = 0.03, t = 0.96, P = 0.33; and ß = 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 t = 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.

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 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 Postnatal Depression scale (EPDS): new results about use and psychometric properties. Eur Psychiatry 1998;13:83–9.

Author(s)

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

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