HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS		QUICK SEARCH:   [advanced] Author: Keyword(s): Year:  Vol:  Page:

This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by GEORGIOPOULOS, A. M. Articles by THERNEAU, T. M. Search for Related Content PubMed PubMed Citation Articles by GEORGIOPOULOS, A. M. Articles by THERNEAU, T. M.

Population-Based Screening for Postpartum Depression

From the Mayo Medical School, Mayo Clinic; the Department of Research, Olmsted Medical Center; and the Departments of Family Medicine, Psychiatry and Psychology, and Biostatistics, Mayo Clinic, Rochester, Minnesota.

Address reprint requests to: Barbara P. Yawn, MD, MSc Department of Research Olmsted Medical Center 210 Ninth Street SE Rochester, MN 55905 E-mail: yawnx002{at}gold.tc.umn.edu

	Abstract

Top Abstract Methods Results Discussion References

 
Objective: To estimate the community prevalence in Olmsted County, Minnesota of elevated scores on the Edinburgh Postnatal Depression Scale, a self-report screening tool for postpartum depression.

Methods: At the 6-week postpartum visit, the Edinburgh Postnatal Depression Scale was administered to women who gave birth in Olmsted County between July 28, 1997 and March 28, 1998. Study sites included all ambulatory clinics that provide pregnancy care in the county, and women who missed postpartum visits were contacted by mail. A threshold of 12 or more points on the scale was selected for clinical use; data for scores of ten and above were also examined.

Results: Of the 909 Olmsted County women studied (response rate 83.2%), 11.4% (n = 104) had scores of 12 or greater, with a 95% confidence interval (CI) of 9.4%, 13.5%. The percentage of women with a positive screen increased to 19.8% (n = 180; 95% CI 17.2%, 22.4%) when scores of 10 or higher were included, as has been recommended for screening in primary care settings. Forty-eight or 5.3% of the subjects (95% CI 3.8%, 6.7%) indicated experiencing suicidal ideation during the previous week.

Conclusion: More than 11% of women had elevated scores on the Edinburgh Postnatal Depression Scale, indicating a high likelihood of postpartum depression and the need for further assessment. The screening process required little extra time and was acceptable to the subjects and clinicians. Screening for postpartum depression is appropriate and feasible for clinical practice and increases the identification of women suffering from this serious, common, and highly treatable disorder.

Affective disorders occur commonly in the postpartum period, ranging in severity from mild and transient "baby blues" experienced by 50–80% of women to postpartum psychosis, which affects less than 1% of women.¹ Postpartum major depression lies along this spectrum of postnatal mood disorders. Studies of the prevalence of postpartum depression have yielded widely varying estimates, ranging from 3% to more than 25% of women in the year after delivery.^2–4 These rates vary according to the methods used to diagnose depression and to identify patients and by whether the studies were retrospective or prospective.^3,4

The debilitating effects of postpartum depression can involve an entire family,^5,6 and women afflicted with postpartum depression are at high risk for recurrent depression.⁷ The majority of them exhibit symptoms by 6 weeks postpartum, and, if left untreated, many women are still depressed at the end of the first postpartum year.¹ Despite its serious consequences and amenity to treatment, postpartum depression often remains unrecognized. Systematic use of a self-report screening measure at the nearly universal 6-week post-partum visit could be an efficient and cost-effective means of identifying women with depressive symptoms.⁷

The Edinburgh Postnatal Depression Scale is a self-report tool that has been widely used in many countries to assist in the identification of women likely to be suffering from postpartum depression.^8–10 It was developed to counter the limitations of other well-established depression scales, including the Beck Depression Inventory, when screening postpartum women.¹¹ The scale is brief and easy to use and avoids interpreting common postpartum changes such as fatigue, poor appetite, and altered sleep patterns as evidence of depression.^11–13 It has ten items relating to symptoms of depression, each with four possible responses. For example, one question asks the patient how often she has "been so unhappy that [she’s] had difficulty sleeping," and another asks how frequently "the thought of harming [herself] has occurred to [her]." Women are asked to underline the response that comes closest to how they felt during the past week. Individual items are scored from 0 to 3 and are totaled to give an overall score between 0 and 30. Like any screening tool, the Edinburgh Postnatal Depression Scale is not a substitute for full clinical evaluation for depression, but high scores do indicate that further assessment is necessary.¹²

The Edinburgh Postnatal Depression Scale has been well validated by standardized psychiatric interviews in a large community sample (n = 702) of British primiparas at 6 weeks postpartum. In this setting, screening scores of at least 12 on the scale permitted identification of 88.0% of women with major depression and more than 63% of those with minor depression, with a specificity of 92.5% and a positive predictive value of 56.8%. The positive predictive value with a scoring threshold of 10 was 39.2%.¹⁴ In an unpublished study, married U.S. women were screened close to 6 weeks postpartum; scores of 10 or greater provided 90.5% sensitivity for major and minor depression diagnosed by full psychiatric interview, with 86.1% specificity and a positive predictive value of 79.2%.

A few studies in the United States have used the Edinburgh Postnatal Depression Scale as a screening tool, but none were based on a community population.^15–17 The present study examined the community prevalence of women with abnormally high scores on the Edinburgh Postnatal Depression Scale. To confirm the feasibility of community use of this screening tool, we instituted routine screening at all Olmsted County clinics that provided ambulatory postnatal care. The retrospective incidence rate for postpartum depression before systematic screening in our community was among the lowest reported in the medical literature (3.7%).¹⁸ We sought to compare the proportion of women with likely postpartum depression as identified by this screening tool with the incidence rate of post-partum depression previously diagnosed in this community.

	Methods

Top Abstract Methods Results Discussion References

 
After approval by the Institutional Review Boards of Olmsted Medical Center and the Mayo Clinic, the research was conducted in Olmsted County, Minnesota, which has more than 106,000 residents; 97.6% are white non-Hispanic, and socioeconomic and educational levels are above average for most U.S. counties. There are approximately 2700 births each year in the county, and approximately 1750 of these are to Olmsted County residents (Department of Vital Statistics, Olmsted County, MN). Olmsted County serves as a valuable site for population-based epidemiologic research. All hospital births there occur at Rochester Methodist Hospital or Olmsted Community Hospital, and nearly all post-partum care for county residents is given at the Mayo Clinic, Olmsted Medical Center, and their satellite practices.

All Olmsted County residents who gave birth in the county between July 28, 1997 and March 28, 1998 were asked to complete the Edinburgh Postnatal Depression Scale and a demographic questionnaire at a routinely scheduled clinic visit near the sixth week postpartum. Data were collected from September 9, 1997 to May 29, 1998 in the Departments of Obstetrics and Gynecology and Family Medicine affiliated with the Mayo Clinic and Olmsted Medical Center. Eligible women not presenting for postnatal care were identified by birth and administrative records, contacted by mail, and asked to complete and return the survey. Women whose pregnancies terminated before 24 weeks’ gestation were excluded from the study, as were women who presented for postpartum care at the study sites but had not given birth in Olmsted County during the specified time or were not Olmsted County residents.

We introduced the scale to the subjects as a "Maternal Feelings Survey" to reduce recruitment and response biases and attached a cover sheet offering participation in the study and detailing patients’ rights to ensure confidentiality and to decline participation. The completed scale and a simple scoring template were made available to each woman’s clinician during the visits. The surveys were also entered into a database and scored weekly. We evaluated Edinburgh Postnatal Depression Scale cutoffs of 12 or higher and 10 or higher, both of which have been suggested as appropriate for routine screening in a primary care setting.^11,13 We alerted health care providers of any woman who had a score of 12 or greater or who indicated suicidal ideation, whether responding in the clinic or by mail. Further care of identified women remained at the discretion of individual clinicians.

The primary analysis was the calculation of the proportion of women identified as having Edinburgh Postnatal Depression Scale scores above various thresholds. The associations between screening scores and basic demographic information were assessed using ² tests. Comparisons of continuous variables were made using two-sample t tests and Wilcoxon rank-sum tests. Confidence intervals (CIs) were calculated for proportions and the differences between proportions. All statistical tests were two-sided, and the level of significance was =.05. All analyses were done using SAS version 6.12 (SAS Institute, Cary, NC).

The estimated prevalence rate of postpartum depression was calculated using our screening results and the sensitivities and specificities of the Edinburgh Postnatal Depression Scale previously determined by Swain et al (Swain AM, Stuart S, O’Hara MW. Validation of the Edinburgh Postnatal Depression Scale with an American community sample. Unpublished manuscript, 1996, Lincoln, NE) and others.^11,12,14 This was compared with the rate of recognized postpartum depression found in Olmsted County before screening. In a previous study,¹⁸ medical records were reviewed for a randomly selected sample of 403 Olmsted County women who gave birth in 1993. All diagnoses of depression and episodes of treatment with onset during the first year postpartum were identified. The rate of recognized postpartum depression was 3.7%.¹⁸

	Results

Top Abstract Methods Results Discussion References

 
Of the 1093 eligible women, 909 (83.2%) completed the Edinburgh Postnatal Depression Scale during the 8-month study period and were included in the analysis. Eighty-nine percent (810 of 909) of the subjects completed the scale and demographic sheets while at a clinic visit, and 10.9% (99 of 909) were recruited by mail. An additional 0.3% of women (three of 1093) responded to fewer than eight of the ten screening questions and were excluded from analysis. We were unable to collect surveys from 181 of the 1093 eligible women (16.6%). Nine of these women explicitly refused to participate, and the remainder did not respond to mail contact. Nearly 25% (45 of 181) of the nonrespondents had Southeast Asian, Somali, Arabic, or Hispanic surnames, a high percentage given that only 2.4% of county residents belong to minority racial or ethnic groups.

Almost half of the responding subjects (450 of 909; 49.5%) were 25–32 years old; more than 5% (47 of 909) were less than 19 years old, 18.6% (169 of 909) were 19–24 years old, and 26.7% (243 of 909) were at least 33 years old. Most women were married (763 of 905; 84.3%). An additional 11 (1.2%) reported being divorced or separated. Sixty-two (6.9%) were single and living with a partner; 69 (7.6%) were single and not living with a partner. Four women did not report marital status.

Most subjects (773 of 903; 85.6%) reported finishing the questionnaires in less than 5 minutes. Fourteen percent (122 of 903) took 5–10 minutes, and only 1% (eight of 903) required more than 10 minutes. Six women did not report the length of time required to complete the questionnaires. Twelve of the 909 participants (1.3%) required assistance with translation, and another 12 English speakers (1.3%) needed help reading or writing to fill out the forms.

Figure 1 illustrates the distribution of Edinburgh Postnatal Depression Scale scores in the study population. The median score was 5.5. Table 1 shows that 11.4% of women scored at least 12 on the scale (104 of 909), with a 95% CI of 9.4%, 13.5%. At the cutoff of 10 or greater, the percentage of women with positive screens increased to 19.8% (n = 180; 95% CI 17.2%, 22.4%).

View larger version (34K): [in this window] [in a new window]   Figure 1. Distribution of scores on the Edinburgh Postnatal Depression Scale (EPDS).

Study subjects completed the Edinburgh Postnatal Depression Scale at a median of 6.4 weeks postpartum. Time elapsed since delivery had no discernible effect on the subjects’ scores. The numbers of deliveries were similar each month and there were no significant differences in scoring patterns by month of delivery, suggesting that seasonal changes were of minor importance. There were also no significant differences in screening scores between women who completed the scale in the clinic and those who responded by mail.

Almost 11% (93 of 862) of women aged 19 and older scored 12 or above on the scale. Subjects under age 19 had elevated scores roughly twice as often, with 23.4% (11 of 47) scoring 12 or above (P = .047). More than half (54.6%; n = 6) of divorced or separated women had screening scores of 12 or greater, a rate significantly higher than in other subjects (P = .001). More than 11% (n = 8) of single but not cohabitating subjects, 17.7% (n = 11) of women living with a partner, and 10.4% (n = 79) of married women scored 12 or higher. Similar results for age and marital status were obtained at other scoring thresholds, including 10 and above.

	Discussion

Top Abstract Methods Results Discussion References

 
Universal screening with the Edinburgh Postnatal Depression Scale found a much higher percentage of women in need of assessment for postpartum depression than was previously recognized in Olmsted County. Worrisome scores were found in 11–20% of postpartum women, and suicidal ideation was reported by more than 5%. Before the introduction of mass screening in Olmsted County, Bryan et al¹⁸ found a 3.7% incidence rate for depression in the first year postpartum. The 15 of 403 women identified in that study represented virtually all of those with any evaluation for depression documented in their medical records.¹⁸

A screening tool cannot be used alone to determine precisely the community prevalence of postpartum depression for epidemiologic purposes. However, by considering positive predictive values from the validation studies likely to be most applicable to this U.S. community setting, we conservatively estimate that at least 7.5% of Olmsted County women in this sample have postpartum depression correctly predicted by high scores on the Edinburgh Postnatal Depression Scale. This is a statistically and clinically significant increase over the 3.7% incidence rate previously documented in the same county (P < .001).¹⁸ Including women with false-negative (low) scores would further raise the estimated community prevalence rate.

The rates of elevated scores on the Edinburgh Post-natal Depression Scale reported in this study are similar to rates found in other prospective U.S. studies. For example, 19.8% of our subjects had scores of 10 or greater, as did 17.4% of women presenting for postpartum care at a Wisconsin clinic.¹⁵ The cutoff point of 10 or higher has been suggested by Swain et al and others¹¹ as ideal for use in primary care settings to avoid missing women who may be depressed. However, sufficient resources must be available to assess the additional women identified by lowering the screening threshold to this level, and using scores of 12 or higher should yield a higher positive predictive value.

Whereas 11.4% of our subjects scored at least 12 on the Edinburgh Postnatal Depression Scale, more than 17% of women receiving postpartum care at Long Island Jewish Medical Center in New York and at a county health department in rural North Carolina had scores this high.^16,17 As many as 23.4% of innercity subjects in a recent U.S. study were found by diagnostic interview to suffer from postpartum depression.¹⁹ The prevalence rate of women with likely postpartum depression estimated in our study may be a conservative figure for the U.S. population as a whole, and mass screening may be even more urgent in communities more socioeconomically diverse than ours.

Women younger than 19 exhibited nearly twice the rate of elevated scores as other age groups. Some research has shown young maternal age to be a risk factor for postpartum depression, but an age association has not been found in all studies and may be culturally related.^2,20 Divorced and separated mothers also scored significantly higher than others. The stress of separation and divorce may have predisposed these women to postpartum depression, or perhaps previous depressive episodes in these women contributed to marital distress.^6,20 Our results suggest that women under 19 and divorced or separated women may require especially close evaluation because they may be at greater risk for developing depressive symptoms after delivery.

Although suicidal ideation tended to correlate with high overall scores, some women who reported suicidal ideation during the previous week had total scores less than the screening cutoff of 12. Regardless of total score, any positive response to the suicidal ideation item on the Edinburgh Postnatal Depression Scale indicates an urgent need for further assessment and therapy. Women who acknowledge even infrequent thoughts of self-harm need to be treated seriously, and clear systems for evaluation or referral should be in place.¹³

The screening tool was acceptable to most participants, with very few refusals in the clinic and with more than 85% of women spending less than 5 minutes on the survey. Health care providers at the study sites stated that the scale and scoring templates were easy to use and provided a quick and objective method to help determine who needed additional assessment. Clinicians reported that the survey provided a forum from which further discussions about postnatal difficulties could evolve, and they are incorporating screening with the Edinburgh Postnatal Depression Scale into the care of all postpartum women in Olmsted County.

The main limitation of this study was the homogeneous nature of the population. The overall socioeconomic and educational levels of Olmsted County residents are high. Limited numbers of racial and ethnic minorities live in the community, making generalizability to inner-city or nonwhite populations difficult. Women who may have language or cultural barriers to health care, as determined by surname, were disproportionately represented (25%) among eligible nonparticipants in our study. These women may require closer postnatal follow-up.

We were unable to assess fully other characteristics of the nonrespondents in this study (16.6%), making it difficult to ascertain the effects of recruitment bias on our results. Women who do not report to their scheduled postpartum visits may represent a group more likely to be suffering from depression. Nonparticipants in epidemiologic studies tend to have higher rates of psychiatric disorders than those who agree to participate.²¹ Thus, the true prevalence rate of women suffering from postpartum depression in the community may be higher than we report here.¹⁴

There is strong evidence that depression is under-treated in this country, at high cost to individuals and society, and substantial barriers to the diagnosis and treatment of depression have been identified.^22,23 Maternity care provides an important point of contact with the health care system for women at risk for depression. Because postpartum depression is a common condition with serious consequences and readily available treatments, a routine screening program is appropriate.^1,7,24 The Edinburgh Postnatal Depression Scale is a sensitive and specific screening tool supported by excellent previous validation and extensive clinical use worldwide.^8,13

	Footnotes

 
Support for this study was provided by the Mayo Foundation.

PII S0029-7844(98)00543-2

Received July 31, 1998. Received in revised form October 23, 1998. Accepted November 13, 1998.

	References

Top Abstract Methods Results Discussion References

 
1. Stowe ZN, Nemeroff CB. Women at risk for postpartum-onset major depression. Am J Obstet Gynecol 1995;173:639–45.[Medline]

2. O’Hara MW. Postpartum depression: Causes and consequences. New York: Springer-Verlag, 1995.

3. Dobie SA, Walker EA. Depression after childbirth. J Am Board Fam Pract 1992;5:303–11.

4. Gotlib IH, Whiffen VE, Mount JH, Milne K, Cordy NI. Prevalence rates and demographic characteristics associated with depression in pregnancy and the postpartum. J Consult Clin Psychol 1989;57: 269–74.[Medline]

5. Weinberg MK, Tronick EZ. Maternal depression and infant maladjustment: A failure of mutual regulation. In: Nospitz JD, ed. Handbook of child and adolescent psychiatry. New York: John Wiley & Sons, 1997:177–91.

6. Boyce P. Personality dysfunction, marital problems and postnatal depression. In: Cox J, Holden J, eds. Perinatal psychiatry: Use and misuse of the Edinburgh Postnatal Depression Scale. London: Gaskell, 1994:82–102.

7. Cohen LS, Altshuler LL. Pharmacologic management of psychiatric illness during pregnancy and the postpartum period. Psychiatr Clin North Am 1997;4:21–60.

8. O’Hara MW. Postpartum depression: Identification and measurement in a cross-cultural context. In: Cox J, Holden J, eds. Perinatal psychiatry: Use and misuse of the Edinburgh Postnatal Depression Scale. London: Gaskell, 1994:145–68.

9. Jadresic E, Araya R, Jara C. Validation of the Edinburgh Postnatal Depression Scale (EPDS) in Chilean postpartum women. J Psychosom Obstet Gynaecol 1995;16:187–91.[Medline]

10. Wickberg B, Hwang CP. The Edinburgh Postnatal Depression Scale: Validation on a Swedish community sample. Acta Psychiatr Scand 1996;94:181–4.[Medline]

11. Cox JL, Holden JM, Sagovsky R. Detection of postnatal depression. Development of the 10-item Edinburgh Postnatal Depression Scale. Br J Psychiatry 1987;150:782–6.[Abstract/Free Full Text]

12. Harris B, Huckle P, Thomas R, Johns S, Fung H. The use of rating scales to identify post-natal depression. Br J Psychiatry 1989;154: 813–7.[Abstract/Free Full Text]

13. Holden J. Using the Edinburgh Postnatal Depression Scale in clinical practice. In: Cox J, Holden J, eds. Perinatal psychiatry: Use and misuse of the Edinburgh Postnatal Depression Scale. London: Gaskell, 1994:125–44.

14. Carothers AD, Murray L. Estimating psychiatric morbidity by logistic regression: Application to post-natal depression in a community sample. Psychol Med 1990;20:695–702.[Medline]

15. Schaper AM, Rooney BL, Kay NR, Silva PD. Use of the Edinburgh Postnatal Depression Scale to identify postpartum depression in a clinical setting. J Reprod Med 1994;39:620–4.[Medline]

16. Reighard FT, Evans ML. Use of the Edinburgh Postnatal Depression Scale in a southern, rural population in the United States. Prog Neuropsychopharmacol Biol Psychiatry 1995;19:1219–24.[Medline]

17. Roy A, Gang P, Cole K, Rutsky M, Reese L, Weisbord J. Use of Edinburgh Postnatal Depression Scale in a North American population. Prog Neuropsychopharmacol Biol Psychiatry 1993;17: 501–4.[Medline]

18. Bryan TL, Georgiopoulos AM, Harms RW, Huxsahl JE, Larson DR, Yawn BP. Incidence of postpartum depression in Olmsted County, Minnesota: A population-based retrospective study. J Reprod Med (in press).

19. Hobfoll SE, Ritter C, Lavin J, Hulsizer MR, Cameron RP. Depression prevalence and incidence among inner-city pregnant and postpartum women. J Consult Clin Psychol 1995;63:445–53.[Medline]

20. Kendell RE. Emotional and physical factors in the genesis of puerperal mental disorders. J Psychosom Res 1985;29:3–11.[Medline]

21. Cox A, Rutter M, Yule B, Quinton D. Bias resulting from missing information: Some epidemiological findings. Br J Prev Soc Med 1977;31:131–6.[Medline]

22. Hirschfeld RM, Keller MB, Panico S, Arons BS, Barlow D, Davidoff F, et al. The National Depressive and Manic-Depressive Association consensus statement on the undertreatment of depression. JAMA 1997;277:333–40.[Abstract]

23. Schmidt LA, Greenberg BD, Holzman GB, Schulkin J. Treatment of depression by obstetrician-gynecologists: A survey study. Obstet Gynecol 1997;90:296–300.[Abstract]

24. Sackett DL, Haynes RB, Guyatt GH, Tugwell P. Clinical epidemiology: A basic science for clinical medicine. 2nd ed. Boston: Little, Brown, 1991.

This article has been cited by other articles:

				A. L. Kozyrskyj, X.-M. Mai, P. McGrath, K. T. HayGlass, A. B. Becker, and B. MacNeil Continued Exposure to Maternal Distress in Early Life Is Associated with an Increased Risk of Childhood Asthma Am. J. Respir. Crit. Care Med., January 15, 2008; 177(2): 142 - 147. [Abstract] [Full Text] [PDF]

				D. K. Gjerdingen and B. P. Yawn Postpartum Depression Screening: Importance, Methods, Barriers, and Recommendations for Practice J Am Board Fam Med, May 1, 2007; 20(3): 280 - 288. [Abstract] [Full Text] [PDF]

				S. J. B. McCoy, J. M. Beal, S. B. M. Shipman, M. E. Payton, and G. H. Watson Risk Factors for Postpartum Depression: A Retrospective Investigation at 4-Weeks Postnatal and a Review of the Literature J Am Osteopath Assoc, April 1, 2006; 106(4): 193 - 198. [Abstract] [Full Text] [PDF]

				D. A. Seehusen, L.-M. Baldwin, G. P. Runkle, and G. Clark Are Family Physicians Appropriately Screening for Postpartum Depression? J Am Board Fam Med, March 1, 2005; 18(2): 104 - 112. [Abstract] [Full Text] [PDF]

				L. H. Chaudron, P. G. Szilagyi, H. J. Kitzman, H. I.M. Wadkins, and Y. Conwell Detection of Postpartum Depressive Symptoms by Screening at Well-Child Visits Pediatrics, March 1, 2004; 113(3): 551 - 558. [Abstract] [Full Text] [PDF]

This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by GEORGIOPOULOS, A. M. Articles by THERNEAU, T. M. Search for Related Content PubMed PubMed Citation Articles by GEORGIOPOULOS, A. M. Articles by THERNEAU, T. M.