Brief report
Can we identify mothers at risk for postpartum depression in the immediate postpartum period using the Edinburgh Postnatal Depression Scale?

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Abstract

Background: Postpartum depression is a major health issue for many women around the world with well-documented negative health consequences for the mother, child and family. While research has demonstrated the amenability of postpartum depression to treatment, there is preliminary evidence suggesting maternal mood in the immediate postpartum period may be predictive of postpartum depression such that secondary preventive interventions may be implemented. Methods: A population-based sample of 594 mothers completed the Edinburgh Postnatal Depression Scale (EPDS) at 1, 4 and 8 weeks postpartum. The sensitivity, specificity and predictive power of the 1-week EPDS in relation to identifying mothers with elevated EPDS scores at 4 and 8 weeks was determined. The predictive power of the 1-week EPDS was further assessed using odds ratios and receiver operator characteristic (ROC) curves. Results: At 1 week postpartum, 29.5% of mothers scored >9 on the EPDS, decreasing to 23% at 4 weeks and 20.5% at 8 weeks. Using the cut-off score of 9/10, the 1-week EPDS accurately classified 85.4% mothers at 4 weeks and 82.5% mothers at 8 weeks with or without postpartum depression symptomatology. The 1-week EPDS was significantly correlated to the 4-week (r=0.72, P<0.001) and 8-week (r=0.65, P<0.001) EPDS. Mothers with a 1-week EPDS score >9 were 30.3 times more likely at 4 weeks (95% CI=17.5–42.3) and 19.1 times more likely at 8 weeks (95% CI=11.0–32.9) to exhibit postpartum depression symptomatology. Limitations: Psychiatric interviews were not completed in collaboration with the EPDS. Conclusion: The EPDS administered in the 1st week postpartum was predictive of maternal mood at 4 and 8 weeks postpartum. To identify mothers at high risk for postpartum depression, health care professionals could consider screening all new mothers in the immediate postpartum period such that secondary preventive interventions may be implemented.

Introduction

Childbirth represents for women a time of great vulnerability to become mentally unwell, with postpartum mood disorders representing the most frequent form of maternal morbidity following delivery (Stocky and Lynch, 2000). These affective disorders range in severity from the early maternity blues to postpartum psychosis, a serious state affecting less than 1% of mothers usually requiring hospitalization (Evins and Theofrastous, 1997). Along this spectrum is postpartum depression, a disabling condition affecting ∼13% of mothers (O’Hara and Swain, 1996). The inception rate is greatest in the first 12 weeks (Cooper and Murray, 1998) and, while residual depressive symptoms are common (O’Hara, 1997), up to 50% of mothers will remain clinically depressed at 6 months postpartum (Kumar and Robson, 1984).

This hidden maternal morbidity has well documented public health consequences for the mother, child and family. While women who have suffered from postpartum depression are twice as likely to experience future episodes of depression over a 5-year period (Cooper and Murray, 1995), infants and children are particularly vulnerable. Inauspiciously, postpartum depression is mediated through impaired maternal–infant interactions (Murray et al., 1996) and negative perceptions of infant behaviour (Campbell et al., 1995), and has been linked to various adverse outcomes including attachment insecurity (Murray, 1992), emotional and cognitive developmental delay (Whiffen and Gotlib, 1989, Hipwell et al., 2000), social difficulties (Murray et al., 1999), and long-term behavioural problems (Beck, 1999).

While postpartum depression is amenable to treatment (Ray and Hodnett, 2000), preliminary research suggests mothers at risk may be identified early in the postpartum period such that secondary preventive interventions may be implemented. For example, using the Edinburgh Postnatal Depression Scale (EPDS; Cox et al., 1987), significant correlations have been detected between maternal mood at 5 days and 6 weeks postpartum (r=0.60, P<0.001) with mothers scoring >9 at 5 days being eight times more likely to score >9 at 6 weeks than those scoring ≤9 (Hannah et al., 1992). In a similar study, mothers scoring >9 at 5 days postpartum were 20 times more likely to be diagnosed with postpartum depression during the first 12 weeks postpartum (Yamashita et al., 2000). The saliency of maternal mood within the first 2 weeks postpartum as a predictor of postpartum depression has been further substantiated in a recent meta-analysis of 85 studies (Beck, 2001). However, no study has specifically assessed the stability of maternal mood or the concordance between EPDS scores in the immediate postpartum period to 8 weeks postpartum. The purpose of this population-based study was to determine the prevalence and stability of low maternal mood at 1 week postpartum and to evaluate the sensitivity, specificity and predictive power of the EPDS when administered at 1 week postpartum on depressive symptomatology at 4 and 8 weeks postpartum.

Section snippets

Subjects

Participants completed questionnaires at 1, 4 and 8 weeks postpartum as part of a longitudinal study conducted in a health region near Vancouver, British Columbia from April to October 2001. Eligible women were at least 18 years of age, able to understand English, and either >32 weeks pregnant or within the 1st week postpartum. Mothers who did not return the 1-week questionnaire were excluded from this study.

Instrument

The Edinburgh Postnatal Depression Scale (EPDS) is a 10-item self-report instrument

Sample characteristics

A total of 166 participants were recruited antenatally with 115 (69%) returning the 1-week postpartum questionnaire. Of the ∼971 women screened postnatally, 857 were eligible; the most common reason for ineligibility was inability to read English (24%). Of the eligible women, 190 (22%) declined enrolment. Of the 667 new mothers who agreed to participate in the study, 479 returned the 1-week postpartum questionnaire for a 72% response rate. In total, 594 participants returned the 1-week

Discussion

The aim of this study was to assess the stability of maternal mood over the first 8 weeks postpartum and determine the sensitivity, specificity and predictive validity of the 1-week EPDS on future EPDS scores and postpartum depression symptomatology. This is the first known population-based study to specifically evaluate these outcomes and examine the clinical utility of screening new mothers with the EPDS in the immediate postpartum period. While the EPDS has good sensitivity and specificity

Acknowledgments

I gratefully acknowledge the research team including: Margaret Gander (Fraser Valley Regional Director for Prevention and Early Intervention), Patricia Whitehead (Manager for Public Health Nursing, Mission and Hope Health Units), Linda Bachmann (project co-ordinator), research assistants (Alana Boucher, Terry Gust, Pam Munro, Tina Regehr, Phyllis Randle, Lorraine Friesen), and the research liaison public health nurses (Heidi Beckerleg, Yvette Szabo, Mona Taylor, Linda Winner). Finally, I would

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