Screening and diagnosing postpartum depression: when and how?

Prevalence rates of postpartum depression (PPD) vary widely, depending on the methodological parameters used in studies: differences in study populations, diagnostic methods, and postpartum time frame. There is also no consensus on the ideal time to perform screening, on whether PPD can only be diagnosed in the early postnatal period, or on how soon after a delivery depression may be related to it.

Objective:

To review which instruments have been used over recent years to screen and diagnose PPD and the prevailing periods of diagnosis.

Methods:

Only articles published within 5 years and related exclusively to screening and diagnosis were selected. The sample comprised 22 articles.

Results:

The Edinburgh Posnatal Depression Scale (EPDS) was the most common screening tool, used in 68% of the sample (15 articles), followed by the Beck Depression Inventory (BDI-II) (27%, 6 articles), and the Patient Health Questionnaire-9 (PHQ-9) (18%, 4 articles). Screening time frame was reported in 21/22 articles: 0 to 3 months postpartum in 9 (43%), up to 6 months in 4 (19%), and up to 12 months or more in 8 (38%). In short, 13 articles screened during the first 6 months (59%) while only 8 (36%) screened up to 1 year.

Conclusion:

The most frequent PPD diagnosis tool was the EPDS, but other scales were also used. The most common period for diagnosis was up to 3 months postpartum. However, some researchers diagnosed PPD 12 months or more postpartum. Greater standardization of parameters for investigation of this disease is needed.

Keywords:
Postpartum depression; perinatal depression; postnatal depression; screening; diagnosis

Author and year	Country	Sample size	Screening tool	EPDS cutoff score	Last time for screening after delivery		Comments
Author and year	Country	Sample size	Screening tool	EPDS cutoff score	Weeks	Months	Comments
Horowitz et al.¹⁹19 Horowitz JA, Murphy CA, Gregory KE, Wojcik J. Best practices: community-based postpartum depression screening: results from the CARE study. Psychiatr Serv. 2009;60:1432-4.	USA	5,169	EPDS	> 10	04	01	PPD was defined as beginning by 4 weeks. Of this group, 674 (13%) women had EPDS scores > 10.
Miller et al.²⁰20 Miller L, Shade M, Vasireddy V. Beyond screening: assessment of perinatal depression in a perinatal care setting. Arch Womens Ment Health. 2009;12:329-34.	USA	5,439	EPDS	> 10	48	12	Among women eligible for screening, 62.5% completed screening and 17.1% of the women screened were identified as having depressive symptoms (EPDS > 10).
Shelton & Herrick²¹21 Shelton NJ, Herrick KG. Comparison of scoring methods and thresholds of the General Health Questionnaire-12 with the Edinburgh Postnatal Depression Scale in English women. Public Health. 2009;123:789-93.	UK	394	EPDS	> 10	48	12	There was reasonable correlation between the scoring methods over time, except at 4 months after delivery when the EPDS showed an upward spike and the GHQ-12 showed a plateau. This difference was statistically significant (p < 0.000, 95%CI -3.330-0.550, n = 27) and would result in mothers being diagnosed using the EPDS but not the GHQ-12. The prevalence of PPD was 24.4% using the EPDS.
Yawn et al.²²22 Yawn BP, Pace W, Wollan PC, Bertram S, Kurland M, Graham D, et al. Concordance of Edinburgh Postnatal Depression Scale (EPDS) and Patient Health Questionnaire (PHQ-9) to assess increased risk of depression among postpartum women. J Am Board Fam Med. 2009;22:483-91.	USA	481	EPDS PHQ-9	≥ 10	12	03	There was concordance between the EPDS and PHQ-9 in 399 women (83%): 326 (67.8%) had a "normal" score on both, and 73 (15.2%) had elevated scores for both. Discordant scores in the remaining 82 women included 17 with elevated PHQ-9 scores, but normal EPDS scores, and 65 with elevated EPDS scores and PHQ-9 scores < 10.
O'Mahen et al.²³23 O'Mahen HA, Flynn HA, Chermack S, Marcus S. Illness perceptions associated with perinatal depression treatment use. Arch Womens Ment Health. 2009;12:447-50.	USA	1,285	EPDS BDI-II IPQ	≥ 10	06	1.5	In this group,15.9% (n = 204) scored ≥ 10 on the EPDS.
Phillips et al.²⁴24 Phillips J, Charles M, Sharpe L, Matthey S. Validation of the subscales of the Edinburgh Postnatal Depression Scale in a sample of women with unsettled infants. J Affect Disord. 2009;118:101-12.	Australia	309	EPDS BDI-II BAI	≥ 13	48	12	For the total scale (EPDS), 30 of the 42 women diagnosed with a DSM-IV major depressive episode were correctly identified using a cutoff score of 13 or more (sensitivity 71%), and there were 24 false positives (misclassification rate 22%).
Goodman & Tyer-Viola⁴4 Goodman JH, Tyer-Viola L. Detection, treatment, and referral of perinatal depression and anxiety by obstetrical providers. J Womens Health (Larchmt). 2010;19:477-90.	USA	491	EPDS	≥ 10	06	1.5	Twenty-three percent of participants screened positive for an anxiety disorder or high levels of depressive symptoms or both prenatally, and 17% screened positive at 6 weeks postpartum.
Hayes et al.⁷7 Hayes DK, Ta VM, Hurwitz EL, Mitchell-Box KM, Fuddy LJ. Disparities in self-reported postpartum depression among Asian, Hawaiian, and Pacific Islander Women in Hawaii: Pregnancy Risk Assessment Monitoring System (PRAMS), 2004-2007. Matern Child Health J. 2010;14:765-73.	USA (Hawaii)	7,154	SRPDS PHQ-2	-	-	-	Of all women in Hawaii with a recent live birth, 14.5% had SRPDS. This study assessed estimates of postpartum depression in the Hawaiian community and demonstrated that almost half (45.6%) of women who recently gave birth to a live infant reported symptoms that might warrant further evaluation for postpartum depression.
Zubaran et al.¹⁶16 Zubaran C, Foresti K, Schumacher MV, Amoretti AL, Thorell MR, Müller LC. The correlation between postpartum depression and health status. Matern Child Health J. 2010;14:751-7.	Brazil	101	SCID GHQ-12 PHQ PDSS EPDS	≥ 13	12	03	In effect, the GHQ and the EPDS were considered valuable screening tools for detecting depression during the postpartum period as well as anxiety and adjustment disorders when conjointly tested.
Lau et al.²⁵25 Lau Y, Wong DF, Chan KS. The utility of screening for perinatal depression in the second trimester among Chinese: a three-wave prospective longitudinal study. Arch Womens Ment Health. 2010;13:153-64.	China	610	EPDS	> 9 > 14	06	1.5	The percentage of women with an EPDS score > 9 was 36.5% (n = 796) in the second trimester, decreasing to 32.0% (n = 502) in the third trimester and 31.6% (n = 193) at 6 weeks postpartum. The rates were 9.9%, 7.8%, and 8.7% for an EPDS score of > 14 in the second and third trimesters and at 6 weeks postpartum, respectively. Women with a second trimester EPDS score > 14 were 11.78 times more likely in the third trimester and 7.15 times more likely at 6 weeks postpartum to exhibit perinatal depressive symptomology.
Flynn et al.²⁶26 Flynn HA, Sexton M, Ratliff S, Porter K, Zivin K. Comparative performance of the Edinburgh Postnatal Depression Scale and the Patient Health Questionnaire-9 in pregnant and postpartum women seeking psychiatric services. Psychiatry Res. 2011;187:130-4.	USA	185	EPDS PHQ-9	≥ 13	52	13	This study found few significant differences in the performance of the PHQ-9 and EPDS for detecting clinician-diagnosed major depressive disorder in a psychiatric outpatient sample of pregnant and postpartum women.
Gjerdingen et al.²⁷27 Gjerdingen D, McGovern P, Center B. Problems with a diagnostic depression interview in a postpartum depression trial. J Am Board Fam Med. 2011;24:187-93.	USA	506	SCID PHQ-9	-	36	09	Forty-five women (8.9%) had a positive SCID interview and 112 (22.1%) had a positive PHQ-9 at 0 to 9 months postpartum.
Reichenheim et al.²⁸28 Reichenheim ME, Moraes CL, Oliveira AS, Lobato G. Revisiting the dimensional structure of the Edinburgh Postnatal Depression Scale (EPDS): empirical evidence for a general factor. BMC Med Res Methodol. 2011;11:93.	Brazil	811	EPDS	≥ 12	20	05	The mean EPDS score was 7.8 (95%CI 7.4-8.2) and 24.3% (95%CI 21.3-27.2) of the women scored at or above the cutoff point of 12.
Christensen et al.²⁹29 Christensen AL, Stuart EA, Perry DF, Le HN. Unintended pregnancy and perinatal depression trajectories in low-income, high-risk Hispanic immigrants. Prev Sci. 2011;12:289-99.	USA	215	BDI-II	-	48	12	Women who reported unintended pregnancies were over five times more likely to follow the "Postpartum High" depression pattern (RR = 5.22, p < 0.05), compared to women with an intentional pregnancy.
Tandon et al.³⁰30 Tandon SD, Cluxton-Keller F, Leis J, Le HN, Perry DF. A comparison of three screening tools to identify perinatal depression among low-income African American women. J Affect Disord. 2012;136:155-62.	USA	95	EPDS CES-D BDI-II	≥ 13	24	06	Over a quarter of women (28.4%) were experiencing major depression. Each screening tool was highly accurate in detecting major depression and major or minor depression among prenatal and postpartum women.
O'Hara et al.³¹31 O'Hara MW, Stuart S, Watson D, Dietz PM, Farr SL, D'Angelo D. Brief scales to detect postpartum depression and anxiety symptoms. J Womens Health (Larchmt). 2012;21:1237-43.	USA	1,077	BDI IDAS-GD EPDS	> 12	56	14	Rates of moderate to severe depression, based on the EPDS, BDI, and IDAS-GD ranged from 11 to 16%.
Mann et al.³²32 Mann R, Adamson J, Gilbody SM. Diagnostic accuracy of case-finding questions to identify perinatal depression. CMAJ. 2012;184:E424-30.	UK	152	Two brief case-finding questions	-	13	3.25	The proportion of participants who met the criteria for depression (minor and major) during the postnatal phase was 19.2% (95%CI 12-28.9). The brevity of the case-finding questions has substantial appeal for identification of perinatal depression in frontline health care services.
Kim et al.³³33 Kim HG, Geppert J, Quan T, Bracha Y, Lupo V, Cutts DB. Screening for postpartum depression among low-income mothers using an interactive voice response system. Matern Child Health J. 2012;16:921-8.	USA	324	EPDS	≥ 10	1.43	0.33	Postpartum depression symptoms were present in 17% (n = 55) (EPDS ≥ 10)
Maia et al.³⁴34 Maia BR, Pereira AT, Marques M, Bos S, Soares MJ, Valente J, et al. The role of perfectionism in postpartum depression and symptomatology. Arch Womens Ment Health. 2012;15:459-68.	Portugal	386	BDI-II	-	12	03	Observed postpartum period prevalence rates (from birth to the 3rd month postpartum) were 11.7 % (n = 45) (major depression/DSM-IV) and 16.6 % (n = 64) (depressive disorder/ICD-10).
Čuržik & Begić³⁵35 Čuržik D, Begić NJ. The utility of BDI-II in assessment of pre- and postpartum depression symptoms and their relation to labor pain. Psychiatr Danub. 2012;24:167-74.	Croatia	46	BDI-II	-	08	02	Depression symptoms measured two months postpartum were significantly lower than when measured during the late stage of pregnancy (t = 8.377, df = 49, p < 0.01). During the late stage of pregnancy, BDI-II items with highest mean scores were those measuring somatic symptoms of depression. Depression measured during the late stage of pregnancy correlated significantly with maximum labor pain expectancies (r = 0.41, p < 0.01). Use of standardized questionnaires with a high rate of somatic items such as BDI-II may not be the best solution when screening for mood disorders in pregnant women.
Apter et al.³⁶36 Apter G, Devouche E, Gratier M, Valente M, Nestour AL. What lies behind postnatal depression: is it only a mood disorder? J Pers Disord. 2012;26:357-67.	France	109	MADRS	-	12	03	Of 109 women in the sample, 39 had a MADRS score of 15 or more; i.e., 36% met the criteria for a depressive episode. Five had a score of 30 or more, indicating a severe depressive condition.
Baines et al.³⁷37 Baines T, Wittkowski A, Wieck A. Illness perceptions in mothers with postpartum depression. Midwifery. 2013;29:779-86.	UK	43	EPDS PHQ-9	≥10	16	04	The EPDS median was 17 (range1⁄410-27) confirming that participants were experiencing probable depression, with 39 participants scoring 12 or above, 2 scoring 11 and 4 scoring 10.

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[1] Correspondence: Amaury Cantilino Rua Padre Carapuceiro, 968, sala 108, Boa Viagem 51020-280 - Recife, PE - Brazil E-mail: cantilino@hotmail.com