Postpartum depression: terminological considerations

LETTER TO THE EDITORS

Postpartum depression: terminological considerations

Lucas Spanemberg

Specialist in Psychiatry. Treasurer, Centro de Estudos em Psiquiatria Integrada (CENESPI), and psychiatrist, Ambulatório de Auxílio à Cessação do Tabagismo, Hospital São Lucas, Pontifícia Universidade Católica do Rio Grande do Sul (PUCRS), Porto Alegre, RS, Brazil. Guest Professor, Instituto Fernando Pessoa (IFP), Porto Alegre, RS, Brazil. Correspondence: [e-mail]

Dear Editors,

Regarding the article "Postpartum depression epidemiology in a Brazilian sample,"¹ I would like to make a few criticisms as to the terminology used, which may create confusion and yield false data on depressive conditions.

Firstly, it is known that the specialized literature has a number of diagnostic instruments (qualitative) and for symptom severity (quantitative) for the assessment of depression.² The authors have to choose from a range of options, according to the criteria that consider what is under assessment. In the present study, a screening scale for depression was used (Edinburgh Postnatal Depression Scale - EPDS),³ which is widely used in the international literature. However, based on the results of the aforementioned study, there was a terminological confusion between "depressive symptoms" (suggesting a disorder, but not defining it) and diagnosis of postpartum depression. In addition, all the tables used the diagnosis of "postpartum depression" or "depressed vs. non-depressed women," instead of characterizing what was really studied, i.e., postpartum depressive symptoms. That scale was then used to define diagnosis of postpartum depression, which is not its purpose. The authors of this scale suggest that the scores should be submitted to a careful clinical evaluation to confirm the diagnosis.³

In our country, prevalence studies commonly use quantitative or screening scales to diagnose depression.^4-7 Some of these studies correctly describe the use of instruments (EPDS, Beck, Hamilton, etc.), but fail to describe results, considering cut-off points as defining the diagnosis. In addition, different cut-off points make it difficult to compare the data.

Bernardi⁸ warns about the paradoxes generated by advances in mental health studies: on the one hand, the possibility of new therapeutic resources; on the other, a possible flexibility of some nosological entities (and tendency to medicalization) due to non-scientific reasons. It can also be considered that improper use of scales may result in a diagnostic overestimation or diagnostic confusion, since overlapping of symptoms in different diagnostic categories is common.

It should be added that the study on postpartum depressive symptoms using EPDS is extremely important and highly pertinent, as it provides a fast and simple screening that can be applied by any practitioner. The validity of such an approach is mainly justified in primary care environments, where most puerperal women are given care. However, patients with symptom scores suggestive of depression should be assessed using more thorough approaches. Finally, the scientific literature should stress adequate use of technical terms and instruments, otherwise it runs the risk of publishing wrong information, which contributes to the saturated ocean of controversial statistics found in modern times.

AUTHORS' REPLY

Dear editors,

In contrast with other medical areas, subsidiary diagnostic resources are rarely used in psychiatry, an eminently clinical specialty.¹ Even the DSM-IV, by listing symptoms, does not aim at replacing the comprehensiveness of a clinical diagnosis.² The use of standardized instruments to assess psychiatric symptoms in clinical research has been justified by accurate and reproducible measurements.¹

The article "Postpartum depression epidemiology in a Brazilian sample"³ is quite clear in explaining that the Edinburgh Postnatal Depression Scale (EPDS) was chosen because it is an instrument specifically developed for application in women within a 12-month period after delivery. Although there is a large variation in cut-off points used in validations performed in different countries that are culturally, socially and economically different from Brazil,⁴ the national validation study adopted a 11/12 score because it had the best prediction indexes.⁵

One of the limitations in our study is the fact that the EPDS is a screening instrument of depressive symptoms, and there was no intention to create a controversy or even to lower the value of the work performed by a mental health team. We consider assessment scales as valuable instruments for the Basic Health Care of a country that lacks specialized professionals.

Although we have inserted tables and charts relative to diagnostic confirmation of depression in the graphic printing of the article, the text maintained its coherence by informing that the instrument used is for diagnostic screening, and does not dismiss clinical assessment by a specialist.

Gustavo Enrico Cabral Ruschi

Specialist in Gynecology and Obstetrics. MSc. in Health Sciences, Emphasis on Obstetrics, Universidade Federal de São Paulo - Escola Paulista de Medicina (UNIFESP-EPM), São Paulo, SP, Brazil. Obstetrician and Gynecologist, Instituto Estadual de Saúde Pública do Espírito Santo (IESP) and Prefeitura Municipal de Vitória, Vitória, ES, Brazil. Assistant professor, Programa de Interação Serviço-Ensino-Comunidade (PISEC), Centro Universitário Vila Velha (UVV), Vila Velha, ES, Brazil. Correspondence: [e-mail]

Referências (carta aos editores) / REFERENCES (letter to the editors)

Resposta dos autores

Prezados editores,

Contrastando com outras áreas da medicina, recursos diagnósticos subsidiários são pouco utilizados em psiquiatria, especialidade eminentemente clínica¹. Mesmo o DSM-IV, ao listar os sintomas, não tem o propósito de substituir a abrangência do diagnóstico clínico². A utilização de instrumentos padronizados de avaliação dos sintomas psiquiátricos nas pesquisas clínicas tem se justificado pela obtenção de medidas acuradas e reprodutíveis¹.

O artigo intitulado "Aspectos epidemiológicos da depressão pós-parto em amostra brasileira"³ deixa bem claro que a escolha da Escala de Depressão Pós-parto de Edimburgo (EPDS) deveu-se ao fato de ser um instrumento desenvolvido especificamente para aplicação em mulheres no período de 12 meses após o parto. Mesmo havendo grandes variações nos pontos de corte adotados nas validações realizadas em diversos países que se diferenciam cultural e socioeconomicamente do Brasil⁴, o estudo de validação nacional adota pontuação 11/12 por ter apresentado melhores índices de predição⁵.

Apontamos como limitação do estudo o fato da EPDS ser um instrumento de triagem dos sintomas depressivos, não havendo intenção de polemizar e até mesmo desvalorizar o trabalho da equipe de saúde mental. Consideramos as escalas de avaliação instrumentos indispensáveis na Atenção Básica de Saúde de um país carente de profissionais especializados.

Embora tenhamos inserido tabelas e gráficos que se referem à confirmação diagnóstica de depressão na impressão gráfica do artigo, o texto manteve sua coerência ao informar que o instrumento adotado é de triagem diagnóstica, não dispensando a avaliação clínica do especialista.

Referências ( resposta dos autores ) / REFERENCES (authors' reply)

• 1. Ruschi GE, Sun SY, Mattar R, Chambô Filho A, Zandonade E, Lima VJ. Aspectos epidemiológicos da depressão pós-parto em amostra brasileira. Rev Psiq RS. 2007;29(3):274-80.
• 2. Calil HM, Pires MLN. Aspectos gerais das escalas de avaliação da depressão. Rev Psiq Clin. 1998;25(5):240-4.
• 3. Cox JL, Holden MJ, Sagovsky R. Detection of postnatal depression: development of the 10-item Edinburgh Postnatal Depression Scale. Br J Psychiatry. 1987;150:782-6.
• 4. Furegato ARF, Silva EC, Campos MC, Cassiano RPT. Depressão e auto-estima entre acadêmicos de enfermagem. Rev Psiquiatr Clin. 2006;33(5);239-44.
• 5. Moraes IG, Pinheiro RT, Silva RA, Horta BL, Sousa PL, Faria AD. Prevalence of postpartum depression and associated factors. Rev Saude Publica. 2006;40(1):65-70.
• 6. Cruz EBS, Simões GL, Faisal-Cury A. Rastreamento da depressão pós-parto em mulheres atendidas pelo Programa de Saúde da Família. Rev Bras Ginecol Obstet. 2005;27(4):181-8.
• 7. Da-Silva VA, Moraes-Santos AR, Carvalho MS, Martins ML, Teixeira MA. Prenatal and postnatal depression among low income Brazilian women. Braz J Med Biol Res. 1998;31(6):799-804.
• 8. Bernardi R. Transtornos de humor bipolar: uma visão integradora. Rev Psiq RS. 2007;29(3):259-61.
• 1. Jorge MR, Custódio O. Utilidade das escalas de avaliação para clínicos e pesquisadores. Rev Psiquiatr Clin. 1999;26(2):102-5.
• 2. Gomes de Matos E, Gomes de Matos TM, Gomes de Matos GM. A importância e as limitações do uso do DSM-IV na prática clínica. Rev Psiquiatr RS. 2005;27(3):312-8.
• 3. Ruschi GEC, Sun SY, Mattar R, Chambô Filho A, Zandonade E, Lima VJ. Aspectos epidemiológicos da depressão pós-parto. Rev Psiq RS. 2007;29(3):274-80.
• 4. Halbreich U, Karkun S. Cross-cultural and social diversity of prevalence of postpartum depression and depressive symptoms. J Affect Disord. 2006;91(2-3):97-111.
• 5. Santos MFS. Depressão pós-parto: validação da Escala de Edimburgo em puérperas brasilienses [tese]. Brasília: Instituto de Psicologia; 1995.

Publication Dates

• Publication in this collection
  01 Dec 2008
• Date of issue
  Apr 2008