SEARCH

SEARCH BY CITATION

Keywords:

  • postpartum depression;
  • antepartum depression;
  • Edinburgh Postnatal Depression Scale;
  • systematic review;
  • validation

Abstract

  1. Top of page
  2. Abstract
  3. Summations
  4. Considerations
  5. Introduction
  6. Material and methods
  7. Results
  8. Discussion
  9. Acknowledgements
  10. Declaration of interest
  11. References
  12. Appendices

Objective:  The Edinburgh Postnatal Depression Scale (EPDS) is the most widely used screening tool for postpartum depression (PPD). We systematically reviewed the published evidence on its validity in detecting PPD and antepartum depression (APD) up to July 2008.

Method:  Systematic review of validation studies of the EPDS included 1987–2008. Cut-off points of 9/10 for possible PPD, 12/13 for probable PPD and 14/15 for APD were used.

Results:  Thirty-seven studies met the inclusion criteria. Sensitivity and specificity of cut-off points showed marked heterogeneity between different studies. Sensitivity results ranged from 34 to 100% and specificity from 44 to 100%. Positive likelihood ratios ranged from 1.61 to 78.

Conclusion:  Heterogeneity among study findings may be due to differences in study methodology, language and diagnostic interview/criteria used. Therefore, the results of different studies may not be directly comparable and the EPDS may not be an equally valid screening tool across all settings and contexts.


Summations

  1. Top of page
  2. Abstract
  3. Summations
  4. Considerations
  5. Introduction
  6. Material and methods
  7. Results
  8. Discussion
  9. Acknowledgements
  10. Declaration of interest
  11. References
  12. Appendices
  • • 
    There is a wide variation across different settings in sensitivity, specificity, positive and negative likelihood ratios in validation studies of the Edinburgh Postnatal Depression Scale (EPDS).
  • • 
    Differences in methodology of the included studies are likely to account for the variation in results.
  • • 
    There are only three studies evaluating the EPDS for use in antenatal populations.

Considerations

  1. Top of page
  2. Abstract
  3. Summations
  4. Considerations
  5. Introduction
  6. Material and methods
  7. Results
  8. Discussion
  9. Acknowledgements
  10. Declaration of interest
  11. References
  12. Appendices
  • • 
    Because of considerable differences in the methodology of included studies, quantitative approaches using meta-analysis were not performed.

Introduction

  1. Top of page
  2. Abstract
  3. Summations
  4. Considerations
  5. Introduction
  6. Material and methods
  7. Results
  8. Discussion
  9. Acknowledgements
  10. Declaration of interest
  11. References
  12. Appendices

Postpartum depression (PPD) is a non-psychotic depressive episode of mild to moderate severity, beginning in or extending into the first postnatal year (1). A meta-analysis of 59 studies (n = 12 810) found an average prevalence rate of non-psychotic PPD of 13% (95% CI 12.3–13.4) (2). PPD is an important public health problem, having a significant impact on the mother, the family (3), her partner (4), mother–baby interaction (5) and on the long-term emotional (6) and cognitive development of the baby (7).

Antepartum depression (APD) is defined as a non-psychotic depressive episode of mild to moderate severity, beginning in or extending into pregnancy. APD is less well documented than PPD; however, it is at least as common as PPD (8) and for some, but by no means all women, it may continue into the postnatal period (9).

The Edinburgh Postnatal Depression Scale (EPDS) is the most widely used screening questionnaire for PPD (10). It is a 10-item self-report questionnaire in which women are asked to rate how they have felt in the previous 7 days. Each question is scored 0–3 (resulting range 0–30) and completion takes around 5 min. In many areas of the UK, the EPDS is routinely administered to women at 6–8 weeks postnatally by their health visitor. A cut-off for ‘probable depression’ has been suggested at 12/13, and for ‘possible depression’ at 9/10 (11). However, the EPDS is only a screening instrument and a subsequent clinical diagnosis must be made by an appropriately trained health professional. The cut-off points of 9/10 and 12/13 are also used as markers of possible minor and major depression respectively. The EPDS has been translated into, and validated in, many languages other than English. The EPDS has also been validated as a screening tool for APD in pregnant women, with a cut-off point of 14/15 for ‘probable depression’ (12). There is as yet no research tool which can serve as a universally agreed ‘gold standard’ for the diagnosis of PPD or APD. Nevertheless, many structured and semistructured psychiatric interviews have been used as comparators including the Structured Clinical Interview for DSM disorders (SCID) (13), the Mini International Neuropsychiatric Interview (MINI) (14), the Present State Examination (PSE) (15) and others.

Screening for PPD is currently recommended in Australia and the USA, but not the UK (16). In the UK, the policy has shifted towards opportunistic case finding for PPD. The National Institute for Health and Clinical Excellence guideline ‘Antenatal and postnatal mental health’ (17) recommends the use of the two Whooley questions (18) by all healthcare professionals at each appointment from first detection of pregnancy to the postnatal period, despite a lack of evidence of effectiveness in this context. These are ‘During the past month, have you often been bothered by feeling down, depressed or hopeless?’ and ‘During the past month, have you often been bothered by having little interest or pleasure in doing things?’.

Three other groups have surveyed validation studies of the EPDS (10, 19, 20). Boyd et al. (10) conducted a review of screening instruments for PPD which included a literature review up to December 2004. This paper focused on comparing the psychometric data of eight self-report measures including the EPDS. This was not a systematic review, and data are quoted for 11 studies as opposed to 37 studies included in this paper. Gaynes et al. (19) addressed three key questions in their paper, including assessment of the accuracy of various screening tools in detecting APD and PPD. They identified 23 studies for all screening tools, of which only eight specifically addressed the accuracy of the EPDS. The results for the English-speaking studies only were analysed in detail. Eberhard-Gran et al. (20) systematically reviewed validation studies of the EPDS up to 2000. They concluded that the EPDS had limited utility because of its high level of heterogeneity. They only included papers until October 2000. Therefore, a systematic review of studies comparing the EPDS with a diagnostic ‘gold standard’ for APD and PPD, which includes more recently published studies, is desirable. This systematic review used a comprehensive search strategy, which generated a larger group of relevant studies than the previous reviews. This area is still relevant and important because of the differences in approach to screening in different countries and because of the variation in administration across different parts of the UK.

Aims of the study

The aim of this study was to determine, by systematically reviewing the literature, whether the Edinburgh Postnatal Depression Scale compares favourably with a structured clinical interview for the detection of antepartum depression and postpartum depression across a variety of settings and in different languages of administration.

Material and methods

  1. Top of page
  2. Abstract
  3. Summations
  4. Considerations
  5. Introduction
  6. Material and methods
  7. Results
  8. Discussion
  9. Acknowledgements
  10. Declaration of interest
  11. References
  12. Appendices

Data search

A computerised literature search was undertaken using webspirs software in the following databases: Medline, Embase, Cinahl, PsychInfo and SIGLE. The time frame of the search was from 1987 (when the EPDS was published) to July 2008. A broad search strategy was employed first using the terms ‘EPDS’ (or ‘EPDS’) and ‘validation’ as search terms. A focused search strategy including more precise descriptions such as ‘screening tool’ and ‘likelihood ratio’ was used later (Appendix 1). In addition, the bibliographies of retrieved papers were inspected by the authors and experts in the field were contacted for unpublished findings.

Inclusion/exclusion criteria

Studies were included: i) if the population of interest was antepartum or postpartum women (up to 1 year postpartum), ii) if the EPDS was used as a screening instrument, iii) if the EPDS was compared with a gold standard, defined as a structured or semistructured clinical interview to diagnose depression and iv) if data on sensitivity, specificity, positive likelihood ratio (LR +ve) and negative likelihood ratio (LR −ve) for relevant cut-off points could be extracted or sufficient data were available to enable these parameters to be calculated.

Studies were excluded: i) if the population was ≤1 week postpartum (to avoid the period when symptoms of the baby blues may be confused with emerging PPD) or ii) if there was a delay of ≥24 h between administration of the EPDS and gold standard (when information was available) to avoid measurement of changing symptoms over time or iii) if the postpartum population was restricted to a subgroup, e.g. to mothers with learning disability. Any disagreements were resolved by discussion between the two reviewers or by a third investigator if required.

A number of studies were reported in more than one publication. Every effort was made to ensure that only one paper per study was included in the review.

Data extraction

All abstracts were read by two reviewers independently to identify relevant papers. Papers deemed relevant or of uncertain relevance, were obtained and read in full. Data extraction was performed independently by two researchers for each study using a standardised data extraction form (see Appendix 2). A third reviewer was used in the few cases when the original reviewers could not agree.

Data quality

The quality of the selected studies was assessed using a grading system based on the York CRD system (21). Each study was assigned a grade according to blinding of the assessors, comparison with a reference standard for diagnosis and the population spectrum.

Meta-analysis of included studies was considered inappropriate because of the likely heterogeneity of the included studies and based on the previous report by Eberhard Gran et al. (20).

Data analysis

We tabulated extracted data, plotted the results from studies reporting findings for major and combined depression on a scatterplot of true-positive rate (sensitivity) against false-positive rate (1 − specificity), and calculated relevant summary statistics.

Results

  1. Top of page
  2. Abstract
  3. Summations
  4. Considerations
  5. Introduction
  6. Material and methods
  7. Results
  8. Discussion
  9. Acknowledgements
  10. Declaration of interest
  11. References
  12. Appendices

The combined broad and focused searches yielded 274 studies for further inspection. The focused search strategy yielded a number of papers not generated by the broad strategy. Of these 274 studies, there were 135 which were not relevant; 20 which did not compare the EPDS to a ‘gold standard’; 18 which did not use a structured/semistructured interview as a diagnostic reference standard; 17 which did not use the EPDS; 17 which were of an inappropriate study type; 13 which reported insufficient data for calculations (this included papers which did not present figures for at least one of the EPDS cut-off point of interest, as described below); six which used an inappropriate population sample, e.g. men included or breast-feeding mothers only; five which had a delay between EPDS and interview; five in which data were repeated from the same sample as in other papers; and one in which the mothers were assessed at <1 week postpartum. Therefore, a total of 37 studies met the inclusion criteria. A full list of excluded studies with reasons for exclusion is available from the corresponding author on request. Figure 1 shows the flow of studies through the review.

image

Figure 1.  Flow of studies through review process.

Download figure to PowerPoint

Edinburgh Postnatal Depression Scale cut-off points at 9/10 and 12/13 for PPD were used. As described in the Introduction, these are the widely accepted cut-off points to indicate ‘possible’ and ‘probable’ depression respectively. For studies in antepartum populations, a cut-off point of 14/15 was presented. This is the value found to be most predictive of probable depression during pregnancy (12). Many papers provided data for multiple cut-off points.

Study sample/setting/selection

The size of the study samples varied between 23 and 876 (details in attached file to the online version of this article). Of the 37 studies included, three validated the EPDS for use in an antepartum population (12, 23, 24) and the remaining 34 used a postpartum population. The majority of samples were drawn from the community (recruited at antenatal or postnatal clinics). However, some samples contained a higher proportion of women who were depressed or women identified as likely to be depressed (11, 25–29).

Diagnostic criteria

Twenty-two studies (22, 24, 27–46) validated the EPDS against the Diagnostic and Statistical Manual of Mental Disorders (47–49) criteria for depression. Six studies (11–13, 26, 50, 51) used the Research Diagnostic Criteria (RDC) (52) as the gold standard. The International Classification of Diseases (53, 54) was used in six studies (23, 55–59), and two studies (60, 61) used the PSE (15) as the reference standard. One study (62) did not state which criteria were used.

Most studies included assessment for both major and minor depressive disorders in the definition of PPD (11, 12, 22–24, 28–32, 34–39, 41, 50, 51, 55–62) whilst other studies used a stricter definition of major depression only (25, 27, 33, 40, 42, 43). All three studies validating the EPDS in the antenatal population included minor and major depression in the definition of APD and used a higher cut-off point to screen for illness (12, 22, 23).

Diagnostic instruments

Eleven different diagnostic instruments were used across studies. The SCID (13) was used in 10 studies (24, 27, 29, 31, 32, 37, 39, 42, 44, 45); the MINI (14) in five studies (22, 30, 34, 35, 41); Goldberg’s Standardised Psychiatric Interview (SPI) (63) in four studies (11, 12, 25, 28); the Composite International Diagnostic Interview (CIDI) (64) in three studies (56–58) and the PSE (15) was used in a further four studies (26, 56, 60, 61). The Clinical Interview Schedule (CIS) (65) was used in three studies (23, 59, 62); the Montgomery–Asberg Depression Rating Scale (MADRS) (66), which is an observer rating scale, was used in two studies (38, 43); the Schedule of Affective Disorders and Schizophrenia (SADS) (67), the Psychiatric Assessment Schedule (PAS) (68), the Diagnostic Interview Schedule (DIS) (69), and the PRIME-MD (70) were used in one study each (33, 36 and 51). One study (40) used a ‘structured clinical interview based on the criteria defined in the current fourth edition of the DSM-IV’ and another (46) used a ‘semistructured interview’ but neither named the interview.

Quality assessment

Table 1 summarises the results of the quality assessment. Study quality was generally reasonable with 12 of 37 studies achieving a grade A. This denoted that an appropriate study design was used in a representative population and that the comparison of the EPDS result to the ‘gold standard’ was blind. Of the remaining 25 studies, 24 achieved a grade B because of one or two of the following characteristics: lack of/uncertain blinding, narrow population sample and differential use of the reference standard. For one study (59), there was insufficient data available to grade its quality.

Table 1.   Table to show quality grading system for included studies
GradeTest accuracyNumber of studies
  1. Modified from Sackett et al.

AHigh quality studies with a blind comparison of test to reference standard in an appropriate population spectrum12
BAny one or two of the following:24
 Narrow population spectrum
 Differential use of reference standard
 Reference standard not blind
 Case control study design
CAny three or more of the above0
DExpert opinion0
OtherInsufficient data available to grade study1

Sensitivity1 and specificity2

There was a large variation in estimates of sensitivity and specificity between studies (see Tables 2–5). Using an EPDS score cut-off point of 9/10, the sensitivity for detecting postnatal depression ranged from 59 to 100% and the specificity ranged from 44 to 97%. Using an EPDS cut-off point of 12/13, the sensitivity for postnatal depression ranged from 34 to 100% and the specificity from 49 to 100%. For the three studies validating the EPDS in an antenatal sample, the cut off point of 14/15 was selected. The sensitivity for major depression ranged from 57 to 100% and the specificity from 93 to 99%.

Table 2.   Summary of studies validating the EPDS for detection of minor depression in the postpartum period
Author, countryNo. womenLanguage and postpartum timing of EPDS administrationDiagnostic instrument Diagnostic criteriaSensitivity % at EPDS cut-off point of 9/10 Specificity % at EPDS cut-off point of 9/10PPV %NPV %Positive likelihood ratio at EPDS cut-off point of 9/10Negative likelihood ratio at EPDS cut-off point of 9/10
  1. PPV, positive predictive value; NPV, negative predictive value.

Benvenuti, Italy (34)67Italian EPDS at 8–12 weeksMINI DSM-IIIR839060N/A7.90.2
Murray, UK (28)646English EPDS at 6 weeksSPI DSM-III828217N/A4.60.22
Table 3.   Summary of studies validating the EPDS for detection of major depression in the postpartum period
Author, countryNo. womenLanguage and postpartum timing of EPDS administrationDiagnostic instrument Diagnostic criteria Sensitivity (%) at different EPDS cut-off points Specificity (%) at different EPDS cut-off points PPV (%) at different EPDS cut-off points NPV (%) at different EPDS cut-off pointsPositive Likelihood Ratio at different EPDS cut-off pointsNegative Likelihood Ratio at different EPDS cut-off points
9/1012/139/1012/139/1012/139/1012/139/1012/139/1012/13
  1. AC, Anglo-Celtic; A, Arabic; V, Vietnamese; PPV, positive predictive value; NPV, negative predictive value.

Adewuya, Nigeria (29)876English/Yoruba EPDS at 6 weeks postnatal/infant clinicSCID-NP DSM-IIIRN/A100N/A 98N/A100N/A91N/A50N/A0
Barnett, Australia (33)105 AC* 98 A* 113 V*English, Arabic and Vietnamese EPDS at 6 weeks DIS DSM-IIIRAC86 A 78 V 100AC57 A 56 V 100AC84 A 80 V 69AC94 A 91 V 89AC27 A 29 V 13AC40 A 39 V 29N/AN/AAC5.4 A 3.9 V 3.2AC9.4 A 6 V 9AC0.17 A 0.28 V 0AC0.46 A 0.49 V 0
Beck, USA (24)150English EPDS at at 2–12 weeks SCID DSM-IV N/A78N/A9964938296N/A78N/A0.22
Benvenuti, Italy (34)67Italian EPDS at 8–12 weeks MINI DSM-IIIRN/A56N/A9960N/A91N/AN/A56N/A0.4
Berle, Norway (35)100Norwegian EPDS at 6–12 weeksMINI DSM-IV 965662894865N/AN/A2.535.090.060.49
Boyce, Australia (25)103English EPDS at mean of 12 weeksSPI RDC100100899647691001009.12500
Cox, UK (11)84English EPDS at 6 weeksSPI RDCN/A96N/A70N/A56N/A98N/A3.2N/A0.06
Eberhard-Gran, Norway (20)310Norwegian EPDS at 3 and 6 weeksPRIME-MD DSM-IVN/A44N/A96N/AN/AN/AN/AN/A10.43N/A0.58
Garcia Esteve, Spain (37)334Spanish EPDS at 6 weeksSCID DSM-IV 100868995N/A46N/A1009.117.200.15
Kadir, Malaysia (62)52Malay EPDS at 4–12 weeksCIS1007583943350N/AN/A5.912.500.27
Lawrie, South Africa (38)102English EPDS with translator at 6 weeksMADRS DSM-IV 1008851721521100992.043.1500.17
Murray, UK (28)646English EPDS at 6 weeks SPI DSM-III96818296N/A43N/AN/A5.318.80.050.2
Muzik, Austria (27)49Community sample 2–3 months SCID DSM-IIIR78677595447594923.1213.40.290.35
Regmi, Nepal (40)100Nepalese EPDS at 2–3 monthsStructured clinical interview based on DSM-IV criteria, DSM-IVN/A100N/A93N/A42N/A100N/A14.29N/A0
Vega-Dienstmaier, Peru (42)321Spanish EPDS within 1st postpartum yearSCID DSM-IV 9090447291799991.613.220.240.15
Wickberg, Sweden (43)128Swedish EPDS at 2–3 monthsMADRS DSM-IIIRN/A85N/A63N/A64N/A47N/A2.3N/A0.24
Table 4.   Summary of studies validating the EPDS for detection of combined minor and major depression in the postpartum period
Author, countryNo. womenLanguage and postpartum timing of EPDS administrationDiagnostic instrument Diagnostic criteria Sensitivity (%) at different EPDS cut-off points Specificity (%) at different EPDS cut-off points PPV (%) at different EPDS cut-off points NPV (%) at different EPDS cut-off pointsPositive Likelihood Ratio at different EPDS cut-off pointsNegative Likelihood Ratio at different EPDS cut-off points
9/10 12/139/10 12/139/1012/139/1012/139/10 12/13 9/10 12/13
  1. PPV, positive predictive value; NPV, negative predictive value; E, English; P, Punjabi; J, sample of Japanese women in Japan; UK, sample of Japanese women living in UK.

  2. *Includes 1 case of mania, 1 case of ‘anxiety neurosis’ and 1 case of paranoid psychosis.

  3. †Sensitivity and specificity reported in reverse order in paper.

Adewuya, Nigeria (29)876English/Yoruba EPDS at 6 weeksSCID-NP DSM-IIIR881009949931009792881.960.120
Agoub, Morocco (30)144Arabic EPDS at 15–20 daysMINI DSM-IV N/A92N/A966586N/AN/AN/A23N/A0.08
Ascaso, Spain (31)334Spanish EPDS at 6 weeksSCID DSM-IV 89627192N/AN/AN/AN/A3.017.640.160.41
Aydin, Turkey (32)341Turkish EPDS in first postpartum yearSCID DSM-IV96764772233099951.812.720.090.33
Beck, USA (24)150English EPDS at 2–12 weeksSCID DSM-IV 59N/A86N/A649382964.21N/A0.48N/A
Berle, Norway (35)100Norwegian EPDS at 6–12 weeksMINI DSM-IV90957195N/A87N/AN/A3.19.810.140.54
Carpiniello, Italy (60)61Italian EPDS at 4–6 weeksPSE PSE-ID-Catego100678310050100100955.8800.33
Clarke, Canada (44)103English EPDS up to 1 year postpartumSCID DSM-IVN/A81N/A88N/A56N/A96N/A6.75N/A0.22
Cox, UK (11)84English EPDS at 6 weeksSPI RDC89N/A51N/A58N/A93N/A1.82N/A0.22N/A
Eberhard-Gran, Norway (20) 310Norwegian EPDS at 3 and 6 weeksPRIME-MD DSM-IV67789798N/AN/AN/AN/A2338.90.340.23
Felice, Malta (23)229Maltese EPDS used at 8–10 weeksCIS-R ICD-10837892984356989610.04390.180.22
Garcia Esteve, Spain(37)334Spanish EPDS at 6 weeksSCID DSM-IV 8962939856469910012.7310.120.39
Gausia, Bangla-desh (45)126Bangla EPDS at 6–8 weeksSCID DSM-IV89678093315099974.410.30.140.35
Ghubash, UAE (61)95Arabic EPDS at 1 weekPSE ICD-1091738490445099965.697.30.110.3
Guedeney, France (26)87French EPDS at 4 months postpartum PSE RDC806092976478969310200.220.41
Jadresic, Chile (50)108Spanish EPDS at 2–3 monthsPAS RDC10055809437501009559.1200.48
Kadir, Malaysia (62)52Malay EPDS at 4–12 weeksCIS735590100675093987.300.45
Lawrie, South Africa (38)102English EPDS with translator at 6 weeksMADRS DSM-IV 84765782395892911.954.180.280.29
Lee, Hong Kong (39)145Chinese EPDS used at 6 weeksChinese SCID-NP DSM-IV8241869544N/A97N/A5.868.20.210.62
Leverton, UK (55)207*English EPDS at 3 monthsPSE ICD-1090708493233399985.6100.120.32
Mahmud, Malaysia (56)64Malay EPDS at 4–12 weeksCIDI ICD-10100†78†93†98†69881009613.743.200.23
Murray, UK (28)646English EPDS at 6 weeks postnatal SPI DSM-III896882963967N/AN/A5.015.70.10.34
Pitanupong, Thailand (46)615Thai EPDS at 6–8 weeks‘Semistructured interview’ DSM-IV6034909742599592611.30.440.68
Rushidi, Malaysia (59)54Malay EPDS at 4–12 weeksCIS ICD-1077†62†90†100†7110093897.700.260.38
Teng, Taiwan (41)531Chinese EPDS at 3 days (n = 328) or 6 weeks (= 203) postpartumMINI DSM-IV N/A96N/A85N/A46N/A99N/A6.4N/A0.05
Uwakwe, Nigeria (57)225Igbo EPDS at 7 days CIDI ICD-10755097987580978425250.260.51
Werrett, UK (58)23English and Punjabi EPDS at 5–8 weeksCIDI ICD-10E 100 P 71E 71 P 71E 63 P 69E 81 P 94E 54 P 50E 63 P 83N/AN/AE 2.67 P 2.28E 5.71 P 11.33E 0 P 0.42E 0.35 P 0.31
Yoshida, Japan (51)186Japanese EPDS at 1 monthSADS RDCJ 82 UK N/A J 55 UK N/AJ 95 UK N/AJ 98 UK 100N/AN/AN/AN/AJ 16.4 UK N/AJ 27.5 UK N/AJ 0.19 PUK N/AJ 0.46 UK 1
Table 5.   Summary of studies validating the EPDS for detection of depression in the antepartum period
Author, countryNo. womenLanguage and antepartum timing of EPDS administrationDiagnostic Criteria Diagnostic InstrumentEPDS cut-off point Sensitivity (%) Specificity (%) PPV (%) NPV (%)Positive likelihood ratioNegative likelihood ratio
MajorCombMajorCombMajorCombMajorCombMajorCombMajorComb
  1. Comb, combined major and minor depression; PPV, positive predictive value; NPV, negative predictive value.

Adewuya, Nigeria (22)182Yoruba EPDS at >32 weeks gestationMINI DSM-IV 14–1578N/A99N/A88N/A97N/A78N/A0.22N/A
Felice, Malta (23)229Maltese EPDS at 36–40 weeks gestation CIS-R ICD-1014–1573669397N/A81N/A9410220.290.35
Murray, UK (12)100English EPDS at 28–34 weeks gestation SPI RDC14–15100579698608010095252900.44

Positive3 and negative predictive values4

The positive predictive values (PPV) of the EPDS for detecting depression (major, or major and minor combined) at a cut-off score of 9/10 ranged from 9 to 64% for major depression and from 23 to 93% for combined depression. At a cut-off score on the EPDS of 12/13, the PPV was 17–100% for major depression and 30–100% for combined major and minor depression. If used in an antenatal population to detect APD, a cut-off of 14/15 was used and the PPV for major depression ranged from 60 to 80% (two studies) and from 80 to 90% (three studies) for major and minor depression combined.

The range of negative predictive values (NPV) of the EPDS for detecting depression (major, or major and minor combined) at a cut-off score of 9/10 was 82–100% for both major and combined depression. For a cut-off score of 12/13 on the EPDS, the NPV for major depression was 47–100% and for combined major and minor depression was 84–100%. The median values and ranges for the PPV and NPV from all postpartum studies are reported in Table 6.

Table 6.   Summary statistics for performance of EPDS in detecting postpartum depression at different cut-off points
 PPV Median (range)NPV Median (range)LR+ Median (range)LR− Median (range)
  1. PPV, positive predictive value; NPV, negative predictive value; LR+, positive likelihood ratio; LR−, negative likelihood ratio.

  2. Median values could not be calculated for the antenatal group as there were only data for 2 studies within each category.

Minor depression EPDS cut-off 9/10N/AN/AN/AN/A
Major depression EPDS cut-off 9/1033 (9–64)97 (82–100)3.9 (1.61–9.1)0.05 (0–0.29)
Major depression EPDS cut-off 12/1348 (17–100)98.5 (47–100)10.47 (2.7–78)0.22 (0–0.58)
Combined depression EPDS cut-off 9/1050 (23–93)97 (82–100)5.88 (1.81–88)0.15 (0–0.48)
Combined depression EPDS cut-off 12/1361 (30–100)96 (84–100)10.3 (0–∞)0.35 (0–1)

In antepartum populations, the range of PPV results was 60–88% for major depression and 80–81% for combined major and minor depression. The NPV results ranged from 97 to 100% for major depression and from 94 to 95% in combined depression. Median values could not be calculated for the antepartum studies as there were data for only two studies within each category.

Likelihood ratios5

Estimates of the positive likelihood ratios for the presence of any postnatal depression (i.e. combined minor and major) ranged from 1.81 to 88 using an EPDS cut-off of 9/10, and from 0 to ∞ using a cut-off point of 12/13. Estimates of the negative likelihood ratio ranged from 0 to 0.48 at a cut-off point of 9/10 and from 0 to 1 at a cut-off point of 12/13.

In the group of antepartum women, estimates of the positive likelihood ratios for the presence of any APD ranged from 22 to 29 and the negative likelihood ratio ranged from 0.35 to 0.44.

Scatterplots

Scatterplots of the rate of true positives (sensitivity) against the rate of false positives (1 − specificity) were drawn for studies validating the EPDS in detecting major depression and combined major and minor depression in the postpartum period (Figs 2 and 3). Scatterplots for the validity of the EPDS in detecting minor PPD or APD were not constructed because of the small number of studies in each category (two and three respectively). The plots show some scattering of the results, reflecting the level of heterogeneity in performance of the EPDS in different populations and at different times in the postnatal period.

image

Figure 2.  Scatterplot of sensitivity vs. 1 − specificity for detecting major depression in each study.

Download figure to PowerPoint

image

Figure 3.  Scatterplot of sensitivity vs. 1 − specificity for detecting major/minor depression in each study.

Download figure to PowerPoint

Language of administration

There were six studies (12, 24, 25, 28, 38, 44) using the English language version of the EPDS alone in postpartum populations. There were 25 using alternative languages and two studies which administered the EPDS in English and one or more other languages (33, 58). In addition, one paper administered the EPDS in English and Yoruba but did not present results separately for the two languages (29). The three papers which used two or more different language versions of the EPDS were not included in the examination.

The authors considered the hypothesis that the language of administration of the EPDS may have contributed to the heterogeneity of results. We therefore examined the results from English-speaking populations separately from non-English-speaking groups. At a diagnostic threshold of 9/10 on the EPDS, there was no appreciable difference between the two groups for specificity (English language EPDS 51–89%; non-English language EPDS 44–97%). The sensitivity range was larger for the non-English papers (English language EPDS 82–100%; non-English language EPDS 60–100%). At a diagnostic threshold of 12/13, both the sensitivity and specificity ranges showed a more marked difference depending upon language of administration. Sensitivity values for English language EPDS studies ranged from 76 to 100% and for non-English language EPDS studies from 49 to 100%. Specificity values for English language EPDS papers ranged from 70 to 99%, whilst for non-English language EPDS studies the range was from 34 to 100%. It was not possible to consider the difference between countries as very few countries produced more than one study.

For the antepartum studies, only one was conducted in English (12) and its results did not differ appreciably from the other two studies.

Discussion

  1. Top of page
  2. Abstract
  3. Summations
  4. Considerations
  5. Introduction
  6. Material and methods
  7. Results
  8. Discussion
  9. Acknowledgements
  10. Declaration of interest
  11. References
  12. Appendices

In conclusion, 37 validation studies of the EPDS had been published up to the end of July 2008, which met our inclusion and exclusion criteria. However, the degree of heterogeneity among studies was such that it was not possible to form distinct groups for further subanalysis. There were significant differences in study design, population sampled, the timing of testing, language version of the EPDS used and diagnostic criteria. As a result, each subgroup of interest that we considered was itself too heterogeneous to analyse statistically. Were we to do so, we were concerned that the results would not be valid or useful. The degree of heterogeneity may also suggest that these studies have not provided evidence for the EPDS as a valid screening tool across different cultural groups.

There was a wide range of values for sensitivity and specificity at all cut-off points. There are various explanations to be considered. Both methods and populations varied greatly between the studies. Samples were drawn from rural and urban areas, from affluent and poor women, and from countries with different cultural attitudes to feeling and expressing distress. Different diagnostic interviews and criteria were used, and screening was performed at various times in the antepartum/postpartum period. Another important consideration is that the screening and diagnostic instruments used in the studies have been developed in the West. Although an international qualitative study of the experience of women in pregnancy and the postpartum suggests that there is a universal experience of morbid unhappiness with similar signs and symptoms to APD and PPD (8), the understanding of the nature of this state and its aetiology differ according to the cultural setting. It is possible that instruments devised to detect the Western concept of depression do not accurately detect the presence of significant unhappiness in other cultural settings. If so, this would contribute to the heterogeneity of the results.

The degree of variation found in the PPV and NPV results is likely to be explained by several factors. First, the prevalence of major and/or minor depression varied across studies. As the prevalence of the disorder increases, so too does the PPV. Therefore, the studies in which women with PND were over-represented showed higher PPV values. The PPV also varies according to the EPDS cut-off used. Barnett et al. (33) found that a higher cut-off score (14/15) was recommended to identify PND in a Vietnamese-speaking sample of mothers in Australia, compared with their English- and Arabic-speaking counterparts where a cut-off score of 9/10 was suggested. This may imply that different cut-off scores should be used in different cultural groups and could contribute to the heterogeneity found in these studies.

It has been suggested that, for use in clinical practice, ‘a positive likelihood ratio of greater than 10 … may provide convincing diagnostic evidence, whilst those greater than 5 … give strong diagnostic evidence’ (71). The median positive likelihood ratios (Table 6) show that, at a cut-off point of 9/10, for major PPD, performance is modest. However, when the cut-off point is increased to 12/13, the ‘average’ study suggests that the EPDS provides ‘convincing diagnostic evidence’ for the presence of major depression. When the EPDS is used to screen for women with any type of PPD (i.e. combined minor and major), at a cut-off point of 12/13, the average study suggests that the EPDS provides ‘convincing diagnostic evidence’, while at a cut-off point of 9/10 the average study suggests that the EPDS provides only ‘strong diagnostic evidence’.

Regarding the negative likelihood ratio, it has been suggested that ‘a negative likelihood ratio of <0.1 may provide convincing diagnostic evidence … and below 0.2 gives strong diagnostic evidence’ (71). Again, the range of likelihood ratios throughout the studies is wide. The median negative likelihood ratios (Table 6) show that at the higher EPDS cut-off point of 12/13, the test performs poorly in screening out those women without PPD, both with regard to major depression alone and combined minor/major depression. However, at the lower cut-off point of 9/10 the EPDS performs considerably better and the average study suggest that it provides ‘strong evidence’ (combined depression) or ‘convincing evidence’ (major depression) by which to rule out the diagnosis. As with any screening tool, in selecting a cut-off point, there is a trade-off between the accuracy of ruling out a diagnosis and the accuracy of ruling in a diagnosis. To determine the most appropriate EPDS cut-off, it is therefore necessary to determine the needs of the specific population, the resources available and the consequences both of missing diagnoses and of over-diagnosis.

In terms of the results for likelihood ratios, it has been suggested that for use in clinical practice ‘a positive likelihood ratio of greater than 10 … may provide convincing diagnostic evidence, whilst those greater than 5 … give strong diagnostic evidence’ (71). There are wide ranges of results for the likelihood ratios, but the median positive likelihood ratios (Table 6) show that at a cut-off point of 9/10 there is little evidence to suggest that the EPDS can accurately identify women with major PPD. However, when the cut-off point is increased to 12/13 there is ‘convincing diagnostic evidence’ for the test. When the EPDS is used to screen for women with any type of PPD (i.e. combined minor and major depression) over half of the studies at cut-off points of both 9/10 and 12/13 show ‘convincing diagnostic evidence’. This suggests that the EPDS can be an effective screening tool for detecting combined depression in postpartum women at a cut-off point of 9/10, but that its accuracy increases in both major and combined PPD if the cut-off point is increased to 12/13.

Regarding the negative likelihood ratio, it has been suggested that ‘a negative likelihood ratio of <0.1 may provide convincing diagnostic evidence … and below 0.2 gives strong diagnostic evidence’ (71). Again, the range of likelihood ratios throughout the studies is wide. The median negative likelihood ratios (Table 6) show that at the higher EPDS cut-off point of 12/13, the test performs poorly in screening out those women without PPD, both when considering major depression alone, or minor and major depression combined. However, at the lower cut-off point of 9/10 the EPDS performs considerably better and in over half of the studies presented it provides ‘strong diagnostic evidence’ (combined depression) or ‘convincing diagnostic evidence’ (major depression).

Thus, in over half of the studies the EPDS could convincingly rule out the presence of PPD in non-depressed women when a cut-off point of 9/10 is used. However, if the cut-off point is increased to 12/13 the EPDS no longer provides either ‘strong’ or ‘convincing’ evidence for excluding the disorder.

It is therefore necessary to determine, according to the characteristics of the population, whether it is more important to use the EPDS to rule in cases of PPD, or rule out women who do not have the disorder. This will determine the most useful EPDS cut-off point to select.

Whilst the included studies scored well on the quality rating scale (all achieving a grade A or B) there were some general points of weakness. The method of selection of study samples was not always clearly described and in some cases was ‘ad hoc’ which may bias the results towards including more motivated, such as psychologically vulnerable women. In several cases, it was unclear if the comparison of the EPDS results to the reference standard was blind (and in some there was clearly no blinding) which again could bias the results. Four of the studies (28, 38, 55, 58) were conducted on a narrowly defined population, e.g. women who had experienced obstetric complications, and the results are not likely to be generalisable to a standard community setting.

Studies were excluded if there was a delay of more than 24 h between the administration of the EPDS and the diagnostic interview. This was to avoid the possibility of measuring different symptom profiles in the same individual, given the potential for fluctuations in the mental state in the postpartum period. We examined the five studies excluded for this reason. There was a delay of up to 8 weeks in these studies. We found that there was no appreciable difference in any of the results. However, because of the small number of studies involved, we could not conclude that the EPDS remains a valid screening tool for PND when a time delay occurs between screening and the diagnostic interview.

In addition, the wide range of values for both sensitivity and specificity across studies make interpretation of the utility of this screening instrument difficult. The heterogeneity in results may suggest that the accuracy of the EPDS varies depending on the clinical setting, country and language of administration. This may be complicated by the use of diagnostic interviews and instruments devised to detect depression as it is understood and expressed in Western societies.

The examination of the language of administration of the EPDS found a larger difference in the sensitivity range at a cut-off point of 12/13, implying that the tool may be more sensitive when administered in the English language. This may suggest that the EPDS performs best at a higher cut-off point and for women who are familiar with expressing their distress in English, and that the screening and diagnostic tools are geared towards identifying more severe illness in English-speaking populations. There may be systematic differences in the foreign language versions of the EPDS and the way it is applied between countries. It is possible also that these findings result from the differences in study design and population sampled.

At present, when the EPDS is used in the general population it will generate a substantial proportion of false positives, which is costly to service providers in terms of further assessment. In addition, it will miss a considerable number of cases. However, the majority of screening tools suffer from the same difficulties. It should be noted that such tools are designed to indicate the possibility of illness. A clinical assessment is required to make a definitive diagnosis. It is also the case that clinical assessment carries a higher cost. The utility of the EPDS rests in its free availability, ease of administration and general acceptability to women, if given sympathetically. Therefore, if the above caveats are observed, this remains a useful tool in the field of perinatal mental health.

Strengths

This systematic review used both a broad and focused search strategy. It was able to include studies published between 2000 and 2008 thus making the review more up to date than the existing Eberhard-Gran review. It additionally considered studies examining an antepartum population.

Limitations

This systematic review was not able to answer the question of whether or not the EPDS is an accurate screening tool for APD and PPD. The heterogeneity of included studies prevented progression to meta-analysis and therefore statistical comparison of the EPDS across settings was not possible.

Future research

A point which emerges from this, and other, studies (19, 20) is the high level of heterogeneity. Therefore, future quantitative and qualitative research should focus on identifying the underlying causes of this. Finally, there are only three validation studies in antenatal populations and therefore further studies in this group are important.

Footnotes
  • 1

    Sensitivity is the proportion of those with the disease who test positive.

  • 2

    Specificity is the proportion of those without the disease who have negative test results.

  • 3

    Positive predictive value is the proportion of people scoring positive in a test who actually have the disorder.

  • 4

    Negative predictive value is the proportion of people scoring negative in a test who actually do not have the disorder.

  • 5

    Likelihood ratios describe how many times more (or less) likely a person with disease is to receive a particular test result (positive or negative) than a person without disease.

Acknowledgements

  1. Top of page
  2. Abstract
  3. Summations
  4. Considerations
  5. Introduction
  6. Material and methods
  7. Results
  8. Discussion
  9. Acknowledgements
  10. Declaration of interest
  11. References
  12. Appendices

We thank the authors who provided further information about their studies. We also thank Maria Quigley for commenting on an earlier draft of this paper. This paper reports on an independent study, which is part-funded by the Policy Research Programme in the Department of Health. The views expressed are not necessarily those of the Department.

Declaration of interest

  1. Top of page
  2. Abstract
  3. Summations
  4. Considerations
  5. Introduction
  6. Material and methods
  7. Results
  8. Discussion
  9. Acknowledgements
  10. Declaration of interest
  11. References
  12. Appendices

Jonathan Price received a research grant from Servier R&D Limited for the development of a questionnaire to measure antidepressant side-effects.

References

  1. Top of page
  2. Abstract
  3. Summations
  4. Considerations
  5. Introduction
  6. Material and methods
  7. Results
  8. Discussion
  9. Acknowledgements
  10. Declaration of interest
  11. References
  12. Appendices
  • 1
    Scottish Intercollegiate Guidelines Network. Management of postnatal depression and puerperal psychosis. A national clinical guideline, guideline number 60. Edinburgh: SIGN Executive, 2002.
  • 2
    O’hara MW, Swain AM. Rates and risk of postpartum depression – a meta-analysis. Int Rev Psychiatry 1996;8:3754.
  • 3
    Boath EH, Pryce AJ, Cox JL. Postnatal depression: the impact on the family. J Reprod Infant Psychol 1998;16:199203.
  • 4
    Lovestone S, Kumar R. Postnatal psychiatric illness: the impact on partners. Br J Psychiatry 1993;163:210216.
  • 5
    Murray L, Cooper PJ. Postpartum depression and child development. Psychol Med 1997;27:253260.
  • 6
    Caplan HL, Cogill SR, Alexandra H, Robson KM, Katz R, Kumar R. Maternal depression and the emotional development of the child. Br J Psychiatry 1989;154:818822.
  • 7
    Murray L, Sinclair D, Cooper P, Ducournau P, Turner P, Stein A. The socio-emotional development of 5-year-old children of postnatally depressed mothers. J Child Psychol Psychiatry 1999;40:12591271.
  • 8
    Evans J, Heron J, Francomb H, Oke S, Golding J. Cohort study of depressed mood during pregnancy and after childbirth. BMJ 2001;323:257260.
  • 9
    Green JM. Postnatal depression or perinatal dysphoria? Findings from a longitudinal community-based study using the Edinburgh Postnatal Depression Scale. J Reprod Infant Psychol 1998;16:143155.
  • 10
    Boyd RC, Le HN, Somberg R. Review of screening instruments for postpartum depression. Arch Womens Ment Health 2005;8:141153.
  • 11
    Cox JL, Holden JM, Sagovsky R. Detection of postnatal depression. Development of the 10-item Edinburgh Postnatal Depression Scale. Br J Psychiatry 1987;150:782786.
  • 12
    Murray D, Cox J. Screening for depression during pregnancy with the Edinburgh Depression Scale (EPDS). J Reprod Infant Psychol 1990;8:99107.
  • 13
    Spitzer RL, Williams JB, Gibbon M, First MD. The Structured Clinical Interview for DSM-III-R (SCID): History, rationale, description. Arch Gen Psychiatry 1992;49:624629.
  • 14
    Sheehan DV, Lecrubier Y, Sheehan KH et al. The Mini International Neuropsychiatric Interview (MINI); the development and validation of a structured diagnostic psychiatric interview for DSM-IV and ICD-10. J Clin Psychiatry 1998; 59(suppl. 20):2233; quiz 34–57. Review.
  • 15
    Wing JK, Stuart E. The PSE-ID-Catego System supplementary manual. London: MRC Social Unit, 1978.
  • 16
    Postnatal Depression Screening. National Screening Committee UK, 2006 [Cited 16 December 2007]. Available at: http://www.library.nhs.uk/screening/ViewResource.aspx?resID=60978.
  • 17
    Antenatal and Postnatal Mental Health. Clinical management and service guidance. Clinical Guideline 45. London:National Institute for Clinical Excellence (NICE), 2007
  • 18
    Whooley MA, Avins AL, Miranda J, Browner WS. Case-finding instruments for depression. Two questions are as good as many. J Gen Intern Med 1997;12:439445.
  • 19
    Gaynes BN, Gavin N, Meltzer-Brody S et al. Perinatal depression: prevalence, screening accuracy, and screening outcomes [Cited 20 March 2008]. Available at: http://www.ahrq.gov/clinic/epcsums/peridepsum2.htm.
  • 20
    Eberhard-Gran M, Eskild A, Tambs K, Opjordsmoen S, Samuelson SO. Review of validation studies of the Edinburgh Postnatal Depression Scale. Acta Psychiatr Scand 2001;104:243249.
  • 21
    Khan KS, Ter Riet G, Popay J, Nixon J, Kleijnen J. In: KhanKS, Ter Riet G, Glanville J, Snowden AJ, Kleijnen J, eds. Understanding Systematic Reviews on Effectiveness. 2nd edn. Centre for Reviews and Dissemination Report Number 4 2001. Available at: http://www.york.ac.uk/inst/crd/report4.htm (accessed 20 February 2009).
  • 22
    Adewuya AO, Ola BA, Dada AO, Fasoto OO. Validation of the Edinburgh Postnatal Depression Scale as a screening tool for depression in late pregnancy among Nigerian women. J Psychosom Obstet Gynecol 2006;2:267272.
  • 23
    Felice E, Saliba J, Grech V, Cox J. Validation of the Maltese version of the Edinburgh Postnatal Depression Scale. Arch Womens Ment Health 2006;9:7580.
  • 24
    Beck CT, Gable RK. Comparative analysis of the performance of the Postpartum Depression Screening Scale with two other depression instruments. Nurs Res 2001;50:242250.
  • 25
    Boyce P, Stubbs J, Todd A. The Edinburgh Postnatal Depression Scale: validation for an Austrian sample. Aust N Z J Psychiatry 1993;27:472476.
  • 26
    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;13:8389.
  • 27
    Muzik M, Klier CM, Rosenblum KL, Holzinger A, Umek W, Katschnig H. Are commonly used self-report inventories suitable for screening postpartum depression and anxiety disorders? Acta Psychiatr Scand 2000;102:7173.
  • 28
    Murray L, Carothers AD. The validation of the Edinburgh Postnatal Depression Scale on a community sample. Br J Psychiatry 1990;157:288290.
  • 29
    Adewuya AO, Eegunranti AB, Lawal AM. Prevalence of postnatal depression in Western Nigerian Women: a controlled study. Int J Psychiatry Clin Pract 2005;9:6064.
  • 30
    Agoub M, Moussaoui D, Battas O. Prevalence of postpartum depression in a Moroccan sample. Arch Womens Ment Health 2005;8:3743.
  • 31
    Ascaso Terren C, Garcia Esteve L, Navarro P, Aguado J, Ojuel J, Jesus Tarragona M. Prevalence of postpartum depression in Spanish mothers: a comparison between structured clinical interview and the Edinburgh postpartum depression scale. Med Clin (Barc) 2003;120:326329.
  • 32
    Aydin N, Indani T, Yigit A, Hodoglugil NNS. Validation of the Turkish version of the Edinburgh Postnatal Depression Scale among women within their first postpartum year. Soc Psychiatry Psychiatr Epidemiol 2004;39:483486.
  • 33
    Barnett B, Matthey S, Gyaneshwar R. Screening for postnatal depression in women of non-English speaking background. Arch Womens Ment Health 1999;2:6774.
  • 34
    Benvenuti P, Maurizio F, Niccolai C, Valoriani V, Cox JL. The Edinburgh Postnatal Depression Scale: validation for an Italian sample. J Affect Disord 1999;53:137141.
  • 35
    Berle JO, Aarre TF, Mykletum A, Dahl AA, Holsten F. Screening for postnatal depression. Validation of the Norwegian version of the Edinburgh Postnatal Depression Scale, and assessment of risk factors for postnatal depression. J Affect Disord 2003;76:151156.
  • 36
    Eberhard-Gran M, Eskild A, Tambs K, Schei B, Opjordsmoen S, Samuelson SO. The Edinburgh Postnatal Depression Scale: validation in a Norwegian community sample. Nord J Psychiatry 2001;55:113117.
  • 37
    Garcia-Esteve L, Ascaso C, Ojuel J, Navarro P. Validation of the Edinburgh Postnatal Depression Scale (EPDS) in Spanish mothers. J Affect Disord 2003;75:7176.
  • 38
    Lawrie TA, Hofmeyr GJ, De Jager M, Berk M. Validation of the Edinburgh Postnatal Depression Scale in a cohort of South African women. S Afr Med J 1998;86:13401344.
  • 39
    Lee DT, Yip SK, Chiu HF. Detecting postnatal depression in Chinese women. Validation of the Chinese version of the Edinburgh Postnatal Depression Scale. Br J Psychiatry 1998;172:433437.
  • 40
    Regmi S, Sligl W, Carter D, Grut W, Seear M. A controlled study of postpartum depression among Nepalese women: validation of the Edinburgh Postnatal Depression Scale in Kathmandu. Trop Med Int Health 2002;7:378382.
  • 41
    Teng HW, Hsu CS, Shih SM, Lu ML, Pan JJ, Shen WW. Screening postpartum depression with the Taiwanese version of the Edinburgh Postnatal Depression Scale. Compr Psychiatry 2005;46:261265.
  • 42
    Vega-Dienstmaier JM, Mazzotti Suarez G, Campos Sanchez M. Validation of a Spanish version of the Edinburgh Postnatal Depression Scale. Actas Esp Psiquiatr 2002;30:106111.
  • 43
    Wickberg B, Hwang CP. The Edinburgh Postnatal Depression Scale: validation on a Swedish community sample. Acta Psychiatr Scand 1996;94:181184.
  • 44
    Clarke PJ. Validation of two postpartum depression screening scales with a sample of First Nations and Metis women. Can J Nurs Res 2008;40:112125.
  • 45
    Gausia K, Fisher C, Algin S, Oosthuizen J. Validation of the Bangla version of the Edinburgh Postnatal Depression Scale for a Bangladeshi sample. J Reprod Infant Psychol 2007;25:308315.
  • 46
    Pitanupong J, Liabsuetrakul T, Vittayanont A. Validation of the Thai Edinburgh Postnatal Depression Scale for screening postpartum depression. Psych Res 2007;149:253259.
  • 47
    American Psychiatric Association. Diagnostic and statistical manual of mental disorders, 3rd edn. Washington, DC: American Psychiatric Press, 1980.
  • 48
    American Psychiatric Association. Diagnostic and statistical manual of mental disorders, revised 3rd edn. Washington, DC: American Psychiatric Press, 1987.
  • 49
    American Psychiatric Association. Diagnostic and statistical manual of mental disorders, 4th edn. Washington, DC: American Psychiatric Press, 1994.
  • 50
    Jadresic E, Araya R, Jara C. Validation of the Edinburgh Postnatal Depression Scale (EPDS) in Chilean postpartum women. J Psychosom Obstet Gynecol 1995;16:187191.
  • 51
    Yoshida K, Yamashita H, Ueda M, Tashiro N. Postnatal depression in Japanese mothers and the reconsideration of ‘Satogaeri bunben’. Ped Int 2001;43:189193.
  • 52
    Spitzer RL, Endicott J, Robins E. Research Diagnostic Criteria Instrument no. 58. New York: New York State Psychiatric Institute, 1975.
  • 53
    World Health Organisation. Mental disorders, glossary and guide to their classification in accordance with the 8th REVISION of the international classification of diseases (ICD-8). Geneva: WHO, 1974.
  • 54
    World Health Organisation. The ICD-10 classification of mental and behavioural disorders. Clinical descriptions and diagnostic guidelines. Geneva: WHO, 1992.
  • 55
    Leverton TJ, Elliott SA. Is the EPDS a magic wand? 1. 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;18:279296.
  • 56
    Mahmud WMRW, Awang A, Mohamed MN. Revalidation of the Malay version of the Edinburgh Postnatal Depression Scale (EPDS) among Malay postpartum women attending the Bakar Bata Health Center in Alor Setar, Kedah, North West of Peninsular Malaysia. Malay J Med Sci 2003;10:7175.
  • 57
    Ukwakwe R. Affective (depressive) mornidity in puerperal Nigerian women: validation of the Edinburgh Postnatal Depression Scale. Acta Psychiatr Scand 2003;107:251259.
  • 58
    Werrett J, Clifford C. Validation of the Punjabi version of the Edinburgh postnatal depression scale (EPDS). Int J Nurs Stud 2006;43:227236.
  • 59
    Rushidi WMWM, Azidah AK, Shaiful Bahari I, Janil MY. Validation of the Malay version of the Edinburgh Postnatal Depression Scale (EPDS). Malaysian Journal of Psychiatry 2002;10:4449.
  • 60
    Carapinello B, Pariante C, Serri F, Costa G, Carta MG. Validation of the Edinburgh Postnatal Depression Scale in Italy. J Psychom Obstet Gynecol 1997;18:280285.
  • 61
    Ghubash R, Abou-Saleh MT, Daradekh TK. The validity of the Arabic Edinburgh Postnatal Depression Scale. Soc Psychiatr Epidemiol 1997;32:474476.
  • 62
    Kadir AA, Nordin R, Shaiful BI, Mohd JY, Wan Mohd RWM. Validation of the Malay version of Edinburgh Postnatal Depression Scale for Postnatal Women in Kelantan, Malaysia. IMJ 2005;12:105109.
  • 63
    Goldberg D. The detection of psychiatric illness by questionnaire. Maudsley monograph 21. Oxford: Oxford University Press, 1972.
  • 64
    World Health Organisation. The composite international diagnostic interview – version 2.0. Geneva: WHO, 1997.
  • 65
    Lewis G, Pelosi AJ. Manual if the revised clinical interview schedule (CIS-R). London: MRC Institute of Psychiatry, 1990.
  • 66
    Montgomery SA, Asberg M. A new depression scale designed to be sensitive to change. Br J Psychiatry 1984;144:3547.
  • 67
    Spitzer RL, Endicott J. Schedule for affective disorders and schizophrenia, 3rd edn. New York: New York State Psychiatric Institute, 1979.
  • 68
    Dean C, Surtees P, Sashidharan S. Comparison of research diagnostic systems in an Edinburgh community sample. Br J Psychiatry 1983;142:247256.
  • 69
    Robins L, Helzer J, Cottler L, Goldring E. NIMH diagnostic interview schedule, version 3, revised. Bethesda, MA: NIH, 1989.
  • 70
    Spitzer RL, Williams JB, Kroenke K et al. Utility of a new procedure for diagnosing mental disorders in primary care. The PRIME-MD 1000 study. JAMA 1994;272:17491756.
  • 71
    Egger M, Davey Smith G, Altman D. Systematic reviews in health care. London: BMJ Publishing Group, 2001.

Appendices

  1. Top of page
  2. Abstract
  3. Summations
  4. Considerations
  5. Introduction
  6. Material and methods
  7. Results
  8. Discussion
  9. Acknowledgements
  10. Declaration of interest
  11. References
  12. Appendices

Appendix 1

Focused search strategy

Medline search: (((Puerper* or Pos?tnatal or Post?partum or Ante?natal or Ante?partum or Pregnan* or Pre?natal) near5 (depress*)) or (explode ‘Depression-Postpartum’/all subheadings in MIME,MJME)) and ((EPDS or Edinburgh Postnatal Depression Scale) or ((diagnos* or screen*) near (tool* or questionnaire* or scale* or inventor*)) or (depress* near (scale* or questionnaire* or inventor*)) or (explode ‘Questionnaires-’/all subheadings in MIME,MJME) or (explode ‘Severity-of-Illness-Index’/all subheadings in MIME,MJME) or (‘Diagnostic-and-Statistical-Manual-of-Mental-Disorders’/all subheadings in MIME,MJME)) and (Diagnos* interview or Clinical interview* or semi?structured interview*) and ((explode ‘Sensitivity-and-Specificity’/all subheadings in MIME,MJME) or (explode ‘Likelihood-Functions’/all subheadings in MIME,MJME) or (Valid* or Specificity or Sensitivity or predict* value* or Ppv or Npv or Likelihood ratio*)).

PsychInfo search: (((Puerper* or Pos?tnatal or Post?partum or Ante?natal or Ante?partum or Pregnan* or Pre?natal) near5 (depress*)) or (explode ‘Postpartum-Depression’ in MJ,MN)) and ((EPDS or Edinburgh Postnatal Depression Scale) or ((diagnos* or screen*) near (tool* or questionnaire* or scale* or inventor*)) or (depress* near (scale* or questionnaire* or inventor*)) or (explode ‘Personality-Measures’ in MJ,MN) or (explode ‘Questionnaires-’ in MJ,MN) or (explode ‘Diagnostic-and-Statistical-Manual’ in MJ,MN)) and ((Diagnos* interview or Clinical interview* or semi?structured interview*) or (explode ‘Psychodiagnostic-Interview’ in MJ,MN) or (explode ‘Interview-Schedules’ in MJ,MN)) and ((Valid* or Specificity or Sensitivity or predict* value* or Ppv or Npv or Likelihood ratio*) or (‘Statistical-Validity’ in MJ,MN) or (‘Predictability-Measurement’ in MJ,MN) or (explode ‘Probability-’ in MJ,MN) or (‘Consistency-Measurement’ in MJ,MN) or (‘Test-Reliability’ in MJ,MN)).

Embase search: ((explode ‘puerperal-depression’/all subheadings in DEM,DER,DRM,DRR) or ((Puerper* or Pos?tnatal or Post?partum or Ante?natal or Ante?partum or Pregnan* or Pre?natal) near5 (depress*))) and ((EPDS or Edinburgh Postnatal Depression Scale) or ((diagnos* or screen*) near (tool* or questionnaire* or scale* or inventor*)) or (depress* near (scale* or questionnaire* or inventor*)) or (explode ‘psychologic-test’/all subheadings in DEM,DER,DRM,DRR) or (explode ‘questionnaire-’/all subheadings in DEM,DER,DRM,DRR)) and ((Diagnos* interview or Clinical interview* or semi?structured interview*) or ((explode ‘clinical-examination’/all subheadings in DEM,DER,DRM,DRR) and (explode ‘interview-’/all subheadings in DEM,DER,DRM,DRR))) and ((Valid* or Specificity or Sensitivity or predict* value* or Ppv or Npv or Likelihood ratio*) or (explode ‘sensitivity-and-specificity’/all subheadings in DEM,DER,DRM,DRR)).

Appendix 2: Data extraction form

inline image