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The Edinburgh Postnatal Depression Scale in routine screening: errors and cautionary advice

Published:November 14, 2016DOI:https://doi.org/10.1016/j.ajog.2016.11.1020
      To the Editors:
      We read with interest the recent article by Venkatesh et al
      • Venkatesh K.K.
      • Nadel H.
      • Blewett D.
      • Freeman M.P.
      • Kaimal A.J.
      • Riley L.E.
      Implementation of universal screening for depression during pregnancy: feasibility and impact on obstetric care.
      regarding the implementation of routine antenatal and postnatal screening for depression for women in the perinatal period in Massachusetts, using the Edinburgh Postnatal Depression Scale (EPDS) (Cox et al
      • Cox J.
      • Holden J.
      • Sagovsky R.
      Detection of postnatal depression: development of the 10 item Edinburgh Postnatal Depression Scale.
      ). We would like to make some observations about this study and its wider implications for other services considering the use of this self-report scale.
      • 1.
        As the authors correctly state, many studies use a cut-off score of ≥12 on the EPDS.
        • Cox J.
        • Holden J.
        • Sagovsky R.
        Detection of postnatal depression: development of the 10 item Edinburgh Postnatal Depression Scale.
        This, however, is often due to an error in these studies reporting the validation study by Cox et al,
        • Cox J.
        • Holden J.
        • Sagovsky R.
        Detection of postnatal depression: development of the 10 item Edinburgh Postnatal Depression Scale.
        in which ≥13 was in fact the validated cut-off score for English-speaking women in the postpartum period. This error has previously been shown to be frequent, and that a difference of just 1 point in the cut-off score does indeed have a significant impact on findings and is not just trivial.
        • Matthey S.
        • Henshaw C.
        • Elliott S.
        • Barnett B.
        Variability in use of cut-off scores and formats on the Edinburgh Postnatal Depression Scale–implications for clinical and research practice.
        Unfortunately this mistake is often still being made, and thus gives the impression that ≥12 is the validated cut-off score for English-speaking postpartum women, when it is not.
      Indeed, it is somewhat concerning that the authors themselves have made a similar type of error. They cite Murray and Carothers
      • Murray L.
      • Carothers A.D.
      The validation of the Edinburgh Post-natal Depression Scale on a community sample.
      as evidence for studies using ≥12 as the cut-off score, when that article does not in fact make any recommendation for this score, but highlights (without making any specific score recommendations) the scores of ≥11 and ≥13, and discusses that Cox et al
      • Cox J.
      • Holden J.
      • Sagovsky R.
      Detection of postnatal depression: development of the 10 item Edinburgh Postnatal Depression Scale.
      found ≥13 to be the optimal cut-off score.
      • 2.
        Venkatesh et al
        • Venkatesh K.K.
        • Nadel H.
        • Blewett D.
        • Freeman M.P.
        • Kaimal A.J.
        • Riley L.E.
        Implementation of universal screening for depression during pregnancy: feasibility and impact on obstetric care.
        used the same EPDS cut-off score for the antenatal and postnatal periods, without commenting on the research showing that different cut-off scores are required for the 2 time periods.
        • Matthey S.
        • Henshaw C.
        • Elliott S.
        • Barnett B.
        Variability in use of cut-off scores and formats on the Edinburgh Postnatal Depression Scale–implications for clinical and research practice.
        In addition it is important that services know that there is considerable evidence that different cut-off scores on the EPDS are required for women (and men) from different cultures.
        • Matthey S.
        • Henshaw C.
        • Elliott S.
        • Barnett B.
        Variability in use of cut-off scores and formats on the Edinburgh Postnatal Depression Scale–implications for clinical and research practice.
      • 3.
        While Venkatesh et al
        • Venkatesh K.K.
        • Nadel H.
        • Blewett D.
        • Freeman M.P.
        • Kaimal A.J.
        • Riley L.E.
        Implementation of universal screening for depression during pregnancy: feasibility and impact on obstetric care.
        report that the EPDS data were successfully entered into the electronic medical record, this does not necessarily mean that the score that was entered was in fact correct. Services need to be aware that the accuracy of clinicians scoring the EPDS has been shown to be very poor,
        • Matthey S.
        • Lee C.
        • Crncec R.
        • Trapolini T.
        Errors in scoring the Edinburgh Postnatal Depression Scale.
        even among those who provide training in the use of this scale.

      References

        • Venkatesh K.K.
        • Nadel H.
        • Blewett D.
        • Freeman M.P.
        • Kaimal A.J.
        • Riley L.E.
        Implementation of universal screening for depression during pregnancy: feasibility and impact on obstetric care.
        Am J Obstet Gynecol. 2016; 215: 517.e1-517.e8
        • Cox J.
        • Holden J.
        • Sagovsky R.
        Detection of postnatal depression: development of the 10 item Edinburgh Postnatal Depression Scale.
        Br J Psychiatry. 1987; 150: 782-786
        • Matthey S.
        • Henshaw C.
        • Elliott S.
        • Barnett B.
        Variability in use of cut-off scores and formats on the Edinburgh Postnatal Depression Scale–implications for clinical and research practice.
        Arch Women Ment Health. 2006; 9: 309-315
        • Murray L.
        • Carothers A.D.
        The validation of the Edinburgh Post-natal Depression Scale on a community sample.
        Br J Psychiatry. 1990; 157: 288-290
        • Matthey S.
        • Lee C.
        • Crncec R.
        • Trapolini T.
        Errors in scoring the Edinburgh Postnatal Depression Scale.
        Arch Women Ment Health. 2013; 16: 117-122

      Linked Article

      • Implementation of universal screening for depression during pregnancy: feasibility and impact on obstetric care
        American Journal of Obstetrics & GynecologyVol. 215Issue 4
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          Given the growing policy and public health interest in the identification and treatment of depression in pregnancy, an understanding of the feasibility, challenges, and implications for resource utilization of the implementation of a universal screening program is crucial.
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        American Journal of Obstetrics & GynecologyVol. 216Issue 4
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          We thank Dr Matthey and colleagues for their interest in our work, and for highlighting the impact of varying cut-off scores of the Edinburgh Postnatal Depression Scale (EPDS) and its implications for depression screening. The authors highlight the impact of using a higher cut-off score to screen positive for depression used in some earlier validation studies of the EPDS (ie, ≥13 rather than ≥12), as well as evidence suggesting different cut-off scores may be optimal for the antepartum and postpartum periods, and in women of different sociocultural backgrounds.
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