Further Assessment of Perinatal Depression Following Screening

Screening tools, such as the 10 item Edinburgh Postnatal Depression Scale (EPDS), are useful for quickly identifying women with a higher likelihood of depression. However, an elevated score on a screening tool should be followed by a diagnostic assessment. Below is a summary of the EPDS scores and the appropriate action that is recommended to be taken depending on the score.

FOR ALL EPDS scores

• Check Question 10 for any positive response.
• Ask about risk to mother and baby.

Summary of actions if EPDS ≥13

• Ask further questions (see below)
• Read more on diagnostic criteria (see below)
• Refer on to health professional for further assessment of depression
• Assess for safety of mother and infant and need for crisis support if score ≥ 15, (see Risk Assessment Protocol)

Diagnostic Criteria for Depression

For a diagnosis of clinical depression (DSM-5), a mother should experience at least five symptoms from the list below, of which one must be symptom 1, depressed or irritable mood or symptom 2, diminished interest or pleasure in activities, occurring on most days in the previous two weeks.

1. Depressed mood/irritability
2. Diminished interest and pleasure in activities.
3. Significant weight or appetite change.
4. Sleeping problems e.g. insomnia or hypersomnia.
5.  Fatigue.
6. Feelings of worthlessness/guilt.
7. Inability to think clearly or concentrate.
8. Recurrent thoughts of death and/or suicide.
9. Psychomotor agitation and/or retardation.

Further questions health professionals may ask to assess for Depression, its severity and impact on daily life.

• How long have you been feeling so low? When did you start to feel like this?
• On average, what would you rate your mood out of 10 (0 being the worst and 10 being the best)
• When your mood is the worst, how low would you rate it? How often do you feel this low and how long does this feeling last?
• What would a typical day look like for you?
• What areas of your life is your low mood affecting? How has your low mood impacted on your relationships with others? Ability to take care of your baby?/things at home/engage in activities you enjoy?

Limitations of the EPDS

It is important to remember that the EPDS cannot diagnose depression, but is very useful as a rapid screening tool that will allow informed clinical judgements about the emotional health and wellbeing of the women being cared for. The EPDS is purely a screening tool, so those who score positive are best thought of simply as a sub-group of women among whom there is a higher likelihood of depression compared to the general perinatal population: that is, it is not true that everyone in this ‘positive’ sub-group is clinically depressed. However, those that score high may have other difficulties and be going through a difficult patch that may require some support.

Always be aware that a low score may not mean a woman is not depressed. That is, some depressed women will score below the threshold (a false ‘negative’ result) so you must always follow your own clinical judgement and discuss the results with her. The EPDS result must not replace your clinical judgment.

The EPDS does not predict who will become depressed later on. That is, it is not a measure of the risk of becoming depressed. There is no tool currently available, including the EPDS that can reliably forecast the development of future depression in advance.