Variability in use of cut-off scores and formats on the Edinburgh Postnatal Depression Scale: implications for clinical and research practice.

OBJECTIVES: i) To highlight the increasing use in the literature of unvalidated cut-off scores on the Edinburgh Depression Scale (EDS/EPDS), as well as different wording and formatting in the scale; ii) to investigate and discuss the possible impact of using an unvalidated cut-off score; iii) to highlight possible reasons for these 'errors'; and iv) to make recommendations to clinicians and researchers who use the EDS/EPDS. METHOD: A convenience sample of studies that have used unvalidated cut-off scores, or different formatting, are cited as evidence that these types of 'errors' are occurring fairly frequently. Examination of previous data from one of the authors is undertaken to determine the effect of using an unvalidated cut-off score. SUMMARY: Many studies report rates of high scorers on the EDS/EPDS using different cut-off scores to the validated ones. The effect of doing this on the overall rate can be substantial. The effect of using different formatting is not known, though excluding items from the EDS/EPDS must also make a substantial difference. RECOMMENDATIONS: We recommend that i) the validated score of 13 or more is used when reporting on probable major depression in postnatal English-speaking women, and 15 or more when reporting on antenatal English-speaking women; ii) that the wording used is "13 or more" (or equivalent), and not other terms that may cause confusion (e.g., '>12'; 'more than 12'; '13' etc), iii) if a different cut-off score to the validated one is used, a clear explanation is given as to why this has been done; and iv) that the scale should be worded and formatted as originally described by its authors.

The prevention of postnatal depression: a narrative systematic review.

This systematic review assessed the success of randomized controlled trials of preventative interventions for postnatal depression (PND). Outcomes examined were estimates of PND prevalence. Methodological quality was determined through the examination of key components individually with independent data extraction by all three authors. Data sources included Medline, PsycINFO, Sociofile, CINAHL, COPAC, EMBASE, Cochrane library; hand searches and a newsletter requests for unpublished trials to the Marcé Society and Postpartum Support International. Twenty-one RCTs were included in this review. Nine of these trials demonstrated short-term preventative success (seven psychological and supportive interventions, one unpublished antidepressant trial and a calcium carbonate trial) but none provided any evidence of long-term success. Furthermore, the results of three of the psychological intervention trials should be viewed with caution due to a lack of methodological rigour. There is a need for future research into the prevention of PND to be tightly designed and maybe include an exploration of the experience of postnatal depression for multiparous women.

Antidepressant prevention of postnatal depression.

BACKGROUND: Postnatal depression is a common and important complication of childbearing. Untreated depression can lead to potentially negative effects on the foetus and infant, in addition to serious morbidity for the mother. The use of antidepressants during pregnancy for prevention of postnatal depression is unclear, due to the possibility of adverse effects on the mother and developing foetus, and the difficulty of reliably identifying the women who would go on to develop postnatal depression. OBJECTIVES: To evaluate the effectiveness of different antidepressant drugs in addition to standard clinical care in the prevention of postnatal depression. To compare the effectiveness of different antidepressant drugs and with any other form of intervention for postnatal depression i.e. hormonal, psychological or social support. To assess any adverse effects of antidepressant drugs in either the mother or the foetus/infant. SEARCH STRATEGY: The register of clinical trials maintained and updated by the Cochrane Depression, Anxiety and Neurosis Group and the Cochrane Pregnancy and Childbirth Group. SELECTION CRITERIA: Randomised studies of antidepressants alone or in combination with another treatment, compared with placebo or a psychosocial intervention in non-depressed pregnant women or women who had given birth in the previous six weeks (i.e. women at risk of postnatal depression) DATA COLLECTION AND ANALYSIS: Data were extracted independently from the trial reports by the authors. Missing information was requested from investigators wherever possible. Data were sought to allow an "intention to treat" analysis. MAIN RESULTS: Two trials fulfilled the inclusion criteria for this review. Both looked at women with a past history of postpartum depression. Nortriptyline (n=26) (Wisner 2001) did not show any benefit over placebo (n=25). Sertraline (n=14) Wisner 2004 reduced the recurrence of postnatal depression and the time to recurrence when compared with placebo (n=8). Intention to treat analyses were not carried out in either trial. AUTHORS' CONCLUSIONS: It is not possible to draw any clear conclusions about the effectiveness of antidepressants given immediately postpartum in preventing postnatal depression and, therefore, cannot be recommended for prophylaxis of postnatal depression, due to the lack of clear evidence. Larger trials are needed which also include comparisons of antidepressant drugs with other prophylactic treatments to reflect clinical practice, and examine adverse effects for the foetus and infant, as well as assess womens' attitudes to the use of antidepressants at this time.

Contextual Assessment of the Maternity Experience: development of an instrument for cross-cultural research.

BACKGROUND: There is evidence that stressors may trigger the onset of a depressive episode in vulnerable women. A new UK interview measure, the Contextual Assessment of the Maternity Experience (CAME), was designed to assess major risk factors for emotional disturbances, especially depression, during pregnancy and post-partum. AIMS: With in the context of a cross-cultural study, to establish the usefulness of the CAME, and to test expected associations of the measure with characteristics of the social context and with major or minor depression. METHOD: The CAME was administered antenatally and postnatally in ten study sites, respectively to 296 and 249 women. Affective disorder throughout pregnancy and up to 6 months postnatally was assessed by means of the Structured Clinical Interview for DSM-IVAxis I Disorders. RESULTS: Adversity, poor relationship with either a partner or a confidant, and negative feelings about the pregnancy all predicted onset of depression during the perinatal period. CONCLUSIONS: The CAME was able to assess major domains relevant to the psychosocial context of the maternity experience in different cultures. Overall, the instrument showed acceptable psychometric properties in its first use in different cultural settings.

Maternal attachment style and depression associated with childbirth: preliminary results from a European and US cross-cultural study.

BACKGROUND: Insecure attachment style relates to major depression in women, but its relationship to depression associated with childbirth is largely unknown. A new UK-designed measure, the Attachment Style Interview (ASI), has potential for cross-cultural use as a risk marker for maternal disorder. AIMS: To establish there liability of the ASI across centres, its stability over a 9-month period, and its associations with social context and major or minor depression. METHOD: The ASI was used by nine centres antenatally on 204 women, with 174 followed up 6 months postnatally. Interrater reliability was tested and the ASI was repeated on a subset of 96 women. Affective disorder was assessed by means of the Structured Clinical Interview for DSM-IV. RESULTS: Satisfactory interrater reliability was achieved with relatively high stability rates at follow-up. Insecure attachment related to lower social class position and more negative social context. Specific associations of avoidant attachment style (angry-dismissive or withdrawn) with antenatal disorder, and anxious style (enmeshed or fearful) with postnatal disorder were found. CONCLUSIONS: The ASI can be used reliably in European and US centres as a measure for risk associated with childbirth. Its use will contribute to theoretically under pinned preventive action for disorders associated with childbirth.

Postnatal blues: a risk factor for postnatal depression.

Postnatal blues have been regarded as brief, benign and without clinical significance. However, several studies have proposed a link between blues and subsequent depression but have methodological problems. We report a prospective, controlled study of postpartum women with severe blues which uses systematically devised and validated instruments for that purpose which tests the hypothesis that severe blues increases the risk of depression in the six months following childbirth. 206 first-time mothers were recruited in late pregnancy. Blues status was defined using the Blues Questionnaire and those with severe blues and their controls who had no blues (matched for age, marital status and social class) were followed for 6 months with postal Edinburgh Postnatal Depression Scale. RDC diagnoses were made following SADS-L interview at the end of the protocol. Backwards stepwise Cox regression analysis found severe blues and past history of depression to be independent predictors each raising the risk by almost 3 times. Depression in those with severe blues onset sooner after delivery and lasted longer. The difference was largely accounted for by major depression. Severe postpartum blues are identified as an independent risk factor for subsequent postpartum depression. Screening and intervention programs could be devised.

Women's views of antidepressants in the treatment of postnatal depression.

Little research has been carried out on the treatment of postnatal depression and clinicians must currently rely on general recommendations for the use of antidepressants. Antidepressant medication as the main treatment for depression in general practice has been shown to be effective when used as prescribed. However, research has shown that depressed patients consistently receive either no medication or consistently low doses of medication. This study will investigate women's experiences of taking antidepressant medication for postnatal depression. Thirty-five women with a clinical diagnosis of postnatal depression who had been prescribed antidepressant medication completed a questionnaire detailing their experiences of taking medication. Four open-ended questions and responses were discussed with the women. Of the 35 women who were prescribed medication, 4 chose not to take it because they were breast-feeding. Twenty of the women described finding medication helpful. Although only 4 women directly reported not taking antidepressants as prescribed, the comments made by a further 9 women suggest that compliance may have been poor. This study suggests a need to improve information about medication for postnatal depression. If this information is not provided, women are likely to continue to self-manage medication at a dosage that may be clinically ineffective.

Mood disturbance in the early puerperium: a review.

This paper reviews the range of symptoms, timing and measurement of mood disturbance in the early puerperium. The prevalence and risk factors for postpartum blues and elation are discussed. The most convincing relationships are between blues and dysphoria during pregnancy, a past history of depression, neuroticism and premenstrual depression. Biological research is inconclusive. Blues and elation are predictors of subsequent postpartum depression and appear to be an index of affective vulnerability.

Can one induce premenstrual symptomatology in women with prior hysterectomy and bilateral oophorectomy?

Nine women who had undergone hysterectomy and oophorectomy and who previously suffered from severe premenstrual syndrome (PMS) were given estrogen and progesterone in a naturalistic single-blind paradigm. The 13-item Beck Depression Inventory, Spielberger State Anxiety Inventory, Menstrual Distress Questionnaire and the Daily Ratings Form of the Premenstrual Assessment Form were all given daily. Estradiol and progesterone concentrations were estimated. When results from all subjects were considered together, these measures were not correlated with hormonal status. However, individual subjects showed correlations between some symptom scores and serum progesterone concentrations. We conclude that women diagnosed as having PMS do not respond in a uniform fashion to ovarian hormones. Further quantitative studies are needed to relate these individual differences to the syndrome of PMS.

Assessment of xylazine hydrochloride epidural analgesia for open castration of rams.

Epidural xylazine injected at the sacrococcygeal site 40 to 150 min prior to surgery (at a dose of 0.05 to 0.10 mg/kg) provided good analgesia during scrotal skin incision in all 20 experimental rams but in only 10 rams (50%) at incision and separation of tunica vaginalis, and 6 rams (30%) during ligation of the spermatic cord. There was a significant correlation between the decrease in heart rate and the dosage of epidural xylazine. Heart rate increased significantly during incision of the tunics and spermatic cord ligation but was not significantly correlated to the clinical assessment of analgesia. There was no significant correlation between the presence of surgical analgesia and the dosage of epidural xylazine: Pelvic limb ataxia was still evident in 12 rams (60%) at 8 h after epidural xylazine injection. Epidural xylazine provided good somatic analgesia during open castration of 20 rams but visceral analgesia was unpredictable. Factors in addition to the dosage of sacrococcygeal epidural xylazine affects the degree of surgical analgesia obtained for open castration of rams.