Reappraising the dimensional structure of the PTSD Checklist: lessons from the DSM-IV-based PCL-C

Objective: The dimensional structure of posttraumatic stress disorder (PTSD) has been extensively debated, but the literature is still inconclusive and contains gaps that require attention. This article sheds light on hitherto unvisited methodological issues, reappraising several key models advanced for the DSM-IV-based civilian version of the PTSD Checklist (PCL-C) as to their configural and metric structures. Methods: The sample comprised 456 women, interviewed at 6-8 weeks postpartum, who attended a high-complexity facility in Rio de Janeiro, Brazil. Confirmatory factor analysis (CFA) and exploratory structural equation models (ESEM) were used to evaluate the dimensional structure of the PCL-C. Results: The original three-factor solution was rejected, along with the four-factor structures most widely endorsed in the literature (PTSD-dysphoria and PTSD-numbing models). Further exploration supported a model comprised of two factors (re-experience/avoidance and numbing/hyperarousal). Conclusion: These findings are at odds with the dimensional structure proposed in both DSM-IV and DSM-5. This also entails a different presumption regarding the latent structure of PTSD and how the PCL should be operationalized.

Reappraising the dimensional structure of the PTSD Checklist: lessons from the DSM-IV-based PCL-C.

OBJECTIVE: The dimensional structure of posttraumatic stress disorder (PTSD) has been extensively debated, but the literature is still inconclusive and contains gaps that require attention. This article sheds light on hitherto unvisited methodological issues, reappraising several key models advanced for the DSM-IV-based civilian version of the PTSD Checklist (PCL-C) as to their configural and metric structures. METHODS: The sample comprised 456 women, interviewed at 6-8 weeks postpartum, who attended a high-complexity facility in Rio de Janeiro, Brazil. Confirmatory factor analysis (CFA) and exploratory structural equation models (ESEM) were used to evaluate the dimensional structure of the PCL-C. RESULTS: The original three-factor solution was rejected, along with the four-factor structures most widely endorsed in the literature (PTSD-dysphoria and PTSD-numbing models). Further exploration supported a model comprised of two factors (re-experience/avoidance and numbing/hyperarousal). CONCLUSION: These findings are at odds with the dimensional structure proposed in both DSM-IV and DSM-5. This also entails a different presumption regarding the latent structure of PTSD and how the PCL should be operationalized.

Psychologic intimate partner violence and the risk of intrauterine growth restriction in Rio de Janeiro.

OBJECTIVE: To evaluate whether psychologic intimate partner violence (IPV) during pregnancy is a risk factor for intrauterine growth restriction (IUGR). METHODS: The cross-sectional study enrolled randomly selected mothers of infants younger than 5 months attending basic health services in Rio de Janeiro, Brazil, from January to July 2007. Psychologic and physical IPV were evaluated by the Revised Conflict Tactics Scale; IUGR was defined as below the 10th percentile of the Alexander curve. Socioeconomic status, housing conditions, stressful events, life habits, social support, and medical information were obtained by interview or from medical records. Multivariate hierarchical logistic regression models, taking into account potential confounders, were used to evaluate the relationship between mounting acts of psychologic IPV and IUGR. RESULTS: There were 810 women included in the study. Psychologic IPV during pregnancy was reported by 665 women (82.1%) and 126 newborns (15.6%) showed growth restriction. In the final model, each 1-unit increase in psychologic IPV score during pregnancy led to a 15% higher risk of IUGR at birth (odds ratio 1.15; P<0.001). CONCLUSION: Psychologic IPV during pregnancy seems to be a significant and independent risk factor for IUGR. This finding reinforces the importance of preventive and intervention procedures for IPV to reduce adverse perinatal outcomes.

Childhood sexual abuse, intimate partner violence during pregnancy, and posttraumatic stress symptoms following childbirth: a path analysis.

The aim of the study was to explore the pathways by which childhood sexual abuse (CSA), psychological and physical intimate partner violence (IPV) during pregnancy, and other covariates relate to each other and to posttraumatic stress disorder (PTSD) symptoms in the postpartum period. The sample comprised 456 women who gave birth at a maternity service for high-risk pregnancies in Rio de Janeiro, Brazil, interviewed at 6-8 weeks after birth. A path analysis was carried out to explore the postulated pathways between exposures and outcome. Trauma History Questionnaire, Conflict Tactics Scales and Posttraumatic Stress Disorder Checklist were used to assess information about exposures of main interest and outcome. The link between CSA and PTSD symptoms was mediated by history of trauma, psychiatric history, psychological IPV, and fear of childbirth during pregnancy. Physical IPV was directly associated with postnatal PTSD symptoms, whereas psychological IPV connection seemed to be partially mediated by physical abuse and fear of childbirth during pregnancy. The role of CSA, IPV, and other psychosocial characteristics on the occurrence of PTSD symptoms following childbirth as well as the intricate network of these events should be acknowledged in clinic and intervention approaches.

Applying the maternal near miss approach for the evaluation of quality of obstetric care: a worked example from a Multicenter Surveillance Study.

OBJECTIVE: To assess quality of care of women with severe maternal morbidity and to identify associated factors. METHOD: This is a national multicenter cross-sectional study performing surveillance for severe maternal morbidity, using the World Health Organization criteria. The expected number of maternal deaths was calculated with the maternal severity index (MSI) based on the severity of complication, and the standardized mortality ratio (SMR) for each center was estimated. Analyses on the adequacy of care were performed. RESULTS: 17 hospitals were classified as providing adequate and 10 as nonadequate care. Besides almost twofold increase in maternal mortality ratio, the main factors associated with nonadequate performance were geographic difficulty in accessing health services (P < 0.001), delays related to quality of medical care (P = 0.012), absence of blood derivatives (P = 0.013), difficulties of communication between health services (P = 0.004), and any delay during the whole process (P = 0.039). CONCLUSIONS: This is an example of how evaluation of the performance of health services is possible, using a benchmarking tool specific to Obstetrics. In this study the MSI was a useful tool for identifying differences in maternal mortality ratios and factors associated with nonadequate performance of care.

The role of intimate partner violence and other health-related social factors on postpartum common mental disorders: a survey-based structural equation modeling analysis.

BACKGROUND: Although studies suggest the relevance of intimate partner violence (IPV) and other health-related social characteristics as risk factors for postpartum mental health, literature lacks evidence about how these are effectively connected. This study thus aims to explore how socio-economic position, maternal age, household and marital arrangements, general stressors, alcohol misuse and illicit drug abuse, and especially psychological and physical IPV relate in a framework leading to postpartum common mental disorder (CMD). METHODS: The study was carried out in five primary health care units of Rio de Janeiro, Brazil, and included 810 randomly selected mothers of children up to five postpartum months waiting for pediatric visits. The postulated pathways between exposures and outcome were based on literature evidence and were further examined using structural equation models. RESULTS: Direct pathways to postpartum CMD arose from a latent variable depicting socio-economic position, a general stressors score, and both IPV variables. Notably, the effect of psychological IPV on postpartum CMD ran partly through physical IPV. The effect of teenage pregnancy, conjugal instability and maternal burden apparently happens solely through substance use, be it alcohol misuse, illicit drug abuse or both in tandem. Moreover, the effect of the latter on CMD seems to be entirely mediated through both types of IPV. CONCLUSION: Although the theoretical model underlying the analysis still requires in-depth detailing, results of this study may have shed some light on the role of both psychological and physical IPV as part of an intricate network of events leading to postpartum CMD. Health initiatives may want to make use of this knowledge when designing preventive and intervention approaches.

[The Hospital Information System of the Brazilian Unified National Health System: a performance evaluation for auditing maternal near miss]. / Sistema de Informações Hospitalares do Sistema Único de Saúde (SIH-SUS): uma avaliação do seu desempenho para a identificação do near miss materno.

This study aimed to investigate the performance of the Hospital Information System of the Brazilian Unified National Health System (SIH-SUS) in identifying cases of maternal near miss in a hospital in Rio de Janeiro, Brazil, in 2008. Cases were identified by reviewing medical records of pregnant and postpartum women admitted to the hospital. The search for potential near miss events in the SIH-SUS database relied on a list of procedures and codes from the International Classification of Diseases, 10th revision (ICD-10) that were consistent with this diagnosis. The patient chart review identified 27 cases, while 70 potential occurrences of near miss were detected in the SIH-SUS database. However, only 5 of 70 were "true cases" of near miss according to the chart review, which corresponds to a sensitivity of 18.5% (95%CI: 6.3-38.1), specificity of 94.3% (95%CI: 92.8-95.6), area under the ROC of 0.56 (95%CI: 0.48-0.63), and positive predictive value of 10.1% (IC95%: 4.7-20.3). These findings suggest that SIH-SUS does not appear appropriate for monitoring maternal near miss.

Sistema de Informações Hospitalares do Sistema Único de Saúde (SIH-SUS): uma avaliação do seu desempenho para a identificação do near miss materno / The Hospital Information System of the Brazilian Unified National Health System: a performance evaluation for auditing maternal near miss / Sistema de Información Hospitalaria del Sistema Único de Salud (SIH-SUS): una evaluación de su rendimiento para la identificación de near miss materno

Este estudo avaliou o desempenho do Sistema de Informações Hospitalares do Sistema Único de Saúde (SIH-SUS) na identificação de casos de near miss materno ocorridos em hospital do Rio de Janeiro, em 2008. Os casos foram captados pela revisão de todos os prontuários médicos de gestantes ou puérperas internadas na unidade, e a busca por potenciais eventos de near miss na base do SIH-SUS valeu-se de uma lista de procedimentos e códigos da Classificação Internacional de Doenças, 10ª revisão (CID-10), que fossem compatíveis com esse diagnóstico. A revisão de prontuários identificou 27 casos, enquanto na base do SIH-SUS encontrou-se 70 possíveis ocorrências de near miss. Porém, dessas 70 apenas cinco efetivamente eram casos near miss conforme os prontuários, correspondendo então à sensibilidade de 18,5% (IC95%: 6,3-38,1), especificidade de 94,3% (IC95%: 92,8-95,6), área sob a curva ROC de 0,56 (IC95%: 0,48-0,63) e valor preditivo positivo de 10,1% (IC95%: 4,7-20,3). Esses achados sugerem que o SIH-SUS não é adequado para o monitoramento dos casos de near miss materno.

This study aimed to investigate the performance of the Hospital Information System of the Brazilian Unified National Health System (SIH-SUS) in identifying cases of maternal near miss in a hospital in Rio de Janeiro, Brazil, in 2008. Cases were identified by reviewing medical records of pregnant and postpartum women admitted to the hospital. The search for potential near miss events in the SIH-SUS database relied on a list of procedures and codes from the International Classification of Diseases, 10th revision (ICD-10) that were consistent with this diagnosis. The patient chart review identified 27 cases, while 70 potential occurrences of near miss were detected in the SIH-SUS database. However, only 5 of 70 were "true cases" of near miss according to the chart review, which corresponds to a sensitivity of 18.5% (95%CI: 6.3-38.1), specificity of 94.3% (95%CI: 92.8-95.6), area under the ROC of 0.56 (95%CI: 0.48-0.63), and positive predictive value of 10.1% (IC95%: 4.7-20.3). These findings suggest that SIH-SUS does not appear appropriate for monitoring maternal near miss.

Este estudio evaluó el desempeño del Sistema de Información Hospitalaria del Sistema Único de Salud (SIH-SUS) en la identificación de casos de near miss materno en un hospital de Río de Janeiro en 2008. Los casos se obtuvieron mediante revisión de los historiales clínicos de las embarazadas y puérperas ingresadas en la unidad, y la búsqueda de posibles eventos near miss en la base del SIH-SUS se basó en una lista de procedimientos y códigos de la Clasificación Internacional de Enfermedades (CIE-10) que son compatibles con este diagnóstico. Una revisión retrospectiva de historiales clínicos identificó 27 casos, mientras que la base de la SIH-SUS localizó 70 posibles casos con este diagnóstico. Sin embargo, sólo cinco de los 70 casos fueron en realidad casos de near miss, por ello, la sensibilidad correspondiente fue de un 18,5% (IC95%: 6,3-38,1), una especificidad del 94,3% (IC95%: 92,8-95,6), el área bajo la curva ROC de un 0,56 (IC95%: 0,48-0,63) y el valor predictivo positivo de un 10,1% (IC95%: 4,7-20,3). Estos hallazgos sugieren que SIH-SUS no es adecuado para el seguimiento de near miss.

Comparing different diagnostic approaches to severe maternal morbidity and near-miss: a pilot study in a Brazilian tertiary hospital.

OBJECTIVE: Despite recent guidelines proposed by the World Health Organization (WHO), the operational definition of maternal near-miss (MNM) is still heterogeneous. This study aimed at evaluating the pros and cons of three instruments in characterizing MNM cases. The performance of two of the three instruments was also investigated vis-à-vis the WHO criteria. STUDY DESIGN: A retrospective chart review study was carried out in a tertiary maternity hospital in Rio de Janeiro, Brazil. The medical records of 1163 obstetric hospital admissions from January to December 2008 were reviewed. Cases were first classified as 'positive' or otherwise according to the WHO, Waterstone and literature-based criteria. A descriptive analysis was then carried out focusing on divergent classifications. Finally, diagnostic properties of the Waterstone and the literature-based criteria were calculated taking the WHO criteria as reference standard. RESULTS: There were eight maternal deaths, 157 cases classified as 'positive' by at least one of the three approaches and 998 cases without severe morbidities. Twenty-seven cases of MNM were detected according to the WHO criteria, whereas the Waterstone and the literature-based criteria identified 123 and 153 cases, respectively. Among the 130 cases identified as 'negative' by the WHO criteria and 'positive' by the Waterstone or literature-based criteria, 119 presented hypertensive disorders (91.5%). Additionally, four cases were identified exclusively by the WHO criteria because of acute thrombocytopenia (platelets<50,000). Estimates of sensitivity, specificity, accuracy and negative predictive values were all above 75% for the Waterstone and literature-based approaches, but both criteria presented positive predictive values (PPV) below 60% even with high magnitudes of MNM. CONCLUSION: These results underline that different approaches entail heterogeneous estimates of MNM. The Waterstone and the literature-based criteria are not suitable for a definitive diagnosis of MNM in view of their low PPV, but they seem adequate as a first approach in investigating MNM. While negative results by both alternative criteria virtually rule out MNM, a positive result would require a reassessment using the WHO criteria to confirm the diagnosis of maternal near-miss.

Reappraising the relationship between maternal age and postpartum depression according to the evolutionary theory: Empirical evidence from a survey in primary health services.

BACKGROUND: Postpartum depression (PPD) is a widespread worldwide phenomenon, but its etiology remains unclear. This study reappraised how evolutionary theory could explain PPD as an adaptation through investigating the relationship between maternal age and PPD, and if this relationship is modified according to the number of children at home. METHODS: A cross-sectional study carried out in five primary health care units included 811 participants randomly selected among mothers of children up to five postpartum months in Rio de Janeiro, Brazil. Postpartum depression was defined by scores above 11 on Edinburgh Postnatal Depression Scale (EPDS), and statistical analysis was based on multivariate logistic regression models. RESULTS: One hundred and ninety-seven (24.3%, CI 95% 21.3-27.2) participants were classified as PPD positives. Maternal age was significantly associated to PPD (OR=0.96, p-value=0.019) independently of socioeconomic and reproductive characteristics, conjugal status or substance consumption by the couple. Thus, for each additional year, a reduction of 4% in the chance of developing PPD could be anticipated, effect which was not modified by the number of children at home (p-value=0.602). LIMITATIONS: Information on social support was not included in this analysis since its relationship with maternal mental health would be better evaluated in a prospective fashion. CONCLUSIONS: These findings suggest that adaptive mechanisms shaped through human generations persist contributing to the development of PPD in contemporary societies. According to this evolutionary approach, as maternal age advances the reproductive potential diminishes and, consequently, mothers are less prone to develop PPD and reduce investment in new offspring.

Alcohol misuse among partners: a potential effect modifier in the relationship between physical intimate partner violence and postpartum depression.

PURPOSE: This study evaluated if the probability of postpartum depression (PPD) increases with an upward gradient of physical intimate partner violence (IPV) during pregnancy and whether substance use by any member of the couple modifies this relationship. METHODS: The sample comprised 811 randomly selected mothers of children under 5 months old attending primary health services of Rio de Janeiro, Brazil. The Revised Conflict Tactics Scale (CTS2) gauged physical IPV, and the Edinburgh Postnatal Depression Scale (EPDS) assessed PPD. A hierarchical logistic regression model was employed to deal with confounding. Specific interaction terms between physical IPV and alcohol misuse or use of illicit drugs were also tested. RESULTS: Physical IPV during pregnancy was reported by 37.8% of respondents and 24.3% were presumably depressed (EPDS score ≥ 12). Interaction between physical IPV and partners' alcohol misuse was statistically significant (p = 0.026). Although there was a significant increase in PPD with just one act of physical IPV in the absence of a partners' alcohol misuse, mounting acts did not have any further influence. Conversely, when partners misused alcohol, the probability progressively and steeply increased from two acts onwards, reaching almost sevenfold by six cumulative physical IPV events as opposed to none. CONCLUSIONS: The results reinforce the relevance of physical IPV as a risk factor to PPD. They also suggest that context matters, partners' alcohol misuse acting as an important effect modifier. These evidences justify tailored preventive, screening and intervention procedures for IPV and alcohol misuse during pregnancy and the postpartum period.

Magnitude da depressão pós-parto no Brasil: uma revisão sistemática / The extent of post-partum depression in Brazil: a systematic review

OBJETIVOS: realizar uma revisão sistemática dos estudos sobre a magnitude da depressão pós-parto (DPP) no Brasil. MÉTODOS: a busca e seleção da literatura baseouse em artigos publicados em periódicos nacionais e internacionais, nas bases de dados eletrônicas Lilacs, SciELO e Medline. RESULTADOS: foram selecionados 14 estudos, sendo que 13 deles reportavam a prevalência de DPP e apenas um estudo de seguimento com limitada casuística (n=21) trazia estimativa da incidência do agravo (42,8 por cento). A grande heterogeneidade em relação à população de estudo, método diagnóstico utilizado e período pós-parto focalizado dificultou a obtenção de uma estimativa agregada da prevalência de DPP no Brasil. Contudo, estudos conduzidos em unidades básicas de saúde, no âmbito da Estratégia de Saúde da Família ou em populações carentes apontaram uma prevalência entre 30 e 40 por cento de DPP, enquanto pesquisas que incluíram amostras de base populacional e populações de unidades hospitalares terciárias revelaram uma prevalência de cerca de 20 por cento. CONCLUSÕES: embora novos estudos sejam necessários para melhor caracterizar as peculiaridades que envolvem a magnitude da DPP no Brasil, as evidências disponíveis justificam uma atenção prioritária para os agravos à saúde mental materna no âmbito da saúde pública no país.

OBJECTIVES: to carry out a systematic review of studies of the extent of post-partum depression (PPD) in Brazil. METHODS: articles were searched for and selected from national and international periodicals included in the Lilacs, SciELO and Medline electronic databases. RESULTS: fourteen studies were selected, thirteen of which reported the prevalence of PPD and one, which followed up a limited number of cases (n=21) estimated the incidence of the disorder at 42.8 percent. The wide range of different populations studied, diagnostic methods used, and post-partum period monitored made it difficult to obtain an aggregate estimate for the prevalence of PPD in Brazil. Nevertheless, studies conducted at Family Health Program basic health units and among underprivileged populations suggest a prevalence of around 30 to 40 percent, although studies that are based on population-wide samples and tertiary hospital units reveal a prevalence of around 20 percent. CONCLUSIONS: although further studies are needed to characterize the specific features of the extent of PPD in Brazil, the available evidence provides sufficient justification for prioritizing treatment of mental health disorders in mothers attending the public health services.

[Birth in Baby-Friendly Hospitals in Rio de Janeiro, Brazil: a protective factor for breastfeeding?]. / Nascer em Hospital Amigo da Criança no Rio de Janeiro, Brasil: um fator de proteção ao aleitamento materno?

This article aims to investigate the impact of the Baby-Friendly Hospital Initiative (BFHI) on exclusive breastfeeding (EBF). This was a cross-sectional study with 811 mothers of infants under five months of age, randomly selected at five health centers in Rio de Janeiro, Brazil. The exposure variable was hospital of birth, categorized in accredited hospitals (BFH), certified hospitals (CBFH), and hospitals without accreditation. The data were analyzed by complementary log-log transformation models, which capture cohort longitudinal experience (current status data). Even after adjusting the analysis for maternal socio-demographic, lifestyle, and psychological factors, health services use, and infants' age and health status, duration of EBF was longer in infants born in BFH and CBFH. The findings suggest the effectiveness of BFHI in maintaining EBF throughout the early months of life. To extend EBF through the first six months of life would require not only strengthening the BFHI but also developing and encouraging more actions in favor of breastfeeding, focusing on primary healthcare facilities.

Severe physical violence between intimate partners during pregnancy: a risk factor for early cessation of exclusive breast-feeding.

OBJECTIVE: To investigate the role of severe physical violence during pregnancy (SPVP) between intimate partners in early cessation of exclusive breast-feeding (EBF). DESIGN: A health services survey. The revised Conflict Tactics Scale was used to characterize SPVP; premature breast-feeding cessation was identified using a current status data approach, which was based on the information reported from food recall during the preceding 7 d. The cumulative hazard function was estimated by complementary log-log transformation models, which allowed the ensuing estimation of early breast-feeding cessation rates in different age groups and the ratio of rates of weaning between women exposed and not exposed to violence. SETTING: Five large public primary health-care facilities of Rio de Janeiro, Brazil. SUBJECTS: The sample comprised 811 randomly selected mothers of children under 5 months of age who were waiting to be consulted. RESULTS: SPVP is an independent risk factor of cessation of EBF since, after controlling for socio-economic, demographic, reproductive and lifestyle variables, women exposed to violence presented an incidence density that was 31% higher than those who were not exposed (hazard ratio = 1·30, 95% CI 1·01, 1·69). CONCLUSIONS: The findings corroborate the hypothesis that SPVP is an important risk factor for EBF. This indicates the need for incentives to adequately train health-care personnel in dealing with lactating women in order to gain a broader view of breast-feeding beyond the biological aspects of lactation, including the maternal psychological dimension.

Nascer em Hospital Amigo da Criança no Rio de Janeiro, Brasil: um fator de proteção ao aleitamento materno? / Birth in Baby-Friendly Hospitals in Rio de Janeiro, Brazil: a protective factor for breastfeeding?

Este artigo pretende avaliar o papel da Iniciativa Hospital Amigo da Criança (IHAC) na duração do aleitamento materno exclusivo (AME). Trata-se de estudo transversal, com população constituída de 811 mães de crianças menores de cinco meses de idade, selecionadas aleatoriamente em cinco unidades básicas de saúde (UBS) no Município do Rio de Janeiro, Brasil. A exposição de interesse central foi o local de nascimento da criança: Hospital Amigo da Criança (HAC), em vias de receber a titulação (EVHAC) e sem a titulação. Optou-se pelo modelo de análise de sobrevida log-log complementar, que recompõe a experiência longitudinal da coorte, caracterizando abordagem do tipo current status. Mesmo após o controle por variáveis sociodemográficas, relativas ao estilo de vida e aos aspectos psicossociais maternos, à utilização dos serviços de saúde, idade e saúde da criança, houve maior duração do AME em crianças nascidas em HAC e EVHAC. Os resultados sugerem a efetividade da IHAC na manutenção de AME nos primeiros meses de vida, reforçando a necessidade de ampliar sua cobertura para todo o território nacional.

This article aims to investigate the impact of the Baby-Friendly Hospital Initiative (BFHI) on exclusive breastfeeding (EBF). This was a cross-sectional study with 811 mothers of infants under five months of age, randomly selected at five health centers in Rio de Janeiro, Brazil. The exposure variable was hospital of birth, categorized in accredited hospitals (BFH), certified hospitals (CBFH), and hospitals without accreditation. The data were analyzed by complementary log-log transformation models, which capture cohort longitudinal experience (current status data). Even after adjusting the analysis for maternal socio-demographic, lifestyle, and psychological factors, health services use, and infants' age and health status, duration of EBF was longer in infants born in BFH and CBFH. The findings suggest the effectiveness of BFHI in maintaining EBF throughout the early months of life. To extend EBF through the first six months of life would require not only strengthening the BFHI but also developing and encouraging more actions in favor of breastfeeding, focusing on primary healthcare facilities.

Revisiting the dimensional structure of the Edinburgh Postnatal Depression Scale (EPDS): empirical evidence for a general factor.

BACKGROUND: The Edinburgh Postnatal Depression Scale (EPDS) has been proposed as a one-dimensional instrument and used as a single 10-item scale. This might be considered questionable since repeated psychometric studies have shown multi-dimensionality, which would entail using separate component subscales. This study reappraised the dimensional structure of the EPDS, with a focus on the extent of factor correlations and related factor-based discriminant validity as a foundation for deciding how to effectively scale the component items. METHODS: The sample comprised 811 randomly selected mothers of children up to 5 months attending primary health services of Rio de Janeiro, Brazil. Strict Confirmatory Factor Analysis (CFA) and Exploratory Factor Analysis modeled within a CFA framework (E/CFA) were sequentially used to identify best fitting and parsimonious model(s), including a bifactor analysis to evaluate the existence of a general factor. Properties concerning the related 10-item raw-score scale were also investigated using non-parametric items response theory methods (scalability and monotonicity). RESULTS: An initial CFA rejected the one-dimensional structure, while an E/CFA subscribed a three-dimensional solution. Yet, factors were highly correlated (0.66, 0.75 and 0.82). The ensuing CFA showed poor discriminant validity (some square-roots of average variance extracted below the factor correlations). A general bifactor CFA was then fit. Results suggested that, although still weakly encompassing three specific factors, the EPDS might be better described by a model encompassing a general factor (loadings ranging from 0.51 to 0.81). The related 10-item raw score showed adequate scalability (Loevinger's H coefficient = 0.4208), monotonicity e partial double monotonicity (nonintersections of Item Step Response Functions). CONCLUSION: Although the EPDS indicated the presence of specific factors, they do not qualify as independent dimensions if used separately and should therefore not be used empirically as sub-scales (raw scores). An all-encompassing scale seems better suited and continuing its use in clinical practice and applied research should be encouraged.