Mass General Hospital

Harvard Medical School

Identifying Postpartum Depression: A Three Question Screening Tool

While postpartum depression is common among new mothers, our ability to reliably detect this illness remains poor.  Recent studies have indicated that most obstetricians report that they screen for postpartum psychiatric problems at routine follow-up visits but typically do not use standardized instruments to assess for postpartum depression.  Unfortunately, studies which have measured the success of routine screening suggest that without the use of standardized screening tools like the Edinburgh Postnatal Depression Scale, many women with postpartum depression are not identified.

What is the best screening tool?

The Edinburgh Postnatal Depression Scale (EPDS) is the screening instrument most commonly used to identify women with postpartum mood disorders.  This is a 10-item questionnaire which has been validated in many different populations and is available in almost every language. On this scale, a score of 10 or greater or an affirmative answer on question 10 (presence of suicidal thoughts) is suggestive of postpartum depression.  (Setting the cut-off score of 12 improves the specificity of the EPDS for identifying major depression; however, the sensitivity falls off significantly, making it less useful for screening.)  Most importantly it should be emphasized that an elevated score on the EPDS does not necessarily confirm the diagnosis of postpartum depression; this requires a more thorough diagnostic evaluation.

A recent study indicated that the EPDS may be further abbreviated to a three question version which can be used to screen for postpartum depression.  Given the prevalence of anxiety symptoms among women with postpartum depression, the authors chose a screening tool using the 3 items which comprise the anxiety subscale of the EPDS:

1.      I have blamed myself unnecessarily when things went wrong

2.      I have been anxious or worried for no good reason

3.      I have felt scared or panicky for no very good reason

The EPDS-3 exhibited a sensitivity of 95% and a negative predictive value or 98%; interestingly, this study indicated that the short version of the EPDS had greater sensitivity and thus may be a better screening tool than the full version of the EPDS.

Other screening tools have been used to screen for postpartum depression.  The Postpartum Depression Screening Scale (PDSS) was created specifically for postpartum women and is a 35-item, self-report questionnaire which about 5 to 10 minutes to complete.

Other tools, like the Hamilton Depression Rating Scale and the Beck Depression Inventory, have not been validated in pregnant and postpartum populations.

When is the best time to screen?

Mood fluctuations are extremely common during the first postpartum week, with approximately 60%-85% of women reporting mild to moderate mood symptoms, or “the blues”.  While this may complicate screening, studies which have used the EPDS to screen for depressive symptoms within the first postpartum week suggest that the EPDS may be used to predict which women will go on to have postpartum depression.  In this study, women who scored 9 or greater on the EPDS were about 30 times as likely to have postpartum depression at week 4 than women with lower EPDS scores.  Similar results were observed when the EPDS was administered at 2-3 days postpartum.

Ruta Nonacs, MD PhD

Kabir K, Sheeder J, Kelly LS. Identifying postpartum depression: Are 3 questions as good as 10? Pediatrics 2008, 122(3):e696-e702

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2 Responses to Identifying Postpartum Depression: A Three Question Screening Tool

  1. amorten December 25, 2008 at 2:47 pm #

    Good tip.

  2. Sonya January 13, 2013 at 1:52 am #

    Excellent article. As a woman who suffered from postpartum mood disorders – I’m happy to see more investigation and discussion about screening. I am certain the 3 question screening questionnaire would have caught my PPA. I’m not sure if it would have caught my PPMD after my second daughter – it was more like severe mood swings so I don’t think I would have answered those questions but of course that was in the past so it’s difficult to look back.

    An important thing that I find is often overlooked is informing women about the different manifestations of postpartum mood disorder. We hear about PPD and of course when a tragedy occurs due to postpartum psychosis. What we don’t hear enough about is postpartum anxiety, OCD, bipolar and PTSD. Also mood disorders during pregnancy are rarely discussed.

    I didn’t know that postpartum anxiety even existed yet I was vigilant for depression (with my third baby because I had suspected I had postpartum mood disorder after my second). Because I was vigilant for only depression I failed to mention my anxiety to my OB/GYN and my family doctor that I did tell didn’t relate it to postpartum anxiety.

    So for the women who aren’t being screened – being informed can make all the difference. I eventually realized that my extreme anxiety was related to the postpartum hormone fluctuation and contacted my OB/GYN. Fortunately for me I only suffered for a few short months before getting help. Had I known to watch for anxiety I VERY LIKELY would have made the connection sooner.

    I think the term Postpartum Depression should only be used in the case of a specific diagnosis. Women would be better served if the general use of the term was replaced with Postpartum Mood Disorder or better yet, Perinatal Mood Disorder. This would help ensure women and their families become better educated about the broader spectrum of perinatal mood disorders.

    Thanks for sharing valuable information.

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