While perinatal mood and anxiety disorders (PMAD) have a global footprint, the majority of research related to this group of illnesses has come largely from more affluent, Westernized countries.  Similarly, the tools used to detect and screen for PMADs were developed and tested in these Westernized countries.  

The instrument most commonly used to detect PMADs is the Edinburgh Postnatal Depression Scale (EPDS), which was originally developed in Great Britain.  While it has been translated into many different languages and used in many different countries, it is unclear if these translated versions of the EPDS accurately identify PMAD in disparate, non-English speaking countries.  Specifically there has been concern that simply translating the EPDS may not fully capture the cultural determinants of mood and anxiety disorders.  

Particularly vulnerable to mental health problems are the women who are pregnant or have recently given birth living in resource-constrained, low- and lower-middle-income countries (LALMICs) as defined by the World Bank.  A  recent systematic review appraised formally validated local language versions of the EPDS used in resource-constrained settings (Shrestha et al., 2016).

The authors analyzed the findings from 12 LALMICs in 14 native languages. Most of these local language versions of the EPDS (LLV-EPDS) had lower precision for identifying true cases of PMADs among women in the general perinatal population, as compared to the original English version. Only one study met all criteria for culturally sensitive translation.  Furthermore, many studies tested the LLV-EPDS in convenience samples recruited only from a single health facility.

How to Improve the Detection of Perinatal Mood and Anxiety Disorders?

Based on the findings of this study, it appears that the local language versions of the EPDS are not optimal screening tools for PMADs in non-English speaking low- and lower-middle-income-countries.  None of the versions met the recommended validation standard of ?80 % cutoff for the three key parameters of screening validity: sensitivity, specificity and positive predictive value.

The researchers speculate that the lower psychometric property of these native language versions of the EPDS might be related to compromises made during the process of translation and cultural adaptation.  In order to improve the reliability and validity of these screening tools, they urged the application of six key steps in order to render a culturally sensitive translation of the EPDS: forward translation, backward translation, resolution of difficulties and differences in translations by committee approach, pretesting, amendments and test of conceptual and operational equivalence (outlined in Table 3 in the article).

While this may seem like an academic issue, it is not.  Much of the world lives in low- and lower-middle-income countries.  If you look only at India, you can get a sense of the vast scope of the problem.  In 2016, there were about 27 million births in India.  If we estimate that about 15% of the mothers in India suffer from a perinatal mood or anxiety disorder (which is most likely an underestimate of the prevalence), we would, without screening, be missing at least 4 million mothers with PMADs.  Because the vast majority of these women will not get any treatment, it is vital that we develop screening tools that are culturally sensitive and accurate in terms of identifying women with psychiatric illness in these diverse settings.

Ruta Nonacs, MD PhD


Shrestha SD, Pradhan R, Tran TD, Gualano RC, Fisher JR.Reliability and validity of the Edinburgh Postnatal Depression Scale (EPDS) for detecting perinatal common mental disorders (PCMDs) among women in low-and lower-middle-income countries: a systematic review. BMC Pregnancy Childbirth. 2016 Apr 4;16:72. Review.  Free Article


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