A core component of Australia’s National Perinatal Depression Initiative (NPDI) is universal screening of all pregnant women and new mums using the Edinburgh Postnatal Depression Scale. The Commonwealth Department of Health and Ageing (DoHA) suggests using it twice – once antenatally, and again a month or so postpartum [reference here]. In Queensland’s public health service, the aim is to use it four times: twice in the antenatal period (usually around 20 weeks, and again midway through the third trimester), and twice postpartum (at 6-8 weeks, and again at 12-16 weeks).
There’s a heap of academic papers about the Edinburgh Postnatal Depression Scale (EPDS), as this simple internet search reveals. This post won’t attempt to replicate such highfalutin work, but just give a few practical tips for clinicians using it.
Tip One: Don’t Believe The Hype
Meaning no disrespect to the authors of the EPDS or those who decided to build Australia’s universal perinatal mental health screening around it, but let’s clearly call the EPDS exactly what it is: a quick and dirty screening tool. Yes it’s been validated in about eleventy-seven different studies, but like all screening tools the EPDS doesn’t pretend to replicate or replace clinical judgement and it certainly doesn’t masquerade as a diagnostic tool. All it does it measure some signs and symptoms of depression and, to a lesser extent, anxiety (more about that in a moment).
The EPDS intentionally limits the screening questions to one week in time. So we need to keep in mind that it’s only takes a snapshot of what’s happening – it doesn’t show us the whole movie. It’s up to the Midwife/General Practitioner/Indigenous Health Worker/Child Health Nurse/whoever to chat with the woman* about whether the snapshot that the EPDS reveals is an accurate glimpse of the big picture. If the woman has had a particularly good or bad week prior to screening the EPDS result will reflect this.
So, when we’re using the EPDS let’s always remind ourselves, and the woman/family we’re working with, that the EPDS isn’t a measure of someone’s psychological strengths or vulnerabilities, nor is it a psychiatric diagnosis. It’s just a reminder, an aide–mémoire, that anxiety and depression are pretty common in the perinatal period**, and that we should keep an eye out for some of the common early warning signs.
Tip Two: There’s More Than One Score
Casually (and irreverently) stated, the usual way EPDS results are interpreted goes a bit like this:
- zero = this person does not trust this service at this time
- single digits = about what’s expected
- between ten and twelve = dodgy mood: we had better check-up on the supports in place and arrange to do the EPDS again in a fortnight or so
- over thirteen = nudge the woman to chat with someone she loves and trusts and/or accept referral for follow-up
That’s pretty good, but we can, and probably should, get a bit smarter about using the results.
Let’s think of the EPDS as four scales.
The first (most crude) scale is the overall EPDS result [range = 0 to 30]. Interpret as above.
The second (most important) scale is the self-harm/suicide ideation scale: question 10 on the EPDS [range = 0 to 3]. Question 10 asks for a response to the statement, “The thought of harming myself has occurred to me [in the last week]”. If the result is zero that means one of two things: this person hasn’t had thoughts of self-harm recently or this person doen’t trust this service at this time. The response to a score of zero could be something like, “Cool. Just so you know for when you’re chatting to other Mums: it’s not unusual for somebody to feel so overwhelmed that they have uninvited thoughts about hurting themselves. It doesn’t always mean they’re going to do anything silly, of course, but we do like to make sure that they know there are supports available.” Any result on question ten other than zero will require your sensitive, authentic care and some follow-up questions to check on the woman’s safety. Check on whether these thoughts have ever become actions, whether the thoughts are about suicide or non-suicidal self harm, whether there are protective factors in place, and whether this person is safe to go home today (Have you thought about what you would do? When would you would act on those plans?). In my experience people are usually pleased to have an opportunity to speak openly about thoughts of self harm to someone who is caring, not-freaked-out, and non-judgemental. All you’re doing is sensibly, calmly, professionally following-up on a question about depression/risk with the goal of greater understanding.
The third (most ignored) scale is the seven-question depression sub-scale. Questions one and two are fishing around for anhedonia***. Question six seeks to find out whether the woman is feeling overwhelmed, question eight intends to measure mood. Questions seven and nine look to measure for uncharacteristic tearfulness and sleep disturbance. Question ten may be an indicator of feelings of worthlessness. Together, these seven questions measure some of the common neurovegetative symptoms of depression. So, the EPDS depression sub-scale can be expressed as a result out of twenty-one.
The fourth (most handy) scale is the three-question anxiety sub-scale: a measure obtained from scoring questions 3, 4 and 5 in isolation. I find this score out of nine surprisingly useful in clinical practice. Most weeks I’ll get at least one referral where the EPDS total result isn’t very high: say 6 or 7 out of 30. However, a cursory glance at the EPDS reveals that the entire score was generated over just those three questions exploring anxiety symptoms. This transforms a low score into a high score: 6 or 7 out of 30 on the EPDS usually isn’t a big deal, but 6 or 7 out of 9 on the anxiety sub-scale deserves attention.
Confused? Don’t be. Further down the page we will put the four scales into practice using an example EPDS.
A spin-off from the beyondblue and beyondbabyblues web sites is the site justspeakup.com.au. There’s some good info there: a first-time Mum I was meeting with earlier this year found Jessica Rowe’s description of her experience of postnatal depression more recognisable, more poignant, and more helpful than anything I said or did. Empowering for her, humbling for me. Sometimes there’s nothing more powerful than sharing stories of the lived experience.
Another good thing about the Just Speak Up site is the self-scoring online version of the Edinburgh Postnatal Depression Scale here: justspeakup.com.au/epds.
If in a room with a PC and it’s appropriate to check the EPDS, you could bring that site up and ask that it be completed (ten mouse-clicks; takes no time) while you busy yourself with another task. Instant scoring! No mathematical challenges or errors! “Shall I print a copy for you to take home or to give your GP?”
Why not email the justspeakup.com.au/epds link to the woman as a way to promote self-monitoring of changes in mood? If the partner doesn’t quite get with the whole depression/talking about depression thing, suggest that s/he has a go too (it’s fine to use with blokes). You could suggest to the woman that she puts a reminder in her phone to re-visit the EPDS on the first of every month, “You and your partner can compare and contrast scores, if you like. Also, if you’re not sure how to start a chat with your Midwife/GP/Child Health Nurse about your mood you could just print-off the results page and take it in with you to your next appointment… Hey Doc: what do you make of this?”
Tip Four: EPDS? There’s an app for that.
There are three iPhone apps that I know of that include the Edinburgh Postnatal Depression Scale (EPDS). NovoPsych is frightfully expensive for the full version so I havent bought it/tried it. SadScale has the EPDS, but it’s kind of… umm… sad. It’s the least attractive iPhone app I’ve ever seen and has a really dodgy email set-up which I’m reluctant to use (no other app has asked me for my email password). The graphing of the results is laughably bad. It’s cheap to try for yourself if you’d like, but I have another suggestion…
The best app I’ve found so far for the Edinburgh Postnatal Depression Scale is on Mediquations – it’s available for iPhone/iPod Touch/iPad and Android devices for about AU$5. It’s very easy and intuitive to use, calculates the result instantly, and allows you to quickly and easily email the results, including the answer to each of the variables (see below). At least a couple of times a week I’ll hand over my phone the woman I’m meeting with at the time, so we can both compare/contrast today’s EPDS result with previous results. Then I can email the (unidentified) results to my work email address. Why bother? Well, it’s pretty handy to be able to cut and paste the EPDS results directly into the electronic health record, and/or into the letter to the GP, and/or into the follow-up email to the pregnant woman/new mum.
Here’s a cut and paste example of the emailed EPDS result as served-up by Mediquations (for fun: spot the typo on Q9):
Edinburgh Postnatal Depression Scale
Able to laugh and see funny side of things: Not so much now (+1)
Have looked forward with enjoyment to things: Rather less than I used to (+1)
Blamed self unnecessarily when things went wrong: Yes, some of the time (+2)
Been anxious or worried for no good reason: Yes, very often (+3)
Felt scared/panicky for no good reason: Yes, quite a lot (+3)
Things have been getting on top of me: No. Coping as well as ever (+0)
So unhappy resulting in difficulty sleeping: Not very often (+1)
Felt sad or miserable: No, never (+0)
So unhappy that I’ve been crying: Only occassionaly (+1)
Thoughts of harming self: Never (+0)
Results: Score: 12 Depression: Possible
Sent with Mediquations Medical Calculator for iPhone and iPad.
While we’ve got this example here in front of us let’s revisit the four scales thing and see if we can come up with some info that could guide us in clinical practice:
EPDS = 12/30 [let’s repeat it in a fortnight or so]
Q10 = 0/3 [estimate low risk at present]
Depression Sub-Scale = 4/21 [not very indicative of depression, is it?]
Anxiety Sub-Scale = 8/9 [this person is REALLY anxious]
So, despite being a quick and dirty screening tool, the EPDS can be pretty useful. In the example above we would steer the conversation away from depression and get some information and support with the anxiety instead.
Tip Five: Hate Bagpipes but love Didgeridoo?
From the lofty mountains of science/academia the stone tablets have been handed-down: if you change the questions on a scale it will need to be studied to see if it still has validity and fidelity. In the swampy lowlands of clinical practice we sometimes need to be more pragmatic: if the woman/family we are with don’t understand the wording of a tool written for use in Scotland in the mid-1980s, and/or aren’t all that literate with written English, we need to be adaptive. After all, we’re not doing pure research; we’re doing screening, and we’re doing the best we can with what we’ve got.
One example of how the language of the EPDS can be adapted to be more user-friendly for Aboriginal and Torres Strait Islander women is online courtesy of the Kimberley Aboriginal Medical Services Council; see page 3 of their resource here. I’m not suggesting for a moment that you automatically use this version for every Aboriginal or Torres Strait Islander woman who walks through your door, but it might be a handy reference point for other ways to frame the questions if/when required. There’s probably a lot of non-Indigenous Australians who rather use the style of language of this resource too.
Tip Six: English isn’t for Everyone
Half the fun of travelling overseas is practicing (well, mangling) other languages in pursuit of transport, coffee, toilets, hotel rooms and beer. Using bad translations is fine for that sort of stuff, but it’s pretty dopey to go down that path when looking at something important like emotions or, as per question 10 on the EPDS, about thoughts of self harm.
So, what’s a dude to do? Pull out a translated version: there is a very handy resource with 36 translations into languages other than English. Please note that half of the translations aren’t validated, and have a look at the other tips about working across languages/cultures included on the resource.
Reference: Department of Health, Government of Western Australia. (2006). Edinburgh Postnatal Depression Scale (EPDS): Translated versions – validated. Perth, Western Australia: State Perinatal Mental Health Reference Group.
I mean that it the nicest possible way.
The EPDS is a static screening tool that was written over 25 years ago in place 15000km away from Australia. It relies on the woman’s literacy and your numeracy to make it work, and even then it’s not replacing your clinical judgement. The EPDS certainly has validity and usefulness, but at the end of the day it’s still just a screening tool and an aide-mémoire.
You, however, are an educated, empathetic, responsive and proactive human being. You have emotional intelligence, a desire to be of use/service, and an incredible capacity to use your communication and life skills in a warm, caring manner. The EPDS can’t compete with you. You are a potent screening tool for emotional distress. You are more subtle and more powerful than ten questions on a form could ever hope to be. You’re a really sophisticated screening tool: please don’t let that dumb EPDS make you leave the best tool available sitting around unused.
What About Your Tips?
Thanks for reading this far (oops: I didn’t intend to be so verbose). Please feel free to add your tips/suggestions in comments section below.
* Every now and then you’ll see that the term “the woman” is used in this post; there’s an explanation for that. Nomenclature is taken pretty seriously in mental health: years ago the term “patient” was replaced with “client”, which has subsequently been replaced with “consumer” or “service user”. There are other terms that are getting bandied-about and trialled too. Midwives call the pregnant people and new mums they see “women” as a collective noun, or “the woman” if using the de-identified singular. I’m currently working with the same customer group and in the same venues as the Midwives, that’s why I’m speaking their language,
** The definition of “perinatal period” varies quite a bit. For data purposes, the Australian Institute of Health and Welfare defines the perinatal period being from 20 weeks gestation until 4 weeks postpartum. In clinical practice the perinatal period includes all of the antenatal period and (here comes the confusing bit) either up to one, two or three years postpartum. Many clinical services, including the one I’m currently working for, include pre-pregnancy, ie: women preparing for pregnancy. In everyday use, it’s accurate enough to think of perinatal women as those who are planning pregnancy, pregnant or new mums.
*** Anhedonia is
psychobabble jargon for loss of pleasure/joy. Anhedonia is the opposite of being hedonistic. Somebody who is being hedonistic might dance on the tables at nightclubs, shag backpackers, and say “Whoohoo!” a lot. Somebody experiencing anhedonia might still do things that would usually be fun, but just not get much enjoyment from them.
Paul McNamara, 14th November 2012
Short URL meta4RN.com/EPD
Paul this is fantastic. Definitley user friendly (not Psychobabble jargon!!). I will be sharing this site with as many staff as I can
Fantastic and sooo clever.Have forwarded this off to my collegue.Thanks,Di.
Great stuff. I’ll add this to my bag of tricks.
Thanks Paul, an excellent discussion of the pros and cons of the EPDS (and fun to read while learning heaps). Personally I think it is an excellent tool that helps determine if clinical assessment is warranted, or more clinical assessment would be advisable.
As you mentioned it is not diagnostic and what has given rise to a great deal of debate or criticism is the misuse of the scale as a diagnostic tool. One of the other things I love about the scale is it is a discussion starter about risk so if the caregiver (aka health provider) is feeling awkward about when to raise it, the EPDS provides a fairly ‘natural’ entry point. This is from my point of view and experience (as someone who has worked in the field for a number of years) but also for new staff who are ‘learning the ropes’. I think your comments about ‘trusting the service’ are valid. My PIMH service likes to think that because people self select to come to us they may be more inclined to disclose ie they know we are a mental health service, they want to know what is wrong and they want to feel better (and most importantly they want to be the best parent they can and the way they are feeling is interfering with that). On an Insight program a couple of years ago a number of women with perinatal mental illness disclosed they did not answer the EPDS honestly when it was used for screening in a Maternal & CHild Health setting…………This is not a criticism of MCH (I have worked in that field) but rather some women think the MCHS is about the infant and therefore they don’t disclose what is happening for the woman or the EPDS is offered fairly early in the relationship before trust has developed.
The anxiety subscale is a great little bonus because it can help uncover anxiety and again be useful as a discussion starter. I think Stephen Matthey and colleagues validated this subscale in an Australian population. I will try to find the reference and post it here.
In my service we use the score along with the clinical assessment to develop a care pathway eg ‘After all we have discussed and given that you scored above 13 it suggests that you may be depressed. However after having a baby/ breastfeeding it might also be that there could be some thyroid dysfunction or anaemia that can mimic the symptoms you are reporting. During pregnancy the thyroid gland revs up to cope and usually in the first 3 months after the birth it reverts to normal. In up to a third of women it might over correct or uncorrect so we recommend a thorough physical by your doctor to rule out any treatable causes (organic causes). I would be happy to write to him/her and let her know what we have discussed……….95% of women then agree to have their GP in the loop which is ideal (it may also help us to find a regular GP if she does not have one).’ Also looking at a score above 20 and in the context of a thorough clinical assessment we might also talk about symptom distress and considering seeing a Psychiatrist (not if she hasn’t slept for 5 days due to a sick infant and severe sleep disturbance). Again this is the decision for a GP in consultation with the woman but we might suggest it in our letter. Feedback from some women has been that the EPDS plus a thorough clinical assessment (we allow 90-120 mins) and the explanations sound reasonable/ logical and as though we know what we are doing ie there is trust developing.
BTW we also use the DASS 21 and MHQ but I find the EPDS easier to use, explain, and clients in my service do generally relate to the language.
One final comment about changing wording: there have been widely circulated versions of the EPDS that in item 4 says ‘for no very good reason’ (your example above is correct as there is no ‘very’ in the validated scale). However in item 5 the correct version is ‘for no very good reason’ so your example above is incorrect. Even beyondblue have used the incorrect version in different places. I did spot the typo though!
Oops I meant the thyroid gland might undercorrect (not uncorrect)
Pingback: Nominated: Paul McNamara »
Thanks Paul for taking the time and energy to provide such a fun creative explanation for the using the EPDS.. Well done Carol- beyondblue perinatal team
Brillaint job Paul. Shame Obama got in before you, as you could have run for President!
An absolute stroke of brilliance. I have been trying to persuade fellow midwives and child health nurses that EPNDS sporadically used and without reasonable clinical education on how to score within the original guidelines inclusive of a clinical assessment is prejudicial to outcomes and an impediment to early intervention. Following the party line and not engaging in research is breeding a generation of anxious insecure attached adults. Barriers to attachment (Bowlby) clearly recognizes the effect of depression and anxiety on children in the social, emotional, psychological and cognitive domains and trajectory on adult personality development. Pregnancy and parenting is one of the most stressful life events and I calculate the Holmes and Rahe Stress Scale (1967) as being moderate to high risk of illness, not just psychopathology. Dr Stephen Matthey has been researching this for over a decade with valid and quantifiable results. What I want to know from you Mr Paul McNamara is how to we influence change in clinical practice?
Thanks for your comments Antonia. I deliberately delayed responding to your question because I was hoping to come-up with something more brilliant than this kind-of-dopey answer… maybe we influence change in clinical practice by first having a good level of engagement and trust with our colleagues. Then, the rest is about time and persistance, I think. What do you think? Any good ideas I can s̶h̶a̶m̶e̶l̶e̶s̶s̶l̶y̶ ̶s̶t̶e̶a̶l̶ borrow?
Pingback: The National Perinatal Depression Initiative and the Canary at the Coal Face | meta4RN
Pingback: Perinatal Mental Health Workshop: an experiment in social media enhanced education | meta4RN
Great post and blog. I am also a geeky apple enthusiast and old fart nurse, though a midwife with a long term addiction to remote area nursing. I am now working a s a midwife in a great woman centred midwifery group practice in Hobart and am trying to review the new antenatal care guidelines about to be released by DoHa, a huge 400 page document and that’s just module 2. Your concise and humorous style are great and the info you give very appropriate; esp the geeky references to apps and websites. I certainly agree with one of your correspondents that there is great value in raising the issue antenatally, enabling discussion of PND with the woman and her family. I also like the reference to the Kimberley protocols where they recommend the use of regular questioning during the antenatal period (presumably also postnatally) and then applying the EPDS.
As a mental health specialist do you think there is a best time to apply this tool? Our health service protocols, with their poor view of practitioners ability, seem to need a very structured approach.
That’s very generous feedback – thanks Chris.
As for timing, I reckon we can take the advice of FNQ Midwives.
The hospital/clinic-based RMs up this way do the EPDS during the booking-in interview at 20/40, and again around 32/40ish. The feedback I hear is that the booking-in interview is so cram-packed with tasks and info that meaningfully completing/responding to psychosocial screening is tricky – rapport may be tenuous and time is pushed.
Most of the Mareeba Group Practice RMs delay doing the EPDS/other sensitive screening (DV, A&OD) until the 3rd or 4th visit usually. The feedback I get from them is that wait until they feel that rapport has been established before tackling potentially confronting issues. The “hard” questions are easy to ask when there’s a therapeutic relationship and, from the woman’s point-of-view, easier to answer.
Overall, I reckon a good workflow would aim to include the EPDS (and/or sensitive, respectful conversation about mood) in the perinatal workflow twice antenatally (2nd trimester + not-too-late in the 3rd) and at about 7ish weeks and 3 months postpartum. Group practice RMs have an advantage with continuity of care – that should be emphasised over and above rigid schedules, I reckon.
Hi Paul et al, I am pretty sure the Clinical Guidelines (Beyondblue) recommend similar time frames for antenatal EPDS (ie beginning second trimester and then a month or two before the birth). There certainly are lots of issues and tasks to consider antenatally from a midwive’s perspective but the question we need to ask is ‘are these things more important than a mental health assessment?’. I would argue that the more we incorporate mental health assessment as part of routine health care the sooner it becomes destigmatised and more ‘routine’. I agree that psycho-social assessment incorporating family violence and AOD can require the ‘trusting relationship’ to have been established but would argue that may never happen antenatally (or postnatally for that matter). As I explore aspects related to introducing psycho-social screening currently the more I wonder if EPDS/ psycho-social screening needs to go together or even whether they should go together ALL OF THE TIME. IN the private sector it is highly probable that there is only one AN contact with midwives (the rest being with private Obstetricians who may or may not support screening) and therefore we need to ‘seize the day’. I believe that gradually more and more midwives are becoming comfortable with more wholistic care and hopefully more inclined to intuitively incorporate psycho-social assessment ( in various depths) as part of every contact when opportunities arise. At least there is more discussion about it and for that we need to thank you for being so media savvy…..
Pingback: Hits and Misses: The First Twelve Months of meta4RN | meta4RN
In Puerto Rico it is mandatory for this questionnaire to be filled out for each HMO patient. However it is not called a “tool” It is called a “Mental health discernment” questionnaire. This is an insult to the female race. Why? If one is labeled, publicly, as all will be once all medical records are placed on the web, one cannot work for the government under any law enforcement jobs or jobs that require security clearance, etc. Thus women will be limited to only certain jobs again….
Just wondering if you had a reference regarding how common it is for paper based EPDS results to have been added up/scored incorrectly. I once heard it was pretty high >20% but can’t find the research.
The funding that supported my perinatal mental health work was pulled in June 2013, so I’m out of touch with what’s happening in that space nowadays. 😕
So, sorry – I’m no help with a reference.
I hadn’t heard of that stat before, but back in the day I certainly made and stumbled-across quite a few adding-up errors. If you do find a credible reference/source, I’d be grateful if you add it to our conversation here. This page still attracts heaps of hits per month, so I’m sure others will be interested too.
Kind regards, Paul
Pingback: That’ll do. Seeya. | meta4RN
Appreciate this blog poost