Brief report
Screening for postnatal depression: are specific instruments mandatory?

https://doi.org/10.1016/S0165-0327(00)00193-2Get rights and content

Abstract

Background: Few studies have examined the utility of rating scales developed in non-puerperal context in detecting postnatal depression. This study evaluated the utility of the General Health Questionnaire (GHQ) and the Beck Depression Inventory (BDI) in screening for depression among recently delivered women in Hong Kong. Methods: A prospective cohort of 145 Chinese women completed the GHQ, BDI and Edinburgh Postnatal Depression Scale (EPDS) 6 weeks after delivery. They were then assessed using the non-patient version of the Structured Clinical Interview for DSM-III-R (SCID-NP) to establish psychiatric diagnosis, against which the criterion validity of the GHQ and BDI was evaluated against this clinical diagnosis. The psychometric performance of the GHQ, BDI and EPDS in detecting postnatal depression was assessed using the receiver operating characteristic (ROC) curves. Results: Both Chinese GHQ and BDI had satisfactory sensitivity and positive predictive value in detecting postnatal depression. Their receiver operating characteristic (ROC) curves were comparable to that of the EPDS. Limitation: The study was conducted in Chinese women using translated version of the rating scales. Conclusions: The GHQ and BDI are useful for detecting postnatal depression among recently delivered Chinese women. The results of this study suggest that rating scales developed in non-puerperal context may also be applicable for postnatal depression.

Introduction

Although postnatal depression affects 10–15% of recently delivered women (O’Hara and Swain, 1996, Lee et al., 1998), only a small minority of the depression is identified by primary health workers during routine care (Holden, 1996). The majority of depressed mothers in the community are unrecognised. Leaving depressed mothers untreated not only causes profound suffering, it may also bring about marital estrangement, absenteeism from work, child abuse, cognitive and emotional maldevelopment of the infants, and sometimes, suicides and infanticides.

Better detection of postnatal depression can be achieved by administering self-report rating scales during one or more of the postnatal visits to identify women who have substantial depressive symptomatology. The Edinburgh Postnatal Depression Scale (EPDS) was specifically developed for this purpose and, as such, has become the mostly widely applied screening scale in the postpartum context (Cox et al., 1987). Although the EPDS was originally designed for, and validated amongst, postnatal women, the scale has subsequently been found to be effective in detecting depression among antenatal women (Murray and Cox, 1990), among women with pregnancy loss (Lee et al., 1997), and among non-pregnant women in the general population (Cox et al., 1996).

These findings are not surprising given that postnatal depression shares similar profile of symptoms with depression in other contexts. It is therefore commonsensical that postnatal depression scale and generic depression scale share a good degree of reciprocity, and generic depression rating scales developed in non-puerperal contexts would be useful in screening for postnatal depression.

Two well-known generic rating scales are potentially applicable in detecting postnatal psychiatric morbidity. The General Health Questionnaire (GHQ) is a self-report rating scale originally designed to detect psychiatric morbidity in general medical and outpatient settings. The scale has also been widely applied as a screening instrument in community based epidemiological studies. In contrast to the EPDS, the GHQ is designed to identify a range of neurotic conditions, such as anxiety disorders, and hence is potentially superior in terms of a broader coverage of postnatal psychiatric morbidity. Previous studies have already shown that the GHQ is useful in detecting postnatal depression in English and Japanese women (Nott and Cutts, 1982, Kitamura et al., 1994).

Apart from the GHQ, the Beck Depression Inventory (BDI) may also be applicable in detecting depression in the postpartum period. The BDI is a 21-item rating scales established to measure severity of depression. A shorter-version of the BDI has also been developed to screen for depression in general practice (Beck and Beck, 1972). Previous evaluations of the BDI in detecting postnatal depression were limited and have not yielded encouraging results. Using pre-determined cut-off score of 10/11, Harris et al. (1989) showed that the BDI was only able to identify 13 out of 19 major depressions in a series of 147 mothers. In another study of 120 postpartum women, Whiffen (1988) reported that the BDI was not sensitive to minor depression, leading to substantial false negatives. It is suggested that the somatic items of the BDI might render the scale unsuitable for postpartum women, who may have a few somatic symptoms even when not depressed. Nevertheless, as there have been only two studies, further investigations are warranted.

Section snippets

Subjects

A prospective cohort study was conducted in the Prince of Wales Hospital, a University-affiliated general hospital in Hong Kong, which has a catchment population of one million with diverse socio-economic background. Subjects comprised consecutive Chinese women who were admitted to the postnatal wards of the Department of Obstetrics and Gynaecology over a 3-month period. Non-Chinese women and those who did not have permanent residency rights in Hong Kong, e.g., illegal immigrants, were excluded

Sample characteristics

Among the 330 women admitted during the study period, 220 women (67%) agreed to participate in the study. The mean age of the 220 participating subjects was 29 years (range 16–42). Two hundred and thirteen subjects (97%) were married and seven subjects (3%) cohabited. The median number of children was 1 (range 0–6). Ninety-six subjects (44%) had full-time employment, two subjects (1%) worked part-time, 109 subjects (50%) were housewives and 13 subjects (6%) were unemployed. The socio-economic

Discussion

Our data suggest that the GHQ and BDI are useful for screening for postnatal depression among recently delivered Chinese women. Apart from good concurrent validity with the EPDS, both GHQ and BDI have good sensitivity and specificity in detecting depression in early postnatal period. At optimal cut-off scores, the BDI and GHQ are able to detect 82 and 89% of postnatal depression with positive predictive value of approximately 50%. These figures are comparable to those of the EPDS obtained in

Acknowledgments

The study was supported by grant 621019 of the Hospital Services Research Fund, Hong Kong.

References (19)

  • J.L. Cox et al.

    Prospective study of the psychiatric disorders of childbirth by self report questionnaire

    J. Affect. Disorder

    (1983)
  • J.L. Cox et al.

    Validation of the Edinburgh postnatal depression scale (EPDS) in non-postnatal women

    J. Affect. Disord.

    (1996)
  • A.T. Beck et al.

    Screening depressed patients in family practice: a rapid tech

    Postgrad. Med.

    (1972)
  • A.T. Beck et al.

    An inventory for measuring depression

    Arch. Gen. Psychiatry

    (1961)
  • J.L. Cox et al.

    Detection of postnatal depression: development of the 10-item Edinburgh Postnatal Depression Scale

    Br. J. Psychiatry

    (1987)
  • D. Goldberg
  • B. Harris et al.

    The use of rating scales to identify post-natal depression

    Br. J. Psychiatry

    (1989)
  • J. Holden

    The role of health visitors in postnatal depression

    Int. Rev. Psychiatry

    (1996)
  • E. Horwath et al.

    Depressive symptoms as relative and attributable risk factors for first-onset major depression

    Arch. Gen. Psychiatry

    (1992)
There are more references available in the full text version of this article.

Cited by (80)

  • Psychiatric disorders in the puerperium: Our role as obstetricians

    2014, Clinica e Investigacion en Ginecologia y Obstetricia
View all citing articles on Scopus
View full text