Does the Edinburgh Postnatal Depression Scale measure anxiety?

Exploration of the psychometric properties of the EPDS-US, a validation study

INTRODUCTION

The purpose of this study was to explore the reliability and construct validity of the EPDS-US.

METHODS

To enhance the perinatal mental health screen, we adapted the Edinburgh Postnatal Depression Screen (EPDS) for application in the United States, and evaluated reliability and construct validity of the EPDS-US in a sample of 100 postpartum individuals. We explored reliability by estimating internal consistency of the scale and evaluating concurrent validity with correlations to the Patient Health Questionnaire (PHQ-9) and the Generalized Anxiety Disorder Assessment (GAD-7); and construct validity using factor analysis and discriminant validity with correlations to the Perceived Stress Scale (PSS).

RESULTS

We present both a one-factor (Cronbach's alpha of 0.83) and two-factor model consisting of depressive (Cronbach's alpha 0.76) and anxiety symptoms (Cronbach's alpha 0.78) of the EPDS-US. Related to discriminant validity, the EPDS-US and PSS exhibited a moderate correlation of 0.71. For measures of concurrent validity, correlations with the PHQ-9 and GAD-7 were moderate; 0.63 and 0.68, respectively.

CONCLUSION

The EPDS-US was adapted to enhance the perinatal mental health screening experience for populations in the US while maintaining the reliability and validity of the original Edinburgh Postnatal Depression Scale. These findings contribute to the evidence of reliability and validity of the EPDS-US in perinatal populations in the United States; presenting initial evidence supporting construct validity and concurrent validity of this newly adapted 10-item scale.

Factor structure and longitudinal invariance for the Chinese Mainland version of the Edinburgh postnatal depression scale during pregnancy

BACKGROUND

There are inconsistent results on the Edinburgh Postnatal Depression Scale's (EPDS) factor structure and longitudinal invariance among different cultures. Furthermore, limited relevant studies in Chinese pregnant women exist.

PURPOSE

To test the factor structure of the Chinese Mainland EPDS during pregnancy and conduct longitudinal invariance analyses.

METHODS

A national multi-centre cohort study was conducted among 1207 pregnant women selected consecutively by convenience sampling from five hospitals in Zhuhai, Taiyuan, Haidian, Changchun, and Shenzhen in China between August 2015 and October 2016. Depression was measured by the EPDS during gestational weeks 10-13, 15-18, 23-25, 30-32 and 36-37, respectively.s RESULTS: Three factors with eigenvalues nearly larger than 1.0 were optimal for the Chinese Mainland EPDS, labelled "anxiety," "anhedonia," and "depression," and contained items 3-5, 1-2, and 6-10, respectively. The confirmatory factor analysis results of standardized root mean square residual (SRMR) = 0.034, root mean square error of approximation (RMSEA) = 0.049, comparative fit index (CFI) = 0.968, Tucker-Lewis index (TLI) = 0.954, and χ2, p < 0.05 indicated good fit. For the longitudinal invariance tests, the configural invariance was met, with the CFI and TLI both higher than 0.90 and the RMSEA lower than 0.08 (CFI = 0.919, TLI = 0.908, and RMSEA = 0.034). The metric-, scalar-, and strict invariances were met.

CONCLUSIONS

The three-factor model of the Chinese Mainland EPDS is invariant in pregnancy, suggesting stability and comparability in identifying the women screened positive at different points during pregnancy and making the scale feasible to screen prenatal depression and anxiety simultaneously.

Can EPDS and EPDS-3A be used to replace GAD-7 to screen the anxiety of pregnant women during pregnancy examination?

OBJECTIVE

To examine the screening ability and cut-off scores of the Edinburgh Postnatal Depression Scale (EPDS) and EPDS-3A for pregnancy anxiety in pregnancy examination.

METHODS

This was a prospective repetitive measurement study. A follow-up survey was performed in Chinese pregnant women with the EPDS, the 7-item Generalized Anxiety Disorder (GAD-7) scale and a basic information questionnaire. A total of 609 women participated in all surveys at three trimesters, and all data were complete with no missing values. Receiver operating characteristic curves, Cohen's kappa and cross-tabulation were used to test the single and combined screening ability of EPDS and EPDS-3A for pregnancy anxiety.

RESULTS

The areas under the curves of EPDS and EPDS-3A were close to or more than 0.90. EPDS scores greater than 14 in the first trimester and greater than 13 in the second and third trimesters could be used as the cut-off values. EPDS-3A score greater than 4 could be used as the cut-off value in each trimester. Adding the EPDS-3A to the EPDS would lead to correct identification of an additional 6.33%, 6.35%, and 7.25% of anxious women and misdiagnosis of an additional 6.60%, 2.56%, and 2.41% of normal women in each trimester, respectively.

CONCLUSION

The EPDS and EPDS-3A can be used alone or in combination for initially screening of pregnancy anxiety. Under certain conditions, they can even be used to replace GAD-7 for anxiety screening to reduce the adverse influence of excessive screening on pregnant women, and improve the quality of survey data and efficiency of clinical services.

Validation of the anxiety subscale of the Spanish version of the Edinburgh Postnatal Depression Scale (EPDS-A)

Introduction

There is a need to implement routine perinatal mental health screening in Spain. Therefore, it is necessary to systematise the detection of depressive and anxious symptoms in pregnancy and postpartum using the same instrument. The Edinburgh Postnatal Stress Depression Scale (EPDS) is frequently used as a rapid, effective and cross-culturally validated screening tool for perinatal depression. In several countries, an Anxiety subscale, the EPDS-A, was identified within the EPDS. Although the factorial structure of the EPDS has been investigated in Spanish population, the EPDS-A has not yet been validated. This study aimed to validate the EPDS-A as a measure of perinatal anxiety in Spanish population.

Methods

161 women were evaluated with the EPDS and the State-Trait Anxiety Inventory (STAI) during pregnancy and postpartum. Confirmatory factor analysis (CFA) was used to confirm the trifactorial structure of the EPDS, comprising the dimensions of Depression, Anhedonia and Anxiety. Likewise, the invariance of the trifactorial model between pregnancy and postpartum was tested. Finally, the correlations between the EPDS-A and the STAI subscales (State Anxiety and Trait Anxiety) were calculated.

Results

The Exploratory factor analysis (EFA) driven three-factor structure of the EPDS, consisting of an Anhedonia factor (Items 1, 2, and 10), an Anxiety factor (Items 3, 4, 5, and 6) and a Depression factor (Items 7, 8, and 9), was the best measurement model for the current data compared to the alternative model tested [χ2 = 34.592, df = 32, p = 0.34; χ2/df = 1.08; RMSEA = 0.023, 90% Confidence Interval [CI] [0.000, 0.064], CFI = 0.996, GFI = 0.960]. The model's invariance between pregnant and postpartum women was confirmed. The existence of an Anxiety subscale within the EPDS was also confirmed. The scores obtained with the EPDS-A correlated moderately with scores on both subscales of the STAI during pregnancy and after delivery. Using the STAI as a criterion and prioritising the instrument's sensitivity, a cut-off point of 4 points was established for the EPDS-A.

Conclusion

Our results confirm the trifactorial structure of the EPDS in Spanish population. The Anxiety subscale was validated for routine perinatal mental health screening.

Multidimensionality within the Edinburgh postnatal depression scale: application issues of specific structure

OBJECTIVE AND BACKGROUND

The 10-item Edinburgh Postnatal Depression Scale (EPDS) is a widely-used screening measure for postnatal depression. Factor analysis studies have suggested an embedded sub-scale could be used for screening for anxiety disorders. The current investigation sought to replicate and extend a recent study supporting this assertion.

METHODS

A cross-sectional design. EPDS data were collected at up to two years postpartum. Confirmatory factor analysis, correlational and distributional characteristics of the measure were examined. Participants were a large sample (N = 985) of postpartum women in the Czech Republic.

RESULTS

Factor structure findings substantially replicated the models evaluated by Della Vedova et al. (2022). Bifactor models, however, offered a better fit to data. A general factor of depression explained most of the variance in data in most models compared to embedded sub-scales across models.

CONCLUSION

The model proposed by Della Vedova et al. (2022) offered an excellent fit to data. However, the findings from the bifactor modelling suggest the dominance of a general factor of depression which indicates the potential application of an embedded anxiety sub-scale for screening may be overstated.

Stage 2 Registered Report: Epigenetic Intergenerational Transmission: Mothers' Adverse Childhood Experiences and DNA Methylation

OBJECTIVE

Individual differences in risk for mental disorders over the lifespan are shaped by forces acting before the individual is born-in utero, but likely even earlier, during the mother's own childhood. The environmental epigenetics hypothesis proposes that sustained effects of environmental conditions on gene expression are mediated by epigenetic mechanisms. Recent human studies have shown that adversities in childhood are correlated with DNA methylation (DNAm) in adulthood. In the current study, we tested the following pre-registered hypotheses: Mothers' adverse childhood experiences (ACEs) are correlated with DNAm in peripheral blood during pregnancy (hypothesis 1) and in cord blood samples from newborn infants (hypothesis 2), and women's depression and anxiety symptoms during pregnancy mediate the association between mothers' ACE exposure and prenatal/neonatal DNA methylation (hypothesis 3).

METHOD

Data were from the Avon Longitudinal Study of Parents and Children Accessible Resource for Integrated Epigenomic Studies substudy. Women provided retrospective self-reports during pregnancy of ACE exposure. We conducted an epigenome-wide association study testing whether mothers' ACE exposure, cumulative score (0-10), was associated with DNAm in maternal antenatal blood and infant cord blood in more than 450,000 CpG (point on DNA sequence where cytosine and guanine base pairs are linked by a phosphate, where methylation usually occurs) sites on the Illumina 450K BeadChip. Analyses for cord blood were separated by infant sex, a pre-registered analysis.

RESULTS

Hypothesis 1: In 896 mother-infant pairs with available methylation and ACE exposure data, there were no significant associations between mothers' ACE score and DNAm from antenatal peripheral blood, after controlling for covariates. Hypothesis 2: In infant cord blood, there were 5 CpG sites significantly differentially methylated in relation to mothers' ACEs (false discovery rate [FDR] < .05), but only in male offspring. Effect sizes were medium, with partial eta squared values ranging from 0.060 to 0.078. CpG sites were in genes related to mitochondrial function and neuronal development in the cerebellum. Hypothesis 3: There was no mediation by maternal anxiety/depression symptoms found between mothers' ACEs score and DNAm in the significant CpG sites in male cord blood. Mediation was not tested in antenatal peripheral blood, because no direct association between mothers' ACE score and antenatal peripheral blood was found.

CONCLUSION

Our results show that mothers' ACE exposure is associated with DNAm in male offspring, supporting the notion that DNAm could be a marker of intergenerational biological embedding of mothers' childhood adversity.

STUDY REGISTRATION INFORMATION

Epigenetic Intergenerational Transmission: Mothers' Adverse Childhood Experiences and DNA Methylation; https://doi.org/10.1016/j.jaac.2020.03.008.

Breastfeeding continuation is associated with trait mindfulness but not with trajectories of postpartum depressive symptoms

OBJECTIVE

The WHO recommends breastfeeding for at least six months as breastfeeding has many benefits for both infant and mother. The association of breastfeeding continuation with trait mindfulness during pregnancy and trajectories of postpartum depressive symptoms has not been examined yet. The current study aimed to assess this association using cox regression analysis.

DESIGN, SETTING AND PARTICIPANTS

The current research is part of a large longitudinal prospective cohort study following women from 12 weeks of pregnancy onwards in the South-East part of the Netherlands.

MEASUREMENTS

A total of 698 participants filled out the Three Facet Mindfulness Questionnaire-Short Form (TFMQ-SF) at 22 weeks of pregnancy and completed both the Edinburgh Postnatal Depression Scale (EPDS) and questions on breastfeeding continuation one week, six weeks, four months, and eight months postpartum. Breastfeeding continuation was defined as exclusive breastfeeding or both breastfeeding and formula. The assessment eight months postpartum was used as a proxy for the WHO recommendation to continue breastfeeding for at least six months.

FINDINGS

Two trajectories (classes) of EPDS scores were determined using growth mixture modeling: 1) low stable (N = 631, 90.4%), and 2) increasing (N = 67, 9.6%). Cox regression analysis showed that the trait mindfulness facet non-reacting was significantly and inversely associated with the risk of breastfeeding discontinuation (HR = 0.96, 95% CI [0.94, 0.99], p = .002), while no significant association was found for belonging to the increasing EPDS class versus belonging to the low stable class (p = .735), adjusted for confounders.

KEY CONCLUSIONS

This study is the first to show that higher trait mindfulness non-reacting scores, but not persistently low levels of postpartum depressive symptoms, increase the likelihood of breastfeeding continuation.

IMPLICATIONS FOR PRACTICE

Improving non-reacting in perinatal women by meditation practice as part of a mindfulness-based intervention may lead to better breastfeeding continuation outcomes. Several mindfulness-based programs may be suitable.

Factor Structure and Measurement and Structural Invariance of the Edinburgh Postnatal Depression Scale during the Perinatal Period among Japanese Women: What Is the Best Model?

The Edinburgh Postnatal Depression Scale (EPDS) is a widely used screening tool for perinatal depression. Its factor structure is still a debatable topic. Our study aimed to examine the factor structure and measurement invariances of the Japanese version of the EPDS from late pregnancy to early postpartum. A total of 633 women were followed with the EPDS at three times over the perinatal period: late pregnancy (n = 633), 5 days after childbirth (n = 445), and 1 month after childbirth (n = 392). We randomly divided the participants into two groups: one for exploratory factor analyses (EFAs) and another for confirmatory factor analyses (CFAs). The result of the EFAs indicated different factor models at each time point. Hence, CFAs were performed using the second sample set to compare different models including the ones previously reported. A 3-factor model consisting of depression (items 7, 9), anxiety (items 4, 5), and anhedonia (items 1, 2) (Kubota et al., 2018) was consistently stable during the whole perinatal period. Kubota's 3-factor model showed invariance across the perinatal period.

Individual participant data meta-analysis to compare EPDS accuracy to detect major depression with and without the self-harm item

Item 10 of the Edinburgh Postnatal Depression Scale (EPDS) is intended to assess thoughts of intentional self-harm but may also elicit concerns about accidental self-harm. It does not specifically address suicide ideation but, nonetheless, is sometimes used as an indicator of suicidality. The 9-item version of the EPDS (EPDS-9), which omits item 10, is sometimes used in research due to concern about positive endorsements of item 10 and necessary follow-up. We assessed the equivalence of total score correlations and screening accuracy to detect major depression using the EPDS-9 versus full EPDS among pregnant and postpartum women. We searched Medline, Medline In-Process and Other Non-Indexed Citations, PsycINFO, and Web of Science from database inception to October 3, 2018 for studies that administered the EPDS and conducted diagnostic classification for major depression based on a validated semi-structured or fully structured interview among women aged 18 or older during pregnancy or within 12 months of giving birth. We conducted an individual participant data meta-analysis. We calculated Pearson correlations with 95% prediction interval (PI) between EPDS-9 and full EPDS total scores using a random effects model. Bivariate random-effects models were fitted to assess screening accuracy. Equivalence tests were done by comparing the confidence intervals (CIs) around the pooled sensitivity and specificity differences to the equivalence margin of δ = 0.05. Individual participant data were obtained from 41 eligible studies (10,906 participants, 1407 major depression cases). The correlation between EPDS-9 and full EPDS scores was 0.998 (95% PI 0.991, 0.999). For sensitivity, the EPDS-9 and full EPDS were equivalent for cut-offs 7-12 (difference range - 0.02, 0.01) and the equivalence was indeterminate for cut-offs 13-15 (all differences - 0.04). For specificity, the EPDS-9 and full EPDS were equivalent for all cut-offs (difference range 0.00, 0.01). The EPDS-9 performs similarly to the full EPDS and can be used when there are concerns about the implications of administering EPDS item 10.Trial registration: The original IPDMA was registered in PROSPERO (CRD42015024785).

RAPID-2 study protocol: a cluster randomised feasibility trial of a midwife facilitated intervention for pregnant women with symptoms of mild to moderate anxiety

INTRODUCTION

Many women experience symptoms during pregnancy. Elevated and prolonged anxiety can have negative effects on the woman and baby. The RAPID intervention aims to provide suitable, timely support for women with mild-moderate anxiety. The RAPID intervention is based on social support, relational continuity, psychological and relaxation response theory, and comprises midwife facilitated group discussions, one-to-one support and directed self-help materials.

METHODS AND ANALYSIS

Four National Health Service Trusts in England that provide maternity care will be cluster randomised to the RAPID intervention plus usual care or usual care. At each intervention site, two midwives and two maternity support workers will facilitate the intervention over a 12-week period. Eligibility includes nulliparous women at 16-20 weeks of pregnancy (n=50) with self-report symptoms of mild-moderate anxiety. Community midwives will signpost women to the study. The aim of the study is to establish the feasibility of conducting a definitive trial to examine the effectiveness of the RAPID intervention in addition to usual care. The objectives are to assess recruitment and completion rates, and a qualitative assessment of women's and facilitators' experiences of participation. An estimation of change in the seven-item Generalised Anxiety Disorder scale will inform the sample size for a definitive cluster trial.

ETHICS AND DISSEMINATION

Ethical approval was given by East Midlands-Derby Research Ethics Committee 14 March 2022 (REC Reference: 22/EM/0018). Findings will be made available through publication in peer-reviewed journals, conferences and to participants. A final report will be submitted to HEE/NIHR ICA awards committee for publication.

TRIAL REGISTRATION NUMBER

ISRCTN12834758.

Construct Validity and Responsiveness of Instruments Measuring Depression and Anxiety in Pregnancy: A Comparison of EPDS, HADS-A and CES-D

Depression and anxiety occur frequently in pregnancy and may have unfavourable consequences for mother and child. Therefore, adequate symptom measurement seems important. Commonly used instruments are the Center for Epidemiologic Studies Depression Scale (CES-D), the Edinburgh Postpartum Depression Scale (EPDS), and the Hospital Anxiety and Depression Scale, anxiety subscale (HADS-A). We compared the (1) structural and (2) longitudinal validity of these instruments. The data originated from a study on the effectiveness of an Internet intervention for pregnant women with affective symptoms. (1) A confirmatory factor analysis was used to estimate the construct validity. The theoretical factorial structure that was defined in earlier studies of the CES-D and the EPDS, but not the HADS-A, could be sufficiently replicated with acceptable CFI and RMSEA values. (2) Since there were two measurements in time, the hypotheses concerning plausible directions of the change scores of subscales that were (un)related to each other could be formulated and tested. In this way, longitudinal validity in the form of responsiveness was estimated. Ten of sixteen hypotheses were confirmed, corroborating the longitudinal validity of all constructs, except anhedonia, probably due to inconsistent conceptualization. The HADS-A seems less suitable to screen for anxiety in pregnancy. Anhedonia needs better conceptualisation to assess the change of symptoms over time with the CES-D and the EPDS.

Psychometric analysis of the Edinburgh Postnatal Depression Scale and Pregnancy Related Anxiety Questionnaire in Pakistani pregnant women

BACKGROUND

The Edinburgh Postnatal Depression Scale (EPDS) and the Pregnancy-Related Anxiety Scale (PRAQ) are frequently used perinatal mental health scales.

OBJECTIVE

To identify the factor structure of the Urdu language versions of EPDS and PRAQ in 280 Pakistani pregnant women.

METHOD

The tools were administered at 12-19 weeks' and 22-29 weeks' gestational age (GA). Exploratory factor analyses were undertaken on data collected at 12-19 weeks' GA, to assess both scales. Results obtained at the second time point were used to examine test-retest reliability. The correlation between the scales was computed.

RESULTS

A two-factor model yielded the best fit for both scales, which is consistent with findings from previous studies. For the EPDS, acceptable reliability was attained for the overall score (α = 0.77) and for the factor related to depressive symptoms (α = 0.73), but not for the factor related to anhedonia/suicide (α = 0.64). For the PRAQ, acceptable reliability was attained for the overall score (α = 0.83) and for the factor related to pregnancy concerns (α = 0.84), but not for the factor related to childbirth (α = 0.64). Test-retest reliability was acceptable for both overall scales EPDS: r = 0.50; PRAQ: r = 0.45; both p < .001). The Pearson correlation between the EPDS and PRAQ were r = 0.145, p < .05.

CONCLUSION

Analysis of the tools confirmed a two-factor structure for both depression and anxiety among Pakistani pregnant women. A weak correlation was found between the EPDS and PRAQ. Further research is required to develop screening instruments for perinatal mental disorders that are applicable to cultural contexts.

An exploratory and confirmatory factor analysis study of the EPDS in postnatal Italian-speaking women

BACKGROUND

Depression and anxiety are the most prevalent emotional difficulties in the perinatal period and there is agreement that early intervention is an important strategy to prevent long-lasting effects on mother and child. Literature has recently shown that the Edinburgh Postnatal Depression Scale (EPDS) is able to measure not only depression but also anxiety.

OBJECTIVE

To investigate the factorial structure of the EPDS in Italian-speaking new mothers.

METHOD

416 women attending vaccination services between 2 and 4 months postpartum filled in the EPDS. Exploratory (EFA) and Confirmatory (CFA) analyses were carried out.

RESULTS

The EFA on the first part of the sample (n = 208) showed a two-factor structure. The CFAs on the second sample of mothers (n = 208) provided support for the 'EPDS-4A', with items 3,4,5,6 belonging to the Anxiety factor and items 1,2,7,8,9,10 to the Depression factor. The fit for the model was good: χ2/df = 1.41, p <.001; GFI =.99; CFI =.99; TLI =.88; RMSEA =.04.

CONCLUSION

A two-factor structure of the EPDS was confirmed suggesting that the EPDS can be used to screen for both depression and anxiety for Italian mothers in the postnatal period.

Maternal Mood and Perception of Infant Temperament at Three Months Predict Depressive Symptoms Scores in Mothers of Preterm Infants at Six Months

Postpartum depression is more prevalent in mothers and fathers of preterm infants compared to parents of full-term infants and may have long-term detrimental consequences for parental mental health and child development. The temperamental profile of an infant has been postulated as one of the important factors associated with parental depressiveness in the first months postpartum. This study aimed to examine the longitudinal relationship between depressive symptoms and perceived infant temperament at 3 months corrected age, and depressive symptoms at 6 months corrected age among mothers and fathers of infants born preterm. We assessed 59 families with infants born before the 34th gestational week using the Edinburgh Postnatal Depression Scale (EDPS) and the Infant Behavior Questionnaire-Revised. We found that mothers' scores on EPDS and infants' Orienting/regulation at 3 months corrected age predicted mothers' EPDS scores at 6 months corrected age. In particular, higher depressive scores were related to higher depressive symptoms at 6 months corrected age, whereas higher infant Orienting/regulation was related to lower depressive symptoms at 6 months corrected age. Due to the low internal consistency of EPDS at 6 months for fathers, we were unable to conduct similar analyses for fathers. Our results point to the importance of considering both early indices of maternal mood as well as mother-reported measures of preterm infant temperament in the attempts to predict levels of maternal depressiveness in later months of an infant's life. Further studies are urgently needed in order to better understand the associations between depressiveness and infant temperament in fathers, and with more consideration for the severity of the effects of infant prematurity.

The factor structure of the Edinburgh Postnatal Depression Scale among perinatal high-risk and community samples in London

Timely and accurate detection of perinatal mental health problems is essential for the wellbeing of both mother and child. Growing evidence has suggested that the Edinburgh Postnatal Depression Scale (EPDS) is not a unidimensional measure of perinatal depression, but can be used to screen for anxiety disorders. We aimed to assess the factor structure of the EPDS in 3 different groups of women: n = 266 pregnant women at high-risk of depression ("Perinatal Stress Study"), n = 471 pregnant women from a community sample, and n = 637 early postnatal women from a community sample ("developing Human Connectome Project"). Exploratory factor analysis (40% of each sample) and confirmatory factor analysis (60% of each sample) were performed. The relationship between EPDS scores and history of mental health concerns was investigated. Results suggested that a 3-factor model (depression, anxiety, and anhedonia) is the most appropriate across groups. The anxiety subscale (EPDS-3A) emerged consistently and was related to maternal history of anxiety disorders in the prenatal sample (W = 6861, p < 0.001). EPDS total score was related to history of mental health problems in both the prenatal (W = 12,185, p < 0.001) and postnatal samples (W = 30,044, p < 0.001). In both high-risk and community samples in the perinatal period, the EPDS appears to consist of depression, anxiety, and anhedonia subscales. A better understanding of the multifactorial structure of the EPDS can inform diagnosis and management of women in the prenatal and postnatal period. Further research is required to validate the EPDS-3A as a screening tool for anxiety.

Prevalence of comorbid anxiety and depressive symptomatology in the third trimester of pregnancy: Analysing its association with sociodemographic, obstetric, and mental health features

BACKGROUND

Little is known about the prevalence of comorbid anxiety and depression (CAD) during pregnancy and its risk factors. The aims of this study are to determine the prevalence of CAD in the third trimester of pregnancy and analyse its association with socio-demographic, obstetric, and mental health features.

METHODS

In a sample of 934 Italian pregnant women, CAD was defined as having (1) a score of ≥ 10 on the EPDS - depression subscale and/or on the PHQ-9, and (2) a score of ≥ 40 on the State-Trait Anxiety Inventory State and/or a score of ≥ 6 on the EPDS - anxiety subscale. Logistic regression analyses were used to identify socio-demographic, obstetrics, and mental health risk factors of CAD.

RESULTS

The prevalence of CAD was 6.8%. Age between 30 and 35 years (OR=3.01, 95% CI: 1.22-7.45) compared to younger age, current sleep disorders (OR=7.88, 95% CI: 3.83-16.23), and preconception mood disorders (OR=2.76, 95% CI: 1.31-5.84) were associated with higher odds of CAD. Conversely, the presence of no or few economic problems (OR=0.21, 95% CI: 0.07-0.65; OR=0.26, 95% CI: 0.09-0.77) and the perception of enough or more than enough practical support from friends or relatives (OR=0.32, 95% CI: 0.13-0.80; OR=0.22, 95% CI: 0.09-0.53) were associated with lower odds of developing CAD.

LIMITATIONS

The cross-sectional design; the use of self-report questionnaires.

CONCLUSION

CAD is relatively common among third-trimester antepartum women. The provision of economic/practical support may reduce CAD prevalence and its direct and indirect costs.

Assessment of anxiety during pregnancy: are existing multiple anxiety scales suitable and comparable in measuring anxiety during pregnancy?

BACKGROUND

This study examined the performance of multiple anxiety scales in measuring anxiety during pregnancy, an important issue due to the possible effect of pregnancy-related symptoms on the measurement of anxiety.

METHODS

Secondary data on anxiety, measured by the State-Trait Anxiety Inventory-State (STAI-S) 20-item and six-item scales, the Edinburgh Postnatal Depression Scale-Anxiety Subscale (EPDS-3A) and the Symptoms Checklist-90-Anxiety Subscale (SCL-90), were obtained from two pregnancy cohort studies. Both cohorts completed the EPDS-3A, while 3341 women completed the STAI-S and 2187 women completed the SCL-90, with 231 women participating in both cohorts. Data were analyzed using confirmatory factor analysis and Spearman correlation.

RESULTS

The STAI-6 had adequate model fit, while the STAI-20 and the SCL-90 had inadequate model fit. Model fitness for the EPDS-3A could not be assessed due to its low number of items. The correlation between the STAI-20 and STAI-6 was excellent (r = 0.93). The correlation of EPDS-3A with other anxiety scales was low to moderate (r (STAI-20) = 0.57, r (STAI-6) = 0.53 and r (SCL-90) = 0.44). The correlation of SCL-90 with both STAI-20 and STAI-6 was low (r < 0.50).

CONCLUSION

Findings indicate that these scales do not measure anxiety as a single dimension and that these scales are incomparable and may conceptualize anxiety differently.

Pregnancy-related anxiety and its associated factors during COVID-19 pandemic in Iranian pregnant women: a web-based cross-sectional study

BACKGROUND

Pregnancy is a risk factor for coronavirus disease 2019 (COVID-19). Pregnant women suffer from varying levels of pregnancy-related anxiety (PRA) which can negatively affect pregnancy outcomes. The aim of this study was to assess PRA and its associated factors during the COVID-19 pandemic.

METHODS

This web-based cross-sectional study was conducted in 2020 on 318 pregnant women purposively recruited from primary healthcare centers in Sari and Amol, Iran. Data were collected using questionnaires (PRAQ, Edinburg, KAP of COVID-19, CDA-Q and Demographic questionnaire), which were provided to participants through the social media or were completed for them over telephone. Data were analyzed with the linear regression and the logistic regression analysis, at the significance level of 0.05 using the SPSS software (v. 21).

RESULTS

Around 21% of participants had PRA, 42.1% had depression, and 4.4% had COVID-19 anxiety. The significant predictors of PRA were number of pregnancies (P = 0.008), practice regarding COVID-19 (P < 0.001), COVID-19 anxiety (P < 0.001), depression (P < 0.001), and social support (P = 0.025) which explained 19% of the total variance. Depression and COVID-19 anxiety increased the odds of PRA by respectively four times and 13%, while good practice regarding COVID-19 decreased the odds by 62%.

CONCLUSION

Around 21% of pregnant women suffer from PRA during the COVID-19 pandemic and the significant predictors of PRA during the pandemic include number of pregnancies, practice regarding COVID-19, COVID-19 anxiety, depression, and social support. These findings can be used to develop appropriate strategies for the management of mental health problems during pregnancy in the COVID-19 pandemic.

Elevated depression and anxiety symptoms among pregnant individuals during the COVID-19 pandemic

BACKGROUND

Anxiety and depression symptoms in pregnancy typically affect between 10 and 25% of pregnant individuals. Elevated symptoms of depression and anxiety are associated with increased risk of preterm birth, postpartum depression, and behavioural difficulties in children. The current COVID-19 pandemic is a unique stressor with potentially wide-ranging consequences for pregnancy and beyond.

METHODS

We assessed symptoms of anxiety and depression among pregnant individuals during the current COVID-19 pandemic and determined factors that were associated with psychological distress. 1987 pregnant participants in Canada were surveyed in April 2020. The assessment included questions about COVID-19-related stress and standardized measures of depression, anxiety, pregnancy-related anxiety, and social support.

RESULTS

We found substantially elevated anxiety and depression symptoms compared to similar pre-pandemic pregnancy cohorts, with 37% reporting clinically relevant symptoms of depression and 57% reporting clinically relevant symptoms of anxiety. Higher symptoms of depression and anxiety were associated with more concern about threats of COVID-19 to the life of the mother and baby, as well as concerns about not getting the necessary prenatal care, relationship strain, and social isolation due to the COVID-19 pandemic. Higher levels of perceived social support and support effectiveness, as well as more physical activity, were associated with lower psychological symptoms.

CONCLUSION

This study shows concerningly elevated symptoms of anxiety and depression among pregnant individuals during the COVID-19 pandemic, that may have long-term impacts on their children. Potential protective factors include increased social support and exercise, as these were associated with lower symptoms and thus may help mitigate long-term negative outcomes.

Screening Beyond Postpartum Depression: Occluded Anxiety Component in the EPDS (EPDS-3A) in French Mothers

INTRODUCTION

According to many studies, anxiety in the perinatal period is widespread and has many detrimental effects. Thus, screening measures should not be limited to assessing depression symptoms. The widely used Edinburgh Postnatal Depression Scale (EPDS) might assess depression but also anxiety symptoms. This study explores whether an anxiety dimension (EPDS-3A) was found and valid in French women during pregnancy and the postpartum period.

METHODS

French women were followed-up at late pregnancy and 2 and 4 months postpartum (N = 144, 138 and 129). They completed the EPDS and the Hospital Anxiety and Depression Scale (HADS-A). Exploratory factor analyses were performed. Then to test its validity, the EPDS-3A was correlated with anxiety (HADS-A) and depression (EPDS-D) scores. Finally, prevalence estimates were computed according to recommended cut off.

RESULTS

The anxiety dimension assessed through the EPDS-3A was observed during the postpartum period but not during pregnancy. A two-factor structure (depression and anxiety) increases the variance explained at 2 and 4 months postpartum (respectively 6 and 12%). The EPDS-3A shows good internal consistency (≥ .70) and was more strongly associated with anxiety scores (HADS-A) (.48-.57) than with depression scores (EPDS-D) (.30-.39). Nearly 28% of mothers had scores that exceeded the EPDS-3A cut off (≥ 4) but not the full EPDS cut off (≥ 13 or more).

DISCUSSION

The EPDS contains an anxiety component (EPDS-3A) that can be found in French women during the postnatal period but not during pregnancy. It shows signs of internal consistency and validity. The EPDS-3A could be considered when screening for postpartum anxiety.

Factor structure of the Edinburgh Postnatal Depression Scale in the Japan Environment and Children's Study

The Edinburgh Postnatal Depression Scale (EPDS) is frequently used to screen for postpartum depression. However, its factor structure exhibits noticeable inconsistencies between studies. We examined the EPDS at two postpartum time points using a large dataset from outside Western countries. Participants were 91,063 mothers in an ongoing birth cohort of the Japan Environment and Children's Study. One-, two-, and three-factor structures of the EPDS at 1- and 6-months postpartum were extracted using exploratory factor analysis (EFA) with oblique rotation. Goodness-of-fit indices of extracted factor structures were compared with prior ones by conducting a confirmatory factor analysis (CFA). CFA revealed that a three-factor model extracted from the current EFA-anxiety (items 3, 4, 5, and 6), depression (items 7, 9, and 10), and anhedonia (items 1 and 2)-showed acceptably high goodness-of-fit and invariability across time. These three factors explained about 65% of the total variance with good reliability (all Cronbach's αs ≥ 0.70). Most three-factor structures (vs. two-) showed higher goodness-of-fit indices. In conclusion, although we only examined the postpartum period, the EPDS likely comprises three dimensions: anxiety, depression, and anhedonia. Our findings raise questions about the one- or two-factor structure of the EPDS.Trial registration: UMIN000030786.

Mid-pregnancy insomnia is associated with concurrent and postpartum maternal anxiety and obsessive-compulsive symptoms: A prospective cohort study

BACKGROUND

Although many perinatal women are affected by anxiety, few studies have focused on perinatal anxiety and its potential triggers. The primary aim of this study was to examine concurrent and prospective associations between mid-pregnancy insomnia and perinatal anxiety. Furthermore, we compared psychosocial and reproductive characteristics between participants with and without mid-pregnancy insomnia and explored changes in the prevalence of obsessive-compulsive disorder (OCD) symptoms from mid-pregnancy to 8 weeks postpartum.

METHODS

This study was part of the Norwegian Depression and Anxiety in the Perinatal Period (DAPP) prospective, population-based, cohort study. We analyzed hospital birth records and questionnaire responses from pregnancy week 17 and postpartum week 8 (n = 530). The Bergen Insomnia Scale was used to measure insomnia and the Hopkins Symptom Checklist to measure anxiety. OCD symptoms were measured based on questions from the Mini-International Neuropsychiatric Interview.

RESULTS

Mid-pregnancy insomnia was significantly associated with both concurrent and postpartum anxiety in a linear mixed model adjusted for several potential confounders. Participants with mid-pregnancy insomnia had significantly higher levels of perinatal anxiety and postpartum OCD symptoms than participants with normal mid-pregnancy sleep. OCD symptoms affected more women after delivery than before (6.4% vs. 3.8% p = 0.034).

LIMITATIONS

Immigrants were underrepresented in our sample.

CONCLUSION

Our results suggest that mid-pregnancy insomnia is a marker for concurrent anxiety and predictor of postpartum anxiety. Future research should examine whether insomnia treatment starting in mid-pregnancy reduces both perinatal insomnia and anxiety. Health providers should also be aware that postpartum women have an increased risk of developing OCD symptoms.

Postnatal depressive symptoms display marked similarities across continents

BACKGROUND

Postnatal depressive symptoms measured by the Edinburgh Postnatal Depression Scale (EPDS) are reported to display measurement variance regarding factor structure and the frequency of specific depressive symptoms. However, postnatal depressive symptoms measured by EPDS have not been compared between women representing three continents.

METHODS

A cross-sectional study including birth cohort samples from Denmark, Vietnam and Tanzania. Women were included during pregnancy at routine care sites. Depressive symptoms were self-reported 40-90 days postpartum using the EPDS. Exploratory and confirmatory factor analyses and generalized additive regression models were performed.

RESULTS

A total of N = 4,516 participated in the study (Denmark N = 2,069, Vietnam N = 1,278, Tanzania N = 1,169). Factor analyses identified three factors (anhedonia, anxiety and depression) that were almost identical in the three study populations. The only variation between countries was that the item 'self-harm' loaded differently. Women from Tanzania and Denmark were more likely to have an EPDS total score above cut-off 12 (12.6% and 6.4%), compared to women from Vietnam (1.9%) (p<0.001). A low level of education was associated with significantly more depressive symptoms after adjusting for country (p<0.001).

LIMITATIONS

EPDS data was collected at a later time point in the Danish sample.

CONCLUSIONS

Postnatal depressive symptoms constitute a three-factor model across cultures including the factors anhedonia, anxiety and depression. The frequency of postnatal depressive symptoms differs between high-, medium-, and low-income countries. However, clinicians should bear in mind that low-educated women worldwide are more likely to experience postnatal depressive symptoms.

The Edinburgh Postpartum Depression Scale: Stable structure but subscale of limited value to detect anxiety

PURPOSE

The Edinburgh Postnatal Depression Scale (EPDS) aims at detecting postpartum depression. It has been hypothesized that a subscale (items 3, 4, 5) may detect anxiety. The aim of this study is to assess whether this EPDS anxiety subscale is present in a community-based dataset, and if so, to assess its validity and stability during the first six months postpartum.

METHODS

We obtained EPDS data of a community sample of 1612 women at 1 month, with follow-up at 3 and 6 months, postpartum (Post-Up study). We performed an exploratory factor analysis on the EPDS forcing two- and three-factor solutions. We assessed the correlations of the extracted factor subscales and the total EPDS with the short-form of the STAI (STAI-6). We examined the stability of the identified factors by means of a confirmatory factor analysis (CFA), using the EPDS data collected at 3 and 6 months postpartum.

RESULTS

Both the two- and three-factor solutions contained a hypothesized anxiety subscale of items 3,4,5,10, and fitted well with the 3- and 6-months EPDS data, with CFI and TLI values >.99 and RMSEA and SRMR values < .035 and < .45. The subscale's Pearson correlations with the STAI-6 were moderate: .516, compared to .643 for the total EPDS.

CONCLUSIONS

The factor structure of the EPDS is stable across the first six months postpartum, and includes the subscale assumed to represent anxiety. However, this subscale as well as the total EPDS correlate only moderately with anxiety criteria. Using the EPDS thus does not imply adequate screening for anxiety.

Re-examination of perinatal mental health policy frameworks for women signalling distress on the Edinburgh Postnatal Depression Scale (EPDS) completed during their antenatal booking-in consultation: a call for population health intervention

BACKGROUND

Globally, anxiety and depression are the most common complications of the perinatal period (conception to 1 year postpartum). It is now recognised that anxiety and depression are more commonly found antenatally than postnatally and represent the greatest risk factor for developing postnatal depression. Research in this space has focused on treatment of postnatal depression, with limited attention paid to preventative strategies for women signalling distress, who are subthreshold for diagnosable illness.

MAIN TEXT

The Edinburgh Postnatal Depression Scale (EPDS) was introduced in 1987 and has since been validated as a depression screening tool in the Australian and international setting. The EPDS has been embedded as a depression screening tool within a broader psychosocial assessment for women who receive their maternity care in the public system in Australia. Owing to perceived service restrictions, an EPDS score must reach a threshold of 13 or more to warrant specific assessment or intervention. Current policy frameworks focus on tertiary prevention models, and those women scoring 10 to 12, who could reasonably be considered as signalling distress or early signs of illness, are not currently offered intervention. The consequences of undetected or untreated perinatal mood or anxiety disorder (often co-morbid) include maternal psychological, social, occupational and physical dysfunction, and extend to deleterious infant and child life-course effects. This provides a strong justification to explore the role of preventative programs for women who are distressed. A range of low-resource, population-based interventions are available and effective. We explore the evidence for a selection of these programs. Further research is needed to decipher their effectiveness as a secondary prevention approach in women who are currently signalling distress during antenatal assessment.

CONCLUSION

The burden of perinatal mood disorders, and their potential for prolonged impact, justify the exploration of preventatively-focused programs in women who signal distress during antenatal care.

Identifying postnatal depression: Comparison of a self-reported depression item with Edinburgh Postnatal Depression Scale scores at three months postpartum

BACKGROUND

Early identification of postnatal depression is important in order to minimize adverse outcomes. The Edinburgh Postnatal Depression Scale (EPDS) is commonly used as a screening tool but a single, direct question on depression may offer an alternative means of identifying women in need of support. This study examines the agreement between these methods and characteristics of women who self-identify as depressed and those with EPDS ≥ 13.

METHODS

Secondary analysis of two national maternity surveys conducted in England and Northern Ireland. Agreement between the direct question and EPDS scores was assessed using Cohen's kappa. Logistic regression was used to identify characteristics of women in each group.

RESULTS

6752 women were included. At three months postpartum, 6.1% of women self-identified as having depression, 9.1% scored EPDS ≥ 13, 2.8% were positive on both. Agreement between the two methods was minimal (Cohen's kappa < 0.3). Women who self-identified as having depression had higher odds of being aged > 40 years (OR 1.8; 95% CI 1.2-2.8). EPDS ≥ 13 was associated with < 16 years of education (OR 1.4; 95% CI 1.1-1.8), minority ethnicity (OR 1.4; 95% CI 1.1-1.9), living without a partner (OR 1.7; 95% CI 1.3-2.2), and a less than happy reaction to the pregnancy (OR 1.7; 95% CI 1.4-2.1).

LIMITATIONS

Low survey response limits the representativeness of findings. The absence of a diagnostic interview limits conclusions on accuracy or internal validity of the measures.

CONCLUSIONS

A direct question about postnatal depression may offer a valuable addition to screening tools to identify women in need of support.

Depressive and anxiety symptoms and associated factors among postnatal women in Enugu-North Senatorial District, South-East Nigeria: a cross-sectional study

BACKGROUND

Postnatal depression (PND) and anxiety (PNA) among women are prevalent and impairing health problems, with adverse outcomes for mothers and their infants. This study assessed the prevalence of depression, anxiety and associated factors in a sample of postnatal women.

METHOD

A community-based cross-sectional study was conducted on 270 postpartum women attending public health facilities in the study area. Postnatal depression was measured using the Edinburgh Postnatal Depression Scale (EPDS) and anxiety was measured using the Hospital Anxiety and Depression Scale (HADS-A). Data on maternal demographics, health characteristics, pregnancy-related characteristics, labor and birth characteristics, were collected via structured questionnaire. Binary Logistic and multinomial logistic regression analyses were carried out to identify the factors associated with depressive and anxiety symptoms in women.

RESULTS

The EPDS identified 92 women (34.6%) as possibly depressed (using a cut-off ≥13) while the HADS-A identified 89 women (33.3%) with anxiety symptoms (using a cut-off + 8). A total of 69 women were identified with symptoms of anxiety and depression (anxious-depression). The multinomial regression analysis (MLA) showed that the history of depression (AOR = 0.12, 95% (CI 0.02, 0.76), and being a mother aged 15-29 years (AOR = 10.31, 95% (CI 1.13, 94.11) had a significant effect on the development of anxiety symptoms in women. Although not significant, mother's income level (AOR = 1.53, 95% (CI 0.72, 3.25), and being a younger mother (AOR = 1.06, 95% (CI 0.21, 5.26) were more likely to predict depressive symptoms in postnatal women. Attendance at postnatal care services in the PHCs (AOR = 0.14, 95% CI (0.04, 0.48) was significantly associated with anxious-depressed in the studied postnatal women.

CONCLUSION

The findings of this study showed a direct association between depressive symptoms, anxiety and younger maternal age, rural residence, and low income. The higher prevalence of depressive and anxiety symptoms in this study is a call for postnatal care that is culturally sensitive, patient-centered, accessible and affordable by women, most importantly poor and rural women.

Anxiety scales used in pregnancy: systematic review

BACKGROUND

Anxiety disorders and self-reported symptoms are highly prevalent in pregnancy. Despite their negative impact on maternal and child outcomes, uncertainty remains regarding which symptoms can be considered accurate indicators of antenatal anxiety.AimsTo examine and synthesise the evidence in relation to the psychometric properties and content of self-report scales used to detect anxiety symptoms in pregnant women.

METHOD

A systematic search was carried out and the methodological quality of all included studies was assessed. Only those achieving a rating of good or excellent were considered in a synthesis of the best available evidence.

RESULTS

Several anxiety symptoms and domains were identified as promising for screening for general antenatal anxiety and pregnancy-related anxiety, including elevated levels of worry, symptoms of panic, fear of childbirth and excessive worries about the baby's health.

CONCLUSIONS

This review contributes to the existing knowledge by identifying a number of anxiety symptoms that can be considered psychometrically robust indicators of antenatal anxiety.Declaration of interestNone.

Validation of the Edinburgh Postnatal Depression Scale against both DSM-5 and ICD-10 diagnostic criteria for depression

BACKGROUND

The Edinburgh Postnatal Depression Scale (EPDS) is widely used in many countries to screen women for depression in the perinatal period. However, across studies the psychometric properties and cutoff scores of the EPDS have varied considerably; potentially due to different depression criteria and diagnostic systems being used. Therefore, we validated the Danish EPDS against a depression diagnosis according to both DSM-5 and ICD-10. Furthermore, we examined whether the Danish EPDS is multidimensional, as it has previously been suggested.

METHODS

Women (N = 324) were recruited after routine screenings with the EPDS between 2 and 10 months postpartum (T1). At a subsequent home visit (T2), the EPDS and the Structured Clinical Interview for DSM-5 were administered. Diagnostic interviews were audio recorded to enable subsequent coding for ICD-10 diagnoses and inter-rater reliability analysis. A two-phase stratified sampling strategy with three sampling categories (EPDS-score at T1) was used. Using the distribution of 4931 T1 EPDS-scores from the same population from which we sampled the participants, we used sampling weighing to reweight the sample. The calculation of weights was based upon the mother's sampling category at T1 (i.e. the probability of being sampled) and the weights were applied when assessing the receiver operation characteristics (ROCs) of the EPDS. Sensitivity, specificity, positive predictive value, negative predictive value and area under the ROC curve were computed from the reweighted data for all relevant cutoff values. CIs were computed by embedding the calculations in a weighted logistic regression. Exploratory factor analysis was done using oblique rotation. Parallel analysis was used to assess the number of factors.

RESULTS

A score of 11 or more was found to be the optimal cutoff for depression according to both DSM-5 and ICD-10 criteria. Factor analysis suggested that the Danish EPDS consists of three factors, including an 'anxiety factor'.

CONCLUSIONS

The Danish EPDS has reasonable sensitivity and specificity at a cutoff score of 11 or more. There are no notable differences with respect to using ICD-10 or DSM-5 criteria for depression in terms of optimal cutoff. The variation in cutoff scores is likely to be due to cultural variations in the expression of depressive symptoms.

Prenatal maternal anxiety and children's brain structure and function: A systematic review of neuroimaging studies

BACKGROUND

Maternal anxiety disorders are common during pregnancy and postpartum, and are associated with increased behaviour problems and risk of mental health difficulties in children. Understanding alterations in brain structure and function associated with maternal anxiety may help elucidate potential mechanisms via which high maternal anxiety could affect children.

METHODS

We conducted a systematic review of extant research studying the associations between prenatal anxiety and children's brain structure and function, as assessed through neuroimaging. Data were gathered in accordance with the PRISMA review guidelines.

RESULTS

Ten articles were identified, and all found a significant association between antenatal maternal anxiety and child neurodevelopment. Studies vary considerably in their methods with five studies employing electroencephalography (EEG), one using magnetoencephalography (MEG), and the rest employing magnetic resonance imaging (MRI).

LIMITATIONS

The heterogeneity of neuroimaging techniques undertaken by the reviewed studies precluded a meta-analysis from being performed. The applicability of this systematic review to clinical practice is also limited given that the studies examined children across a wide age range (neonates to 17 years).

CONCLUSIONS

From early infancy to late adolescence, findings suggest alterations of brain structure and function in frontal, temporal, and limbic areas in children born to mothers who experienced prenatal anxiety. These brain abnormalities may underlie associations between prenatal anxiety and children's behaviour, though more research incorporating neuroimaging and behavioural data is necessary to determine this.

The psychometric properties of the Icelandic version of the Edinburgh Postnatal Depression Scale (EPDS) when used prenatal

OBJECTIVE

To evaluate the psychometric properties of the Icelandic version of the Edinburgh Postnatal Depression Scale (EPDS) when used prenatal, explore the dimensionality of the scale and describe its effectiveness in identifying depression.

DESIGN

A sample of Icelandic women filled in the EPDS at week 16 gestation, week 24 and week 36. If screened positive in week 16 they were asked to attend a psychiatric diagnostic interview 2-4 weeks later. Every 10th woman screened negative was also asked to attend an interview.

SETTING

Antenatal clinics at primary health care centres in Iceland.

PARTICIPANTS

In total, 2512 women receiving prenatal care participated in the study. At week 16 gestation, 2397 women filled in the Edinburgh Postnatal Depression Scale, 2025 at week 25, and 1756 at week 36. 474 women attended diagnostic interview two to four weeks after screening.

MEASUREMENTS AND FINDINGS

Internal reliability, convergent validity and test-retest correlation of the Icelandic version of the Edinburgh Postnatal Depression Scale appeared acceptable. An exploratory factor analysis supported a one-factor structure of the Edinburgh Postnatal Depression Scale that was confirmed by confirmatory factor analysis showing best fit for one general factor with two group factors. A cut-off score of 11 or higher had specificity of 0.89, sensitivity of 0.80 and positive predictive value of 0.44.

KEY CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

The Icelandic version of the Edinburgh Postnatal Depression Scale is a valid and reliable one-dimensional instrument suitable to screen for depression prenatally. We recommend using score 11 or higher as a cut-off. If women score 11, they should be re-assessed two weeks later, but if they score 12 or higher, they should be referred directly for a further assessment. A time gap of two to four weeks does weaken the scale's ability to discriminate between those suffering from Major Depression and those who screen negative.

Prevalence and incidence of probable perinatal depression among women enrolled in Option B+ antenatal HIV care in Malawi

BACKGROUND

Perinatal depression is a common condition of pregnancy and the postpartum period. Depression negatively affects engagement in HIV care, but systematic screening for perinatal depression is not done in most sub-Saharan African countries. Estimating the burden and timing of perinatal depression can help inform medical programs with the current scale-up of HIV care for pregnant women.

METHODS

Women (n = 299) initiating antiretroviral therapy for HIV were recruited from a government antenatal clinic in Malawi in 2015-2016 into a cohort study. Probable perinatal depression was assessed at enrollment and at 6 weeks and 3, 6, and 12 months postpartum with the Edinburgh Postnatal Depression Scale (EPDS) and Patient Health Questionnaire-9 (PHQ-9). We estimated point prevalence and incidence of depression as well as concordance between EPDS and PHQ-9 scores.

RESULTS

One in ten women screened positive for probable antenatal depression, whereas 1-6% screened positive postpartum. Sensitivity analyses to account for loss to follow-up suggested that postpartum depression prevalence could have ranged from 1-11%. At postpartum time points, 0-3% of participants screened positive for incident probable depression. EPDS and PHQ-9 scores were concordant for 96% of assessments during antenatal and postpartum visits.

LIMITATIONS

Lack of diagnostic psychiatric evaluation precludes actual diagnosis of major depression, and social desirability bias may have contributed to low postpartum scores.

CONCLUSIONS

Probable depression was more common during the antenatal period than postpartum among our participants. Given the association between depression and negative HIV outcomes, screening for depression during pregnancy should be integrated into antenatal HIV care.

Intergenerational transmission of adverse childhood experiences via maternal depression and anxiety and moderation by child sex

Adverse childhood experiences (ACEs) of parents are associated with a variety of negative health outcomes in offspring. Little is known about the mechanisms by which ACEs are transmitted to the next generation. Given that maternal depression and anxiety are related to ACEs and negatively affect children's behaviour, these exposures may be pathways between maternal ACEs and child psychopathology. Child sex may modify these associations. Our objectives were to determine: (1) the association between ACEs and children's behaviour, (2) whether maternal symptoms of prenatal and postnatal depression and anxiety mediate the relationship between maternal ACEs and children's behaviour, and (3) whether these relationships are moderated by child sex. Pearson correlations and latent path analyses were undertaken using data from 907 children and their mothers enrolled the Alberta Pregnancy Outcomes and Nutrition study. Overall, maternal ACEs were associated with symptoms of anxiety and depression during the perinatal period, and externalizing problems in children. Furthermore, we observed indirect associations between maternal ACEs and children's internalizing and externalizing problems via maternal anxiety and depression. Sex differences were observed, with boys demonstrating greater vulnerability to the indirect effects of maternal ACEs via both anxiety and depression. Findings suggest that maternal mental health may be a mechanism by which maternal early life adversity is transmitted to children, especially boys. Further research is needed to determine if targeted interventions with women who have both high ACEs and mental health problems can prevent or ameliorate the effects of ACEs on children's behavioural psychopathology.

Relevance of anxiety in the perinatal period: prospective study in a Hungarian sample

There is increasing evidence that anxiety occurs frequently during pregnancy and can be one of the most important risk factors and predictors of postpartum depression (PPD). The aim of our study was to investigate whether antenatal anxiety is an independent predictor of PPD. We used the data of 476 women enrolled in a prospective study in a single maternity unit. The first assessment was conducted between 22 and 40 weeks gestation and a second time 8-12 months postpartum. Symptoms were measured using the Edinburgh Postnatal Depression Scale (EPDS) and the State Trait Anxiety Inventory (STAI). Based on our results, antenatal anxiety measured by a subscale of EPDS has predicted better PPD than the antenatal depressive subscale. However, the most relevant predictor of PPD might be the trait anxiety level of a women measured by STAI Trait Scale, whereas a cutoff value of 38 was identified to indicate higher risk of PPD.

Course of depression symptoms between 3 and 8 months after delivery using two screening tools (EPDS and HSCL-10) on a sample of Sudanese women in Khartoum state

BACKGROUND

Effects of depression on parenting and on cognitive development of newborns are augmented when symptoms continue throughout the first postnatal year. Current classification systems recognize maternal depression as postnatal if symptoms commence within four to six weeks. Traditional cultural rituals in Sudan offer new mothers adequate family support in the first 6-8 weeks postpartum. The course of postnatal depression symptoms beyond that period is not explored in such settings. We therefore aim to investigate the change in screening status and in severity of depression and distress symptoms between three and eight months postpartum among a sample of Sudanese women using the Edinburgh Postnatal Depression Scale (EPDS) and a locally used tool: the 10-items Hopkins Symptoms Checklist (HSCL-10).

METHODS

Three hundred pregnant women in their 2nd or 3rd trimester were recruited from two clinics in Khartoum state. They were followed up and screened for depression symptoms eight months after delivery by EPDS at ≥12, and by HSCL-10 at ≥1.85. The same sample was previously screened for depression at three months after birth.

RESULTS

Prevalence of postnatal depression symptoms by EPDS was lower at eight months compared to three months after birth (3.6% at eight months (8/223) compared to 9.2% at three months (22/238), p <  0.001). Eight Mothers exhibited depression symptoms eight months after birth. Depressed mothers at three months had a 56% reduction in EPDS mean scores by eight months and 96.4% of participants either remained in the same EPDS category, or improved eight months after birth. Four participants with major depression symptoms at eight months were also depressed three months after birth and four participants had new onset depression symptoms. The HSCL-10 measured higher distress than EPDS across the two screening points (19.3% at three months, 9.1% at eight months postpartum, p <  0.001). Nonetheless, the two tests correlated positively at both points.

CONCLUSIONS

Repeated screenings by EPDS (depression surveillance) is recommended during the first postnatal year because a subset of mothers can have symptoms beyond the early postnatal period. Existing depression screening instruments can be assessed for their validity to detect PND.

Factors associated with pregnancy-related anxiety in Tanzanian women: a cross sectional study

OBJECTIVE

To identify factors predictive of pregnancy-related anxiety (PRA) among women in Mwanza, Tanzania.

DESIGN

A cross-sectional study was used to explore the relationship between psychosocial health and preterm birth.

SETTING

Antenatal clinics in the Ilemela and Nyamagana districts of Mwanza, Tanzania.

PARTICIPANTS

Pregnant women less than or equal to 32 weeks' gestational age (n=212) attending the two antenatal clinics.

MEASURES

PRA was measured using a revised version of the 10-item PRA Questionnaire (PRA-Q). Predictive factors included social support (Multidimensional Scale of Perceived Social Support), stress (Perceived Stress Scale), depression (Edinburg Postpartum Depression Scale) and sociodemographic data. Bivariate analysis permitted variable selection while multiple linear regression analysis enabled identification of predictive factors of PRA.

RESULTS

Twenty-five per cent of women in our sample scored 13 or higher (out of a possible 30) on the PRA-Q. Perceived stress, active depression and number of people living in the home were the only statistically significant predictors of PRA in our sample.

CONCLUSIONS

Our findings were contrary to most current literature which notes socioeconomic status and social support as significant factors in PRA. A greater understanding of the experience of PRA and its predictive factors is needed within the social cultural context of low/middle-income countries to support the development of PRA prevention strategies specific to low/middle income countries.

Establishing a coherent and replicable measurement model of the Edinburgh Postnatal Depression Scale

The 10-item Edinburgh Postnatal Depression Scale (EPDS) is an established screening tool for postnatal depression. Inconsistent findings in factor structure and replication difficulties have limited the scope of development of the measure as a multi-dimensional tool. The current investigation sought to robustly determine the underlying factor structure of the EPDS and the replicability and stability of the most plausible model identified. A between-subjects design was used. EPDS data were collected postpartum from two independent cohorts using identical data capture methods. Datasets were examined with confirmatory factor analysis, model invariance testing and systematic evaluation of relational and internal aspects of the measure. Participants were two samples of postpartum women in England assessed at three months (n = 245) and six months (n = 217). The findings showed a three-factor seven-item model of the EPDS offered an excellent fit to the data, and was observed to be replicable in both datasets and invariant as a function of time point of assessment. Some EPDS sub-scale scores were significantly higher at six months. The EPDS is multi-dimensional and a robust measurement model comprises three factors that are replicable. The potential utility of the sub-scale components identified requires further research to identify a role in contemporary screening practice.

Assessment of significant psychological distress at the end of pregnancy and associated factors

The aim of this study is to study the prevalence of mental distress at the end of pregnancy and after birth and the impact of selected socio-demographic and obstetric factors. This is a cross-sectional study. The sample is consisted of 351 puerperal women at the age of 18 and over. Sociodemographic, obstetric variables were collected to detect significant psychological distress; the instrument used was General Health Questionnaire (GHQ-28). Logistic multivariable regressions were used to investigate associations. The prevalence of significant mental distress amounted to 81.2%, mostly related to social relationship and anxiety. The women who affirmed having more stress during pregnancy had too significantly increased emotional distress before the birth as well as during early puerperium, increasing somatic symptoms (p < 0.001; OR 2.685; CI 95% 1.583-4.553), anxiety (p < 0.001; OR 4.676; CI 95% 2.846-7.684), and depressive symptoms (p < 0.01). Somatic symptoms (p < 0.05; OR 2.466; CI 95% 1.100-5.528) and social dysfunction (p < 0.001; OR 1.672; CI 95% 0.711-3.932) occur most frequently in women who already had children. Regarding socio-demographic data, being an immigrant is the only protective factor reducing the social dysfunction in the last weeks of pregnancy (p < 0.01; OR 0.478; CI 95% 0.274-0.832). Psychological distress at the end of a full-term pregnancy and in the postpartum period occurs frequently and was associated mainly with stress experienced during pregnancy and parity. It is advisable to perform proper assessment of stress and significant psychological distress at the early stage of pregnancy and repeatedly later on until delivery. Information and support from professionals can help to decrease and prevent their negative impact on maternal and fetal health, as observed in the current evidence.

A longitudinal study of women's depression symptom profiles during and after the postpartum phase

BACKGROUND

An issue of critical importance for psychiatry and women's health is whether postpartum depression (PPD) represents a unique condition. The Diagnostic and Statistical Manual of Mental Disorders asserts that major depressive disorder (MDD) may present with peripartum onset, without suggesting any other differences between MDD and PPD. The absence of any distinct features calls into question the nosologic validity of PPD as a diagnostic category. The present study investigates whether symptom profiles differ between PPD and depression occurring outside the postpartum phase.

METHODS

In a prospective, longitudinal study of parturient women (N = 239), we examine the manifestation of depression symptoms. We assess factor structure of symptom profiles, and whether factors are differentially pronounced during and after the postpartum period.

RESULTS

Factors were revealed representing: Worry, Emotional/Circadian/Energetic Dysregulation, Somatic/Cognitive, Appetite, Distress Display, and Anger symptoms. The factor structure was validated at postpartum and after-postpartum timepoints. Interestingly, the Worry factor, comprising anxiety and guilt, was significantly more pronounced during the postpartum timepoint, and the Emotional/Circadian/Energetic Dysregulation factor, which contained sadness and anhedonia, was significantly less pronounced during the postpartum period.

CONCLUSIONS

These results suggest that PPD may be a unique syndrome, necessitating research, diagnosis, and treatment strategies distinct from those for MDD. Results indicate the possibility that Worry is an enhanced feature of PPD compared to depression outside the postpartum period, and the crucial role of sadness/anhedonia in MDD diagnosis may be less applicable to PPD diagnosis.

The Psychometric Validation of the EPDS-K Among Korean Women: Does It Only Measure Depressive Symptoms?

PURPOSE

The purpose of this study was to test the validity of the Edinburgh Postnatal Depression Scale-Korean (EPDS-K) and compare the specified models (one-, two-, three-factor model, and a model in the current study) in pregnant, first-trimester Korean women.

DESIGN AND METHODS

The study consisted of two groups of 100 first-trimester Korean women recruited from maternity clinics in Korea.

FINDINGS

The results show that the EPDS-K has depression, anxiety, and anhedonia factors, and that the validity of the EPDS-K with Korean women is questionable.

PRACTICE IMPLICATIONS

Healthcare providers should test the psychometric properties of tools for screening accuracy, clinical decision-making, and understanding of a phenomenon within different cultural settings.

Systematic review on maternal depression versus anxiety in relation to excessive infant crying: it is all about the timing

Different types of studies suggest a link between maternal depression/anxiety and excessive infant crying (EC). However, comparability is hampered due to different designs, definitions and measurements. This systematic review investigates the specific role of maternal depression and anxiety considering them as preceding, concurrent and subsequent conditions of EC. A computerised literature search was conducted in January 2017 using Medline, PubMed, PsycINFO and Web of Science. After screening n = 399 records for inclusion/exclusion criteria, n = 33 records based on n = 30 projects were eligible for systematic qualitative data synthesis. All studies on maternal depression/anxiety and EC within the first 3 years of life were included. Included studies investigated predominantly maternal depression (25/30) and secondly maternal anxiety (17/30). Significant positive results were found in the majority of studies for maternal depression (21/25) as well as for maternal anxiety (12/17) in relation to EC. In-depth analyses further revealed that concurrent and subsequent maternal depression was robustly related with EC, whilst preceding maternal depression was not. In contrast, preceding and concurrent (but not subsequent) maternal anxiety was consistently related to subsequent EC. Maternal depression is more likely a correlate or even a consequence of EC, whereas anxiety is rather a temporally preceding condition and thus a potential risk factor or risk marker for both subsequent EC and associated maternal depression. Interventions for EC should address concurrent maternal depression, whilst preventive approaches might target preceding maternal anxiety as early as prior to or during pregnancy.

Depression in people with type 2 diabetes: current perspectives

Type 2 diabetes mellitus (T2DM) is associated with depressive symptoms, and comorbid depression in those with T2DM has been associated with adverse clinical profiles. Recognizing and addressing psychological symptoms remain significant clinical challenges in T2DM. Possible mediators of the reciprocal relationship between T2DM and depression may include physical activity levels, effectiveness of self-management, distress associated with a new T2DM diagnosis, and frailty associated with advanced diabetes duration. The latter considerations contribute to a "J-shaped" trajectory from the time of diagnosis. There remain significant challenges to screening for clinical risks associated with psychological symptoms in T2DM; poorer outcomes may be associated with major depressive episodes, isolated (eg, anhedonic), or subsyndromal depressive symptoms, depressive-like symptoms more specific to T2DM (eg, diabetes-related distress), apathy or fatigue. In this review, we discuss current perspectives on depression in the context of T2DM with implications for screening and management of these highly comorbid conditions.

Using the EPDS to Identify Anxiety in Mothers of Infants on the Neonatal Intensive Care Unit

Despite the prevalence of postpartum depression and anxiety, current screening recommendations are limited to depression symptoms. Screening using the Edinburgh Postnatal Depression Scale-Anxiety subscale (EPDS-A) may enhance ability to detect distress in postpartum women. We aimed to replicate the EPDS-A in 200 mothers with infants hospitalized in the neonatal intensive care unit (NICU) and examine its incremental utility in identifying emotional distress. Presence of the EPDS-A was identified using exploratory factor analysis. Women experiencing elevated anxiety were identified using a previously established cutoff score. Results replicated the EPDS-A for the first time in mothers with infants hospitalized in the NICU. In all, 21.9% of these women had elevated anxiety symptoms and nearly one quarter of them would have been missed in routine depression screening. Use of the EPDS-A, in addition to the total EPDS score, is a promising approach to identifying anxious women in need of further evaluation, treatment, or support.

Internet delivered cognitive behavior therapy for antenatal depression: A randomised controlled trial

Major depression occurs in 5-10% of pregnancies and is associated with many negative effects for mother and child, yet treatment options are scarce. To our knowledge, this is the first published randomised controlled trial on Internet delivered Cognitive Behavior Therapy (ICBT) for this group.

OBJECTIVE

To test the efficacy of a pregnancy adapted version of an existing 10-week ICBT-program for depression as well as assessing acceptability and adherence DESIGN: Randomised controlled trial.

SETTING

Online and telephone.

POPULATION OR SAMPLE

Self-referred pregnant women (gestational week 10-28 at intake) currently suffering from major depressive disorder.

METHODS

42 pregnant women (gestational week 12-28) with major depression were randomised to either treatment as usual (TAU) provided at their antenatal clinic or to ICBT as an add-on to usual care.

MAIN OUTCOME MEASURES

The primary outcome was depressive symptoms measured with the Montgomery-Åsberg depression rating scale-self report (MADRS-S). The Edinburgh Postnatal Depression Scale and measures of anxiety and sleep were used. Credibility, satisfaction, adherence and utilization were also assessed.

RESULTS

The ICBT group had significantly lower levels of depressive symptoms post treatment (p < 0.001, Hedges g =1.21) and were more likely to be responders (i.e. achieve a statistically reliable improvement) (RR = 0.36; p = 0.004). Measures of treatment credibility, satisfaction, utilization, and adherence were comparable to implemented ICBT for depression.

LIMITATIONS

Small sample size and no long-term evaluation.

CONCLUSION

Pregnancy adapted ICBT for antenatal depression is feasible, acceptable and efficacious. These results need to be replicated in larger trials to validate these promising findings.

Perinatal western-type diet and associated gestational weight gain alter postpartum maternal mood

INTRODUCTION

The role of perinatal diet in postpartum maternal mood disorders, including depression and anxiety, remains unclear. We investigated whether perinatal consumption of a Western-type diet (high in fat and branched-chain amino acids [BCAA]) and associated gestational weight gain (GWG) cause serotonin dysregulation in the central nervous system (CNS), resulting in postpartum depression and anxiety (PPD/A).

METHODS

Mouse dams were fed one of four diets (high-fat/high BCAA, low-fat/high BCAA, high-fat, and low-fat) prior to mating and throughout gestation and lactation. Postpartum behavioral assessments were conducted, and plasma and brain tissues assayed. To evaluate potential clinical utility, we conducted preliminary human studies using data from an extant sample of 17 primiparous women with high GWG, comparing across self-reported postpartum mood symptoms using the Edinburgh Postnatal Depression Scale (EPDS) for percent GWG and plasma amino acid levels.

RESULTS

Mouse dams fed the high-fat/high BCAA diet gained more weight per kcal consumed, and BCAA-supplemented dams lost weight more slowly postpartum. Dams on BCAA-supplemented diets exhibited increased PPD/A-like behavior, decreased dopaminergic function, and decreased plasma tyrosine and histidine levels when assessed on postnatal day (P)8. Preliminary human data showed that GWG accounted for 29% of the variance in EPDS scores. Histidine was also lower in women with higher EPDS scores.

CONCLUSIONS

These findings highlight the role of perinatal diet and excess GWG in the development of postpartum mood disorders.

Sleeping for Two: An Open-Pilot Study of Cognitive Behavioral Therapy for Insomnia in Pregnancy

Insomnia and disturbed sleep are common during pregnancy. This study investigated the effectiveness of group cognitive-behavioral therapy for insomnia (CBT-I) delivered in pregnancy. Thirteen pregnant women with insomnia participated in five weekly CBT-I group sessions. All participants completed the study and provided baseline and follow-up data. Significant reductions in insomnia symptoms and increases in subjective sleep quality were observed over the course of the study. Diary and actigraphy assessments of sleep also changed, such that participants reported less time in bed (TIB), shorter sleep onset latency (SOL), increased sleep efficiency (SE), and increased subjective total sleep time (TST). Additionally, symptoms of depression, pregnancy-specific anxiety, and fatigue all decreased over the course of treatment. Effect sizes ranged from medium to large. CBT-I delivered during pregnancy was associated with significant improvements in sleep and mood. The next step in this area of inquiry is to better establish effectiveness via a randomized controlled trial.