Shortening the Edinburgh postnatal depression scale using optimal test assembly methods: Development of the EPDS-Dep-5

AIMS

This study used a large database to develop a reliable and valid shortened form of the Edinburgh Postnatal Depression Scale (EPDS), a self-report questionnaire used for depression screening in pregnancy and postpartum, based on objective criteria.

METHODS

Item responses from the 10-item EPDS were obtained from 5157 participants (765 major depression cases) from 22 primary screening accuracy studies that compared the EPDS to the Structured Clinical Interview for DSM (SCID). Unidimensionality of the EPDS latent construct was verified using confirmatory factor analysis, and an item response theory model was fit. Optimal test assembly (OTA) methods identified a maximally informative shortened form for each possible scale length between 1 and 9 items. The final shortened form was selected based on pre-specified validity and reliability criteria and non-inferiority of screening accuracy of the EPDS as compared to the SCID.

RESULTS

A 5-item short form of the EPDS (EPDS-Dep-5) was selected. The EPDS-Dep-5 had a Cronbach's alpha of 0.82. Sensitivity and specificity of the EPDS-Dep-5 for a cutoff of 4 or greater were 0.83 (95% CI, 0.73, 0.89) and 0.86 (95% CI, 0.80, 0.90) and were statistically non-inferior to the EPDS. The correlation of total scores with the full EPDS was high (r = 0.91).

CONCLUSION

The EPDS-Dep-5 is a valid short form with minimal loss of information when compared to the full-length EPDS. The EPDS-Dep-5 was developed with OTA methods using objective, pre-specified criteria, but the approach is data-driven and exploratory. Thus, there is a need to replicate results of this study in different populations.

Comparison of major depression diagnostic classification probability using the SCID, CIDI, and MINI diagnostic interviews among women in pregnancy or postpartum: An individual participant data meta-analysis

OBJECTIVES

A previous individual participant data meta-analysis (IPDMA) identified differences in major depression classification rates between different diagnostic interviews, controlling for depressive symptoms on the basis of the Patient Health Questionnaire-9. We aimed to determine whether similar results would be seen in a different population, using studies that administered the Edinburgh Postnatal Depression Scale (EPDS) in pregnancy or postpartum.

METHODS

Data accrued for an EPDS diagnostic accuracy IPDMA were analysed. Binomial generalised linear mixed models were fit to compare depression classification odds for the Mini International Neuropsychiatric Interview (MINI), Composite International Diagnostic Interview (CIDI), and Structured Clinical Interview for DSM (SCID), controlling for EPDS scores and participant characteristics.

RESULTS

Among fully structured interviews, the MINI (15 studies, 2,532 participants, 342 major depression cases) classified depression more often than the CIDI (3 studies, 2,948 participants, 194 major depression cases; adjusted odds ratio [aOR] = 3.72, 95% confidence interval [CI] [1.21, 11.43]). Compared with the semistructured SCID (28 studies, 7,403 participants, 1,027 major depression cases), odds with the CIDI (interaction aOR = 0.88, 95% CI [0.85, 0.92]) and MINI (interaction aOR = 0.95, 95% CI [0.92, 0.99]) increased less as EPDS scores increased.

CONCLUSION

Different interviews may not classify major depression equivalently.

Violence and depressive symptoms during pregnancy in BRISA cohort: using structural equation modeling approach

Abstract Objectives: to analyze associations among violence against pregnant women, depressive symptoms during pregnancy and maternal depression symptoms. Methods: a sample of 1,139 mothers was conducted on a prenatal cohort study in the municipality of São Luís in Brazil. Psychological and physical violence against pregnant women were measured by the World Health Organization Violence Against Woman. Depressive symptoms during pregnancy were measured by the Escala de Depressão do Centro de Estudos Epidemiológicos (CES-D) (Depression Scale for Epidemiological Studies Center) and maternal depression symptoms were measured by the Edinburgh Postnatal Depression Scale (EPDS). The conceptual model of the structural equation modeling contained socioeconomic situation, social support, psychological and physical violence and depression during pregnancy as determinants of the maternal depression symptoms. Results: maternal depression symptoms were more frequently reported by pregnant women who suffered psychological violence (Standardized Coefficient, SC=0.256; p-value, p<0.001), physical violence (SC=0.221 p<0.001) and those who presented depressive symptoms during pregnancy SC=0.322, p<0.001). Depressive symptoms during pregnancy mediated the effects on physical and psychological violence on maternal depression. Conclusions: pregnant women who were submitted to psychological and physical violence and presented depressive symptoms during pregnancy frequently reported more of having maternal depression symptoms.

Correlations between changes in the hypothalamic-pituitary-adrenal axis and neurochemistry of the anterior cingulate gyrus in postpartum depression

BACKGROUND

This study aimed to investigate associations between indicators of hypothalamic-pituitary-adrenal axis (HPA) functioning and metabolite levels in the anterior cingulate gyrus (ACG) of women with postpartum depression (PPD).

METHODS

The sample (mean age = 28.5 ± 4.6 years) consisted of 20 women with PPD and 19 postpartum euthymic (PPE) women. Brain metabolites were quantified by proton magnetic resonance spectroscopy (¹H-MRS). Salivary cortisol samples were collected upon awakening and 30 min and 12 h later, at 20.6 ± 6.6 (PPD) and 23.0 ± 7.4 (PPE) weeks after childbirth.

RESULTS

There were no significant differences between groups in respect to metabolite levels in the ACG. Compared with PPE, PPD women had less diurnal variation (DVr%). In the PPD group, positive correlations were found between DVr% and myo-inositol (mI/Cr) levels, and between cortisol awakening response (CARi%) and glutamate + glutamine (Glx/Cr) levels. The correlation between CARi% and Glx/Cr remained significant even after controlling for the interval, in weeks, from birth and MR spectroscopy and to hormonal data collection, and the use of contraceptives.

LIMITATIONS

The limitations of the study include the small sample size and the use of oral contraceptives by around half of the sample.

CONCLUSIONS

In the remote postpartum period (mean 21.8 ± 6.9 weeks) and in the presence of depressive episodes, the decreased responsiveness of the HPA axis after awakening and a smaller decrease in cortisol levels over the day were associated with lower levels of metabolites in the ACG. These results may contribute to the development of biological models to explain the etiology of PPD.

Perceived Stress Scale: confirmatory factor analysis of the PSS14 and PSS10 versions in two samples of pregnant women from the BRISA cohort

This study aimed to assess the dimensional structure, reliability, convergent validity, discriminant validity, and scalability of the Perceived Stress Scale (PSS). The sample consisted of 1,447 pregnant women in São Luís (Maranhão State) and 1,400 in Ribeirão Preto (São Paulo State), Brazil. The 14 and 10-item versions of the scale were assessed using confirmatory factor analysis, using weighted least squares means and variance (WLSMV). In both cities, the two-factor models (positive factors, measuring resilience to stressful situations, and negative factors, measuring stressful situations) showed better fit than the single-factor models. The two-factor models for the complete (PSS14) and reduced scale (PSS10) showed good internal consistency (Cronbach's alpha ≥ 0.70). All the factor loadings were ≥ 0.50, except for items 8 and 12 of the negative dimension and item 13 of the positive dimension. The correlations between both dimensions of stress and psychological violence showed the expected magnitude (0.46-0.59), providing evidence of an adequate convergent construct validity. The correlations between the scales' positive and negative dimensions were around 0.74-0.78, less than 0.85, which suggests adequate discriminant validity. Extracted mean variance and scalability were slightly higher for PSS10 than for PSS14. The results were consistent in both cities. In conclusion, the single-factor solution is not recommended for assessing stress in pregnant women. The reduced, 10-item two-factor scale appears to be more appropriate for measuring perceived stress in pregnant women.

Altered functioning of the HPA axis in depressed postpartum women

BACKGROUND

The present study aimed to evaluate the relationship between the functioning of the hypothalamic-pituitary-adrenal (HPA) axis and major depressive episodes in the remote postpartum period.

METHODS

The sample (mean age, 28.0±5.3 years) consisted of 37 depressed postpartum women (DPP), 42 euthymic postpartum women (EPP) and 25 non-postpartum healthy women (HC). Salivary cortisol samples were collected immediately after awakening and 30min, 3 and 12h later, at approximately the sixth month postpartum (mean, 169.6±60.3 days).

RESULTS

Differences in cortisol levels were observed at awakening (DPP<EPP=HC), at 30min (DPP<EPP<HC), at 3h (DPP=EPP<HC) and at 12h (DPP>EPP=HC). The relative increment in the cortisol awakening response (CARi%) was significantly higher in HC (113.5±94.3) than in EPP (63.1±69.8) and DPP (32.2±49.6). The relative reduction in diurnal variation (DVr%) was lower in DPP (56.5±41.8) than in EPP (75.6±22.4) and HC (75.1±13.0).

LIMITATIONS

The main limitation was cortisol collection on a single day and without measurement at midnight.

CONCLUSIONS

Our findings suggest that the remote postpartum period involves attenuation of HPA axis reactivity; this dysregulation is more pronounced in the presence of DPP, which is associated with a reduction in cortisol diurnal variation. Abnormalities in the neuroendocrine system related to stress processing, present even several months after delivery, can represent vulnerability to mental disorders. Thus, improvements in the mental health care of postpartum women are needed.

Postpartum depression screening by telephone: a good alternative for public health and research

This study verified the reliability and validity of the Edinburg Postpartum Depression Scale (EPDS) administered by telephone interviews. In a cross-sectional study of a cohort from Brazil (BRISA), the EPDS was administered by telephone to 1,083 women within 12 months postpartum, and 257 (23.7 %) participants had an EPDS score ≥10. At 67 ± 48 days after their telephone interview, 199 (EPDS ≥10 = 96; EPDS <10 = 103) participants were interviewed face-to-face using the Structured Clinical Interview for DSM-IV (SCID) and completed the EPDS again by self-report. In 90 participants, the diagnosis of major depressive episode was confirmed by the SCID (EPDS ≥10 = 65; EPDS <10 = 25). The Cronbach's alpha coefficient was 0.861. The Spearman's correlation between the EPDS administered by telephone and the self-reported EPDS was 0.69 (p < 0.001). The receiver-operating characteristic (ROC) curve for the EPDS administered by telephone was 0.78 (95 % confidence interval (CI) = 0.72 to 0.84). Scores ≥10 showed a sensitivity of 72.2 %, a specificity of 71.6 %, and a positive predictive value of 67.7 %. The application of the EPDS by telephone is a suitable alternative for clinical practice and research and represents a method to optimize the diagnosis of postpartum depression.

Factors associated with prolonged non-nutritive sucking habits in two cohorts of Brazilian children

BACKGROUND

Non-nutritive sucking habits (NNSH) are very common during childhood. However, if these habits were maintained for 36 months of age or more, they are considered to be prolonged (PNNSH) and can cause occlusal, physiological and esthetic changes. There is controversy about their prevalence and whether perinatal, social, demographic and health characteristics influence their onset and duration. So, the objectives of this study are to estimate the prevalence of PNNSH and to evaluate perinatal, early life and school age factors associated with their occurrence in children.

METHODS

A sample of 1,463 children aged 7-11 years born in Ribeirão Preto (RP-1994) and São Luís (SL-1997/98), Brazil, was reevaluated at school age in 2004/05. Birth weight, gestational age and perinatal variables were obtained at birth. Type of feeding, occurrence and duration of finger and pacifier sucking were recorded retrospectively at school age. PNNSH were defined when persisted for 36 months of age or more. Crude and adjusted prevalence ratios (PR) were estimated by Poisson regression (alpha = 5%).

RESULTS

Prevalence of PNNSH was higher in RP (47.6%) than in SL (20.2%) - (p < 0.001). Perinatal variables were not associated to PNNSH, whilst female sex (PR = 1.27 in RP; PR = 1.47 in SL) and bottle feeding for 24 months or more (PR = 2.24 in RP; PR = 2.49 in SL) were risk factors in both locations. Breast feeding for 12 months or more (PR = 0.53 in RP; PR = 0.31 in SL) was associated with lower prevalence of PNNSH in both places. In SL, children whose mothers lived in consensual union (PR = 1.62) and worked outside the home (PR = 1.51) showed higher prevalence of PNNSH compared to their counterparts.

CONCLUSIONS

Prevalence of PNNSH was high especially in RP and was not associated with perinatal variables. In both cities there was an association between female sex, shorter breast-feeding duration, longer bottle feeding duration and higher prevalence of PNNSH.

Antinuclear antibodies testing as a routine screening for systemic lupus erythematosus in patients presenting first-episode psychosis

AIMS

This report discusses the use of antinuclear antibody (ANA) detection as a screening test for neuropsychiatry systemic lupus erythematosus (NPSLE) in patients presenting a first-episode psychosis.

METHODS

We reviewed the medical records of 85 patients admitted to an emergency service due to first-episode psychosis, during a 1-year period, for whom ANA detection was performed through an IFI HEp2 cell assay. ANA-positive patients were subsequently evaluated for autoantibodies and neuroimaging exams.

RESULTS

Three patients presented as ANA positive in the initial screening and further investigation confirmed NPSLE in two patients. The patients were treated with antipsychotics and cyclophosphamide pulses with satisfactory outcomes.

CONCLUSION

Even though ANA detection is not specific, it is a low-cost procedure and could be an important screening test for NPSLE in the early-onset psychosis.