Screening

Postpartum depression is treatable, but the women suffering must first be identified. Mothers may not seek help for postpartum depression due to any number of reasons including a lack of knowledge regarding this devastating illness and/or because of the tremendous stigma attached to mental illness. Also, women may fear that if they are diagnosed with postpartum depression, child welfare authorities may take their infants.

Women should be screened for postpartum depression periodically during the first year after delivery. The standard practice of screening just one time during the early postpartum period (i.e., at 6 weeks postpartum) may not detect postpartum depression that develops later. Because a woman is adjusting well during the early postpartum period does not mean she will not develop postpartum depression sometime later during the first 12 months after birth. Without repeated screenings, a mother may fall through the cracks in the health care system. Prior to screening women for postpartum depression, health care providers need to dispel the idealized myths of motherhood and provide a trusting environment in which women can feel free to discuss any negative feelings or thoughts they may be experiencing.

The Postpartum Depression Screening Scale (PDSS) is a survey available to clinicians for screening [8]. This self-report scale consists of 35 items that assess the presence, severity, and type of postpartum depressive symptoms. It has a five-point Likert response format in which women are asked to respond to statements about how they have been feeling since delivery. The response options range from 1 = strongly disagree, to 5 = strongly agree (Table 19.1). Agreement with a statement indicates the mother is experiencing that depressive symptom. The PDSS consists of seven symptoms content scales: Sleeping/Eating Disturbances, Loss of Self, Anxiety/Insecurity, Guilt/Shame, Emotional Lability, Mental Confusion, and Suicidal Thoughts. The range of possible scores is 35-175. A cutoff score of 80 or above indicates a positive screen for postpartum depression and the need to refer the mother for a formal diagnostic evaluation by a mental health clinician. Using this cutoff score of 80, Beck and Gable [8] reported the PDSS had a sensitivity of 94% and a specificity of 98%.

The Edinburgh Postnatal Depression Scale (EPDS) is a second instrument that has been developed to screen for depression [42]. It consists of ten items in a Likert format that assess the following common depressive symptoms: inability to laugh or look forward to things with enjoyment, feeling scared or panicky, feeling like "things have gotten on top of me," difficulty sleeping, and feeling sad. Using that cutoff, reported sensitivity (86%) and specificity (78%) have been reported by Cox et al. [42].

The Edinburgh Postnatal Depression Scale's 10 items assess depression in general. None of the items is written in the context of new motherhood. With a sample of 150

Table 19.1

Postpartum Depression Screening Scale: Selected Items by Dimension*

During the past 2 weeks I... Sleeping/eating disturbances No. 1: I had trouble sleeping even when my baby was asleep No. 8: I lost my appetite Loss of self No. 19: I did not know who I was anymore No. 5: I was afraid that I would never by my normal self again Anxiety/insecurity No. 23: I felt all alone No. : I felt really overwhelmed Guilt/shame

  1. 20: I felt guilty because I could not feel as much love for my baby as I should
  2. 27: I felt like I had to hide what I was thinking or feeling toward the baby Emotional lability No. 3: I felt like my emotions were on a roller coaster No. 31: I felt full of anger ready to explode Mental confusion No. 11: I could not concentrate on anything No. 4: I felt like I was losing my mind Suicidal thoughts No. 14: I started thinking I would be better off dead No. 28: I felt that my baby would be better off without me *Selected items from the PDSS copyright ©2002, by Western Psychological Services. Reprinted by permission of the publisher, Western Psychological Services, 12031 Wilshire Boulevard, Los Angeles, California, 90025 (www. wpspublish.com) Not to be reprinted in whole or in part for any additional purpose without the expressed, written permission of the publisher. All rights reserved new mothers, when using the published recommended cutoff points for major depression, the PDSS achieved a sensitivity of 94% and specificity of 98% while the Edinburgh Postpartum Depression Scale's sensitivity was 78% and specificity was 99% [116].

Formal diagnosis of postpartum depression can be made by conducting a Structured Clinical Interview for DSM-IV Axis 1 Disorders (SCID) [43].

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