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Accuracy of the Whooley questions and the Edinburgh Postnatal Depression Scale in identifying depression and other mental disorders in early pregnancy

  • Louise Michele Howard (a1), Elizabeth G. Ryan (a2), Kylee Trevillion (a3), Fraser Anderson (a3), Debra Bick (a4), Amanda Bye (a3), Sarah Byford (a5), Sheila O'Connor (a3), Polly Sands (a3), Jill Demilew (a6), Jeannette Milgrom (a7) and Andrew Pickles (a2)...
Abstract
Background

There is limited evidence on the prevalence and identification of antenatal mental disorders.

Aims

To investigate the prevalence of mental disorders in early pregnancy and the diagnostic accuracy of depression-screening (Whooley) questions compared with the Edinburgh Postnatal Depression Scale (EPDS), against the Structured Clinical Interview DSM-IV-TR.

Method

Cross-sectional survey of women responding to Whooley questions asked at their first antenatal appointment. Women responding positively and a random sample of women responding negatively were invited to participate.

Results

Population prevalence was 27% (95% CI 22–32): 11% (95% CI 8–14) depression; 15% (95% CI 11–19) anxiety disorders; 2% (95% CI 1–4) obsessive–compulsive disorder; 0.8% (95% CI 0–1) post-traumatic stress disorder; 2% (95% CI 0.4–3) eating disorders; 0.3% (95% CI 0.1–1) bipolar disorder I, 0.3% (95% CI 0.1–1%) bipolar disorder II; 0.7% (95% CI 0–1) borderline personality disorder. For identification of depression, likelihood ratios were 8.2 (Whooley) and 9.8 (EPDS). Diagnostic accuracy was similar in identifying any disorder (likelihood ratios 5.8 and 6).

Conclusions

Endorsement of Whooley questions in pregnancy indicates the need for a clinical assessment of diagnosis and could be implemented when maternity professionals have been appropriately trained on how to ask the questions sensitively, in settings where a clear referral and care pathway is available.

Declaration of interest

L.M.H. chaired the National Institute for Health and Care Excellence CG192 guidelines development group on antenatal and postnatal mental health in 2012–2014.

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Copyright
This is an Open Access article, distributed under the terms of the Creative Commons Attribution licence (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted re-use, distribution, and reproduction in any medium, provided the original work is properly cited.
Corresponding author
Correspondence: Louise Michele Howard, Section of Women's Mental Health, PO31 Institute of Psychiatry, Psychology and Neuroscience, King's College London, De Crespigny Park, London SE5 8AF. Email louise.howard@kcl.ac.uk
References
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Accuracy of the Whooley questions and the Edinburgh Postnatal Depression Scale in identifying depression and other mental disorders in early pregnancy

  • Louise Michele Howard (a1), Elizabeth G. Ryan (a2), Kylee Trevillion (a3), Fraser Anderson (a3), Debra Bick (a4), Amanda Bye (a3), Sarah Byford (a5), Sheila O'Connor (a3), Polly Sands (a3), Jill Demilew (a6), Jeannette Milgrom (a7) and Andrew Pickles (a2)...
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eLetters

Response to Mathey & Della Vedova and Pawlby et al

Louise Howard, King's College London
13 November 2018

Thank you for your interest in our study. Mathey & Della Vedova focussed on the effectiveness of the Whooley questions in identifying any mental disorder, and we agree, an important focus for case identification tools as mental disorders in pregnant women are common. We are not aware of any comparable studies examining the effectiveness of tools to identify "any disorder"; most focus either only on identification of depression or anxiety disorders. We agree that the sensitivity of the Whooley questions is low for "any disorder"; there is always a trade-off between sensitivity and specificity and the challenge of designing a short but sensitive screening instrument, particularly for “any disorder” (but also for depression) remains.

In the meantime, as far as clinicians are concerned, it may be useful to be aware that the positive predictive value (probability that a woman endorsing one Whooley question has a mental disorder) of the Whooley questions, in a population such as ours with a high prevalence (around 25%) of disorders (including depression, anxiety disorders, eating disorders, OCD, PTSD and other disorders), was 66% (or 80% if both Whooley questions are endorsed). Subsequent assessment by a GP or other trained professional is essential - as NICE 2014 highlights, any tool used should not be used in isolation, but rather used in the context of a general discussion of mental health, which should include mental health history and treatment (and response to previous treatment) to facilitate appropriate intervention.

We hope that a short tool to identify presence of a mental disorder in maternity populations will be developed and validated soon, with a higher sensitivity, for use in maternity populations. It is certainly needed as, as Pawlby et al highlight, the prevalence of mental disorders in pregnant women is alarmingly high. We will be developing a predictive tool and examining its effectiveness in different populations in England which we hope will be useful.

Yours sincerely

Louise Howard, Kylee Trevillion, Elizabeth Ryan and Andrew Pickles on behalf of the ESMI team

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Conflict of interest: None declared

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Whooley questions miss ~80% of ‘cases’: are they therefore really “useful” ?

Stephen Matthey, Research & Clinical Psychologist, Univ. of Sydney / Sydney South West Local Health Service
Anna Della Vedova, Research & General Psychologist; Psychotherapist, Università degli Studi di Brescia, Italy.
10 October 2018

One of the conclusions by the authors in this paper (Howard et al., 2018) is that their data confirm that the Whooley questions (Whooley et al., 1997) “are a useful tool for case identification in early pregnancy (by midwives in routine clinical settings)” (p. 54).



This conclusion was principally based upon the obtained positive likelihood ratio in their study (LR+: 5.8 for depression, anxiety and other related disorders) and high specificity (0.96), providing therefore a reasonable positive predictive value (ppv: 0.66). Also, however, the authors explain that the Whooley questions had a low sensitivity of just 0.23. This means that they actually missed almost 80% of the women with these mental health disorders.



We feel that it is difficult to imagine a clinical service agreeing that an instrument that misses almost 80% of people with a condition could be considered “useful”, and “(is) a quick method for identifying that a mental disorder may be present” (p.54), despite the other receiver operating characteristic values reported for the questions.



We accept that the issue of what values, or combination of values, of a test’s various screening metrics (eg., LR+, sensitivity, specificity, ppv etc) are indicative of a ‘good or clinically useful performance’ can be difficult to decide, is open to debate, and will vary depending upon context. And we appreciate that Howard et al are clear in their reporting of their data, including the low sensitivity values and possible reasons for these, which they say include that the questions may not have been asked in a consistent and/or correct way by the midwives.



We would however question their main conclusions, these being that the obtained data “confirm …that they are a useful tool for case identification” (p. 54), and that “(the Whooley questions) can (therefore) be asked routinely by midwives when women attend for their routine antenatal bookings appointment” (p. 55).

Rather, we would suggest that a different conclusion may be more appropriate, given their findings, this being along the lines of : ‘screening positive on the Whooley questions, while being indicative of a reasonable likelihood of a woman having a mental health difficulty, needs to be tempered by the fact that most of the women with such disorders were not in fact detected by the questions in this study. These data therefore indicate that services would be unwise to implement these questions, in the way conducted in this study, if they consider that missing around 80% of women with a mental health difficulty is problematic’.



Adj. A/Prof Stephen Matthey: University of Sydney; SSWLHD, Australia.

Dssa. Anna Della Vedova: Università degli Studi di Brescia, Italy.

References

Howard, L.M., Ryan, E.G., Trevillion, K., Anderson, F., Bick, D., Bye, A., … Pickles, A. (2018). Accuracy of the Whooley questions and the Edinburgh Postnatal Depression Scale in identifying depression and other mental disorders in early pregnancy. Brit. J. Psychiatry, 212, 50-56.

Whooley, M. A., Avins, A. L., Miranda, J., & Browner, W. S. (1997). Case finding instruments for depression: two questions as good as many. J. Gen. Intern. Med., 12, 439-445.

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Conflict of interest: None declared

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Prevalence of maternal psychiatric disorder in pregnancy: 1986 and 2016

Susan Pawlby, Developmental Psychologist, King's College London
Deborah Sharp, Professor of Primary Health Care, University of Bristol
Dale Hay, Professor of Psychology, Cardiff University
05 April 2018

We note that the population prevalence rate for a psychiatric diagnosis for women at the first antenatal appointment is 27%, a disturbing one in 4 women.

In 1986 we used a similar two-stage methodology, the Leeds Anxiety and Depression Scales (Snaith et al., 1976) and the Clinical Interview Schedule (CIS: Goldberg et al., 1970), with women booking in at two GP antenatal clinics in the same inner-city location (Sharp, 1992). The point prevalence for a psychiatric disorder (ICD-9) at 20 weeks was 25% and at 36 weeks was 23.5%. The period prevalence was 38%. One in 3 women suffered from a psychiatric disorder during pregnancy.

The pregnant women recruited into Howard’s study have a mean age of 32 years and could well be the offspring of the mothers whom we interviewed in 1986. Why are the point prevalence rates of psychiatric disorder exactly the same as they were 30 years ago? It is likely that one in 3 pregnant women are still suffering from a psychiatric disorder. We have had 2 sets of NICE Guidelines (2007, 2014) for managing perinatal mental health, but this evidence shows that we have not reduced the number of sufferers. We seem to be good at identifying disorder but what are we doing to prevent the next generation from suffering?

My colleagues and I have interviewed the South London Child Development Study cohort of women and children at 8 time points through pregnancy in 1986 and the following 26 years to 2012. We have shown that women’s mental health in pregnancy is a risk factor for psychiatric disorder in the offspring through childhood, adolescence and into young adulthood (Plant et al., 2015). The evidence from Howard’s paper shows that we have not yet been able to stem the intergenerational transmission of psychiatric disorder. Screening without follow-up intervention does not help prevent later mental ill-health or transmission to the next generation. Isn’t it time that we could and should intervene? 

Professor Debbie Sharp

Professor Dale Hay

Dr Susan Pawlby

Sharp, D., 1992, Childbirth related emotional disorders in primary care: A longitudinal prospective study. Unpublished PhD thesis, Institute of Psychiatry, King’s College London

Snaith, R. P., Bridge, G. W., & Hamilton, M. (1976). The Leeds scales for the self-assessment of anxiety and depression. The British Journal of Psychiatry, 128, 156-165. 

http://dx.doi.org/10.1192/bjp.128.2.156

Goldberg, D. P., Cooper, B., Eastwood, M. R., Kedward, H. B., & Shepherd, M. (1970). A standardized psychiatric interview for use in community surveys. British journal of preventive & social medicine, 24(1), 18.

https://www.nice.org.uk/guidance/cg192

Plant, D. T., Pariante, C. M., Sharp, D., & Pawlby, S. (2015). Maternal depression during pregnancy and offspring depression in adulthood: role of child maltreatment. The British Journal of Psychiatry, 207(3), 213-220

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Conflict of interest: None declared

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