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14 - Perinatal psychiatric emergencies
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- By Carol Henshaw, Consultant in Perinatal Mental Health, Liverpool Women's NHS Foundation Trust, and Honorary Senior Lecturer, University of Liverpool, UK
- Edited by Kevin Nicholls
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- Emergency Psychiatry
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- 01 January 2018
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- 01 April 2015, pp 240-248
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Summary
The conception rate in most women suffering from a mental disorder is the same as in the general population. Only those suffering from moderate to severe intellectual disability, anorexia nervosa or psychosis have lower rates. However, despite the lower conception rate in women with psychosis, estimates of the number of such women who are mothers range from 56 to 63% (McGrath et al, 1999; Howard et al, 2002). Women with affective disorders are more likely to be multiparous (Jablensky et al, 2005). Therefore, mental health professionals working with women of childbearing potential are likely to have to deal with a psychiatric emergency involving a pregnant or postpartum woman at some point, and many of the women they treat have the potential to become pregnant. This chapter will address the treatment of such patients.
Pregnancy
More than a third of pregnant women suffer from a mental disorder (Kelly et al, 2001). Some will be experiencing pre-existing disorders, whereas others will experience a new onset. Pregnancy is a mulitfactorial stressor and might contribute to women with a past history of mental disorder experiencing a recurrence, particularly if medication has been discontinued.
It has previously been thought that pregnancy is protective against relapse; for example, that women with bipolar disorder are less likely to experience an episode of illness during pregnancy (Sharma & Persad 1995; Grof et al, 2000). However, a third to half of all bipolar women experience worsened symptoms during pregnancy (Blehar et al, 1998; Freeman et al, 2002). In the latter study, those who had symptoms in pregnancy were more likely to have a postpartum episode and their episodes were almost exclusively depressive. Akdeniz et al (2003) observed that 32% of bipolar women had episodes during pregnancy or postpartum. Viguera & Cohen (1998) identified that episodes during pregnancy are more likely to be depressive or dysphoric mixed states than in manic states. Half of these occurred in the first trimester.
Pregnancy should be considered as a possibility in any woman who presents as a psychiatric emergency, as 50% of pregnancies in the UK are unplanned. A woman who is very unwell might not tell you or even be aware that she is pregnant. The youngest mother in the UK was 11 years old when she delivered and the oldest was in her 60s, so this is not just an issue for psychiatrists treating women of working age.
2 - The Origins and Development of the Edinburgh Postnatal: Depression Scale
- John Cox, Jeni Holden, Carol Henshaw
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- Perinatal Mental Health
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Summary
Origins of the EPDS
In the early 1980s, the limitations of existing self-report questionnaires for use in community samples were beginning to be recognised. Philip Snaith (1983), for example, had acknowledged the need to modify existing scales for use in specialist settings; and Channi Kumar (1982), in Motherhood and Mental Illness, recognised there was a need for
‘… some form of simple self-administered scale … for use in antenatal and postnatal settings, to pick out potential cases of women with depression and anxiety. Existing questionnaires contain questions which are dissonant with the woman's pregnant or parturient state and, on the other hand, questions about her mental state, which take account of her condition, are lacking.’ (p. 112)
In Edinburgh at that time the serious limitations of existing self-report scales had become very apparent to us. Although we used the best available scale in our prospective study (Cox, 1983) – the Anxiety and Depression Questionnaire (SAD) of Bedford & Foulds (1978) – and although it had the advantage of brevity and few somatic items, it failed to detect any increase in these symptoms in the first postpartum weeks, and the recommended cut-off score was completely inappropriate for use during pregnancy (Cox, 1983). Of the 13 pregnant women with a score of 6+, only 3 had any form of mental disorder, and some items lacked face validity for childbearing women. We concluded:
‘If these difficulties with the SAD are replicated by others using different self-report questionnaires, then the implications for the reliable detection of neuroses in childbearing women are considerable. It might for example be necessary to re-design or re-validate self-report scales specifically for use during pregnancy and again for use in the puerperium.’ (p. 6)
The intent of the grant application to the Scottish Home and Health Department in 1983 was therefore to develop and validate a screening scale specifically for use with childbearing women in the community, and also to carry out an intervention study by health visitors. In the proposal the limitations of existing scales was emphasised, as well as the published evidence that perinatal depression, and postpartum depression in particular, caused distress to the mother, was a threat to family cohesion and had an adverse effect on the growing infant.
5 - Humanistic and Person-Centred Interventions in Perinatal Depression
- John Cox, Jeni Holden, Carol Henshaw
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- Perinatal Mental Health
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- 05 February 2021
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- 01 February 2014, pp 42-59
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Summary
Maternal depression not only affects the quality of a woman's own life and experience of mothering, but can cast a long shadow on her whole family. Her reduced sensitivity may have adverse effects on her infant's emotional and cognitive development, and her other children may also be affected. For partnered women, increased irritability and loss of affectionate responsiveness may affect the couple's relationship or even lead to the break up of the family. Fathers may also have depression. Developing and practising preventive and therapeutic measures is both cost-effective and humane, and the importance of targeting scarce resources is increasingly acknowledged. In this chapter we examine innovative research in many parts of the world with implications for clinical practice.
The Edinburgh counselling intervention
The Edinburgh counselling intervention (Holden et al, 1989) gave health visitors a key role in finding practical ways of helping women with depression in a randomised controlled trial. Health visitors, who are qualified health professionals and part of the primary care team, provide a preventive health service. At the time of our research, most health visitors visited all women 10 days after childbirth, followed by regular assessments at home or clinic. They were thus in a key position to pick up problems and provide a link between a woman and her doctor and other services.
Seventeen health visitors in Edinburgh and Livingston (Scotland) were given brief training based on Rogerian non-directive (person-centred) counselling, using videos, case discussion, role-playing and written information about counselling, postnatal depression and how to administer the EPDS. They were asked to pay eight extra weekly ‘listening’ visits to women in their case-load who had been identified as having depression. Women who had scored 12 or above on the EPDS 6 weeks after giving birth were assessed for depression during a home visit about 3 months after the birth by a research psychiatrist using the CIS (Goldberg et al, 1970), with the diagnosis of depression derived from the RDC (Spitzer et al, 1978). Women with depression were randomly allocated to the treatment group or to a control group that received routine primary care.
Health visitors were only informed of women in the treatment group, who received the weekly visits in their own home, when they were encouraged to talk about their feelings; questions about baby care were to be discussed separately.
Preface to the Second Edition
- John Cox, Jeni Holden, Carol Henshaw
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Summary
The Edinburgh Postnatal Depression Scale (EPDS) has continued to be used throughout the world by clinicians and researchers since the first edition of this book was published in 2003. Its ten items and simple scoring method have remained unchanged for almost three decades and when used as we intended the EPDS has outlasted most of its initial criticisms.
The suggestion of a second edition of our book has therefore been warmly welcomed; it has given us the opportunity to welcome Carol Henshaw as a third author. Carol was a former academic colleague at Keele University and presently works as a consultant perinatal psychiatrist in Liverpool. As a Past President of the Marcé Society she is also well placed to ensure the book's relevance to the postmodern world in which we live, and to help us make sure that the different clinical contexts in which the EPDS is used are fully recognised.
By 2030, depression is predicted to be the leading cause of disability, with only HIV/AIDS and perinatal disorders higher for low- and middleincome countries (Mathers & Looncar, 2006). In the UK there have been striking changes in the delivery of perinatal services, with an emphasis on quality standards and agreed care pathways. It is a key advance that the National Health Service (NHS) in England has included perinatal services within the remit of a separate Specialised Services Commissioning Board which was established in April 2013. In low-income countries, perinatal mental health and the impact of perinatal mental disorder on the developing infant and on educational attainment is now a more widely acknowledged public health priority.
We have updated all the chapters and their references, included a list of the 57 languages and the EPDS translations known to us, modernised the screening sections and re-emphasised the continuity of depression before and after birth in at least a third of mothers, but have left largely unaltered the balance of the book and the preface to the first edition which drew attention to humanistic values and to the need to ensure the questionnaire's cultural validity.
The book's original title has been modified to Perinatal Mental Health: The Edinburgh Postnatal Depression Scale (EPDS) Manual to complement our original publication in the British Journal of Psychiatry (Cox et al, 1987), which is so widely quoted.
Appendix 2 - Translations of the Edinburgh Postnatal Depression Scale
- John Cox, Jeni Holden, Carol Henshaw
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Summary
The English-language Edinburgh Postnatal Depression Scale (EPDS) has been widely translated and this appendix reproduces some of these translations. Key references, including validation studies where applicable, are given for each translation. A full list of all the translations we are aware of is given in Chapter 3. The authors and publishers cannot vouch for the validity of any translations that have not undergone a positive validation, and would be grateful for any additional information on validation studies using these translations. Please contact the publishers if you wish to translate the EPDS into any language not listed below.
Afaan Oromo (source unknown)
Amharic (Hanlon et al, 2008)
Arabic (United Arab Emirates: Ghubash et al, 1997; Morocco: Agoub et al, 2005)
Bangla (Gausia et al, 2007)
Chichewa (Stewart et al, 2013)
Chinese (Hong Kong: Lee et al, 1998; Taiwan: Heh, 2001; Teng et al, 2005; mainland China: Wang et al, 2009; Lau et al, 2010)
Czech (Dragonas et al, 1996)
Dari (Shafiei et al, 2011)
Dutch (Pop et al, 1992)
Estonian (source unknown)
Farsi/Persian (Montazeri et al, 2007; Kheirabadi et al, 2012)
Filipino/Tagalog (Small et al, 2003)
Finnish (source unknown)
French (Guedeney & Fermanian, 1998; Quebec, Canada: Des Rivières- Pigeon et al, 2000)
German (Austria: Herz et al, 1997; Bergant et al, 1998; Muzik et al, 2000)
Greek (Thorpe et al, 1992; Leonardou et al, 2009; Vivilaki et al, 2009)
Hebrew (Katzenelson et al, 2000)
Hindi (Banerjee et al, 2000)
Hungarian (Töreki et al, 2013)
Icelandic (Thome, 1992, 1996, 1999)
Igbo (Uwakwe & Okonkwo, 2003)
Indonesian (source unknown)
Italian (Carpiniello et al, 1997; Benvenuti et al, 1999)
Japanese (Okano et al, 1996, 1998, 2005; Yoshida et al, 2001)
Kannada (Fernandes et al, 2011)
Khmer/Cambodia (Fitzgerald et al, 1998)
Konkani (Patel et al, 2003)
Korean (Kim & Buist, 2005)
Kurdish (Ahmed et al, 2012)
Lithuanian (Bunevicius et al, 2009)
Macedonian (source unknown)
Malay (Rushidi et al, 2002; Mahmud et al, 2003; Kadir et al, 2004)
Maltese (Felice et al, 2006)
Myanmar/Burmese (source unknown)
Nepali (Regmi et al, 2002)
Norwegian (Eberhard-Gran et al, 2001; Berle et al, 2003)
Polish (Bielawska-Batorowicz, 1995)
Portuguese (Portugal: Areias et al, 1996a; Brazil: Da-Silva et al, 1998; Santos et al, 2007b)
Appendix 1 - The Edinburgh Postnatal Depression Scale
- John Cox, Jeni Holden, Carol Henshaw
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Summary
How are you feeling?
As you have recently had a baby, we would like to know how you are feeling now. Please underline the answer which comes closest to how you have felt in the past 7 days, not just how you feel today. Here is an example, already completed:
I have felt happy:
Yes, most of the time
Yes, some of the time
No, not very often
No, not at all
This would mean: ‘I have felt happy some of the time during the past week’. Please complete the other questions in the same way.
In the past 7 days
1. I have been able to laugh and see the funny side of things:
As much as I always could
Not quite so much now
Definitely not so much now
Not at all
2. I have looked forward with enjoyment to things:
As much as I ever did
Rather less than I used to
Definitely less than I used to
Hardly at all
3. I have blamed myself unnecessarily when things went wrong:
Yes, most of the time
Yes, some of the time
Not very often
No, never
4. I have been anxious or worried for no good reason:
No, not at all
Hardly ever
Yes, sometimes
Yes, very often
5. I have felt scared or panicky for no very good reason: Yes, quite a lot
Yes, sometimes
No, not much
No, not at all
6. Things have been getting on top of me:
Yes, most of the time I haven't been able to cope at all
Yes, sometimes I haven't been coping as well as usual
No, most of the time I have coped quite well
No, I have been coping as well as ever
7. I have been so unhappy that I have had difficulty sleeping:
Yes, most of the time
Yes, sometimes
Not very often
No, not at all 8. I have felt sad or miserable:
Yes, most of the time
Yes, quite often
Not very often
No, not at all
9. I have been so unhappy that I have been crying:
Yes, most of the time
Yes, quite often
Only occasionally
No, never
1 - Postnatal Depression: An Overview
- John Cox, Jeni Holden, Carol Henshaw
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Summary
‘My husband wants another baby. The idea is quite nice, but it really frightens me to think that after having the baby I would be like this again. I wouldn't mind the morning sickness or the actual birth. It is the postnatal depression that really frightens me. I don't think I could face that again. It was horrific.’ (Holden, 1988)
Introduction
Postnatal depression affects not only the quality of a woman's own life and her experience of mothering but also her infant, her other children, her partner and everyone around her, including those involved in her care. On an individual level, the experience can be devastating. Pitt (1968) noted that many of the women in his early study felt quite changed from their normal self, and most ‘had never been depressed like this before’. Without help or treatment, the consequences may be long term and expensive for the women, for their families and in the demands made on healthcare resources. In severe depression, especially with psychotic symptoms, there is a risk of suicide and infanticide. The Confidential Enquiries into Maternal Deaths in the United Kingdom (Oates, 2001), which covered the triennium 1996–1999, first reported psychiatric causes as the leading cause of maternal deaths in the UK and this has remained the case in subsequent reports.
The term ‘postnatal depression’ is commonly used to describe a sustained depressive disorder in women following childbirth, characterised by:
a low, sad mood
lack of interest
anxiety
sleep difficulties
reduced self-esteem
somatic symptoms such as poor appetite and weight loss
difficulty coping with day-to-day tasks.
The term was used by Vivienne Welburn (1980) as the title of her book and by Ann Oakley (1980) to describe a sustained depressive disorder occurring in women in the first year after childbirth. It was also used in the Edinburgh study (Cox et al, 1982) to describe women experiencing depression within 3 months of childbirth. Cox et al offered the conservative estimate of 13% for the prevalence of depression at that time and report that half of these women were not identified by the local primary care service. In the USA, the term ‘postpartum depression’ is more commonly used to describe mothers with a non-psychotic mood disorder.
3 - International and Cross-Cultural Issues
- John Cox, Jeni Holden, Carol Henshaw
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Summary
When establishing a perinatal mental health service it is always necessary to consider the local sociocultural context of childbirth and for health professionals to be culturally competent. In this way the likelihood that the EPDS is used inappropriately in different cultures and languages is diminished.
Translations
The EPDS has been translated into 57 languages and used in clinical work and research in all regions of the world. Appendix 2 contains many of these translations. This proliferation suggests that the identification of perinatal mothers with mental health problems has become a more significant public health priority.
The EPDS facilitates international and cross-cultural research as a firststage screening questionnaire in prevalence studies and assists primary care workers to monitor the effectiveness of screening programmes and record outcomes in intervention trials. There are, however, important caveats to consider when using any translation of a questionnaire outside the culture and language in which it was developed. The EPDS, for example, is not a checklist of common depressive symptoms, and cross-cultural comparisons of EPDS scores can be misleading.
When planning to use the EPDS in a cross-cultural study therefore, it is helpful to consider both the ‘etic’ (when the culture is studied from an outside perspective) and the humanistic ‘emic’ approach, derived from an inside perspective of the local language and cultural attitudes. As suggested by Laungani (2000), different assumptions and techniques are often required to understand fully depressive disorders in unfamiliar cultures and this is of particular importance for perinatal mental disorders which are embedded in cultural customs, values and beliefs. Kumar (1994) has summarised this key point:
‘The way in which the impact (of childbirth) is felt by the individual parent must, to some extent, be shaped by the ways in which that parent's society and culture organises its response to parenthood, as well as by the structure of the family into which the child is born.’ (p. 250)
Thus in studies of postnatal depression in Uganda and Scotland (Cox, 1999) the need to understand local ‘folk’ causes of depression as well as the range of available traditional treatments and the explanation for the choice of presenting symptoms was immediately apparent to the research team.
Perinatal Mental Health
- The EPDS Manual
- 2nd edition
- John Cox, Jeni Holden, Carol Henshaw
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- 05 February 2021
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- 01 February 2014
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The Edinburgh Postnatal Depression Scale (EPDS) is a questionnaire and was designed as a simple means of screening for postnatal depression in health care settings. The scale is now in use around the world and this book is a practical guide to using the scale in clinical practice, its origins and development background. This second edition has been revised and contains much advice based on years of experience. All chapters and references have been updated and the chapters on screening and counselling have been considerably revised, the evidence base on interventions for perinatal depression is provided, plus details of innovative methods such as internet-based therapy. The scale can also be used by researchers seeking information on factors which influence the emotional well-being of new mothers and their families and guidance is also given on use of the scale in research settings. The book will be useful for psychologists, psychiatrists, health visitors, midwives, family doctors, obstetricians and community psychiatric nurses, plus researchers in perinatal health.
Index
- John Cox, Jeni Holden, Carol Henshaw
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Abbreviations
- John Cox, Jeni Holden, Carol Henshaw
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References
- John Cox, Jeni Holden, Carol Henshaw
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7 - Using the Edinburgh Postnatal Depression Scale
- John Cox, Jeni Holden, Carol Henshaw
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Summary
This chapter summarises practical information for administering the EPDS based on research experience and on feedback from health professionals.
How to use the EPDS
1 Ask the woman to underline the response that comes closest to how she has felt during the previous 7 days.
2 Ensure that all ten items are completed.
3 The woman should complete the EPDS herself, unless she has difficulty with reading, and she should not discuss her answers with anyone other than the health professional when completing the scale.
4 The EPDS can be used routinely to screen for postnatal depression or to provide further information before referral of a woman who seems to have depression.
5 EPDS items are scored from 0 to 3; the normal response scores 0 and the ‘severe’ response scores 3. Total the individual item scores (see the EPDS scoring sheet in Appendix 1). Take care when scoring items and adding up the total as a recent study found between 13.4 and 28.9% of completed scales had errors (Matthey et al, 2013b).
6 A total score of 12 or above was taken in the three-centre study (Gerrard et al, 1994) as an indicator that the woman should be further assessed. Some authorities prefer a lower cut-off to ensure that depression is not missed (see Chapter 2).
7 Scores alone should not replace clinical judgement: women should be further assessed before deciding on treatment.
Using the EPDS in clinical practice
Routine use of the EPDS has a number of advantages.
1 It raises awareness of the possibility of postnatal depression among health professionals, women themselves and their families.
2 It may provide additional information when referring a woman to the GP or to the perinatal mental health team.
3 It can provide the opportunity for early preventive intervention.
4 It gives women ‘permission to speak’ and health professionals ‘permission to listen’.
5 It can help a woman to recognise and discuss her negative feelings.
6 It may change women's perception of what health professionals can offer.
7 It can provide a structured approach to identification of low mood or depression, clarifying the situation for both the woman and the professional.
8 It can be used to monitor progress in treatment, and Matthey (2004) has calculated that a four-point reduction in the EPDS score is a clinically significant change.
Forntmatter
- John Cox, Jeni Holden, Carol Henshaw
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List of Figures
- John Cox, Jeni Holden, Carol Henshaw
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Acknowledgments
- John Cox, Jeni Holden, Carol Henshaw
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Contents
- John Cox, Jeni Holden, Carol Henshaw
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The authors
- John Cox, Jeni Holden, Carol Henshaw
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4 - Using the Edinburgh Postnatal Depression Scale in Clinical: Settings: Research Evidence
- John Cox, Jeni Holden, Carol Henshaw
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Summary
Does using the EPDS increase detection of perinatal depression?
Health visitors in our original counselling intervention (where health visitor–patient ratios allowed close contact with mothers whose infants were under 6 weeks) were asked to indicate whether they believed that women in their case-load were experiencing depression at their 6-week visit. The women later completed the EPDS. Despite knowing the women well, the health visitors failed to identify 60% of the women who obtained high EPDS scores at 6 weeks and were subsequently found to have depression at a psychiatric interview at about 3 months postpartum. Other UK researchers (e.g. Hearn et al, 1998), who set out specifically to determine the efficiency of the primary care team in identifying postnatal depression in women, found that using the EPDS gave an almost threefold increase in the numbers of women identified with depression.
Overseas studies have also shown that EPDS screening can increase detection rates. In Sweden, where child healthcare nurses pay regular home visits and where staff/patient ratios are considerably higher than in the UK, Wickberg & Hwang (1996b) found that health professionals identified less than half the women found to have depression, and that only a third of the mothers that were identified had spontaneously indicated their feelings. Also working in Sweden, Bågedahl-Strindlund & Monsen Borjesson (1998) found that very few women with postnatal depression were identified in routine care. In both Swedish studies, the EPDS was well accepted by both mothers and nurses, and its use significantly increased the number of identified cases.
Three studies in North America examined the ability of health professionals to detect depression with or without the EPDS. Schaper et al (1994) interviewed physicians and midwives taking part in a community study in Wisconsin to determine whether using the EPDS would increase practitioner awareness and treatment of postnatal depression. Of the professionals interviewed, 83% reported that the EPDS had increased their awareness of the condition and 92% had referred patients with high EPDS scores for treatment. At the Mayo Clinic in Minnesota, Georgiopoulos and colleagues (2001) implemented universal screening with the EPDS in all community postnatal care sites over a 1-year period.
6 - Screening and Intervention Services in the Community
- John Cox, Jeni Holden, Carol Henshaw
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Summary
The consequences of maternal depression are costly not only on a personal level, but also in terms of health service resources, including money as well as personnel. It is important therefore that services should be relevant, targeted and research-based. The fact that women's contact with health professionals is at a peak around the time of childbirth provides an ideal opportunity for intervention and for ensuring that these contacts are used with maximum efficiency to meet the needs of individual women.
In this chapter we discuss the argument for introducing the EPDS in healthcare settings. Information was derived from research and from training groups of health professionals from different disciplines (including psychologists, psychiatrists family doctors, community psychiatric nurses, midwives and health visitors) for the introduction of postnatal depression initiatives. Discussions during training and post-training feedback added to our knowledge of the practical issues of administering the EPDS.
Following our original EPDS and counselling intervention research (Cox et al, 1987; Holden et al, 1989), training was requested by health authorities in England, Scotland, Northern Ireland and Ireland and many primary care trusts introduced routine EPDS screening and intervention programmes. In 2002, the SIGN Development Group carried out a survey of EPDS practice (Scottish Intercollegiate Guidelines Network, 2002). SIGN found that EPDS screening was undertaken routinely in all but one primary care trust area in Scotland. They recommended the use of the EPDS as a screening tool, but the document also pointed out that:
‘the routine use of the EPDS carries significant implications associated with training, health visitor time for screening and intervention, and facilities in general practice and secondary care for treatment.’ (p. 17)
The routine screening debate
It has been suggested that administering the EPDS with all postnatal women is both unnecessary and intrusive (Shakespeare, 2002), and that experienced health professionals who are in frequent contact with their patients should be able to detect depression without such an aid (Barker, 1998). In 2009, Paulden and colleagues evaluated several screening measures for postnatal depression (including the EPDS) to determine their value within the NHS.