Brief report. *, T.F. Aarre, A. Mykletun, A.A. Dahl, F. Holsten. 1. Introduction

Transcription

1 Journl of Affective Disorders 76 (003) locte/ jd Brief report Screening for postntl depression Vlidtion of the Norwegin version of the Edinburgh Postntl Depression Scle, nd ssessment of risk fctors for postntl depression J.Ø. Berle *, T.F. Arre, A. Mykletun, A.A. Dhl, F. Holsten, b c d e Regionl Competence Centre for Child nd Adolescent Psychitry, Deprtment of Psychology, University of Bergen, N-500 Bergen, Norwy b Nordfjord Psychitric Centre, Nordfjordeid, Norwy c Deprtment of Psychology, University of Bergen, Bergen, Norwy d Deprtment of Psychitry, Aker Hospitl, University of Oslo, Oslo, Norwy e Deprtment of Psychitry, University of Bergen, Bergen, Norwy Received 8 My 001; received in revised form Februry 00; ccepted 4 Mrch 00 Abstrct Objective: The Edinburgh Postntl Depression Scle (EPDS) is self-rting scle developed to screen for postntl depression. The im of this study ws to vlidte Norwegin trnsltion of the EPDS, study its psychometric properties, nd identify risk fctors for postntl depression. Method: EPDS ws filled in by 411 women t 6 1 weeks postprtum. Of these, 100 were interviewed using the Mini Interntionl Neuropsychitric Interview for DSM-IV mjor nd minor depressive disorders. Results: When using cut-off of 11 on the EPDS, 6 of 7 women with mjor depression were identified (sensitivity 96%, specificity 78%). An ggregte point prevlence of 10.0% of mjor nd minor depression ws found. A one-fctor model ccounted for 46.6% of the vrince. Strongest risk fctors for postprtum depression were previous depression, depression in current pregnncy, nd current somtic illness. Limittions: Women screened using the EPDS who hd score bove threshold, yet did not ttend the dignostic interview could cuse the point prevlence of depression to be higher thn indicted here. Conclusion: The Norwegin trnsltion of EPDS functions eqully well s other trnsltions s screening tool for postntl depression. The risk fctors tht were found re comptible with other studies. 003 Elsevier B.V. All rights reserved. Keywords: Depression; Postprtum; Primry helth cre; Mentl disorders; Risk fctors; Psychometric 1. Introduction *Corresponding uthor. Tel.: ; fx: E-mil ddress: jn.berle@psyk.uib.no (J.Ø. Berle). In the postprtum period, women show n incresed vulnerbility for mjor depressive episodes / 03/ $ see front mtter 003 Elsevier B.V. All rights reserved. doi: /s (0)0008-4

2 15 J.Ø. Berle et l. / Journl of Affective Disorders 76 (003) (Cox et l., 1987; O Hr nd Swin, 1996). Un- Hospitl Anxiety nd Depression Rting Scle treted postprtum depression cn hve detrimentl (HADS) (Zigmond nd Snith, 1983). effect on mother child interction nd negtive influence on child development (Murry nd Cooper,.3. Procedure 1997). The Edinburgh Postntl Depression Scle (EPDS) is questionnire with 10 items tht re All women with n EPDS sum score of 8 or specificlly designed for detecting depression in the higher, nd every tenth womn who scored below postprtum period (Cox et l., 1987). It hs been this threshold ws included (n 5 100). Ptient hisused extensively in vrious lnguges. The use of the tories were recorded nd dignoses estblished by EPDS s screening tool is prticulrly importnt psychitrist (blind to their pst EPDS-scores) using mong women who re t risk for postprtum the Mini Interntionl Neuropsychitric Interview depression (Nielsen et l., 000). (MINI V4.4) (Lecrubier et l., 1997) nd the Mont- Since its introduction, the EPDS hs been used gomery Asberg Depression Rting Scle (MADRS) extensively in both clinicl settings nd in epi- (Montgomery nd Asberg, 1979). The womn s demiologicl studies. The EPDS hs shown good subjective experience of the delivery in regrds to psychometric properties in the postprtum popul- trumtic severity ws recorded on scle from 1 to tion, is well ccepted by women, nd hs lso, in 4 by the psychitrist. recent yers, been used for pregnnt nd non-puer- The interviews were videotped nd two other perl women (Cox et l., 1996). psychitrists rted 30 of the sessions in order to The EPDS ws designed s one-dimensionl evlute relibility of dignoses nd MADRS scores. instrument for depression, yet the suggestion of two-fctor model exists (Pop et l., 199; Guedeney.4. Sttisticl methods nd Fermnin, 1998). In the first EPDS studies, cut off score of 10 ws Internl consistency ws performed using Cronrecommended for community surveys nd screening bch s. Relibility of dignoses ws evluted (Cox et l., 1987), while cut-off score of 13 ws using k, nd stbility in EPDS ws evluted using seen s more pproprite for clinicl setting. Spermn s r. The im of the present study ws to vlidte Clcultion of sensitivity, specificity, positive predictive vlue nd Receiver Opertion Chrcteris- tics (ROC) ws done bsed on the EPDS sum score ginst the DSM-IV dignoses (Americn Psychitric Assocition, 1994). A Principl Component Anlysis (PCA) with Norwegin trnsltion of the EPDS nd to ssess risk fctors for postntl depression.. Mteril nd methods oblique rottion ws performed in order to investigte the fctor structure of EPDS..1. Trnsltion In identifying risk fctors for postntl depression, independent smples t-test, Levene s test, Fisher s A trnsltion of the EPDS into Norwegin ws exct test nd Person s x -test were used. All tests followed by bck-trnsltion into English. This were two-tiled, nd the level of significnce ws set procedure ws done twice. t P, Smpling Women ttending routine post-ntl visits, 6 1 weeks post prtum, were screened using the EPDS. A mjority of them lso filled in the Beck Depression Inventory (BDI) (Beck et l., 1961) nd the.5. Ethics The Committee for Medicl Ethics of Helth Region III of Norwy pproved this study. All prticipnts in the study gve written informed consent. Women in need of psychitric tretment were referred to tretment.

3 J.Ø. Berle et l. / Journl of Affective Disorders 76 (003) Results According to DSM-IV, 7 women (6.6%) filled the criteri for mjor depressive disorder, nd 14 Items 1 9 correlted between 0.55 nd 0.7 with women (3.4%) for minor depressive disorder. None the EPDS totl score. Item 10 (suicidl idetion) of the controls filled the dignostic criteri for correlted lowest (0.30). The internl consistency of depression when interviewed. Using n EPDS sum EPDS ssessed by Cronbch s ws score of 11 s cut-off, mjor depression ws Interrter relibility hd k of 0.8, 0.84 nd 0.78 detected with sensitivity of 0.96 (screening nd between rter pirs. Dignosis ws concurred upon interview), nd specificity of 0.75 nd 0.78, respecfor 5 of the 30 women who hd hd their vid- tively. The positive predictive vlue for mjor deeotped interview rted. Disgreement on five cses pression ws 0.59 (screening) nd 0.6 (interview) t ws between mjor nd minor depression. this level. For mjor nd minor depression combined, Tble 1 Detection of depression using EPDS t screening nd interview (n 5 100) EPDS Mjor depression Minor nd mjor depression score Sens. Spec. PPV Sens. Spec. PPV Screening Interview ] ] ] ] ] ] Sens, sensitivity; Spec, specificity; PPV, positive predictive vlue. Tble EPDS Correltion with dignosis nd different psychometric instruments HADS HADS HADS BDI EPDS nxiety depression sum-score sum-score sum-score EPDS Sum-score (n 5 54) (n 5 54) (n 5 54) (n 5 3) MADRS Sum-score (n 5 63) (n 5 63) (n 5 63) (n 5 60) (n 5 100) Dignosis (n 5 63) (n 5 63) (n 5 63) (n 5 60) (n 5 100) Numbers re Spermn s r. All correltions re significnt for P, Dignosis is coded ccording to DSM-IV with vlues 0 no depression, 1 minor depression nd mjor depression.

4 154 J.Ø. Berle et l. / Journl of Affective Disorders 76 (003) the sensitivity ws 0.83 (screening) nd 0.88 (inter- prevlence of depression (Tble 4). Other fctors view), with specificity of 0.83 nd 0.90, respectively tht did not significntly ffect the prevlence of (Tble 1). Sensitivity flls considerbly (from 0.96 postprtum depression include: Cesrin birth, conto 0.78) when 1 is chosen s the cut-off level. Are flict with significnt other, nd nursing/not nursing. under the curve (AUC) ws 0.90 for both mjor depression nd for mjor nd minor depression combined t screening. At interview, AUC ws Discussion for mjor depression nd 0.93 for mjor nd minor depression combined. A point prevlence of 10% for postprtum mjor EPDS correlted higher with the dignosis nd nd minor depression using the Norwegin trnsl- MADRS sum-score thn with both HADS nd BDI tion of the EPDS ws found. This prevlence is in (Tble ). ccordnce with other studies. The PCA with oblique rottion extrcted only one In reserch, cut-off score of 1 to detect women fctor, s ws the intention of the originl instru- with mjor depression nd cut-off of 11 to detect ment. This fctor ccounted for 46.6% of the scle both mjor nd minor depression is recommended vrince (Tble 3). ccording to ROC (Fig. 1). In clinicl setting, cut-off of 8 should detect both women t risk for developing depression nd identify those who hve 3.1. Risk fctors for post prtum depression minor depression. In order for self-report instrument to be relible, Cronbch s of t lest 0.60 is Severl possible risk fctors were compred be- recommended (Nunnlly nd Bernstein, 1994). The tween depressed (mjor nd minor depression com- Norwegin trnsltion of the EPDS chieves this. bined) nd non-depressed women. Women with more The gol when developing the EPDS ws to crete thn one child showed significntly higher risk for n instrument tht identifies the fctor depression depression in the postprtum period. This ws not nd omits non-depression fctors such s irritbility function of ge. Importnt risk fctors for postprtum (Cox et l., 1987). Although two studies indicte depression were previous depression, depression in two-fctor model (Pop et l., 199; Guedeney nd current pregnncy, nd positive fmily history of Fermnin, 1998), our findings support the intention ffective disorder. A current somtic illness lso of the EPDS, one fctor mesuring depression. The ppers to be strong risk fctor for postprtum Dutch study, using LISREL to conduct fctor depression. Single mothers did not hve higher nlysis, reported two fctors explining 38.5 nd 16.8% of the vrince, respectively (Pop et l., 199). The French trnsltion, using PCA s the method of extrction, reported two fctors explining Tble 3 Fctor nlysis of the Norwegin EPDS (n 5 411) 40.6 nd 1.7% of the vrince, respectively (Guedeney nd Fermnin, 1998). The single fctor Item Extrction Component 1 described in our study, using PCA extrction, ex plins 46.6% of the vrince. This fctor is some wht stronger thn the first fctor described in the other studies. The second fctor found in these two studies ccounts for only smll portion of the scle vrince. The uthors of the Dutch trnsltion found no prcticl use for subscles nd suggest the use of one-dimensionl scle in prcticl clinicl work (Pop et l., 199). The sensitivity, specificity nd positive predictive Rotted component mtrix. vlue of the EPDS for detecting mjor depression Extrction method: Principl Component Anlysis One component with eigenvlue. 1 extrcted. with cut-off score of 1 is in the rnge of similr Component 1 explined 46.6% of vrince in the PCA. studies.

5 J.Ø. Berle et l. / Journl of Affective Disorders 76 (003) Tble 4 Assessment of risk fctors for post prtum depression Mjor/ minor No Odds Sttistics Level of depression depression rtio significnce (n 5 41) (n 5 59) Age men Indep. smples t-test n.s. Age S.D Levene s test n.s. No prtner 1 (%) 5 (9%) 0.7 Fisher s exct test n.s. Serious conflict 7 (17%) 4 (7%).83 Fisher s exct test n.s. with prtner Multipr 9 (70%) 9 (49%).5 Person s x P, 0.05 Fmily history of 6 (63%) 4 (41%).46 Person s x P, 0.05 ffective disorder Previous depression 9 (71%) 0 (34%) 4.71 Person s x P, Depression in 16 (39%) 5 (8%) 6.91 Person s x P, current pregnncy Reported somtic 7 (17%) 7 (1%) 1.53 Person s x n.s. illness ever Reported somtic 9 (%) 10 (17%) 1.38 Person s x n.s. illness in current pregnncy Present significnt 9 (%) (3%) 8.0 Fisher s exct test P, 0.01 somtic illness Nursing infnt 35 (85%) 55 (93%) 0.4 Fisher s exct test n.s. Cesren section 5 (1%) 7 (1%) 1.03 Fisher s exct test n.s. Subjective experience of 15 (37%) 0 (34%) 1.13 Person s x n.s. delivery s trum Vlid n Fig. 1. Receiver operting chrcteristic curve t interview (n 5 100).

6 156 J.Ø. Berle et l. / Journl of Affective Disorders 76 (003) The ROC method is the preferred method to References determine optiml cut-off vlues for test (Hnley nd McNeil, 198). The ROC curve of test Americn Psychitric Assocition, In: Dignostic nd displys the reltionship between sensitivity (true- Sttisticl Mnul of Mentl Disorders, 4th Edition. Americn positive rte) nd one-specificity (flse-negtive rte) Psychitric Assocition, Wshington, DC. Beck, A.T., Wrd, C.H., Mendelson, M., Mock, J.E., Erbygh, in smple. The ROC results indictes tht EPDS J.K., An inventory for mesuring depression. Arch. Gen. hve very good psychometric properties in dis- Psychitry 4, criminting between cses nd non-cses. Cox, J.L., Chpmn, G., Murry, D., Jones, P., Vlidtion of Our study confirms link between physicl helth the Edinburgh Postntl Depression scle (EPDS) in nonnd emotionl well-being in mothers in the post postntl women. J. Affect. Disord. 39, Cox, J.L., Holden, J.M., Sgovsky, R., Detection of prtum period. The risk fctors found coincide with postntl depression. Br. J. Psychitry 150, other studies (O Hr nd Swin, 1996). Guedeney, N., Fermnin, J., Vlidtion study of the French In conclusion, the point prevlence of postprtum version of the Edinburgh Postntl Depression Scle (EPDS): depression s mesured with the trnslted EPDS in new results bout use nd psychometric properties. Eur. Norwegin popultion ws comprble to other Psychitry 13, studies. The EPDS ws designed s one-dimenunder receiver operting chrcteristic (ROC) curve. Rdiolo- Hnley, J.A., McNeil, B.J., 198. The mening nd use of the re sionl instrument; which mesures symptoms of gy 143, depression. A cut-off of 1 ws recommended for Lecrubier, Y., Sheehn, D., Weiller, E., Amorim, P., Bonor, I., detecting mjor depression. A one-dimensionl fc- Sheehn, K.H., Jnvs, J., Dunbr, G.C., The Mini tor model ws found to be the most pproprite for Interntionl Neuropsychitric Interview (M.I.N.I.) short the Norwegin popultion. The EPDS should be used dignostic structured interview: relibility nd vlidity ccord- ing to the CIDI. Eur. Psychitry 1, s prt of routine postntl visit in Norwy. Women Montgomery, S.A., Asberg, M., A new depression scle who re more susceptible to depression such s those designed to be sensitive to chnge. Br. J. Psychitry 134, with previous depression, depression in current preg nncy, current somtic illness, fmily history of Murry, L., Cooper, P.J., The role of infnt nd mternl ffective disorder, nd multipr re good cndidtes fctors in postprtum depression, mother infnt interctions, for the EPDS screening tool. nd infnt outcome. In: Murry, L., Cooper, P.J. (Eds.), Postprtum Depression nd Child Development. The Guilford Press, New York, pp Nielsen, F.D., Videbech, P., Hedegrd, M., Dlby, S.J., Secher, N.J., 000. Postprtum depression: identifiction of women t Acknowledgements risk. Br J Obstet Gynecol 107, Nunnlly, J., Bernstein, I., In: Psychometric Theory, 3rd Edition. McGrw-Hill, New York. This reserch ws supported by grnt from the O Hr, M.W., Swin, A.M., Rtes nd risk of postprtum Gerd Nyquist Trust in Bergen. We wish to thnk the depression met nlysis. Rev. Psychitry 8, stff t the children s helth clinics in Bergen nd t Pop, V.J., Komproe, I.H., Vn Son, M.J., 199. Chrcteristics of the gynecologist s specilist prctice of Nylnd nd the Edinburgh Post Ntl Depression Scle in The Netherlnds. Johnnessen in Bergen for their ssistnce in this J. Affect. Disord. 6, study. Zigmond, A.S., Snith, R.P., The Hospitl Anxiety nd Depression Rting Scle. Act Psychitr. Scnd. 67,