If we are to prevent "something," our 1st step is to recognize who might be involved in this  "something".............therefore to prevent postpartum depression we must first recognize or identify those women "at risk"
	There are numerous screening instruments/tools available for healthcare professionals  Each tool is designed to identify women who are at risk for developing postpartum depression
	Healthcare professional should select an  instrument/tool that: Is simple, easy for the participant to complete Is reliable and replicable Is appropriate for and reflective of the population being evaluated

The earliest tool was developed by Braverman & Roux in 1978 The authors used their clinical intuition and psychopathology knowledge of the day to develop the tool Initially the tool was a 19-item, yes/no,  self-administered questionnaire Revised by authors after identifying 6 questions with the best predictive value This shortened version of the questionnaire has a: Specificity of 85% Sensitivity of 94%

 

In 1984 Pietrick introduced a 2nd tool  Again it was based on the literature of the day The author identified 16 risk factors: Anxiety regarding pregnancy Support from other pregnant women or women with infants Emotional support of partner/family Was this an unplanned pregnancy Readiness to assume role of parent Depression history Recent major life changes Difficulty making changes Fear of illness Concerns with body image/changes with pregnancy Relationship with own mother Planned to breastfeed Family history of psychiatric illnesses Sadness and/or changing emotions at 3 points in time--premenstrual, while taking birth control pills, with previous pregnancies Again it was a simple, yes/no, self-administered  questionnaire The author suggests that women who answer yes to most of the questions potentially are at high risk for postpartum depression There is no published data on how predictive the tool is

 

Six (6) years later in 1990,  Boyer, Van Der Leden and Bacom published their tool Also using the literature of the day, the authors identified 16 risk factors--combining previously identified risk factors with new ones:  Changing emotions around menstrual periods Prenatal anxiety Prenatal depression Unhappy childhood Support from family Support from friends Feeling unloved by partner Regret(s) about current pregnancy Previous postpartum depression History of mental illness Past emotional problems Lack of control over own life Nervous or worried a great deal Angry about own life situation Self-fault when bad things happen Financial, housing and/or other personal problems Again it was a simple, yes/no, self-administered  questionnaire The authors considered women: "At risk" if they identified 3-6 risk factors  At "high risk" if they identified > 6 risk factors  There is no published data on how predictive the tool is

 

The Antenatal Screening Questionnaire (ASQ) was published by Appleby, Gregoire, Platz, Prince & Kumar in 1994 Based on the research of one of the authors it is a 10-item tool assessing risk factors in the areas of: Psychiatric history Prenatal worries Unwanted pregnancy Life stress Social support It was a self-administered  questionnaire For 8 of the questions a Likert-type scale, ranging from 0-3, was used For the remaining 2 items, the choice was yes/no scoring either zero (0) or 1 Initially the tool predicted 44% of the women who would eventually experience postpartum depression There are no data available re: cutoff score for the number of risk factors nor score for the scale

 

Stamp, Williams & Crowther modified Appleby et al publishing the Modified Antenatal Screening Questionnaire (MASQ) in 1996 It assesses the woman's: Current relationship with partner Problem-solving style Availability of family/friend support systems Previous psychiatric history It is a self-administered 9-item Likert-type scale  Scores for each item ranged from 0-2 An overall score of > 2 was used as predictive of postpartum depression The authors also included the 25-item Crown Crisp Experiential Index (Crown & Crisp, 1979) which evaluated anxiety Receipt of a score of 10 on the Crown Crisp Experiential Index was weighted as a score of 2 on the MASQ  This alone was accepted as predictive of postpartum depression As a predictor of major depression the MASQ had a: Specificity of 43% Sensitivity of 73% As a predictor of minor depression the MASQ had a: Specificity of 48% Sensitivity of 81% The authors concluded their tool was reliable in only predicting minor depression

 

In 1997 Posner, Unterman, Williams and Williams published the Antepartum Questionnaire (APQ) which they had developed in 2 phases/studies

1st phase/study Women in their 2nd trimester of pregnancy completed a self-administered 61-item questionnaire based on the literature of the day and previous studies conducted by the authors Next the women were interviewed and administered the Beck Depression Inventory: At time of delivery (while still hospitalized) At 4-6 weeks postpartum At 12 weeks postpartum Based on data analysis, 23 of the original 61 items were kept, as well as one item from the demographic information These 24 items became the APQ focusing on the woman's: Education Socioeconomic status Marital status Relationships with her mother, father, and  husband/boyfriend Pregnancy and medical history Social support systems Early family life Self-esteem History of postpartum depression Anxiety during pregnancy Sadness during pregnancy 22 of the 24 items are Likert-type questions with scores ranging from 0-6 Final score is obtained by adding the value for all 24 items

2nd phase/study Women in their 2nd trimester of pregnancy completed the 24-item self-administered questionnaire Again, the women were interviewed and administered the Beck Depression Inventory: At time of delivery (while still hospitalized) At 4-6 weeks postpartum At 12 weeks postpartum The authors performed a retrospective data analysis from the 1st study and prospective data analysis from the 2nd study Using a cut off score of 46, the tool was predictive with a: Specificity of 78% and Sensitivity of 82% with the 1st study Specificity of 82% and Sensitivity of 80% with the 2nd study Highly Predictive items were:   An unstable relationship with her partner  Woman's perception of past or current non- availability of loving, caring parents Significantly Predictive items were: History of emotional instability, including previous postpartum depression Poor self-esteem Insufficient income Satisfaction with educational preparation The authors concluded any woman with a score of > 46 should be referred for psychiatric evaluation prior to delivery and followed closely during the postpartum period

 

Edinburgh Postnatal Depression Scale (EPDS) 10-item Likert-type scale Select from 1 of 4 statements Mom self-reports feelings for the last week Instructed to select answer which closest reflects feeling in the past 7 days Takes 5-10 minutes to complete Some mothers need assistance in understanding answer choices as colloquialisms are European in origin Maximum score is 30 Score of > 10 indicates possible depression of varying severity If results doubtful, may be re-administered after 2 weeks EPDS will not detect Anxiety disorders Phobia Personality disorders Positive predictive value of 93%  with a: Specificity of 99%   (One source indicated 78%) Sensitivity of 78%   (One source indicated 86%)

 

Postpartum Depression Screening Scale (PDSS) Self administered, 35-item Likert-type scale focusing on woman's feelings for the last 2 weeks postpartum Written on third-grade reading level Items are brief and easy to understand Takes 5-10 minutes to complete Answer choices range from "strongly disagree" to "strongly agree" Assesses postpartum depression symptoms in seven (7) areas Sleeping/Eating disturbances Anxiety/Insecurity Emotional lability Mental confusion Loss of self Guilt/Shame Suicidal thoughts Provides an overall severity score in one of three ranges Normal adjustment Significant symptoms of postpartum depression Positive screen for major postpartum depression Positive predictive value of 90%  with a: Specificity of 98% Sensitivity of 94%

Postpartum Depression Predictors Inventory (PDPI) This tool was developed Beck in 1998 Inventory checklist consisting of 8 risk factors:  Prenatal depression Prenatal anxiety History of previous depression Social support Marital satisfaction Life stress Child care stress Maternity blues This is not a self-report questionnaire, rather it requires a healthcare professional to interview the woman May be administered either prenatally or during postpartum period

Originally developed from the findings of two meta-analyses on postpartum depression risk factors Author recommended periodic revision to include Additional risk factors Current research reported in the literature Deletion of risk factors no longer relevant

PDPI-Revised As suggested by the author, the tool was revised to keep it current and relevant  In 2001 Beck identified 13 significant risk factors: Prenatal depression Prenatal anxiety History of previous depression Self-esteem Socioeconomic status Social support Life stress Marital status Marital satisfaction Unwanted/unplanned pregnancy Child care stress Infant temperament Maternity " blues" The 1st 10 risk factors (prenatal depression through unwanted/unplanned pregnancy) can be assessed both prenatally and or during postpartum period The last 3 risk factors (child care stress through maternity "blues") can be assessed during postpartum period Highly Predictive items were: Self-esteem Prenatal depression Child care stress Weakest predictive item was:  Unwanted/unplanned pregnancy As with the original tool, the PDPI-Revised is not a self-report questionnaire, rather it requires a healthcare professional to interview the woman Revised tool does not provide an overall or cutoff score, rather it indicates individual risk factors This allows for specific planned nursing interventions Author recommends those women identified "at risk" prenatally be referred for telephone and home visits, if possible, following delivery Development of a self-administered version of the tool is under way

	Remember, the presence of risk factors only indicates there is an increased probability the woman may develop postpartum depression.....it does not guarantee she will
	If a tool is used to identify women "at risk" for postpartum depression, mechanisms and processes need to be in place to respond................