Research report
What is the best tool for screening antenatal depression?

https://doi.org/10.1016/j.jad.2015.02.003Get rights and content

Abstract

Background

Antenatal depression (AD) can have devastating consequences. No existing scales are specifically designed to measure it. Common practice is to adapt scales originally developed for other circumstances. We designed this study to validate and determine the psychometric values for AD screening in Brazil.

Methods

We collected clinical and socio-demographic data in the second gestational trimester. The following instruments were also administered during that period: MINI-PLUS, EPDS, BDI and HAM-D.

Results

At the time of assessment, 17.34% of the patients were depressed, and 31.98% met the diagnostic criteria for lifetime major depression. All instruments showed an area under the curve in a receiver operating characteristic analysis greater than 0.85, with the BDI achieving a 0.90 and being the best-performing screening instrument. A score ≥11 on the EPDS (81.58% sensitivity, 73.33% specificity), ≥15 on the BDI (82.00% sensitivity, 84.26% specificity) and ≥9 on the HAM-D (87.76% sensitivity, 74.60% specificity) revealed great dichotomy between depressed and non-depressed patients. Spearman׳s rank correlation coefficients (ρ) among the scales had good values (EPDS vs. BDI 0.79; BDI vs. HAM-D 0.70, and EPDS vs. HAM-D 0.67).

Limitations

This study was transversal, assessing only women in the second gestational trimester. Results may be applicable only to the Brazilian population since psychometric properties may vary with the population under study. Major depression can amplify somatic symptomatology, affecting depressive rating scale data.

Conclusion

AD is highly prevalent in Brazil. To address the problem of under-recognition, physicians can use the EPDS, BDI and HAM-D to identify AD.

Introduction

Antenatal depression (AD) has been described as a form of clinical depression that affects women during pregnancy and that may increase the risk of postpartum depression if not properly treated (Milgrom et al., 2008, Norhayati et al., 2015).

Moreover, AD is a highly frequent condition, with prevalence estimated as high as 18% of pregnancies (Gavin et al., 2005). The presence of AD can have multiple deleterious effects, not only on women but also on offspring and the entire family. Depressed pregnant women, for example, are more prone to exhibiting high-risk behaviors. They are more likely to use alcohol, tobacco and illicit drugs; to have unhealthy eating habits; to suffer from sleep disturbances; and to attend fewer prenatal follow-up appointments (Bennett et al., 2004a, Field et al., 2008, Hauge et al., 2012, Marcus, 2009, Orr et al., 2007, Zuckerman et al., 1989). These behaviors interact with the intrinsic biological mechanisms of depression to create an increased risk of obstetric complications, such as pre-eclampsia, pre-term birth, restricted fetal growth and/or low birth weight (Bonari et al., 2004, Davalos et al., 2012, Diego et al., 2009, Field et al., 2008, Grote et al., 2010). In addition, an increasingly large body of clinical and experimental evidence suggests that both biological markers and the physiology of the offspring of depressed females can be influenced by maternal hypothalamic–pituitary–adrenal (HPA) axis dysfunction, including increased levels of cortisol and cathecolamines (Brummelte and Galea, 2010, Frodl and O’Keane, 2013, Wadhwa et al., 2002). These abnormalities may have life-long implications for the developing brain of the fetus, such as negative consequences for neural circuits, neurotransmitter activities and epigenetic changes (Davis et al., 2011, Field et al., 2006, Frodl and O’Keane, 2013, Oberlander et al., 2008, Weinstock, 2005), rendering the offspring more vulnerable to mental health disorders later in life (Halligan et al., 2007, O’Donnel et al., 2014, Pawlby et al., 2009, Pearson et al., 2013, Santos et al., 2014, Talge et al., 2007). Finally, a positive correlation between maternal and paternal depression has been demonstrated, emphasizing that AD is not merely a women׳s issue but is a problem that affects entire families (Escriba-Àguir and Artazcoz, 2011, Paulson and Bazemore, 2010).

All of these factors illustrate that AD diagnosis and treatment should be considered a public health issue, and all pregnant women should be screened for signs of AD. Unfortunately, the rate of AD under-diagnosis can be as high as 80% (Kelly et al., 2001a) and is likely higher in areas with deficient healthcare infrastructures. Therefore, studying instruments that could be used in primary care settings by non-doctors and non-specialists is critical to enable broad screening for AD among pregnant women.

The most frequent scales used in the assessment of AD, the Beck Depression Inventory (BDI) (Beck et al., 1961) and the Edinburgh Postnatal Depression Scale (EPDS) (Cox et al., 1987, Bennett et al., 2004a), were developed for general use with major depression across the life span and during the postpartum period, respectively. Because of the sensitivity of these instruments, however, normal symptoms in pregnancy can sometimes be misconstrued as indicators of depression, and although they may resolve as pregnancy nears completion, such symptoms can lead to higher scores on self-report measures (Matthey and Ross-Hamid, 2012). An additional concern pertains to the psychometric characteristics of these scales with regard to cultural population characteristics and their use in populations in which illiteracy remains a problem. Although scholars have debated the extent to which the psychometric properties of those scales are adequate for use in AD, the EPDS and BDI have been utilized extensively in the antenatal period (Areias et al., 1996, Buist et al., 2006, Chung et al., 2001, Da-Silva et al., 1998, Evans et al., 2001, Josefsson et al., 2001, Gotlib et al., 1989, Manikkam and Burns, 2012, Matthey and Ross-Hamid, 2012, Milgrom et al., 2008, Rochat et al., 2011, Seguin et al., 1995). However, questions remain regarding whether there are major differences between the self-fulfillment scales (EPDS and BDI) and those applied by professionals, such as the Hamilton Depression Rating Scale (HAM-D) (Hamilton, 1960).

To the best of our knowledge, none of these three depression screening tools have been validated for use in an antenatal population in Brazil. Our aim was to compare the psychometric characteristics of the EPDS, BDI and HAM-D scales to those of a structured interview (MINI-PLUS) (Amorim, 2000), which is the gold standard for AD diagnosis, in second-trimester pregnant women.

Section snippets

Research protocol

A total of 247 consecutive women who were in their second trimester of pregnancy and were attending antenatal care at a public hospital were enrolled in the study. After a full explanation of the study purpose, written informed consent was obtained from each participant. As part of the study, the patients were evaluated using the Brazilian validated version of the EPDS (Santos et al., 2007) and the BDI (Gorenstein and Andrade, 1996). A trained psychiatrist blinded to the EPDS and BDI scores

Depression prevalence and risk factors

A major depressive disorder was diagnosed during the second trimester of pregnancy or during the lifetime in 17.34% and 31.98% of the women, respectively. Table 1 contains the sociodemographic and clinical characteristics of these women diagnosed with AD.

Pregnant women with more than one child (p=0.004), those who had experienced a previous abortion (p=0.026), those who had a history of suffering aggression (p<0.001) and those who had not received support from their family or friends during

Discussion

In our sample, we found an AD prevalence rate of 17.34% in the second trimester based on the structured MINI-Plus interview, which is similar to that obtained by other researchers (Bennett et al., 2004a, Gavin et al., 2005). By contrast, the prevalence rates obtained using the EPDS, BDI and HAM-D were 32.6% (23.7–43.0), 25.0% (17.1–35.0) and 38.0% (28.6–48.5), respectively.

The results above are consistent with existing variability based on country and study methodology. In high-income countries

Conflict of interest

We declare that we have no conflicts of interest.

Role of funding source

Funding for this study was provided by the National Counsel of Technological and Scientific Development (CNPq) (Grant no. 444254/2014-5) and the Minas Gerais State Research Foundation (FAPEMIG) (Grant no. APQ-01954-14). CNPq/FAPEMIG had no further role in the study design; in the collection, analysis and interpretation of data; in the writing of the report; or in the decision to submit the paper for publication.

Acknowledgments

We thank Mr. Gustavo Coutinho Faria and Mr. Sandro Cançado Silva, who assisted with the collection of some of the data necessary for our analysis.

References (61)

  • M.N. Norhayati et al.

    Magnitude and risk factors for postpartum symptoms: a literature review

    J. Affect. Disord.

    (2015)
  • S. Pawlby et al.

    Antenatal depression predicts depression in adolescent offspring: prospective longitudinal community-based study

    J. Affect. Disord.

    (2009)
  • T.J. Rochat et al.

    The prevalence and clinical presentation of antenatal depression in rural South Africa

    J. Affect. Disord.

    (2011)
  • I.S. Santos et al.

    Antenatal and postnatal maternal mood symptoms and psychiatric disorders in pre-school children from the 2004 Pelotas Birth Cohort

    J. Affect. Disord.

    (2014)
  • A. Sawyer et al.

    Pre- and postnatal psychological wellbeing in Africa: a systematic review

    J. Affect. Disord.

    (2010)
  • L. Seguin et al.

    Chronic stressors, social support, and depression during pregnancy

    Obstet. Gynecol.

    (1995)
  • R.C Stewart et al.

    Validation of screening tools for antenatal depression in Malawi—a comparison of the Edinburgh Postnatal Depression Scale and Self Reporting Questionnaire

    J. Affect. Disord.

    (2013)
  • T.D. Tran et al.

    Screening for perinatal common mental disorders in women in the north of Vietnam: a comparison of three psychometric instruments

    J. Affect. Disord.

    (2011)
  • P.D. Wadhwa et al.

    Behavioral perinatology: biobehavioral processes in human fetal development

    Regul. Pept.

    (2002)
  • B. Weobong et al.

    Prevalence and determinants of antenatal depression among pregnant women in a predominantly rural population in Ghana: the DON population-based study

    J. Affect. Disord.

    (2014)
  • M. Weinstock

    The potential influence of maternal stress hormones on development and mental health of the offspring

    Brain Behav. Immun.

    (2005)
  • B. Zuckerman et al.

    Depressive symptoms during pregnancy: relationship to poor health behaviors

    Am. J. Obstet. Gynecol.

    (1989)
  • A.O. Adewuya et al.

    Validation of the edinburgh postnatal depression scale as a screening tool for depression in late pregnancy among Nigerian women

    J. Psychosom. Obstet. Gynecol.

    (2006)
  • P. Amorim

    Mini International Neuropsychiatric Interview (MINI): validation of a short structured diagnostic psychiatric interview

    Rev. Bras. Psiquiatr.

    (2000)
  • M.E.G. Areias et al.

    Comparative incidence of depression in women and men, during pregnancy and after childbirth: validation of the Edinburgh Postnatal Depression Scale in Portuguese mothers

    Br. J. Psychiatry

    (1996)
  • A.T. Beck et al.

    An inventory for measuring depression

    Arch. Gen. Psychiatry

    (1961)
  • H.A. Bennett et al.

    Depression during pregnancy

    Clin. Drug Investig.

    (2004)
  • H.A. Bennett et al.

    Prevalence of depression during pregnancy: systematic review

    Obstet. Gynecol.

    (2004)
  • L. Bonari et al.

    Perinatal risks of untreated depression during pregnancy

    Can. J. Psychiatry

    (2004)
  • T.K. Chung et al.

    Antepartum depressive symptomatology is associated with adverse obstetric and neonatal outcomes

    Psychosom. Med.

    (2001)
  • Cited by (34)

    • Applying Rasch methodology to examine and enhance precision of the Edinburgh Postnatal Depression Scale

      2022, Journal of Affective Disorders
      Citation Excerpt :

      This use as a monitoring and outcome measure is limited by the properties of the scale, originally developed for screening (Cox et al., 1987) rather than more nuanced assessment. The EPDS been used in a variety of populations, including antenatal (Castro e Couto et al., 2015; Kozinsky and Dudas, 2015; Long et al., 2020) and postnatal mothers (Martin and Redshaw, 2018; Shorey et al., 2018), and fathers (Carlberg et al., 2018; Loscalzo et al., 2015; Matthey et al., 2001). In its use as a screening tool, there are a range of cut-off points recommended for different populations and time periods (Levis et al., 2020).

    • Validation of hindi version of Edinburgh postnatal depression scale as a screening tool for antenatal depression

      2020, Asian Journal of Psychiatry
      Citation Excerpt :

      Although there has been substantial research into postnatal depression (PND) in both western and non-western cultures, antenatal depression remains comparatively unexplored (Adewuya et al., 2006). The literature has described antenatal depression as a form of clinical depression that affects women during pregnancy and may increase the risk of postpartum depression if not properly treated (Bergink et al., 2011; Castro et al., 2015). It is also associated with increased negative emotions, particularly anger and anxiety, and has been linked to fear of childbirth (Ashley et al., 2016).

    View all citing articles on Scopus
    View full text