Women's interpretation, understanding and attribution of the anhedonia question in the PHQ-4 and modified-Whooley questions in the antenatal period.

OBJECTIVES: To report on the rates of misinterpretation, confusion, and attribution of the anhedonia question in the PHQ-4 and Whooley questions by pregnant women. BACKGROUND: The NICE Perinatal Mental Health guidelines recommend the use of the anhedonia question for depression screening, yet evidence suggests it may be misinterpreted or not be related to mood. METHOD: Women attending a public hospital's antenatal clinic, communicating in English as their language of choice, completed either the PHQ-4 or the Whooley questions. Following comments to general evaluation questions in the first sample, women were asked a targeted anhedonia interpretation question, an anhedonia attribution question, and an ease of understanding question (PHQ-4: N = 37-119; Whooley: N = 31-100). RESULTS: Across the PHQ-4 and Whooley formats around 15% of participants completely misinterpreted the anhedonia question, with a further 17% finding it difficult to understand. Around two-thirds of those experiencing the symptom said it was due to normal symptoms of pregnancy, and not related to their mood. In the PHQ-4 format, which included all three questions, 48% of the women had one or more of these issues. While CALD women appear to have greater difficulty understanding the question, there were no meaningful associations with whether English was spoken at home. CONCLUSION: Almost half of the women incorrectly interpreted the anhedonia question, or said that it was confusing, or that it did not reflect low mood. These data indicate that the anhedonia question should not be used in screening women in the antenatal period, whether in the PHQ-4 or Whooley formats.

Is Validating the Cutoff Score on Perinatal Mental Health Mood Screening Instruments, for Women and Men from Different Cultures or Languages, Really Necessary?

Background: The most commonly used mood screening instrument in perinatal health is the Edinburgh Depression Scale. The screen-positive cut-off score on this scale, as for others, has been determined, via validation techniques, for over 20 languages/cultures, and for both women and men. While such validation appears to be considered essential, there are studies that could be interpreted to suggest that this is not an important consideration. Methods: Selective studies have been chosen to indicate these opposing points of view. Results: Examples of studies that support the notion of validating cut-off scores are described, as are examples of studies that appear not to support this point of view. Conclusions: (i) Clinical services and researchers need to be mindful of these opposing points of view, and openly discuss them when using screening cut-off scores for their respective populations. (ii) Researchers and Journals need to be more rigorous in ensuring this issue is correctly reported in studies, and/or openly discussed when relevant.

An exploratory and confirmatory factor analysis study of the EPDS in postnatal Italian-speaking women.

BACKGROUND: Depression and anxiety are the most prevalent emotional difficulties in the perinatal period and there is agreement that early intervention is an important strategy to prevent long-lasting effects on mother and child. Literature has recently shown that the Edinburgh Postnatal Depression Scale (EPDS) is able to measure not only depression but also anxiety. OBJECTIVE: To investigate the factorial structure of the EPDS in Italian-speaking new mothers. METHOD: 416 women attending vaccination services between 2 and 4 months postpartum filled in the EPDS. Exploratory (EFA) and Confirmatory (CFA) analyses were carried out. RESULTS: The EFA on the first part of the sample (n = 208) showed a two-factor structure. The CFAs on the second sample of mothers (n = 208) provided support for the 'EPDS-4A', with items 3,4,5,6 belonging to the Anxiety factor and items 1,2,7,8,9,10 to the Depression factor. The fit for the model was good: χ2/df = 1.41, p <.001; GFI =.99; CFI =.99; TLI =.88; RMSEA =.04. CONCLUSION: A two-factor structure of the EPDS was confirmed suggesting that the EPDS can be used to screen for both depression and anxiety for Italian mothers in the postnatal period.

Depression in pregnancy "strongly predicts" depression postpartum: Are we inadvertently misleading clinicians and researchers?

BACKGROUND: Many perinatal mental health risk factor studies report that antenatal depression is a signifcant risk factor for women being depressed postnatally. They often describe the strength of the risk as being 'strong' or 'strongly predictive' (or similar phrases), though usually without explaining why these terms are used. It is possible that readers of such research may misunderstand these qualitative descriptors. METHOD: As part of routine teaching regarding risk analyses, we explored participants' understanding of the conclusion stated in one specific perinatal risk study, which was that antenatal depression "strongly predicts" postnatal depression. Participants were groups of mental health professionals and postgraduate students, in Italy (N = 56) and Australia (N = 34).They completed an Estimate Survey, in which they indicated the actual number of antenatally depressed women they expected would have been depressed postpartum, given the study's conclusion. RESULTS: The majority of survey respondents (~80%) expected that "strongly predicts" meant that a much higher proportion of women with the risk then became depressed than was actually the case. Some participants expressed major concern at the study's conclusion. LIMITATION: Participants comprised two small convenience samples of health professionals and postgraduate students, and thus may not be representative of the population. CONCLUSION: Studies that rely on the statistical significance of their analyses to conclude whether antenatal depression is a strong predictor or risk for postnatal depression may not accord with how health professionals interpret the data, once the absolute risk information is clearly provided. Recommendations for improving the reporting of results in such studies are made.

Increasing partner communication and understanding during pregnancy: evaluation of 'The Great Pregnancy Quiz'.

OBJECTIVE: To evaluate a Quiz designed to enhance communication and understanding in expectant parents. BACKGROUND: A supportive and understanding relationship is associated with better maternal mental health outcomes. Many services therefore advocate that couples should communicate openly with each other, particularly about worries or concerns either have. To facilitate this a quiz (The Great Pregnancy Quiz) was developed and evaluated in this project. METHOD: English-speaking women (N = 442) and men (N = 146) were recruited from antenatal clinics or classes and were given the 'Great Pregnancy Quiz' to complete at home. Approximately 2-4 weeks (T2) later they participated in either a phone interview, an online survey, or a face-face interview, still during the pregnancy, concerning the impact of the Quiz. Data were available from 90 women and 46 men. Data were analysed using a mixed-methods single group post-test only design. RESULTS: Most women (78 of the 90: 87%) and men (35 of the 46: 76%) reported that the Quiz had positively impacted either their understanding or knowledge of each other. For 30 of the 90 women (33%) and 3 of the 46 men (7%) one or other had implemented some new supportive behaviour due to the Quiz. Qualitative comments highlight the impacts of the Quiz. CONCLUSION: Most couples who did the Quiz reported positive impacts on their communication and understanding. While the issue of low T2 contact rates may have skewed the results, the benefits associated with the quiz make this resource an inexpensive and easily implemented health promotion strategy.

Validation of the MGMQ in screening for emotional difficulties in women during pregnancy.

BACKGROUND: Screening for emotional health difficulties in pregnant or postpartum women is becoming routine practice in health services. This screening is often done using the EPDS, usually using a screen positive score just to identify possible depression. This and other such scales often have a myriad of screen-positive scores, making them impractical within clinical settings. The recent MGMQ screens for a variety of negative moods, is brief, simple, and has just a few screen-positive thresholds. METHOD: At recruitment 391 women attending routine antenatal clinics completed various mood questionnaires. Several weeks later they were re-contacted by phone, at which time 247-252 of them provided valid data on the MGMQ, EPDS, and a diagnostic interview for depression and anxiety disorders (numbers vary depending upon valid combinations). RESULTS: The MGMQ showed good-excellent receiver operating characteristics (sensitivity specificity, positive predictive value) against diagnostic status for depression or anxiety disorders. It also showed good concurrent and concordant validity with the EPDS, and good discriminant validity between women with clinical and subclinical diagnostic caseness. Stability over several weeks was however low, indicating that, as with other measures, women's mood can naturally change during the perinatal period. LIMITATIONS: The findings only apply to English-speaking antenatal women from Sydney, Australia. CONCLUSION: The MGMQ has good psychometric properties when compared to the usual gold-standard applied to emotional health screening measures. Its brevity, simplicity to 'score' and interpret, together with its clinically useful questions, suggest it could be a practical alternative to other more complicated mood screening measures for perinatal women.

Transient vs enduring distress in late pregnancy using the EPDS: a brief longitudinal exploratory study.

Background and Objective: The Edinburgh Postnatal Depression Scale (EPDS) is widely used to detect perinatal distress in women by one single administration. Recently, research has shown that during early pregnancy around half of the women scoring as 'possibly depressed' on the EPDS only have transient distress, when re-tested after few weeks. This finding may not occur if women are screened later in pregnancy, as their worries then may be more enduring; therefore an exploratory study was conducted to further investigate this issue. Methods: Pregnant women (N = 84) attending a public hospital in Italy completed the EPDS in their third trimester (x = 33 weeks) and again 8-42 days later (while still pregnant). They had not received professional mental health intervention in this time interval. Results: Approximately half of the women who initially scored high on the EPDS in late pregnancy no longer scored high just a few weeks later. Conclusions: Approximately half of women who initially score high on the EPDS when screened in pregnancy only have transient distress in both the second and third trimester. To label these women as being 'possibly depressed', and mixing them with women who show enduring distress, represents a possible weakness in research studies, and may also overburden clinical services. We would therefore recommend, as research and clinical practice, a second administration of the EPDS if a woman initially scores in the distressed range at any stage in pregnancy.

Is pregnancy-specific anxiety more enduring than general anxiety using self-report measures? A short-term longitudinal study.

Objective: To investigate whether the rates of transient and enduring distress differ between general and pregnancy-specific anxiety in antenatal English-speaking women. Background: Evidence indicates that half of women with high levels of general anxiety during pregnancy will no longer be highly anxious after a few weeks, without having received treatment. Pregnancy-specific anxiety, however, may be more enduring, as many worries concerning the forthcoming birth, whether the baby will be healthy and the woman's ability to care for a newborn are likely to continue, or increase, during the pregnancy. Method: Women attending a public hospital antenatal clinic completed several mood questionnaires, including a mix of general anxiety and pregnancy-specific anxiety scales (T1). Between 2 and weeks later (T2), still during pregnancy, participants completed the same measures via a phone interview. Results: Between 76 and 243 women completed the different measures at both time points. For each measure the result was similar: about half of women scoring high at the first assessment (T1) continued to score high at T2 on both the general and pregnancy-specific anxiety measures, despite not receiving any specialist intervention. By contrast, over 90% of women initially scoring low on the various measures continued to score low at T2. Conclusion: Whether women are screened for pregnancy-specific or for general anxiety, around half scoring 'high' on the measure will no longer be in the anxious range a few weeks later. They thus have 'transient' anxiety. This transient/enduring finding was also confirmed for those with high levels of depressive symptomatology.

A comparison of the interviewer-administered phone and self-complete online versions of the computerized eMINI 6.0 in a sample of pregnant women.

BACKGROUND: This study compares the prevalence rates of depressive and anxiety disorders identified during pregnancy using an interviewer-administered phone version and a self-complete online version of the computerized eMINI 6.0. METHODS: 888 pregnant women completed the computerized eMINI 6.0 (interviewer-administered phone, n = 253; self-complete online, n = 635). RESULTS: There were no significant differences in the proportions of women meeting eMINI 6.0 criteria for current major depression, any current anxiety disorder, or lifetime panic or depressive disorder, by mode of administration. However, a greater proportion of women in the interviewer-administered phone group than in the self-complete online group met criteria for current minor depression (2.0% vs 0.2%, p = .008). LIMITATIONS: Study limitations include its non-randomized design, overall low prevalence of depressive and anxiety disorders in the sample and inclusion of only a select number of eMINI 6.0 modules. CONCLUSIONS: This study demonstrated few differences in the rates of DSM-IV depressive and anxiety disorders identified between the interviewer-administered and self-administered versions of the eMINI 6.0. Findings provide preliminary support the practical value of self-completed computerized interviews in large scale studies examining common mental disorders in pregnant women.

Validation of the Edinburgh Postnatal Depression Scale against both DSM-5 and ICD-10 diagnostic criteria for depression.

BACKGROUND: The Edinburgh Postnatal Depression Scale (EPDS) is widely used in many countries to screen women for depression in the perinatal period. However, across studies the psychometric properties and cutoff scores of the EPDS have varied considerably; potentially due to different depression criteria and diagnostic systems being used. Therefore, we validated the Danish EPDS against a depression diagnosis according to both DSM-5 and ICD-10. Furthermore, we examined whether the Danish EPDS is multidimensional, as it has previously been suggested. METHODS: Women (N = 324) were recruited after routine screenings with the EPDS between 2 and 10 months postpartum (T1). At a subsequent home visit (T2), the EPDS and the Structured Clinical Interview for DSM-5 were administered. Diagnostic interviews were audio recorded to enable subsequent coding for ICD-10 diagnoses and inter-rater reliability analysis. A two-phase stratified sampling strategy with three sampling categories (EPDS-score at T1) was used. Using the distribution of 4931 T1 EPDS-scores from the same population from which we sampled the participants, we used sampling weighing to reweight the sample. The calculation of weights was based upon the mother's sampling category at T1 (i.e. the probability of being sampled) and the weights were applied when assessing the receiver operation characteristics (ROCs) of the EPDS. Sensitivity, specificity, positive predictive value, negative predictive value and area under the ROC curve were computed from the reweighted data for all relevant cutoff values. CIs were computed by embedding the calculations in a weighted logistic regression. Exploratory factor analysis was done using oblique rotation. Parallel analysis was used to assess the number of factors. RESULTS: A score of 11 or more was found to be the optimal cutoff for depression according to both DSM-5 and ICD-10 criteria. Factor analysis suggested that the Danish EPDS consists of three factors, including an 'anxiety factor'. CONCLUSIONS: The Danish EPDS has reasonable sensitivity and specificity at a cutoff score of 11 or more. There are no notable differences with respect to using ICD-10 or DSM-5 criteria for depression in terms of optimal cutoff. The variation in cutoff scores is likely to be due to cultural variations in the expression of depressive symptoms.

A comparison of two measures to screen for emotional health difficulties during pregnancy.

OBJECTIVE: To compare the performance of a generic mood questionnaire (Matthey Generic Mood Questionnaire, MGMQ) against the established Edinburgh Postnatal Depression Scale (EPDS) in perinatal mental health mood screening. BACKGROUND: Many perinatal clinical services use the EPDS to screen for depression, and some may consider using it to screen for anxiety. A new scale, the MGMQ, is designed to screen for a wide variety of emotions, not just depression or anxiety. It comprises a generic distress question, an impact question, as well as two clinical questions. Its brevity, and categorical scoring format, may also mean it is less susceptible than the EPDS to needing a myriad of different screen-positive scores for women from different cultures and during different perinatal time periods. METHODS: Two hundred and ten Italian women in their third trimester of pregnancy completed the EPDS and MGMQ while attending routine antenatal clinic appointments or antenatal classes in the north of Italy, between 2015 and 2016. RESULTS: The Distress and Lower Impact question thresholds showed acceptable receiver operating characteristics with the various EPDS screen positive thresholds. The Higher Impact question threshold, however, had lower than acceptable sensitivity. By contrast, the EPDS was poor at detecting women who on the MGMQ said that they were distressed and significantly bothered by their mood. The possible reasons for the discrepancies in screen-positive status between the two measures are discussed. CONCLUSION: The MGMQ is a useful tool to aid in screening for a wide range of emotional difficulties in the perinatal period.

A comparison of the PHQ-2 and MGMQ for screening for emotional health difficulties during pregnancy.

BACKGROUND: Routine screening for emotional health difficulties in women during pregnancy is now advocated in several countries. There is a need therefore to compare the performance of different self-report measures to accomplish this. This study reports on the comparative performance of two such measures- the well-established PHQ-2, which aims to detect depression, and the more recent MGMQ, which aims to detect a wide array of negative emotions. METHOD: Women (N = 2292) attending a public hospital antenatal clinic over a 14-month period completed the two measures, either on their own (72%), verbally administered by the midwife (25%), or with an interpreter (3%). RESULTS: Similar rates of women screened positive on each instrument (PHQ-2: 11.6%; MGMQ: 12.3%), but the overlap between the two measures was low. The PHQ-2 only detected 58% of the MGMQ screen positive women, while the MGMQ detected 89.5% of the PHQ-2 screen positive women. No clinically meaningful difference in screen positive rates on either measure was evident for the administration method. LIMITATIONS: No demographic data were available apart from gestational age, and only about half the women presenting to the clinic during the time period were screened with the measures. CONCLUSION: The MGMQ detected a greater proportion of women screening positive on the PHQ-2 than vice-versa. This is part due to the MGMQ's focus on a wider range of negative emotions than just depression. Accumulating evidence for this MGMQ indicates that clinical services can consider using this simple measure if they wish to screen for a broad range of negative emotions during pregnancy and postnatally.

Study protocol for a comparative effectiveness trial of two models of perinatal integrated psychosocial assessment: the PIPA project.

BACKGROUND: Studies examining psychosocial and depression assessment programs in maternity settings have not adequately considered the context in which psychosocial assessment occurs or how broader components of integrated care, including clinician decision-making aids, may optimise program delivery and its cost-effectiveness. There is also limited evidence relating to the diagnostic accuracy of symptom-based screening measures used in this context. The Perinatal Integrated Psychosocial Assessment (PIPA) Project was developed to address these knowledge gaps. The primary aims of the PIPA Project are to examine the clinical- and cost-effectiveness of two alternative models of integrated psychosocial care during pregnancy: 'care as usual' (the SAFE START model) and an alternative model (the PIPA model). The acceptability and perceived benefit of each model of care from the perspective of both pregnant women and their healthcare providers will also be assessed. Our secondary aim is to examine the psychometric properties of a number of symptom-based screening tools for depression and anxiety when used in pregnancy. METHODS: This is a comparative-effectiveness study comparing 'care as usual' to an alternative model sequentially over two 12-month periods. Data will be collected from women at Time 1 (initial antenatal psychosocial assessment), Time 2 (2-weeks after Time 1) and from clinicians at Time 3 for each condition. Primary aims will be evaluated using a between-groups design, and the secondary aim using a within group design. DISCUSSION: The PIPA Project will provide evidence relating to the clinical- and cost- effectiveness of psychosocial assessment integrated with electronic clinician decision making prompts, and referral options that are tailored to the woman's psychosocial risk, in the maternity care setting. It will also address research recommendations from the Australian (2011) and NICE (2015) Clinical Practice Guidelines. TRIAL REGISTRATION: ACTRN12617000932369.

Using the Edinburgh Postnatal Depression Scale for women and men-some cautionary thoughts.

The objective of the study was to critically consider some of the possible limitations in the Edinburgh Depression Scale (EDS), given that great emphasis is put on the results of this measure within both clinical and research fields. Using findings and discussion points from other studies, as well as from a critical analysis of issues by the authors based upon their clinical and research experience, possible limitations with the scale in nine areas are discussed. Possible limitations include the following: (1) ambiguous items, (2) exclusion of certain types of distress, (3) scoring difficulties, (4) low positive predictive value, (5) frequent use of incorrect cut-off scores, (6) a vast array of validated cut-off scores, (7) validation against a questionable gold-standard, (8) limited anxiety detection and of depressive symptoms in men, and (9) many screen positive women only have transient distress. While the EDS has unquestionably been an extremely valuable instrument in aiding in the recognition of the importance of perinatal mental health, users of the scale should be aware that it, like other measures, has limitations. We discuss possible strategies to overcome these limitations and describe a recent scale that has been developed to surmount these shortcomings more effectively.

Antenatal psychosocial risk status and Australian women's use of primary care and specialist mental health services in the year after birth: a prospective study.

BACKGROUND: Poor mental health in the perinatal period can impact negatively on women, their infants and families. Australian State and Territory governments are investing in routine psychosocial assessment and depression screening with referral to services and support, however, little is known about how well these services are used. The aim of this paper is to report on the health services used by women for their physical and mental health needs from pregnancy to 12 months after birth and to compare service use for women who have been identified in pregnancy as having moderate-high psychosocial risk with those with low psychosocial risk. METHODS: One hundred and six women were recruited to a prospective longitudinal study with five points of data collection (2-4 weeks after prenatal booking, 36 weeks gestation, 6 weeks postpartum, 6 months postpartum and 12 months postpartum) was undertaken. Data were collected via face-to-face and telephone interviews, relating to psychosocial risk factors, mental health and service use. The prenatal psychosocial risk status of women (data available for 83 of 106 women) was determined using the Antenatal Risk Questionnaire (ANRQ) and was used to compare socio-demographic characteristics and service use of women with 'low' and 'moderate to high' risk of perinatal mental health problems. RESULTS: The findings indicate high use of postnatal universal health services (child and family health nurses, general practitioners) by both groups of women, with limited use of specialist mental health services by women identified with moderate to high risk of mental health problems. While almost all respondents indicated that they would seek help for mental health concerns most had a preference to seek help from partners and family before accessing health professionals. CONCLUSION: These preliminary data support local and international studies that highlight the poor uptake of specialist services for mental health problems in postnatal women, where this may be required. Further research comparing larger samples of women (with low and psychosocial high risk) are needed to explore the extent of any differences and the reasons why women do not access these specialist services.

Differentiating between Transient and Enduring distress on the Edinburgh Depression Scale within screening contexts.

BACKGROUND: Research has shown that women screened as being 'possibly depressed' on the Edinburgh Depression Scale consist of two distinct duration types: those with Transient distress, and those with Enduring distress. This paper reports on the exploration of antenatal data to ascertain if information from the initial EDS screening can help determine which women may have Transient, and which Enduring, distress after just a few weeks. METHODS: Data from three antenatal studies were explored, where the EDS had been given twice within a psychosocial screening setting. Repeat testing of the EDS, together with a diagnostic interview, was conducted 2-5 weeks later. RESULTS: Women with Enduring distress (those scoring high on both occasions) were significantly more likely to meet criteria for a depressive disorder than those with Transient distress. They also scored significantly and clinically meaningfully higher on their initial EDS, though no cut-off score was optimal in discriminating between the two duration categories. Differentiation could also not be made from the endorsement of the self-harm question, but was best when women were asked to predict how they would be feeling, and why. LIMITATIONS: The data come from three studies just with English-speaking women with slightly different methodologies, producing information on a fairly small number of women with Transient (n=12-29) and Enduring (n=14-25) distress. In addition the EDS re-test interval of between 2 and 5 weeks was quite wide. CONCLUSIONS: Clinical implications are that women who score high initially on the EDS are most likely to continue to score high (have Enduring distress) if they themselves think this will be the case, or if they only give wishful thinking as the reason as to why they think they will feel better. Research studies should also therefore analyse their data taking into account this duration category.