�007 vol. 31 no. 1 AUSTRALIAN AND NEW ZEALAND JOURNAL OF PUBLIC HEALTH �7

Postnatal depression is a significant

public health issue in Australia as

elsewhere, affecting some one

in seven women.1-4 Untreated postnatal

depression may result in depressed mood

continuing for several years.5 As well as

directly affecting the health and well-being of

many mothers, it may also have implications

for the development of their children.6

Identification of depressed women by

primary health care providers tends to be

poor, with up to 50% of cases not being

recognised.7 There is also evidence that

women affected by postnatal depression

are themselves reluctant to seek help from

health care professionals.8,9 The Edinburgh

Postnatal Depression Scale (EPDS) is a

short (10 item) questionnaire developed

to assist in the early detection of postnatal

depression, given problems with somatic

items on most other depression scales that

complicate assessment of childbearing

women in the postnatal period.10 It is simple

to complete and was originally validated in a

study of women identified by health visitors

as probably depressed.10 Validation studies

have also been carried out in community

samples and in an Australian context.11,12 In

an overview of such studies, Shakespeare

notes that in each case the samples had

been recruited for research purposes and

that considerable variability existed in

the populations studied, the choice and

recruitment procedures for the samples

and the administration of the EPDS.13 She

suggests these factors may account for

the considerable variability in the positive

predictive power of the scale. The question of

how the EPDS performs when administered

Screening for postnatal depression:

not a simple task

Susan Armstrong and Rhonda SmallMother & Child Health Research, La Trobe University, Victoria

Abstract

Objective: To evaluate an established

screening program for postnatal

depression using the Edinburgh Postnatal

Depression Scale (EPDS) in a rural

Victorian shire. By protocol, all women

were screened at three time points post

delivery by maternal and child health

nurses. The efficacy of this approach

in detecting probable depression was

examined and referral pathways analysed.

Methods: Records for a 12-month cohort

of women giving birth in the shire were

audited (n=267). Information collected

included EPDS scores, parity, mother’s

age, reasons for non-completion, referral

details and nurses’ comments. Analysis

was completed using database and SPSS

programs.

Results: The process goal of screening on

all three occasions was rarely achieved – a

goal met for only 15.5% of women; 22%

were never screened at all. The highest

rate of screening was 50.6% at one month,

falling to 38.1% at eight months. Reasons

for non-screening varied, suggesting no

simple remedy. The proportions of women

identified as probably depressed at each

screening point (3.1%, 4.8% and 9.2%)

were considerably lower than statewide

figures for rural women. Referrals of

probably depressed women were mainly to

GPs but the results were unclear.

Conclusions: A well-established program

of universal screening was not effective in

detecting probable depression in women.

There was little evidence of direct feedback

from GPs about women referred as a

result of screening and no collaborative

planning for affected women. Before

universal screening of women for postnatal

depression can be recommended, better

evidence of its feasibility and acceptability

are required, alongside convincing

evidence that screening leads to improved

outcomes for women.

(Aust N Z J Public Health 2007; 31: 57-61)

Correspondence to: Ms Susan Armstrong, Mother & Child Health Research, La Trobe University, 324-328 Little Lonsdale Street, Melbourne, Victoria 3000. Fax: (03) 8341 8555; e-mail: sj2armstrong@students.latrobe.edu.au

Submitted: September 2006

Revision requested: November 2006

Accepted: December 2006

in routine primary care settings, rather

than in research studies, appears to remain

unanswered.

Statewide surveys in Victoria utilising

the EPDS have found prevalence rates of

depression of 15.4%, 16.9% and 13.9%.2-4

over the period 1989-2000. Yet in a study

published in 1994 from a rural region

of Gippsland, Griepsma et al. reported

that 57.8% of postnatal women scored as

probably depressed.14 This is an unusually

high prevalence and such rates have not

been replicated in other studies. The authors

of the Gippsland study speculated that

the reason for the high reported rate of

probable depression may have been the

high level of unemployment in the area

at the time. They also used a lower than

generally recommended cut-off for probable

depression on the EPDS. However, these

two factors seem unlikely to explain fully

the high proportion of women scoring as

depressed, and the reasons for the finding

remain unclear. Nevertheless, the study had

a significant effect on postnatal care practice

in the region. One of the recommendations

arising from the study was a proposal that

administration of the EPDS be introduced

as routine practice by maternal and child

health nurses in the region, as they were

seen to be in a unique position to screen for

probable depression and to refer women to

available support services. In response, one

local government shire in the Gippsland

region initiated such a screening protocol

for postnatal depression for all women

presenting at maternal and child health

centres. This involved three screening points

for mothers within an eight-month period

Article Health Promotion

�� AUSTRALIAN AND NEW ZEALAND JOURNAL OF PUBLIC HEALTH �007 vol. 31 no. 1

after a child’s birth. Although the program has been in place for

10 years, until now no formal evaluation has been undertaken.

The effectiveness of universal screening for postnatal depression

is of particular interest in the light of proposals for the use of the

EPDS to screen all recent mothers in Australia. In particular, as

part of the beyondblue National Depression Initiative it has now

been recommended that a national plan be developed to implement

routine antenatal and postnatal depression screening and that a

national steering committee be convened to oversee this.15 However,

in the United Kingdom, after a review of available evidence, the

National Screening Committee recommended against the use of

the EPDS as a screening tool because of concerns relating to its

performance in routine care.16 The existence of a longstanding

postnatal screening program in Gippsland has provided an

opportunity to examine how screening has operated within

primary care.

ObjectiveThe present study has been undertaken to audit and provide an

initial assessment of the screening process for recent mothers in

the rural shire in question, in order to add to the evidence base

about the use of the EPDS in a primary care setting. A secondary

objective has been to enable practitioners in the area to reflect

upon and improve practice. This study has been carried out by a

health services counsellor with the assistance of the maternal and

child health nurses (MCHNs) responsible for the implementation

of the screening program.

To assess the effectiveness of the screening program, the

following issues were addressed in the audit:

• Was the process objective of universal screening being

reasonably met?

• What proportion of women was actually being screened at each

time point?

• Was the screening actually identifying the number of potentially

depressed women expected?

• What referral and treatment options were offered to women

identified as being probably depressed?

• Were the women so identified referred appropriately?

In summary, has the screening program improved detection

and offered the chance of better outcomes for women affected by

postnatal depression?

MethodThe information collection phase of the study began with a

meeting with all the maternal and child health nurses working in

the shire in order to explain the purposes of the research and seek

their agreement and support. The screening protocol being used

was also clarified at this point, necessary since it had been largely

developed through working discussions over time.

The protocol for screening women was that the EPDS was to be

administered by the maternal and child health nurses to all women

attending MCHN centres with infants at one month, four months

and eight months of age. These screening points coincided with the

Healthy Futures Program designated by the Victorian Department

of Human Services for the monitoring of infant health as part of

the universal, widely accepted MCH service. At each of these

three time points any woman scoring ≥13 on the EPDS was to be

referred to her general practitioner for further assessment.

All available records for the cohort of women giving birth in the

shire from 1 July 2002 to 30 June 2003 were reviewed. Records

relating to mothers moving into the shire during the study period

were not included as they may not have had the opportunity to be

screened at all three time points.

To preserve confidentiality of individual women, the attendant

MCHN at each centre read out the relevant screening data to the

researcher, who recorded the results on a data collection form.

Each of the nurses had been working as the primary MCHN at

that centre during the audit period. They had been trained and were

experienced in the use of the EPDS as well as having undergone

wider training relating to postnatal depression. Ongoing peer

support for nurses was used in implementing the screening

program. All were committed to using the EPDS to identify

women who might be depressed. This commitment was clear in

group meetings with the nurses before and after the audit and

individually during information collection. The data collection

procedure had the added benefit that the nurses were able to

provide additional comments relating to the screening process

on a case-by-case basis. Nurses accessed relevant data from their

manual card index as well as the computer-based records system

in use at the centres.

Information collected included:

• The date of birth of the child (necessary to cross-check the

screening dates).

• The age of the mother.

• Number of children in the family designated by birth order of

the child.

• The woman’s score on the EPDS (if administered) at one, four

and eight months, and details of any referrals made.

• Reasons for screening not being completed, where this was

known.

• Any extra information provided by the nurse about the screening

process on a case-by-case basis at the time of the audit.

Table 1: Women screened at each time point.

Time of screen n % (n=257)One month 130 50.6

Four months 125 48.6

Eight months 98 38.1

Table 2: Adherence to protocol standard.

Screening n % (n=257)Screened once 89 34.5

Screened twice 72 28.0

Screened three times 40 15.5

Never screened 56 21.8

Armstrong and Small Article

�007 vol. 31 no. 7 AUSTRALIAN AND NEW ZEALAND JOURNAL OF PUBLIC HEALTH ��

Data from the precoded data collection forms were entered

into an Access database and simple descriptive analyses were

undertaken using SPSS.17 Explanatory comments provided by

nurses were also coded and entered.

After the data had been analysed, a meeting was held with the

MCHNs to provide feedback and to give opportunity for discussion

and clarification. With their consent, this meeting was minuted.

ResultsPopulation sample

Data were collected on a total of 257 women of the 298 living

in the shire who had given birth to 304 babies (including six sets

of twins) during the year 1 July 2002 to 30 June 2003. No data

were collected for 41 women, most of whom had left the shire

at some stage after the birth of their babies and their records

transferred elsewhere. Data were obtained from four centres, three

of approximately the same size and one 60% smaller. The median

age of the women screened was 30, the age distribution similar to

statewide figures with two-thirds of childbearing women between

25 and 35 years of age.18

Proportion of completed screeningsTable 1 shows that the highest proportion of women screened

occurred at the four-week time point, when 50.6% of all women

were recorded as having completed an EPDS. This fell to 38% by

the eight-month screening point.

Table 2 indicates level of adherence to the full protocol, showing

that for only 15.5% of women was the screening protocol fulfilled

and 22% of women were never screened at all. Overall, of the total

of 771 planned screening points (three for each woman), screening

was actually carried out on just 46% of the intended occasions.

At the initial meeting when auditing the screening program

was discussed, some nurses believed that they were more likely

to screen first-time mothers. However, parity and age of the

mother were not significantly associated with the likelihood of

being screened. There was also no difference in screening rates

between the centres.

Reasons for screening not occurringReasons for non-completion of screening were available in 61%

of cases. These were obtained from the records and the nurses’

comments (retrospectively) about what had taken place. There

were multiple reasons for the EPDS not being given (see Table 3).

Some were logistical: a relieving maternal and child health nurse

was in attendance and was not familiar with the screening process

at that centre; someone other than the mother brought child to the Table 4: Women identified as probably depressed on screening and compared with a rural sample from a statewide Survey of Recent Mothers (SRM 2000).4

n/N (Number % OR completing (95% CI) EPDS)Score ≥13 at four weeks 4/130 3.1 0.2 (0.05-0.55)

Score ≥13 at four months 6/125 4.8 0.31 (0.11-0.75)

Score ≥13 at eight months 9/98 9.2 0.63 (0.28-1.37)

SRM 2000 – rural sample 62/449 13.8 1.00 Score ≥13

Table 3: Reasons for the EPDS not being completed.

Reason given n %Relieving health nurse did not administer EPDS 61 23.6

MCH nurse did not administer EPDS 58 22.6

Mother did not attend appointment 59 22.9

Mother refused to be screened 51 19.8

Enhanced Home Visiting Nurse allocated 26 10.1

centre; or the Enhanced Home Visiting Service nurse (EHVS) had

been allocated to the mother to provide a home-based service,

thus temporarily replacing the centre-based MCHN service, and

no screening data were available. However, on 42% of occasions

(when explanations were available) either the MCHN or the

mother made a decision not to do the screening. In addition, in

22% of cases where screening had not occurred, the reason was

non-attendance at the scheduled visit.

The nurses who had assisted with the data collection had all

been involved in delivering the screening program and knew many

of the women well. Their comments about individual screening

decisions were recorded, providing insight into further reasons

for non-completion.

“No need, mother was coping well.”

“Mother with a history of depression refused screening. Said she’d rather not know.”

“Mother cruising, back at work. Said she did not feel she needed to be screened.”

“With twin visits there is not enough time.” (Only one out of six mothers with twins completed all three screens)

“Mother always arrives late for appointments and is hard to engage.”

Women identified as probably depressedOf the 257 women for whom records were available, 201 were

screened at least once. Of these, 18 scored ≥13 on the EPDS,

indicating as probably depressed, with just one woman scoring

≥13 at more than one time point. Table 4 indicates the number

and proportion of women identified as probably depressed at each

screening point. Comparison with the proportion of rural women

identified as probably depressed on the EPDS at 5-6 months after

birth from a statewide survey is also shown.4 It can be seen that

fewer women were identified as depressed by the shire screening

program than might have been expected from the survey findings,

with lower odds of women identified as depressed at all time

points, and significantly so at the four weeks and four-month

time points.

Referral after screeningFifteen of the 18 women scoring ≥13 at any of the screening

points were referred to a GP, as the protocol required. Of the

others, one was referred to a counsellor, one to a neurologist and

one to a naturopath. Five were also referred to the Enhanced Home

Health Promotion Screening for postnatal depression

�0 AUSTRALIAN AND NEW ZEALAND JOURNAL OF PUBLIC HEALTH �007 vol. 31 no. 1

Visiting Service nurse as a result of the screening result. Other

referral outcomes were generally not apparent. Nurses’ comments

indicated that some women scoring <13 were nonetheless

considered to be probably depressed, and were also referred to

their doctor with a view to receiving further assessment.

DiscussionIn the year studied, the screening program for postnatal

depression did not meet its first process objective of screening

all recent mothers three times in the first 12 months after giving

birth. Only 15.5% of women were screened according to the

protocol. Studies suggest that the screening at four weeks may not

be appropriate as women are more likely to be subject to transient

mood changes as they settle into life with a new baby. In this study,

the four-week screening achieved the highest proportion of women

screened but the lowest number of women scoring as probably

depressed. Fewer than half the women were screened at each of

the more critical four and eight-month time points, with only 63%

being screened at either. While screening for depression has been

advocated on the grounds of case finding and early identification of

distress, there is a need for caution when applied on a population

basis. A recent review of the evidence concluded that screening for

depression was not cost efficient and that screening programs have

been implemented without consideration of their effectiveness or

ethical and clinical implications.19 Critical appraisals of the use

of the EPDS for universal screening of mothers differ in their

conclusions. The only available study of an existing, primary care,

universal screening program utilising the EPDS was carried out by

Shakespeare, who conducted an audit of screening in Oxfordshire,

UK. Her finding was that completion rates were low; only 66%

of women were screened at eight weeks post birth and 55% at

eight months post birth. Low numbers of women were detected

as probably depressed – 7% at the first screening point and only

5% at the latter. She concluded that even within a locality with

a well-established strategy, a high level of screening was hard to

achieve.20 In one Australian study, Milgrom et al. concluded that

routine screening with the EPDS did integrate well into a primary

care setting administered by maternal and child health nurses.21

However, in this case screening occurred as part of a research

project and although the number of women participating and

completing the EPDS was estimated at 80%, this was based on

the report of the maternal and child health team leader with no

denominators given. Reporting on the acceptability to women of

screening with the EPDS in the beyondblue National Postnatal

Depression Program, Buist et al. stated that 85% of responders

to the postal survey sent to a random sample of the women who

had participated in screening had no discomfort with screening.22

However, no data are provided on the number of women who

refused the offer of screening and were therefore not subsequently

surveyed. Furthermore, women surveyed were asked to complete

the EPDS again, making it highly likely that the women who

had experienced discomfort on completing the EPDS during the

beyondblue program would be less likely to be among the 59%

of women who responded to the survey. All that can be concluded

with any confidence from this study is that 50% of a random

sample of women who had agreed to the beyondblue screening

process eventually identified themselves as having no discomfort

in completing that screening.

In the current study, the variety of reasons for non-screening

suggests that there is no one solution to low rates of screening.

Examining the nurses’ comments, it would seem that the decision

not to screen was sometimes made on the basis of their own

clinical assessments, which overrode the screening protocol.

This decision making may not always have been explicit but

involved information based on observations at the time, e.g.

“mother cruising”, “mother told me she was well”. It is possible

that better outcomes were achieved by such choices to override

the screening protocol for these women. It is also possible that

in these instances women who were depressed might have been

missed. In other cases, women who scored below the cut-off for

referral were still assessed as depressed and referred. Here the

nurses’ comments suggest that the completion of the EPDS may

have acted to facilitate discussion between the mother and the

nurse, and as a gateway to services. One in five women refused

the nurse’s offer of screening. Follow-up research will explore

why women make this choice. A qualitative research study that

sought women’s views on the acceptability of the EPDS concluded

that fewer than half of those women surveyed found the EPDS

acceptable, with most women preferring to talk about how they

felt rather than filling out a questionnaire.23

The low rates of screening and the low numbers of probably

depressed women detected and referred bring into question the

value of relying on a simple pen-and-paper test as the strategy

to identify and then assist women suffering from postnatal

depression. In real-life primary care settings, a range of factors

may undermine the integrity of universal screening programs. It

would seem that for a significant proportion of women, they, the

nurse, or both consider that screening is inappropriate. Whether for

this reason – or others such as non-attendance at screening visits

– it seems likely that a considerable number of depressed women

are not being identified by the screening program in this rural shire.

The strong suspicion arises that it is not the assessment tool itself

that is of most significance – the EPDS has been found to be very

acceptable to women in research studies – but rather the context in

which it is used and the salience that each party places upon the

interaction. If this is so, then other forms of clinical assessment,

such as more systematic case finding, may prove to be more

effective in detection and the provision of support and treatment

services, and ultimately in better outcomes for women.

The referral component of the audited screening program

operated much as had been intended, with 83% of women

identified as probably depressed referred to a GP and 28% to the

Enhanced Home Visiting Service. The low number of referrals

to other services is likely to reflect the relative deficiencies

of specialist services within this rural environment. However,

during data collection and in meetings the MCHNs indicated

dissatisfaction with the almost complete lack of feedback from

GPs resulting from referrals, which meant that the outcome of

Armstrong and Small Article

�007 vol. 31 no. 7 AUSTRALIAN AND NEW ZEALAND JOURNAL OF PUBLIC HEALTH �1

referral was often not known.

Difficulties with administration, completion rates and low

numbers of depressed women being detected may therefore not

be the only concerns in primary care screening. Screening for

postnatal depression is unlikely to lead to a successful referral

in the absence of acceptable services or a trusting relationship

between the woman and her care providers. In the beyondblue

National Postnatal Depression Program, more than 40,000 women

were screened with the EPDS antenatally and 12,000 women

screened postnatally, with more than 30% of those identified as

probably depressed ignoring the advice to seek help.15 In a New

Zealand study of antenatal screening using the EPDS with a

sample of 400 women (completion rate 92.5%, with 13.2% scoring

as probably depressed), “severe losses occurred subsequently”

when follow-up support was offered, and eventually only one

woman received treatment that she rated as valuable. The authors

concluded that “while the vast majority of pregnant women were

willing to complete a depression screening questionnaire, most

did not agree to additional contact for assessment, and either were

not offered treatment or did not accept treatment”.24 Further, a

systematic review of interventions to reduce depression after

birth concluded that none of the instruments available to screen

women antenatally performed sufficiently well for their use to be

recommended for identifying those women at risk of subsequent

postnatal depression.25

This well-established program of universal screening in one

rural shire was not effective in detecting probable depression in

women. There was little evidence of direct feedback from GPs

of women referred as a result of screening and no collaborative

planning for affected women. Before universal screening of women

for postnatal depression can be recommended, better evidence of

its feasibility and acceptability are required, alongside convincing

evidence that screening leads to improved outcomes for women.

Reasons underlying the problems identified with the screening

program reported in this paper are the subject of ongoing study.

Interviews with participating maternal and child health nurses and

with GPs have been conducted to investigate their views about

the screening program and the referral process, and women’s own

attitudes to screening are soon to be explored in a postal survey

and follow-up interviews. Some changes to the way the shire

screening program operates have also been made since the audit

of screening was completed. These include a common method

for recording women’s EPDS scores, integration of the generic

MCH and EHVS records and a change in the screening protocol

from three screening time points to two, completed with women

at two months and eight months after birth. The new screening

protocol has been in operation since the beginning of 2005 and a

second audit will shortly be undertaken for all women who gave

birth in that year.

AcknowledgementsThank you to all the maternal and child health nurses

who participated in the research for their open and willing

contributions.

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Health Promotion Screening for postnatal depression