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Risk of antenatal depression has been shown to be elevated in Southern Africa and can impact maternal and child outcomes, especially in the context of the Human Immunodeficiency Virus (HIV). Brief screening methods may optimize access to care during pregnancy, particularly where resources are scarce. This research evaluated shorter versions of the Edinburgh Postnatal Depression Scale (EPDS) to detect antenatal depression. This cross-sectional study at a large primary health care (PHC) facility recruited a consecutive series of 109 antenatal attendees in rural South Africa. Women were in the second half of pregnancy and completed the EPDS and Structured Clinical Interview for Depression (SCID). The recommended EPDS cutoff (≥13) was used to determine probable depression. Four versions, including the 10-item scale, seven-item depression, and novel three- and five-item versions developed through regression analysis, were evaluated using receiver operating characteristic (ROC) analysis. High numbers of women 51/109 (47 %) were depressed, most depression was chronic, and nearly half of the women were HIV positive 49/109 (45 %). The novel three-item version had improved positive predictive value (PPV) over the 10-item version and equivalent specificity to the seven-item depression subscale; the novel five-item provided the best overall performance in terms of ROC and Cronbach’s reliability statistics and had improved specificity. The brevity, sensitivity, and reliability of the short and ultrashort versions could facilitate widespread community screening. The usefulness of the novel three- and five-item versions are underscored by the fact that sensitivity is important at first screening, while specificity becomes more important at higher levels of care. Replication in larger samples is required. © 2013 The Author(s).
Data were collected at a large centralized PHC facility located in an area with high HIV prevalence, in a predominantly rural part of South Africa (Tanser et al. 2008). The facility is staffed by 20–30 nurses offering a full range of PHC services to approximately 10,000 patients per month, including antenatal outpatient clinics, with an average of 160 first time antenatal attendees per month. This facility offers a 24-h service managing normal deliveries, with between 70 and 100 deliveries monthly (Houlihan et al. 2010). The subdistrict health services include a district hospital with 250 beds and 17 decentralized PHC clinics servicing a population of 228,000 over a geographical area of approximately 1,500 km2. The research was based on an assessment at one time point, in the second-half of pregnancy, and the details are described elsewhere (Rochat et al. 2011). Eligible women were required to attend routine antenatal care, be at least 16 years of age, and a resident in the study area. As part of Prevention of Mother to Child Transmission Programs (PMTCT), all women were screened for HIV in routine antenatal care. Women learning their HIV status for the first time during this current pregnancy were included, regardless of whether they tested HIV positive or HIV negative. HIV testing took place 2–3 weeks prior to the depression assessment (Rochat et al. 2006). Women living with HIV (WLH) prior to this pregnancy were considered a separate group, with different risk profiles, and referred to nonroutine antenatal care, and thus excluded from the study. Women with chronic health problems such as diabetes and hypertension were also referred to specialist services and excluded. Written informed consent was obtained in writing and ethical approval obtained from the Biomedical Ethics Review Board of the University of KwaZulu-Natal (E193/3) and the Oxford Tropical Research Ethics Committee (OXTREC 014–04). Women were interviewed in the local language (Zulu) using the major depression section of the Structured Clinical Interview for Depression (SCID) for Diagnostic and Statistical Manual of Mental Disorders (4th Edition) diagnoses and the EPDS administered in interview format. Anxiety was not assessed with the clinical interview method. Detailed information on cross-cultural validation and scoring methods for the presence/absence of a DSM-IV Major Depressive Episode (MDE) are available (Rochat et al. 2011). The highest recommended cutoff of ≥13 was used to define probable depression on the EPDS. HIV status was collected via self-report and verified against clinic records. Data were double entered for accuracy into Stata 11. Data analysis examined the sensitivity and specificity and the positive predictive value (PPV) of the EPDS against the depression outcome, determined by the SCID. Multiple regression techniques examined EPDS items to identify those items significantly associated with clinical depression, significance was set at p < 0.001. Previously published scoring techniques for using shorter versions of the EPDS were applied (Mitchell and Coyne 2007; Kabir et al. 2008; Choi et al. 2012). The same recommended EPDS cutoff ≥13 was used for all versions of the scale. Receiver operating characteristic (ROC) analysis examined four versions of the EPDS including the full 10-item EPDS (EPDS10), the traditional depression subscale (EPDS7), and the new five-item (EPDS5R) and three-item versions (EPDS-3R) identified through item regression analysis. Given that anxiety was not measured using a gold standard measure, the three-item anxiety subscale was not examined in this analysis. Effectiveness was determined by the ability of versions or subscales to predict accurately the presence (sensitivity) or absence (specificity) of depression according to the “gold standard” clinical diagnostic measure. Various statistics were examined and included both positive and negative predictive values in order to take prevalence into account, and to fully explore the data, likelihood ratios were calculated conventionally and weighted by prevalence. Kappa statistic and Cronbach's alpha were calculated for each version.
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