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Title of Journal: Arch Womens Ment Health

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Abbravation: Archives of Women's Mental Health

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Springer Vienna

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Detection of antenatal depression in rural HIV-affected populations with short and ultrashort versions of the Edinburgh Postnatal Depression Scale (EPDS)

Authors: Tamsen J. Rochat, Mark Tomlinson, Marie -Louise Newell, Alan Stein,

Publish Date: 2013/04/25
Volume: 16, Issue:5, Pages: 401-410
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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.Prevalence of depression is similar in pregnant, postpartum, and nonpregnant women. However, the onset of new depression is higher during the perinatal period (Vesga-Lopez et al. 2008) and postpartum depression is often preceded by antenatal symptomology (Rahman and Creed 2007; Milgrom et al. 2008). Depression during pregnancy has been associated with poor uptake of antenatal care and adverse fetal and obstetric outcomes (Lancaster et al. 2010; Alder et al. 2007; Grote et al. 2010). Increasingly, anxiety during pregnancy has also been shown to be of concern (Alder et al. 2007; Austin 2004). While increased health care contact during pregnancy provides opportunities for screening, prevention, and treatment (Committee on Psychosocial Aspects of Child and Family Health: Task Force on Mental Health 2009), antenatal depression frequently remains undetected and untreated (Goodman and Tyer-Viola 2010).A systematic review of perinatal mental disorders in low- and middle-income countries (LMIC) found a concerning burden, with weighted mean prevalence between 15 and 20 % (Fisher et al. 2012), with the review highlighting the dearth of research evidence in LMIC (Parsons et al. 2011) and in Africa (Sawyer et al. 2010), a continent also heavily affected by HIV epidemics. In the sub-Saharan African region alone, in 2010, approximately 1.36 million pregnant women were living with HIV (World Health Organization 2011); antenatal depression has been shown to be elevated in the context of HIV with rates above 40 % (Rubin et al. 2011; Rochat et al. 2011; Rochat et al. 2006). Improving early detection and intervention during routine pregnancy care may reduce risks for postnatal depression and may also improve HIV treatment and prevention outcomes (Psaros et al. 2009; Kapetanovic et al. 2009; Levine et al. 2008).Despite significant and growing support for universal screening (Mitchell and Coyne 2007; Breedlove and Fryzelka 2011; Kim et al. 2008; Kuchn 2010), multiple challenges exist in ensuring that health care practitioners screen for depression in primary health care (PHC) and among high risk populations such as pregnant women (Gjerdingen and Yawn 2007; Kopelman et al. 2008; Rice et al. 2007). Resistance to screening is often high where primary care is particularly time pressured, creating a need for short, user-friendly, and sensitive tools. A recent pooled analysis (Mitchell and Coyne 2007) found that ultra short one-item screens have reasonable specificity, but low sensitivity, identifying only three in 10 depressed patients, while two- or three-item ultrashort measures have significantly improved sensitivity, identifying eight in 10 depressed cases. However, there are concerns that this higher sensitivity comes at the expense of high false-positive rates that prove too costly when resources are scarce. Evidence supporting the cost effectiveness of universal screening is mixed (Yonkers et al. 2009; Mitchell and Coyne 2009), with some studies showing that lack of access to treatment undermines the cost effectiveness of universal screening (Paulden et al. 2009), as does offering treatment to women who do not need it or to those who do not want it (Dowswell et al. 2010).The issue of whether universal screening improves access to treatment, whether it is feasible, or benefits patients, is particularly complex in low-resource settings (Kagee et al. 2012; O'Hara et al. 2012). Barriers to routine screening for antenatal depression include lack of time, stigma, incomplete training, inattention by health professionals, and a lack of referral sources (Earls and The Committee on Psychosocial Aspects of Child Family Health 2010; Honikman et al. 2012). In LMIC settings, screening is often restricted by critical shortages in health care professionals at PHC level (Patel et al. 2009) and task shifting of primary care and prevention functions to community health care workers (CHW) is proposed as a means to improve maternal and child outcomes (Lewin et al. 2010). Approaches that incorporate CHWs in the detection and management of perinatal mental disorders have shown potential, with research demonstrating the capacity of CHWs to deliver treatment for both HIV (Selke et al. 2010) and maternal depression (Rahman 2005; Rahman et al. 2008). However, actualizing this potential at a larger scale requires short, effective screening measures to facilitate detection in two ways: firstly, by facilitating screening by CHWs who may identify risk at a household level and secondly, by facilitating screening by busy health practitioners within antenatal services. Shorter tools provide benefits from the health care perspective and have higher acceptability for women (Milgrom et al. 2011; Breedlove and Fryzelka 2011).The Edinburgh Postnatal Depression Scale (EPDS) is the most widely used screening tool for the detection of perinatal depression (Lusskin et al. 2007; Breedlove and Fryzelka 2011). It is frequently used in LMIC settings (Parsons et al. 2011; Sawyer et al. 2010; Halbreich and Karkun 2006) and in HIV-endemic communities (Chibanda et al. 2010; Manikkam and Burns 2012), and is widely used in South Africa (Hartley et al. 2011; Rotheram-Borus et al. 2011; Rochat et al. 2006). Preliminary evidence from research in North America (Kabir et al. 2008) found that the three-item anxiety subscale of a EPDS was as effective as longer versions in identifying depression risk in the postnatal period. Research in Asia (Choi et al. 2012) found that two items of the EPDS predicted antenatal risk as well as the full 10-item version. However, interpretation of these findings is limited by the fact that neither of these studies included a diagnostic measure of depression. However, recent research examining a basket of commonly used items against clinical interview methods in the United States found that a combination of two to three items worked as well in identifying depression when compared to the EPDS10 and other commonly used screening tools (O'Hara et al. 2012).In HIV-epidemic regions of Southern Africa, the burden of antenatal and postnatal depression has been shown to be as high as 30–50 % in multiple studies (Hartley et al. 2011; Manikkam and Burns 2012; Chibanda et al. 2010; Rochat et al. 2006; Rochat et al. 2011; Stewart et al. 2010). In these resource-scarce settings, women are known to be at high risk, but given low availability of resources, they are unlikely to be screened in primary care. Research in antenatal environments in South African illustrates that universal screening is feasible and acceptable but that shorter screening tools are needed to facilitate appropriate use of scarce resources in busy PHC settings (Honikman et al. 2012). Task shifting screening to CHWs who are able to screen at routine home visits requires simple, short screening tools with good sensitivity to ensure detection of women in need of referral, but also balanced with good specificity to ensure that referrals of false positives do not overburden already overburdened PHC resources (Kagee et al. 2012). Furthermore, at PHC level, short reliable screens that help nursing professionals determine which women should be referred to a medical officer would also help in making the most use of extremely scarce resources. Yet, no studies to date using clinical interview methods have examined the effectiveness of short and ultrashort versions of the EPDS for this purpose. The aim of this research is to test the hypothesis that shortened versions of the EPDS are as effective as longer versions in identifying antenatal depression as determined by a clinical interview diagnostic method.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.



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