Edinburgh Postnatal Depression Scale: Scoring, Cutoffs, Accuracy

The Edinburgh Postnatal Depression Scale (EPDS) is a 10-item questionnaire that people complete themselves to screen for depression during pregnancy and after birth^[1][3]. J.L. Cox, J.M. Holden and R. Sagovsky described it in the British Journal of Psychiatry in 1987, after a validation study of 84 mothers against a standardised psychiatric interview^[1].

It was developed at health centres in Livingston and Edinburgh to help health professionals detect postpartum depression, which the scale's scoring guide describes as more prolonged than the "blues" of the first week after delivery but less severe than puerperal psychosis^[3].

The EPDS asks how the person has felt in the past 7 days, not just today, and most mothers finish it in less than five minutes^[3]. The U.S. Preventive Services Task Force lists it among the commonly used depression screening instruments, naming it for pregnant and postpartum persons^[6].

Users may reproduce the scale without further permission if they quote the authors, title and source paper; copyright remains with the British Journal of Psychiatry^[3]. A Spanish version was developed at the University of Iowa^[3].

For how common perinatal depression is, see the postpartum depression data, the depression during pregnancy data and postpartum depression statistics.

Each of the 10 items is a statement with four answer options, scored 0, 1, 2 or 3 according to how severe the symptom is^[3]. Items 1, 2 and 4 list the least severe answer first, while items 3 and 5 through 10 are reverse-scored, so their first answer is worth 3 points^[3][4].

The total is the sum of all 10 item scores, so it runs from 0 to a maximum of 30^[3]. The items cover loss of enjoyment, self-blame, anxiety and panic, feeling overwhelmed, sleep trouble linked to unhappiness, sadness, crying and thoughts of self-harm^[3].

The scoring guide's instructions say all 10 items must be completed and that the mother should fill in the scale herself unless she has limited English or difficulty reading^[3]. They also say care should be taken to avoid her discussing her answers with others^[3].

No single EPDS cutoff is used everywhere. The original validation found that mothers scoring above a threshold of 12/13 were likely to have a depressive illness of varying severity^[3].

ACOG and the AAP use a lower bar. ACOG's perinatal toolkit treats a total of 10 or more, or any answer other than "never" on item 10, as a positive screen^[4], and the AAP describes a score of 10 or greater as indicating possible depression^[7].

The 2020 BMJ individual participant data meta-analysis found that a cutoff of 11 or higher maximised combined sensitivity and specificity^[2]. Its authors suggested 13 or higher to identify women with higher symptom levels, and lower cutoffs when the aim is to avoid false negatives^[2].

Utah's patient version of the form adds a middle band: it tells people who score 9 or 10 to repeat the test in a week or call their provider, and those who score 11 or more to call their provider now^[3].

Whatever the cutoff, the result prompts an assessment rather than settling a diagnosis. The scoring guide states that the EPDS score should not override clinical judgement and that a careful clinical assessment should confirm the diagnosis^[3].

The largest accuracy study obtained individual participant data from 58 studies covering 15,557 participants, 2,069 of whom had major depression^[2]. A cutoff of 11 or higher gave the best combined accuracy across all three types of diagnostic interview it examined^[2].

Raising the cutoff trades sensitivity for specificity. In studies using semi-structured interviews, moving from 10 or higher to 13 or higher lowered sensitivity from 85% to 66% while specificity rose from 84% to 95%^[2].

The USPSTF's 2023 evidence review judged EPDS accuracy similar to the two-item PHQ-2, with sensitivity of 81% to 90% and specificity of 83% to 88% at cutoffs of 11 and 12^[6]. The 1987 validation also found the scale sensitive to change in the severity of depression over time^[1], and the scoring guide notes it can be repeated after two weeks in doubtful cases^[3].

A positive screen often signals more than depression alone. In a JAMA Psychiatry case series of 10,000 mothers screened by phone 4 to 6 weeks after birth, 1,396 (14.0%) scored 10 or higher^[8].

Among screen-positive women who completed a diagnostic interview, 68.5% had a unipolar depressive disorder as the primary diagnosis, almost two-thirds had a co-occurring anxiety disorder, and 22.6% had a bipolar disorder^[8]. Episodes began after delivery in 40.1% of cases, during pregnancy in 33.4% and before pregnancy in 26.5%^[8].

ACOG's toolkit cites that study when noting that 1 in 5 women who screen positive for depression may have bipolar disorder^[5]. Its guideline calls for screening for bipolar disorder before starting medication for depression or anxiety if it has not been done, and its composite screener pairs the EPDS with the Mood Disorder Questionnaire^[5].

Item 10 reads "The thought of harming myself has occurred to me," with the answers "yes, quite often," "sometimes," "hardly ever" and "never"^[8]. Because it asks directly about self-harm, clinical tools read it on its own as well as within the total.

ACOG's scoring sheet treats any answer other than "never" on item 10 as a positive screen regardless of the total score^[4]. The AAP states that immediate action is necessary if question 10 on the EPDS is positive^[7].

ACOG's 2023 guideline says that when someone answers a self-harm or suicide question affirmatively, clinicians should immediately assess the likelihood, acuity and severity of risk and arrange risk-tailored management^[5].

In the 10,000-mother case series, 19.3% of screen-positive women reported self-harm ideation on item 10^[8]. Every mother with the highest intensity of that ideation also had a total score of 10 or higher^[8].

The self-harm item is a single screening question, not a risk assessment. The USPSTF found the evidence insufficient to judge the benefits and harms of screening adults for suicide risk, including pregnant and postpartum persons^[6]. Crisis contacts are listed at the end of this page.

The USPSTF recommends screening adults for depression, including pregnant and postpartum persons, a grade B recommendation issued in 2023^[6]. ACOG recommends screening for depression and anxiety with a validated instrument at the initial prenatal visit, later in pregnancy and at postpartum visits^[5].

The scoring guide says the EPDS may be used at six to eight weeks after birth or during pregnancy, and suggests the child health clinic, postpartum check-up or a home visit as opportunities to complete it^[3].

Pediatric visits are a second checkpoint. The AAP recommends screening mothers with a validated tool at the 1-, 2-, 4- and 6-month well-child visits, so that a mother who does not disclose symptoms at first has later chances to do so^[7].

The AAP notes that, in keeping with CMS recommendations, state Medicaid programs may pay for postpartum depression screening under Early and Periodic Screening, Diagnostic and Treatment (EPSDT) using a validated instrument such as the EPDS^[7].

Being asked is not universal. In CDC's 2018 PRAMS data from 31 sites, 79.1% of women said a provider asked about depression during prenatal care and 87.4% said so for the postpartum checkup, with Puerto Rico lowest on both at about half^[9].

PRAMS does not use the EPDS: it classifies postpartum depressive symptoms from two questions adapted from the PHQ-2, a method that put the 2018 prevalence at 13.2%^[9]. Treatment options after a positive screen are covered in postpartum depression treatment.

ACOG's toolkit offers two parallel composite screeners, one built on the EPDS and one on the PHQ-9, each combined with the MDQ, GAD-7 and PC-PTSD-5^[5]. The USPSTF found EPDS accuracy similar to that of the PHQ-2^[6].

The content differs. The AAP notes that the EPDS contains 2 questions about anxiety, while on the PHQ-9 the suicidality item is question 9^[7].

A 2008 study gave 238 women and 218 men a diagnostic interview and the EPDS at 6 weeks postpartum to test the EPDS-3A anxiety subscale^[10]. Its author concluded the EPDS can screen women for probable depression at a total of 13 or more and probable anxiety at an EPDS-3A score of 6 or more^[10].

The original scoring guide notes that the full scale will not detect anxiety neuroses, phobias or personality disorders^[3], and ACOG's composite screener includes the separate GAD-7^[5]. More on anxiety after birth is in postpartum anxiety and the postpartum anxiety data.

The EPDS was designed for mothers, but it has been tested in fathers. A 2022 meta-analysis of 7 studies with 2,393 participants found acceptable accuracy for paternal postpartum depression at cutoffs of 7 to 10^[11].

That review found accuracy in fathers was unaffected by the prevalence of depression, the fathers' mean age or the translated language^[11]. The 2008 study also cited an existing validated total cutoff of 6 or more for both depression and anxiety in men^[10]. Broader figures are on the depression in men page.