Top

Published in:

Open Access 18-07-2023 | Mood Disorders | Original Article

Comparing the factor structures and reliabilities of the EPDS and the PHQ-9 for screening antepartum and postpartum depression: a multigroup confirmatory factor analysis

Authors: Alberto Stefana, Joshua A. Langfus, Gabriella Palumbo, Loredana Cena, Alice Trainini, Antonella Gigantesco, Fiorino Mirabella

Published in: Archives of Women's Mental Health | Issue 5/2023

Abstract

To evaluate and compare the factor structure and reliability of EPDS and PHQ in antepartum and postpartum samples. Parallel analysis and exploratory factor analysis were conducted to determine the structure of both scales in the entire sample as well as in the antepartum and postpartum groups. McDonald’s omega statistics examined the utility of treating items as a single scale versus multiple factors. Multigroup confirmatory factor analysis (MCFA) was utilized to test the measurement invariance between the antepartum and postpartum groups. Two-factor models fit best for the EPDS in both the antepartum and postpartum groups; however, the most reliable score variance was attributable to a general factor for each scale. MCFA provided evidence of weak invariance across groups regarding factor loadings and partial invariance regarding item thresholds. PHQ-9 showed a two-factor model in the antepartum group; however, the same model did not fit well in the postpartum group. EPDS should be preferred to PHQ-9 for measuring depressive symptoms in peripartum populations. Both scales should be used as a single-factor scale. Caution is required when comparing the antepartum and postpartum scores.

Accortt EE, Wong MS (2017) It is time for routine screening for perinatal mood and anxiety disorders in obstetrics and gynecology settings. Obstet Gynecol Surv 72:553–568. https://doi.org/10.1097/OGX.0000000000000477CrossRefPubMed

ACOG Committee (2018) Opinion No. 757: Screening for perinatal depression. Obstet Gynecol 132(5):e208–e212. https://doi.org/10.1097/AOG.0000000000002927CrossRef

American Psychiatric Association (2013) The diagnostic and statistical manual of mental disorders, (4th edn text revision)(DSM-IVTR). American Psychiatric Publishing

Association American Psychiatric (1994) Diagnostic and statistical manual of mental disorders, 4th edition text revision (DSM-IV- TR). American Psychiatric Publishing

Austin M-P, Highet N, The Expert Working Group (2017) Mental health care in the perinatal period: Australian clinical practice guideline. Centre of Perinatal Excellence

Barthel D, Barkmann C, Ehrhardt S, Schoppen S, Bindt C, International CDS Study Group (2015) Screening for depression in pregnant women from Côte d'Ivoire and Ghana: psychometric properties of the Patient Health Questionnaire-9. J Affective Disord 187:232–240. https://doi.org/10.1016/j.jad.2015.06.042CrossRef

Batt MM, Duffy KA, Novick AM, Metcalf CA, Epperson CN (2020) Is postpartum depression different from depression occurring outside of the perinatal period? A review of the evidence. Focus (American Psychiatric Publishing) 18(2):106–119. https://doi.org/10.1176/appi.focus.20190045CrossRefPubMed

Bedford A, Foulds GA, Sheffield BF (1976) A new personal disturbance scale (DSSI/sAD). Br J Soc Clin Psychol 15:387–394. https://doi.org/10.1111/j.2044-8260.1976.tb00050.xCrossRefPubMed

Benvenuti P, Ferrara M, Niccolai C, Valoriani V, Cox JL (1999) The Edinburgh postnatal depression scale: validation for an Italian sample. J Affect Disord 53:137–141. https://doi.org/10.1016/S0165-0327(98)00102-5

Berle JØ, Aarre TF, Mykletun A, Dahl AA, Holsten F (2003) Screening for postnatal depression validation of the Norwegian version of the Edinburgh Postnatal Depression Scale, and assessment of risk factors for postnatal depression. J Affect Disord 76:151–156. https://doi.org/10.1016/S0165-0327(02)00082-4CrossRefPubMed

Cena L, Biban P, Janos J, Lavelli M, Langfus J, Tsai A, Youngstrom EA, Stefana A (2021) The collateral impact of COVID-19 emergency on neonatal intensive care units and family-centered care: challenges and opportunities. Front Psychol 12:630594. https://doi.org/10.3389/fpsyg.2021.630594

Cena L, Gigantesco A, Mirabella F, Palumbo G, Camoni L, Trainini A, Stefana A (2021a) Prevalence of comorbid anxiety and depressive symptomatology in the third trimester of pregnancy: analysing its association with sociodemographic, obstetric, and mental health features. J Affective Disord 295:1398–1406

Cena L, Gigantesco A, Mirabella F, Palumbo G, Trainini A, Stefana A (2021b) Prevalence of maternal postnatal anxiety and its association with demographic and socioeconomic factors: a multicentre study in Italy. Front Psychol 12:737666. https://doi.org/10.3389/fpsyt.2021.737666

Cena L, Mirabella F, Palumbo G, Gigantesco A, Trainini A, Stefana A (2020) Prevalence of maternal antenatal anxiety and its association with demographic and socioeconomic factors: a multicentre study in Italy. Eur Psychiatry 63:E84. https://doi.org/10.1192/j.eurpsy.2020.82CrossRefPubMedPubMedCentral

Cena L, Palumbo G, Mirabella F, Gigantesco A, Stefana A, Trainini A, Tralli N, Imbasciati A (2020) Perspectives on early screening and prompt intervention to identify and treat maternal perinatal mental health. Protocol for a prospective multicenter study in Italy. Front Psychol 11:365. https://doi.org/10.3389/fpsyg.2020.00365

Coates R, Ayers S, de Visser R (2017) Factor structure of the Edinburgh Postnatal Depression Scale in a population-based sample. Psychol Assess 29:1016–1027. https://doi.org/10.1037/pas0000397CrossRefPubMed

Cox JL, Holden JM, Sagovsky R (1987) Detection of postnatal depression. Br J Psychiatry 150:782–786. https://doi.org/10.1192/bjp.150.6.782CrossRefPubMed

Della Vedova AM, Loscalzo Y, Giannini M, Matthey S (2022) An exploratory and confirmatory factor analysis study of the EPDS in postnatal Italian-speaking women. J Reprod Infant Psychol 40(2):168–180. https://doi.org/10.1080/02646838.2020.1822993CrossRefPubMed

El-Den S, Chen TF, Gan YL, Wong E, O’Reilly CL (2018) The psychometric properties of depression screening tools in primary healthcare settings: a systematic review. J Affective Disord 225:503–522. https://doi.org/10.1016/j.jad.2017.08.060CrossRef

Glorfeld LW (1995) An improvement on Horn’s parallel analysis methodology for selecting the correct number of factors to retain. Educ Psychol Meas 55(3):377–393. https://doi.org/10/b3fjvm

Halbreich U, Karkun S (2006) Cross-cultural and social diversity of prevalence of postpartum depression and depressive symptoms. J Affective Disord 91(2-3):97–111. https://doi.org/10.1016/j.jad.2005.12.051CrossRef

Haroz, E. E., Ritchey, M., Bass, J. K., Kohrt, B. A., Augustinavicius, J., Michalopoulos, L., ... & Bolton, P. (2017). How is depression experienced around the world? A systematic review of qualitative literature. Soc Sci Med, 183, 151-162. https://doi.org/10.1016/j.socscimed.2016.12.030

Hirschtritt ME, Kroenke K (2017) Screening for depression. JAMA 318(8):745–746. https://doi.org/10.1001/jama.2017.9820CrossRefPubMed

Howard LM, Khalifeh H (2020) Perinatal mental health: a review of progress and challenges. World Psychiatry 19(3):313–327. https://doi.org/10.1002/wps.20769CrossRefPubMedPubMedCentral

Howard LM, Molyneaux E, Dennis CL, Rochat T, Stein A, Milgrom J (2014) Non-psychotic mental disorders in the perinatal period. Lancet (London, England) 384(9956):1775–1788. https://doi.org/10.1016/S0140-6736(14)61276-9CrossRefPubMed

Knapp M, Wong G (2020) Economics and mental health: the current scenario. World Psychiatry 19(1):3–14. https://doi.org/10.1002/wps.20692CrossRefPubMedPubMedCentral

Kroenke K (2021) PHQ-9: global uptake of a depression scale. World Psychiatry 20(1):135–136. https://doi.org/10.1002/wps.20821CrossRefPubMedPubMedCentral

Kroenke K, Spitzer RL, Williams JBW (2001) The PHQ-9. Validity of a brief depression severity measure. J Gen Intern Med 16:606–613. https://doi.org/10.1046/j.1525-1497.2001.016009606.xCrossRefPubMedPubMedCentral

Kubota, C., Inada, T., Nakamura, Y., Shiino, T., Ando, M., Aleksic, B., ... & Ozaki, N. (2018). Stable factor structure of the Edinburgh Postnatal Depression Scale during the whole peripartum period: results from a Japanese prospective cohort study. Sci Rep, 8(1), 1-7. https://doi.org/10.1038/s41598-018-36101-z

Langan RC, Goodbred AJ (2016) Identification and management of peripartum depression. Am Fam Physician 93(10):852–858PubMed

Lara-Cinisomo S, Akinbode TD, Wood J (2020) A systematic review of somatic symptoms in women with depression or depressive symptoms: do race or ethnicity matter? J. Women’s Heal 2019:7975. https://doi.org/10.1089/jwh.2019.7975CrossRef

Liu X, Wang S, Wang G (2022) Prevalence and risk factors of postpartum depression in women: a systematic review and meta-analysis. J Clin Nurs 31:19–20. https://doi.org/10.1111/jocn.16121CrossRef

Long, M. M., Cramer, R. J., Bennington, L., Morgan Jr, F. G., Wilkes, C. A., Fontanares, A. J., ... & Paulson, J. F. (2020). Psychometric assessment of the Edinburgh Postnatal Depression Scale in an obstetric population. Psychiatry Res, 291, 113161. https://doi.org/10.1016/j.psychres.2020.113161

Luca DL, Margiotta C, Staatz C, Garlow E, Christensen A, Zivin K (2020) Financial toll of untreated perinatal mood and anxiety disorders among 2017 births in the United States. Am J Public Health 110(6):888–896. https://doi.org/10.2105/AJPH.2020.305619CrossRefPubMedPubMedCentral

Marcos-Nájera R, Le HN, Rodríguez-Muñoz MF, Olivares Crespo ME, Izquierdo Mendez N (2018) The structure of the Patient Health Questionnaire-9 in pregnant women in Spain. Midwifery 62:36–41. https://doi.org/10.1016/j.midw.2018.03.011CrossRefPubMed

Matsumura K, Hamazaki K, Tsuchida A et al (2020) Factor structure of the Edinburgh Postnatal Depression Scale in the Japan Environment and Children’s Study. Sci Rep 10:11647. https://doi.org/10.1038/s41598-020-67321-xCrossRefPubMedPubMedCentral

Mazzotti, E., Fassone, G., Picardi, A., Sagoni, E., Ramieri, L., Lega, I., ... & Pasquini, P. (2003). II Patient Health Questionnaire (PHQ) per lo screening dei disturbi psichiatrici: Uno studio di validazione nei confronti della Intervista Clinica Strutturata per il DSM-IV asse I (SCID-I). Ital J Psychopathol, 9(3), 235-242

Nakić Radoš S, Tadinac M, Herman R (2018) Anxiety during pregnancy and postpartum: course, predictors and comorbidity with postpartum depression. Acta Clinica Croatica 57(1):39–51. https://doi.org/10.20471/acc.2017.56.04.05

Negeri ZF, Levis B, Sun Y, He C, Krishnan A, Wu Y, Bhandari PM, Neupane D, Brehaut E, Benedetti A, Thombs BD, Depression Screening Data (DEPRESSD) PHQ Group (2021) Accuracy of the patient health questionnaire-9 for screening to detect major depression: updated systematic review and individual participant data meta-analysis. BMJ (Clinical research ed.) 375:n2183. https://doi.org/10.1136/bmj.n2183

O’Connor E, Senger CA, Henninger M, Gaynes BN, Coppola E, Weyrich MS (2019) Interventions to prevent perinatal depression. Evidence report and systematic review for the US Preventive Services Task Force. JAMA 321:588–601. https://doi.org/10.1001/jama.2018.20865CrossRefPubMed

Pereira, A. T., Marques, M., Soares, M. J., Maia, B. R., Bos, S., Valente, J., ... & Macedo, A. (2014). Profile of depressive symptoms in women in the perinatal and outside the perinatal period: similar or not?. J Affective Disord, 166, 71-78. https://doi.org/10.1016/j.jad.2014.04.008

Putnam, K. T., Wilcox, M., Robertson-Blackmore, E., Sharkey, K., Bergink, V., Munk-Olsen, T., Deligiannidis, K. M., Payne, J., Altemus, M., Newport, J., Apter, G., Devouche, E., Viktorin, A., Magnusson, P., Penninx, B., Buist, A., Bilszta, J., O'Hara, M., Stuart, S., Brock, R., … Postpartum depression: action towards causes and treatment (PACT) consortium (2017). Clinical phenotypes of perinatal depression and time of symptom onset: analysis of data from an international consortium. Lancet Psychiatry, 4(6), 477–485. https://doi.org/10.1016/S2215-0366(17)30136-0

R Core Team (2022) R: A language and environment for statistical computing. R Foundation for Statistical Computing, Vienna, Austria URL https://www.r-project.org/

Revelle W (2023) Procedures for psychological, psychometric, and personality research. https://cran.r-project.org/web/packages/psych/psych.pdf. Accessed 12 July 2023

Revelle W, Condon DM (2019) Reliability from α to ω: a tutorial. Psychol Assess 31(12):1395–1411. https://doi.org/10.1037/pas0000754CrossRefPubMed

Roomruangwong C, Kanchanatawan B, Sirivichayakul S, Mahieu B, Nowak G, Maes M (2017) Lower serum zinc and higher CRP strongly predict prenatal depression and physio-somatic symptoms, which all together predict postnatal depressive symptoms. Mol Neurobiol 54(2):1500–1512CrossRefPubMed

Rosseel Y (2012) lavaan: an R package for structural equation modeling. J Stat Softw 48(2):1–36. https://doi.org/10.18637/jss.v048.i02

Smith ML, Sanchez SE, Rondon M, Gradus JL, Gelaye B (2022b) Validation of the Patient Health Questionnaire-9 (PHQ-9) for detecting depression among pregnant women in Lima, Peru. Curr Psychol: J Diverse Perspect Diverse Psychol Issues 41(6):3797–3805. https://doi.org/10.1007/s12144-020-00882-2CrossRef

Smith MS, Cairns L, Pullen LSW, Opondo C, Fellmeth G, Alderdice F (2022a) Validated tools to identify common mental disorders in the perinatal period: a systematic review of systematic reviews. J Affective Disord 298:634–643. https://doi.org/10.1016/j.jad.2021.11.011CrossRef

Smith-Nielsen J, Matthey S, Lange T, Væver MS (2018) Validation of the Edinburgh Postnatal Depression Scale against both DSM-5 and ICD-10 diagnostic criteria for depression. BMC Psychiatry 18:393. https://doi.org/10.1186/s12888-018-1965-7CrossRefPubMedPubMedCentral

Snaith RP, Constantopoulos AA, Jardine MY, McGuffin P (1978) A clinical scale for the self-assessment of Irritability. Br J Psychiatry 132:164–171. https://doi.org/10.1192/bjp.132.2.164CrossRefPubMed

Spitzer RL, Williams JB, Kroenke K, Linzer M, deGruy FV 3rd, Hahn SR, Brody D, Johnson JG (1994) Utility of a new procedure for diagnosing mental disorders in primary care. The PRIME-MD 1000 study. JAMA 272(22):1749–1756CrossRefPubMed

Spitzer RL, Williams JBW, Kroeneke K (2014) Test review: Patient Health Questionnaire–9 (PHQ-9). Rehabil Couns Bull 57:246–248. https://doi.org/10.1177/0034355213515305CrossRef

Steiner MD, Grieder S (2020) EFAtools: an R package with fast and flexible implementations of exploratory factor analysis tools. J Open Source Softw 5(53):2521. https://doi.org/10.21105/joss.02521CrossRef

Tabachnick BG, Fidell LS (2019) Using multivariate statistics, 7th edn. Pearson

Viktorin A, Meltzer-Brody S, Kuja-Halkola R, Sullivan PF, Landén M, Lichtenstein P, Magnusson PK (2016) Heritability of perinatal depression and genetic overlap with nonperinatal depression. Am J Psychiatry 173(2):158–165. https://doi.org/10.1176/appi.ajp.2015.15010085

Wakamatsu M, Minatani M, Hada A, Kitamura T (2021) The Patient Health Questionnaire-9 among first-trimester pregnant women in Japan: factor structure and measurement and structural invariance between nulliparas and multiparas and across perinatal measurement time points. Open J Depress 10:121–137. https://doi.org/10.4236/ojd.2021.103008CrossRef

Wang L, Kroenke K, Stump TE, Monahan PO (2021) Screening for perinatal depression with the Patient Health Questionnaire depression scale (PHQ-9): a systematic review and meta-analysis. Gen Hosp Psychiatry 68:74–82. https://doi.org/10.1016/j.genhosppsych.2020.12.007CrossRefPubMed

Woldetensay YK, Belachew T, Tesfaye M, Spielman K, Biesalski HK, Kantelhardt EJ et al (2018) Validation of the patient health qQuestionnaire (PHQ-9) as a screening tool for depression in pregnant women: Afaan Oromo version. PLoS ONE 13(2):e0191782. https://doi.org/10.1371/journal.pone.0191782

World Health Organization. Regional Office for Europe (‎2020)‎ Screening programmes: a short guide. Increase effectiveness, maximize benefits and minimize harm. World Health Organization

Yin, X., Sun, N., Jiang, N., Xu, X., Gan, Y., Zhang, J., ... & Gong, Y. (2021). Prevalence and associated factors of antenatal depression: systematic reviews and meta-analyses Clin Psychol Rev, 83, 101932, https://doi.org/10.1016/j.cpr.2020.101932

Zhong Q, Gelaye B, Rondon M, Sánchez SE, García PJ, Sánchez E, Barrios YV, Simon GE, Henderson DC, Cripe SM, Williams MA (2014) Comparative performance of Patient Health Questionnaire-9 and Edinburgh Postnatal Depression Scale for screening antepartum depression. J Affect Disord 162:1–7. https://doi.org/10.1016/j.jad.2014.03.028CrossRefPubMedPubMedCentral

Zigmond AS, Snaith RP (1983) The Hospital Anxiety and Depression Scale. Acta Psychiatr Scand 67:361–370. https://doi.org/10.1111/j.1600-0447.1983.tb09716.xCrossRefPubMed

Title: Comparing the factor structures and reliabilities of the EPDS and the PHQ-9 for screening antepartum and postpartum depression: a multigroup confirmatory factor analysis
Authors: Alberto Stefana
Joshua A. Langfus
Gabriella Palumbo
Loredana Cena
Alice Trainini
Antonella Gigantesco
Fiorino Mirabella
Publication date: 18-07-2023
Publisher: Springer Vienna
Keywords: Mood Disorders
Affective Disorder
Published in: Archives of Women's Mental Health / Issue 5/2023
Print ISSN: 1434-1816
Electronic ISSN: 1435-1102
DOI: https://doi.org/10.1007/s00737-023-01337-w

Keynote webinar | Spotlight on medication adherence

Springer Medicine

Comparing the factor structures and reliabilities of the EPDS and the PHQ-9 for screening antepartum and postpartum depression: a multigroup confirmatory factor analysis

Abstract

Keynote webinar | Spotlight on medication adherence

Springer Medicine

Abstract

Please log in to get access to this content

Other articles of this Issue 5/2023

Parental bonding style and illness severity in a longitudinal study of individuals with first episode psychosis

Mental health issues following sexual assault among the flood-affected women of Pakistan

Ethnic identity and barriers for using mental health services among Arab-Bedouin women coping with emotional distresses

Assessing decisional conflict and challenges in decision-making among perinatal women using or considering using antidepressants during pregnancy—a mixed-methods study

Changes in mental health symptoms and sociocultural factors across the COVID-19 pandemic in mothers of Mexican descent

Maternal prenatal attachment during the COVID-19 pandemic: exploring the roles of pregnancy-related anxiety, risk perception, and well-being