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Cited by 922Maternal Mental Health During Pregnancy and PostpartumMaternal and Neonatal HealthcareAnxiety, Depression, Psychometrics, Treatment, Cognitive Processes

Accuracy of the Edinburgh Postnatal Depression Scale (EPDS) for screening to detect major depression among pregnant and postpartum women: systematic review and meta-analysis of individual participant data

Open access
Levis, Brooke, Negeri, Zelalem, Sun, Ying, Benedetti, Andrea, Thombs, Brett D·2020·BMJ
DOI 10.1136/bmj.m4022PMC PMC7656313
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Abstract

Objective: To evaluate the Edinburgh Postnatal Depression Scale (EPDS) for screening to detect major depression in pregnant and postpartum women. Design: Individual participant data meta-analysis. Data sources: Medline, Medline In-Process and Other Non-Indexed Citations, PsycINFO, and Web of Science (from inception to 3 October 2018). Eligibility criteria for selecting studies: Eligible datasets included EPDS scores and major depression classification based on validated diagnostic interviews. Bivariate random effects meta-analysis was used to estimate EPDS sensitivity and specificity compared with semi-structured, fully structured (Mini International Neuropsychiatric Interview (MINI) excluded), and MINI diagnostic interviews separately using individual participant data. One stage meta-regression was used to examine accuracy by reference standard categories and participant characteristics. Results: Individual participant data were obtained from 58 of 83 eligible studies (70%; 15 557 of 22 788 eligible participants (68%), 2069 with major depression). Combined sensitivity and specificity was maximised at a cut-off value of 11 or higher across reference standards. Among studies with a semi-structured interview (36 studies, 9066 participants, 1330 with major depression), sensitivity and specificity were 0.85 (95% confidence interval 0.79 to 0.90) and 0.84 (0.79 to 0.88) for a cut-off value of 10 or higher, 0.81 (0.75 to 0.87) and 0.88 (0.85 to 0.91) for a cut-off value of 11 or higher, and 0.66 (0.58 to 0.74) and 0.95 (0.92 to 0.96) for a cut-off value of 13 or higher, respectively. Accuracy was similar across reference standards and subgroups, including for pregnant and postpartum women. Conclusions: An EPDS cut-off value of 11 or higher maximised combined sensitivity and specificity; a cut-off value of 13 or higher was less sensitive but more specific. To identify pregnant and postpartum women with higher symptom levels, a cut-off of 13 or higher could be used. Lower cut-off values could be used if the intention is to avoid false negatives and identify most patients who meet diagnostic criteria. Registration: PROSPERO (CRD42015024785).

AI snapshot

Written from the paper’s full text.

TL;DR

In an individual participant data meta-analysis, the Edinburgh Postnatal Depression Scale (EPDS) maximised combined sensitivity and specificity at a cut-off of 11 or higher for detecting major depression in pregnant and postpartum women. Accuracy was similar across reference standards and subgroups, including pregnant versus postpartum status.

Key findings

  • Among 58 included studies (15,557 participants; 2,069 with major depression), combined sensitivity and specificity was maximised at an EPDS cut-off of 11 or higher across reference standards (Youden’s J=0.70 for semi-structured, 0.73 for fully structured, 0.66 for MINI).
  • For semi-structured interviews (36 studies, 9,066 participants, 1,330 with major depression), sensitivity and specificity were 0.85 (95% CI 0.79 to 0.90) and 0.84 (0.79 to 0.88) at ≥10; 0.81 (0.75 to 0.87) and 0.88 (0.85 to 0.91) at ≥11; and 0.66 (0.58 to 0.74) and 0.95 (0.92 to 0.96) at ≥13.
  • Accuracy was similar across reference standards and subgroups, including pregnant and postpartum women; no other study or participant characteristics were consistently associated with differences in sensitivity or specificity across both semi-structured and MINI categories.
  • For major depression prevalence of 5–25% and a cut-off of ≥11 compared with semi-structured interviews, positive predictive values ranged from 26% to 69% and negative predictive values from 93% to 99%.

Methods

  • Individual participant data meta-analysis (PROSPERO CRD42015024785) of studies administering the EPDS and classifying major depression via validated semi-structured or fully structured diagnostic interviews, with EPDS and interview no more than two weeks apart, in adult women during pregnancy or within 12 months postpartum.
  • Searched Medline, Medline In-Process and Other Non-Indexed Citations, PsycINFO, and Web of Science from inception to 3 October 2018; obtained individual participant data from 58 of 83 eligible studies (70%; 15,557 of 22,788 eligible participants, 68%).
  • Estimated sensitivity and specificity separately for semi-structured, fully structured (MINI excluded), and MINI reference standards using bivariate random effects models across cut-off values 7–15; used one-stage meta-regression to examine accuracy by reference standard categories and participant characteristics.

Limitations

  • The paper states that data were not obtained from 25 of 83 published eligible datasets, moderate heterogeneity was found across studies, and subgroup analyses by cultural aspects, country or language, or specific pregnancy trimesters/postpartum periods could not be conducted because data were insufficient; few studies from low and middle income countries were included.
  • The paper also states that while studies were categorised by interview administered, interviews might not always have been used as intended, and one third of studies were coded as unclear for interviewer qualification in risk of bias assessment.
  • Evident from the text: the fully structured reference standard subgroup was very small (3 studies for sensitivity and 4 for specificity; 3,188 participants, 227 with major depression), and one study included only one participant with major depression; age <25 subgroup analyses excluded four semi-structured and four MINI studies with no participants with major depression.

Model-written summary. Check it against the paper before relying on it.

Integrity signals

Registry

Crossref · 10.1136/bmj.m4022

Cites

41 of 41 references verified0 citation errors · 0 not checkable

Statistics

Nothing to recompute.

Claims the paper makes

0 of 33 cited sources checked · 0 supported · 0 flagged

  • Findingown data

    Among studies with a semi-structured interview (36 studies, 9066 participants, 1330 with major depression), EPDS cut-off value of 10 or higher had sensitivity 0.85 (95% CI 0.79 to 0.90).

    “Among studies with a semi-structured interview (36 studies, 9066 participants, 1330 with major depression), sensitivity and specificity were 0.85 (95% confidence interval 0.79 to 0.90) and 0.84 (0.79 to 0.88) for a cut-off value of 10 or higher, 0.81 (0.75 to 0.87) and 0.88 (0.85 to 0.91) for a cut-off value of 11 or higher, and 0.66 (0.58 to 0.74) and 0.95 (0.92 to 0.96) for a cut-off value of 13”
    Quote in the paperSubstantial claim
  • Findingown data

    EPDS screening accuracy was similar across reference standards and subgroups, including for pregnant and postpartum women.

    “Accuracy was similar across reference standards and subgroups, including for pregnant and postpartum women.”
    Quote in the paperSubstantial claim
  • Findingown data

    Among studies with a semi-structured interview (36 studies, 9066 participants, 1330 with major depression), EPDS cut-off value of 13 or higher had sensitivity 0.66 (95% CI 0.58 to 0.74).

    “Among studies with a semi-structured interview (36 studies, 9066 participants, 1330 with major depression), sensitivity and specificity were 0.85 (95% confidence interval 0.79 to 0.90) and 0.84 (0.79 to 0.88) for a cut-off value of 10 or higher, 0.81 (0.75 to 0.87) and 0.88 (0.85 to 0.91) for a cut-off value of 11 or higher, and 0.66 (0.58 to 0.74) and 0.95 (0.92 to 0.96) for a cut-off value of 13”
    Quote in the paperSubstantial claim
  • Findingown data

    Among the included participants, 2069 had major depression.

    “Individual participant data were obtained from 58 of 83 eligible studies (70%; 15 557 of 22 788 eligible participants (68%), 2069 with major depression).”
    • Also stated in: § Search results and dataset inclusion · plain
      “Authors of included studies contributed data from two other studies that the search did not retrieve for a total of 58 datasets (15 557 participants, 2069 with major depression).”
    Quote in the paperNot a substantial claim
  • Findingown data

    The included individual participant data comprised 15 557 of 22 788 eligible participants (68%).

    “Individual participant data were obtained from 58 of 83 eligible studies (70%; 15 557 of 22 788 eligible participants (68%), 2069 with major depression).”
    • Also stated in: § Search results and dataset inclusion · plain
      “Of 22 788 participants in 83 eligible published studies, 15 557 (68%) were included.”
    Quote in the paperNot a substantial claim
  • May combine two claims. 27
  • Classified as probably not a substantial claim. 23

  • May combine two claims.

    Findingown data

    Eligible studies that did and did not contribute data were generally similar in sample size, proportion of participants with major depression, and country human development index.

    “Eligible studies that did and did not contribute data were generally similar in terms of sample size, proportion of participants with major depression (excluding non-contributing studies where number with major depression was not reported), and country human development index.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Findingown data

    Of 58 included studies, 36 used semi-structured reference standards (34 SCID), 4 used fully structured reference standards excluding MINI (3 CIDI), and 18 used the MINI.

    “Thirty six studies used semi-structured reference standards, including 34 that used the SCID; four used fully structured reference standards (MINI excluded), including three that used the CIDI; and 18 used the MINI (table 1).”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Findingown data

    Of 58 included studies, 25 included pregnant women, 30 postpartum women, and three both pregnant and postpartum women.

    “Of 58 included studies, 25 included pregnant women, 30 postpartum women, and three both pregnant and postpartum women.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    Among studies using a semi-structured interview, there were 36 studies, 9066 participants, and 1330 participants with major depression.

    “Among studies with a semi-structured interview (36 studies, 9066 participants, 1330 with major depression), sensitivity and specificity were 0.85 (95% confidence interval 0.79 to 0.90) and 0.84 (0.79 to 0.88) for a cut-off value of 10 or higher, 0.81 (0.75 to 0.87) and 0.88 (0.85 to 0.91) for a cut-off value of 11 or higher, and 0.66 (0.58 to 0.74) and 0.95 (0.92 to 0.96) for a cut-off value of 13”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingown data

    The proportion of studies with pregnant women only was similar for contributing and non-contributing studies.

    “The proportion of studies with pregnant women only was also similar for contributing and non-contributing studies.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingown data

    Among both contributing and non-contributing studies, most studies used semi-structured interviews as the reference standard, followed by the MINI, and other fully structured interviews.

    “Among both contributing and non-contributing studies, most studies used semi-structured interviews as the reference standard, followed by the MINI, and other fully structured interviews.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    For semi-structured interviews, EPDS sensitivity was 0.66 (95% CI 0.58 to 0.74) and specificity 0.95 (0.92 to 0.96) at a cut-off value of 13 or higher.

    “0.66 (0.58 to 0.74) and 0.95 (0.92 to 0.96) for a cut-off value of 13 or higher”
    • Also stated in: § Principal findings · plain
      “At cut-off values of 10 or higher and 13 or higher, which are commonly used for depression screening,13 sensitivity and specificity were 85% and 84%, and 66% and 95%, respectively.”
    Quote in the paperSubstantial claim
    • Rests on an assumption: The EPDS is the most commonly used depression screening tool in perinatal care, with cut-off values of 10 or higher and 13 or higher typically used to identify women who might be depressed.

  • May combine two claims.

    Findingown data

    For major depression prevalence values of 5-25% and an EPDS cut-off value of 11 or higher compared with semi-structured interviews, positive predictive values ranged from 26% to 69% and negative predictive values ranged from 93% to 99%.

    “For major depression prevalence values of 5-25% and a cut-off value of 11 or higher compared with semi-structured interviews, positive predictive values ranged from 26% to 69% and negative predictive values ranged from 93% to 99%.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    For semi-structured interviews, EPDS sensitivity was 0.81 (95% CI 0.75 to 0.87) and specificity 0.88 (0.85 to 0.91) at a cut-off value of 11 or higher.

    “0.81 (0.75 to 0.87) and 0.88 (0.85 to 0.91) for a cut-off value of 11 or higher”
    • Also stated in: § Principal findings · plain
      “sensitivity and specificity were 81% and 88% for a cut-off value of 11 or higher.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    Based on studies with a semi-structured reference standard, across cut-off values of 10-13, sensitivity estimates in the present IPDMA were 6-13% lower than those in the previous meta-analysis, whereas specificity estimates were 4-7% higher.

    “Based on studies with a semi-structured reference standard, across cut-off values of 10-13, sensitivity estimates in the present IPDMA were 6-13% lower than those in the previous meta-analysis, whereas specificity estimates were 4-7% higher.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [13] source

      Not checked in the free run.

  • May combine two claims.

    Findingown data

    No significant or substantive differences in EPDS accuracy were found based on country human development index, but few studies from low and middle income countries were included.

    “We found no significant or substantive differences based on country human development index, but few studies from low and middle income countries were included.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    For semi-structured interviews, EPDS sensitivity was 0.85 (95% CI 0.79 to 0.90) and specificity 0.84 (0.79 to 0.88) at a cut-off value of 10 or higher.

    “For semi-structured interviews, sensitivity and specificity were 0.85 (95% confidence interval 0.79 to 0.90) and 0.84 (0.79 to 0.88) for a cut-off value of 10 or higher”
    • Also stated in: § Principal findings · plain
      “At cut-off values of 10 or higher and 13 or higher, which are commonly used for depression screening,13 sensitivity and specificity were 85% and 84%, and 66% and 95%, respectively.”
    Quote in the paperSubstantial claim
    • Rests on an assumption: The EPDS is the most commonly used depression screening tool in perinatal care, with cut-off values of 10 or higher and 13 or higher typically used to identify women who might be depressed.

  • May combine two claims.

    Findingown data

    Combined sensitivity and specificity for the EPDS was maximised at a cut-off value of 11 or higher for semi-structured interviews (Youden's J=0.70), fully structured interviews (Youden's J=0.73), and the MINI (Youden's J=0.66).

    “Combined sensitivity and specificity was maximised at a cut-off value of 11 or higher for semi-structured interviews (Youden’s J=0.70), fully structured interviews (Youden’s J=0.73), and the MINI (Youden’s J=0.66).”
    • Also stated in: § Principal findings · plain
      “Our main finding was that combined sensitivity and specificity was maximised at a cut-off value of 11 or higher across reference standards.”
    • Also stated in: § Conclusions · plain
      “we found that combined sensitivity and specificity for the EPDS is maximised at a cut-off value of 11 or higher.”
    Quote in the paperSubstantial claim

  • Classified as probably not a substantial claim. May combine two claims.

    Premisecitation

    The systematic review conducted to support the USPSTF guideline reported the range of accuracy estimates for EPDS cut-off values of 10 or higher (14 studies) and 13 or higher (17 studies) in 23 primary studies, but did not include a meta-analysis.

    “The systematic review conducted to support the USPSTF guideline reported the range of accuracy estimates for EPDS cut-off values of 10 or higher (14 studies) and 13 or higher (17 studies) in 23 primary studies, but did not include a meta-analysis.14 15”
    Quote in the paperSubstantial claim0 of 2 sources checked
    • cites [14] O’Connor E Rossom RC Henninger M . Screening for depression in adults: an updated systematic evidence review for the US Preventive Services Task Force: evidence synthesis No. 128. [AHRQ Publication No. 14-05208-EF-1] Agency for Healthcare Research and Quality, 2016.

      Not checked in the free run.

    • cites [15] source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Premisecitation

    Fully structured interviews are intended to increase standardisation, but this could be at the cost of reduced validity.

    “By design, fully structured interviews are intended to increase standardisation, but this could be at the cost of reduced validity.39 40 41 42”
    Quote in the paperNot a substantial claim0 of 3 sources checked
    • cites [39] source

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    • cites [40] source

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    • cites [41] Nosen E Woody SR . Diagnostic assessment in research. In: Handbook of research methods in abnormal and clinical psychology. Sage, 2008.

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Study design and conductnone given

    Two reviewers independently reviewed titles and abstracts, and full texts were reviewed independently by two reviewers, with conflicts resolved by consensus and a third reviewer if necessary.

    “Two reviewers independently reviewed titles and abstracts. For publications deemed potentially eligible by either reviewer, a full text review was done by two reviewers, also independently. Any conflicts were resolved by consensus and a third reviewer was consulted if necessary.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    The 10-item EPDS is the most commonly used depression screening tool in perinatal care.

    “The 10 item EPDS is the most commonly used depression screening tool in perinatal care; cut-off values of 10 or higher and 13 or higher are most often used to identify women who might have depression.11 12 13 14 15”
    Quote in the paperNot a substantial claim0 of 3 sources checked
    • cites [11] source

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    • cites [12] source

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    • cites [13] source

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  • Classified as probably not a substantial claim. May combine two claims.

    Premisecitation

    The USPSTF recommends screening pregnant and postpartum women with the EPDS, but does not specify a cut-off value.

    “The USPSTF recommends screening pregnant and postpartum women with the EPDS, but does not specify a cut-off value.9”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [9] source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    An existing meta-analysis found that combined sensitivity and specificity to detect major depression in postpartum women was greater for an EPDS cut-off value of 12 or higher than for cut-off values of 10 or higher or 13 or higher.

    “An existing meta-analysis that has examined EPDS screening accuracy searched databases through February 2007 and found that combined sensitivity and specificity to detect major depression in postpartum women was greater for a cut-off value of 12 or higher (sensitivity 0.86, specificity 0.87, 15 studies) than for a cut-off value of 10 or higher (sensitivity 0.92, specificity 0.77, 14 studies) or 13”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [13] source

      Not checked in the free run.

  • Classified as probably not a substantial claim.

    Premisecitation

    EPDS cut-off values of 10 or higher and 13 or higher are most often used to identify women who might have depression.

    “The 10 item EPDS is the most commonly used depression screening tool in perinatal care; cut-off values of 10 or higher and 13 or higher are most often used to identify women who might have depression.11 12 13 14 15”
    Quote in the paperSubstantial claim0 of 3 sources checked
    • cites [11] source

      Not checked in the free run.

    • cites [12] source

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    • cites [13] source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Study design and conductown data

    The IPDMA was registered in PROSPERO (CRD42015024785), a protocol was published, and results were reported following PRISMA-DTA and PRISMA-IPD guidelines.

    “This IPDMA was registered in PROSPERO (CRD42015024785), a protocol was published,20 and the results were reported following PRISMA-DTA (preferred reporting items for a systematic review and meta-analysis of diagnostic test accuracy studies)21 and PRISMA-IPD (preferred reporting items for systematic review and meta-analyses of individual participant data)22 guidelines.”
    Quote in the paperNot a substantial claim0 of 3 sources checked
    • cites [20] source

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    • cites [21] source

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    • cites [22] source

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  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Study design and conductnone given

    Participant characteristics and accuracy results from individual datasets were verified against published results, and discrepancies were resolved with primary study investigators.

    “We verified that participant characteristics and accuracy results from individual datasets matched those that had been published. If any discrepancies were found, we worked with the primary study investigators to understand and resolve differences.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S1 (asserted), S2 (checkable).

    Premisereasoning

    Whether different EPDS cut-off values are needed for women with different characteristics needs to be determined.

    “Therefore, the optimal cut-off value for screening remains unknown, and whether different cut-off values are needed for women with different characteristics needs to be determined.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Study design and conductreasoning

    In analyses of the age less than 25 subgroup, four semi-structured studies and four MINI studies without any participants with major depression were excluded, resulting in exclusion of 21 participants (1%) from semi-structured studies and 77 (9%) from MINI studies.

    “For analyses in the age less than 25 subgroup, we excluded four semi-structured studies and four MINI studies that did not have any participants with major depression because the bivariate random effects model could not be applied. Therefore, 21 participants (1%) younger than 25 were excluded from semi-structured studies, and 77 (9%) from MINI studies.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Premisecitation

    The MINI is a brief version of a fully structured interview designed for rapid administration and tends to be overinclusive.

    “The MINI is a brief version of a fully structured interview that was designed for rapid administration and tends to be overinclusive.36”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [36] source

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  • May combine two claims.

    Premisecitation

    Controlling for depressive symptom levels, the CIDI might classify more participants with low level symptoms as having depression but fewer with high level symptoms.

    “We analysed studies that used different types of reference standards separately because we previously found that, controlling for depressive symptom levels, the MINI might classify depression more than other diagnostic interviews, and the CIDI might classify more participants with low level symptoms as having depression but fewer with high level symptoms.16 17 18”
    Quote in the paperSubstantial claim0 of 3 sources checked
    • cites [16] source

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    • cites [17] source

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    • cites [18] source

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  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Study design and conductown data

    Risk of bias was assessed using QUADAS-2, with two investigators independently performing the assessment and differences resolved through consensus or a third investigator.

    “We used the Quality Assessment of Diagnostic Accuracy Studies-2 tool (QUADAS-2; eMethods2)31 to assess risk of bias of included studies. Two investigators independently performed this assessment and any differences were resolved through consensus or by involving a third investigator if necessary.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [31] source

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  • May combine two claims.

    Interpretationown data

    An EPDS cut-off value of 13 or higher was less sensitive but more specific than a cut-off value of 11 or higher.

    “An EPDS cut-off value of 11 or higher maximised combined sensitivity and specificity; a cut-off value of 13 or higher was less sensitive but more specific.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductnone given

    Two investigators independently extracted information on the diagnostic interview administered and the country of study from the published reports.

    “Two investigators independently extracted information on the diagnostic interview administered and the country of study from the published reports.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductcitation

    A medical librarian designed a peer-reviewed search strategy.

    “A medical librarian designed a peer reviewed29 search strategy (eMethods1 in supplementary material) and searched Medline, Medline In-Process and Other Non-Indexed Citations, and PsycINFO through OvidSP, and Web of Science through ISI Web of Knowledge from inception to 3 October 2018.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [29] McGowan J, Sampson M, Salzwedel DM, et al. PRESS – Peer Review of Electronic Search Strategies: 2015 Guideline Explanation and Elaboration (PRESS E&E). CADTH. https://www.cadth.ca/sites/default/files/pdf/CP0015_PRESS_Update_Report_2016.pdf 2016 source

      Not checked in the free run.

  • May combine two claims.

    Premisecitation

    The existing meta-analysis did not pool results for pregnant women because there were too few studies, and no subgroup analyses were conducted among postpartum women because primary studies did not report the necessary data.

    “The results were not pooled for pregnant women because there were too few studies, and no subgroup analyses were conducted among postpartum women because primary studies did not report the necessary data.”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [13] source

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  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductnone given

    No participants had missing data for any covariates in the meta-regressions.

    “No participants had missing data for any covariates in the meta-regressions.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Study design and conductown data

    Data were not obtained from 25 of 83 published eligible datasets, although results did not change when published results from studies that did not contribute data but published eligible accuracy results were incorporated.

    “Firstly, we did not obtain data from 25 of 83 published eligible datasets, although the results did not change when we incorporated published results from studies that did not contribute data but published eligible accuracy results.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Study design and conductcitation

    The study analysed data from more than twice the number of studies compared with the previous conventional meta-analysis and included results for all cut-off values from all studies.

    “Strengths include analysis of data from more than twice the number of studies compared with the previous conventional meta-analysis,13 and including results for all cut-off values from all studies.”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [13] source

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  • May combine two claims.

    Interpretationcitation

    The cut-off value of 11 or higher that maximised combined sensitivity and specificity in the present study is lower than both the most commonly used cut-off value of 13 or higher and the cut-off value of 12 or higher that maximised combined sensitivity and specificity in a previous EPDS accuracy meta-analysis.

    “The cut-off value of 11 or higher that maximised combined sensitivity and specificity in the present study is lower than both the most commonly used cut-off value of 13 or higher13 and the cut-off value of 12 or higher that maximised combined sensitivity and specificity in a previous EPDS accuracy meta-analysis.13”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [13] source

      Not checked in the free run.

    • Rests on an assumption: The EPDS is the most commonly used depression screening tool in perinatal care, with cut-off values of 10 or higher and 13 or higher typically used to identify women who might be depressed.

  • May combine two claims.

    Premisecitation

    The previous EPDS meta-analysis did not pool results for pregnant women because too few studies were found, and no subgroup analyses were conducted among postpartum women because primary studies did not report the necessary data.

    “The previous meta-analysis did not pool results for pregnant women because too few studies were found, and no subgroup analyses were conducted among postpartum women because primary studies did not report the necessary data”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [13] source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    A previous meta-analysis of the screening accuracy of the EPDS, conducted more than 13 years ago, found that a cut-off value of 12 or higher maximised combined sensitivity and specificity in postpartum women (21 studies).

    “A previous meta-analysis of the screening accuracy of the EPDS, which was conducted more than 13 years ago, found that a cut-off value of 12 or higher maximised combined sensitivity and specificity in postpartum women (21 studies)”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [13] source

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  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductown data

    One third of studies were coded as unclear for interviewer qualification in the risk of bias assessment.

    “one third of studies were coded as unclear for interviewer qualification in our risk of bias assessment.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Interpretationreasoning

    Differences in results between the current IPDMA and the previous meta-analysis might have occurred because the current IPDMA consisted of 58 primary studies, including 36 with a semi-structured reference standard, versus 21 primary studies with various types of reference standards in the previous meta-analysis.

    “Differences in results between the current IPDMA and the previous meta-analysis might have occurred because the current IPDMA consisted of 58 primary studies, including 36 with a semi-structured reference standard, versus 21 primary studies with various types of reference standards in the previous meta-analysis.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [13] source

      Not checked in the free run.

39 of 39

  • The paper relies on this without support.

    The EPDS is the most commonly used depression screening tool in perinatal care, with cut-off values of 10 or higher and 13 or higher typically used to identify women who might be depressed.

    “The Edinburgh Postnatal Depression Scale (EPDS) is the most commonly used depression screening tool in perinatal care, with cut-off values of 10 or higher and 13 or higher typically used to identify women who might be depressed”
1 of 1

Claims other papers make about this one

Each is checked against this paper’s own text: does it say what the citing paper says it does?

  • Selection of the lower EPDS threshold score maximizes sensitivity of the screening tool to detect major depression.

    “Additionally, selection of this lower threshold score maximizes sensitivity of this screening tool to detect major depression [37].”

    From Factors associated with postpartum depression symptoms following antepartum hospitalization (2026) · cites this paper as [37]

    The Discussion (Implications; page not available) says a lower EPDS cut-off may be preferred to avoid false negatives, and the Results show higher sensitivity at lower cut-offs. But the paper does not establish that the unspecified lower threshold maximizes sensitivity; it identifies 11 or higher as maximizing combined sensitivity and specificity, not sensitivity alone. (LLM, conf=0.83)

    Experimental — accuracy not yet measured

  • The EPDS cut-off scores ≥10 and ≥13 have sensitivity and specificity values of 85% and 84%, and 66% and 95%, respectively.

    “The most commonly used cut-off scores are ≥10 and ≥ 13 with sensitivity and specificity values of 85 % and 84 %, and 66 % and 95 %, respectively (Levis et al., 2020).”

    From PandaMom – Feasibility and acceptability of an internet- and mobile-based intervention to enhance peripartum mental well-being and to prevent postpartum depression (2024) · cites this paper as Levis et al., 2020

Self-check

Percentages, sums and reported differences re-computed from the paper’s own numbers.

Each contradiction between two passages listed here was confirmed by an independent check.

  • Conflicting counts of studies that did not contribute data

    Minor

    The results section says 26 eligible studies did not contribute individual participant data, but the limitations section says data were not obtained from 25 of 83 eligible datasets. The reported totals of 83 eligible and 58 included also leave 25 without data.

1 of 1

Cites

Flagged first, then by citations

1 of the 42 references couldn’t be matched to a known paper.

Research works printed but not linked: 1

  1. O’Connor E Rossom RC Henninger M . Screening for depression in adults: an updated systematic evidence review for the US Preventive Services Task Force: evidence synthesis No. 128. [AHRQ Publication No. 14-05208-EF-1] Agency for Healthcare Research and Quality, 2016.

Cited by

Sorted by citations

Related

Authors
Levis, B., Negeri, Z., Sun, Y., Benedetti, A., & Thombs, B. D.
Affiliations
  • Jewish General Hospital (CA)
  • McGill University Health Centre (CA)
Corresponding author
Thombs, Brett D
ORCID
Venue
BMJ
Publisher
BMJ
Published
2020-11-11
Volume
371
Pages
m4022
ISSN
1756-1833 (ISSN-L)
DOI
10.1136/bmj.m4022
PMC
PMC7656313
OpenAlex
W3093810429
Semantic Scholar
78cf2d7bf5e2dc7094c88c17b4deb98714fadfab
Cited by
922
References
42
Citations by year
2026: 174 · 2025: 216 · 2024: 190 · 2023: 167 · 2022: 123 · 2021: 50 · 2020: 1
FWCI
14.25
Type
journal article
Language
en
Open access
Licence
Locations
  • BMJ (publishedVersion, cc-by-nc)
  • PubMed Central (publishedVersion, cc-by-nc)
  • PubMed (publishedVersion)
  • Edinburgh Research Explorer (University of Edinburgh) (acceptedVersion, other-oa)
  • IRIS Research product catalog (Sapienza University of Rome) (submittedVersion, cc-by-nc)
  • Diva portal (Dalarna University Library) (submittedVersion, other-oa)
  • eScholarship@McGill (McGill) (submittedVersion, cc-by-nc)
  • HighWire Press Open Archive (submittedVersion)
Funders
  • National Science Foundation
  • Patrick and Catherine Weldon Donaghue Medical Research Foundation
  • Yale University
  • Universidad de Santiago de Chile
  • University of Connecticut
  • McGill University
  • Faculty of Medicine, McGill University
  • Sveučilište u Zagrebu
  • Wellcome Trust (211374/Z/18/Z, 082384/Z/07/Z/, 071571)
  • McGill University Health Centre
  • Australian Government
  • National Institute for Health and Care Research (RP-PG-1210-12002, RP-DG-1108-10012)
  • Department of Health and Social Care
  • University of Southampton
  • King's College London
  • University of Oxford
  • University of Bristol
  • National Research Foundation
  • Schweizerischer Nationalfonds zur Förderung der Wissenschaftlichen Forschung (0000000, 10002, 32003B, 125493)
  • University of New South Wales
  • Deakin University
  • Monash University
  • Fundação de Amparo à Pesquisa do Estado de São Paulo
  • Chulalongkorn University (CU-56-457-HR)
  • Conselho Nacional de Desenvolvimento Científico e Tecnológico (POCI 2010, 00000-00, 2014-5)
  • Sapienza Università di Roma
  • China Medical University Hospital
  • Università degli Studi di Firenze
  • Harry Crossley Foundation
  • Fundação de Amparo à Pesquisa do Estado de Minas Gerais (0000000, POCI 2010)
  • Department of Families, Housing, Community Services and Indigenous Affairs
  • Université de Genève
  • Ministério da Saúde
  • Uppsala Universitet
  • University of Cape Town
  • China Medical University
  • Universidade do Minho
  • Ingham Institute for Applied Medical Research
  • Szegedi Tudományegyetem
  • Werner Otto Stiftung
  • Duke Global Health Institute, Duke University (453-0751)
  • Feinberg School of Medicine
  • Institute of Psychiatry, Psychology and Neuroscience, King’s College London
  • Canadian Institutes of Health Research (140994_1)
  • Fonds de Recherche du Québec - Santé
  • Medical Research Council (MR/S035818/1)
  • National Health and Medical Research Council
  • Faculty of Medicine, Chulalongkorn University
  • Programme Grants for Applied Research (RP-PG-1210-12002)
  • Universitätsklinikum Hamburg-Eppendorf
  • National Institute of Mental Health (K23MH64476)
  • Fondo Nacional de Desarrollo Científico y Tecnológico (1130230)
Topics
  • Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Maternal Mental Health During Pregnancy and Postpartum
  • Health Sciences › Health Professions › General Health Professions › Maternal and Neonatal Healthcare
  • Social Sciences › Psychology › Experimental and Cognitive Psychology › Anxiety, Depression, Psychometrics, Treatment, Cognitive Processes
Keywords
Edinburgh Postnatal Depression Scale, postpartum depression, major depressive disorder, pregnancy, screening accuracy, sensitivity and specificity, cut-off values, diagnostic interview, MINI, semi-structured interviews, reference materials, subgroup analysis, maternal mental health
MeSH terms
Depressive Disorder, Major, Major Depressive Disorder, Female, Humans, Pregnancy, Pregnancy Complications, Prenatal Care, Psychometrics, Sensitivity and Specificity, Depression, Postpartum

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Registry, retraction, Cites and statistics results are computed, not judged, with one exception: a printed reference that no index lists is read once by a model before it counts as a citation error. Claims are extracted by a model and kept only when their quote appears verbatim in the text; each cited source is then checked, with a model’s help, for whether it says what the claim relies on. Those verdicts can be wrong — read the claim’s quote and the cited source before relying on one.

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Classified by jev-1.13-20260917 (gold-guideline-v0.2) on 2026-10-08.

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