- Each response has a value between 0 and 3. Add the scores for the ten items together to obtain a total score out of 30. Note: Several items are reverse-scored.
- The overall score should be checked as mistakes can easily be made.
For English speaking women:
- antenatal score for probable major depression is 15 or more
- antenatal score for probable minor depression is 13 or more
- postnatal score for probable major depression 13 or more
- postnatal score for probable minor depression is 10 or more
It is recommended a second EDS/EPDS be administered two weeks after the initial screen before any intervention is planned or agreed for women scoring:
- 15 and above antenatally and 0 (zero) on question 10 or
- 13 and above postnatally and 0 (zero) on question 10.
- Repeat testing of the scale after just two weeks will help to differentiate transient from enduring distress.
- Immediate intervention should occur after the first screening if clinical judgment identifies the need or if the individual score for question 10 is more than zero (0).
- If the score after the second screening reaches cut-off, or where clinical judgment determines the existence of depressive symptoms, referral for further assessment should be arranged. It is important to note that as the EDS/EPDS is a screening instrument a clinical diagnosis of depression (major or minor) cannot be made based on the EDS/EPDS alone. While the scale detects current depressive symptoms, it is not a diagnostic tool. Formal assessment is necessary to make a diagnosis of depression.
Things to check:
- inconsistency between low and high scores and the clinical presentation and verbal responses of the woman
- individual items that receive a high score
- any score above zero on question 10 even if the overall score does not reach a cut-off threshold
- the woman’s literacy level and comprehension of the items (particularly important if the woman is from a non-English speaking background)
- cut-off scores for women from non-English speaking backgrounds
A woman who scores above 0 (zero) on question 10 of the EDS/EDPS must be provided with an immediate intervention
- Question 10 asks whether the woman has had thoughts of self-harm or suicidality within the last seven days, and any score above 0 indicates a potential safety risk to the woman and the infant.
- For any score above zero on question 10, further sensitive questioning using Family Partnership Skills or a similar supportive questioning style to commence a risk assessment if required
- The clinician should seek support from a colleague or senior clinician when risk of self-harm is identified, and response will be guided by local protocols.
- Support from the Area Mental Health Service may also be sought.
- Consideration should be given to making a report to DoCS if children or unborn babies are considered at risk of harm.
Proceed to 'Describe relevant information to feed back to the patient after they complete the screen'