Investigations
1st investigations to order
Depression identification questions
Test
Although they have not been investigated specifically in the postnatal population, the following questions are recommended by UK guidelines (as a screening tool for all women in the perinatal period), at her first antenatal appointment, and postnatally (first year after childbirth):[5]
'During the past month, have you often been bothered by feeling down, depressed, or hopeless?' and 'During the past month, have you often been bothered by having little interest or pleasure in doing things?'
Result
identification of patients requiring further clinical assessment for depression
Edinburgh Postnatal Depression Scale (EPDS)
Test
One of a number of self-reported measures specifically designed to screen for depression in the postnatal period; of these, the EPDS has been the most widely studied.[134]
Psychometrically tested extensively in postnatal women and used throughout the world. Sensitivity and specificity of cut-off points showed marked heterogeneity between different studies. Sensitivity results ranged from 34% to 100% and specificity from 44% to 100%.[110]
The cut-off score of >12 has an overall positive predictive value of 57% and negative predictive value of 99%.
Result
score >11 suggestive of depression, warranting a need for further clinical assessment for depression, although lower cut-off values may be used if the intention is to avoid false negatives; the American College of Obstetricians and Gynecologists notes that a score of 10-14 often represents mild symptomatology, 15-19 often represents moderate symptomatology, and that a score higher than 19 is consistent with severe symptomatology as well as an increased risk for bipolar disorder[4]
Patient Health Questionnaire-9 (PHQ-9)
Test
In one large meta-analysis of studies comparing the PHQ-9 and EPDS, operating characteristic characteristics were nearly identical.[111]
Result
score >11 suggestive of depression, warranting a need for further clinical assessment for depression, although lower cut-off values may be used if the intention is to avoid false negatives; the American College of Obstetricians and Gynecologists notes that a score of 10-14 often represents mild symptomatology, 15-19 often represents moderate symptomatology, and that a score higher than 19 is consistent with severe symptomatology as well as an increased risk for bipolar disorder[4]
Mood Disorder Questionnaire (MDQ)
Test
Routinely screen women with postnatal depression for past and current symptoms of mania and hypomania. Screening should include questions about a family history of bipolar disorder. Until a validated assessment tool is established, the MDQ is considered one of the most promising tools for screening for bipolar disorder in perinatal women.[15][126] It incorporates all pertinent information included in the other scales, with the addition of an assessment of irritability and impulsive behaviour.
Result
identification of patients requiring further clinical assessment for bipolar disorder
Investigations to consider
Thyroid function tests
Test
Required in patients with symptoms suggestive of hypothyroidism.
Elevated serum thyroid-stimulating hormone level suggests hypothyroidism.
The time frame for postnatal (painless/lymphocytic) thyroiditis, which is characterised by transient hyper- and hypothyroid phases, may overlap with that for postnatal depression, although no causal relationship has been established between the two conditions.[135]
Result
normal
FBC
Test
Required if anaemia is suspected; excludes anaemia as a cause of fatigue.
Result
normal
urine drug screen
Test
Required if substance misuse is suspected; a positive result identifies the substance taken.
Drug screens are not definitive for drug misuse.
Result
normal
brain CT or MRI
Test
May be used to identify a structural neurological abnormality if this is suspected as a cause of symptoms.
Result
normal
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