Running head: MORE THAN JUST THE BABY BLUES

More Than Just The Baby Blues: An Examination of Peripartum

Depression, Suicidal Ideation, and the Edinburgh Postnatal Depression
Scale
Lauren Moretti
James Madison University

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Abstract
Peripartum depression is a mental health concern affecting a number
of new or expecting mothers today. More so, those mothers
experiencing peripartum depression are at an increased risk for
suicidal ideation. To protect the health and safety of mothers and their
families, it is necessary that health workers screen for these
occurrences routinely. The Edinburgh Postnatal Depression Scale is a
commonly used screening tool for postnatal depression that is also
relevant and valid for screening for suicidal ideation. This paper will
further explain its use and relevance.

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More Than Just The Baby Blues: An Examination of Peripartum

Depression, Suicidal Ideation, and the Edinburgh Postnatal Depression
Scale
Peripartum depression is a rather common mental health
occurrence, though it is not always talked about and certainly is not
talked about freely and openly. The birth of a child is supposed to be a
happy event. For many, though, having a child comes with many
emotional struggles. Out of fear of stigma, many women hide their
struggle and their depression rather than receive the professional help
that they need and deserve. This work describes the nature of
perinatal depression, how it is screened, and the impact of suicidal
ideation.
Peripartum depression is a mental health condition that
negatively affects a number of pregnant or new mothers. Though
various studies give a range of results on the prevalence of peripartum
depression, the American Psychiatric Association (2013) estimated that
between 3% and 6% of women experience peripartum depression. The
peripartum period is defined by the time at which a major depressive
episode occurs during pregnancy or within the first few weeks after
delivery (American Psychiatric Association, 2013). This condition was
once called postpartum depression, however, the American Psychiatric

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Association (2013) discovered that half of the postpartum depressive

episodes actually occurred during pregnancy. Therefore, peripartum
is a term used to encompass both depressive episodes that occur
during pregnancy and shortly after delivery. Because of this more
inclusive term, a number of women who would have previously been
overlooked are now being recognized and evaluated for perinatal
depression.
Peripartum depression meets the same criteria as major
depression. The women who experience this condition may experience
depressive mood, changes in appetite and/or weight, changes in sleep
pattern and/or energy levels, anhedonia, trouble concentrating and
making decisions, feelings of worthlessness or guilt, and psychomotor
retardation or agitation. Though it is not always met, there is also a
criterion for recurrent thoughts of death, suicidal ideation, and/or
suicide attempts (American Psychiatric Association, 2013).
Understandably, it is not a necessity for all of the criteria to be met
before receiving a diagnosis of peripartum depression. In fact, no two
people will present the same symptoms.
Peripartum depression falls along a continuum, which ranges
from the baby blues to peripartum depression to peripartum
psychosis. Women are most likely to experience the baby blues (60 to
80% of pregnant or recent mothers) and are least likely to experience
peripartum psychosis (3 to 5%) (St. Pierre, 2007). The baby blues, a

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very common syndrome, first occurs within the first few days after
delivery (St. Pierre, 2007). However, unlike with the syndromes further
down the continuum, the baby blues stop within about ten days to two
weeks after delivery and do not require treatment (St. Pierre, 2007;
Cohen et al., 2010). A mother experiencing the baby blues is often sad
and has crying episodes, is irritable and/or anxious, and does not sleep
well (Cohen et al., 2010). These mothers do not experience suicidal
ideation, however, which is an important distinction from the other
types of depression along the continuum.
Perinatal psychosis is a very serious condition and a cause for
immediate treatment. The onset is sudden and happens within two
weeks of delivery. Symptoms include sleep disturbances, mood lability,
and obsessions about the newborn (Bergink et al., 2015). As it
continues, more severe symptoms become present. The mother may
have hallucinations, delusions, and disorganized speech or behavior
(Cohen et al., 2010; Bergink et al. 2015). Much of the concern
surrounding peripartum psychosis comes from the high risk of suicide
and infanticide (Cohen et al., 2010).
Suicide accounts for a significant number of deaths in pregnant
and postpartum women. Suicidal ideation, planning, and/or attempts
are also related to depression. Gavin et al. (2011) reported that 52.5%
of women who reported suicidal ideation also had comorbid perinatal
depression. Of those who did report suicidal ideation, 78% reported

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having thoughts of suicide several days in the last two weeks, 15.3%
reported having those thoughts more than half the days, and 2.7%
reported suicidal ideation nearly everyday (Gavin et al., 2011). With
such significant numbers of women reporting suicidal ideation during
the perinatal period, it is incredibly important that clinicians screen for
perinatal depression and suicidal ideation. Nevertheless, most women
who are receiving perinatal health care are not being screened (Kelly et
al., 2001).
Cox, Holden, and Sagovsky (1987) developed a tool to screen for
perinatal depression, the Edinburgh Postnatal Depression Scale. The
researchers noted several limitations in other commonly used
screening measures when applied to new or expecting mothers.
Namely, they believed that the poor validity of these tools with this
population was due to the fact that the tools relied heavily on somatic
symptoms. They believed that many of the somatic symptoms
described in a psychiatric disorder might simply be the result of natural
pregnancy, for example, fatigue and loss of energy (Cox, Holden, &
Sagovsky, 1987). The final result is a ten-question screen. The
questions are on a four point Likert scale between 0 and 3. The scale
was designed so that health workers other than clinicians, such as
home visitors, could administer this screening and then make the
appropriate referral. This screening can be both completed and scored
quickly because there are only ten questions and the scoring system is

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not complex. When answering the questions, the woman reflects on

her experiences within the past seven days and uses that timeline to
answer. The cut offs for this tool are 12/13 or 9/10 for routine use (Cox,
Holden, & Sagovsky, 1987). Interestingly, Cox, Holden, and Sagovsky
(1987) include questions that are not reflective of the American
Psychiatric Associations Diagnostic and Statistical Manual 5 (2013)
criteria for major depression. They include a question on anxiety (I
have been anxious or worried for no good reason) and loss of control
(Things have been getting on top of me).
Many health workers have wondered if the Edinburgh is an
appropriate tool to screen for suicidal ideation and a possible eventual
suicide attempt. The Edinburgh Postnatal Depression Scale does
measure suicidal ideation briefly (Question 10, The thought of
harming myself has occurred to me) (Cox, Holden, & Sagovsky, 1987).
Researchers have tested the use of question 10 to determine its
validity. Sit, Seltman, and Wisner (2011) found that suicidal ideation
dramatically rose as the total Edinburgh scores rose, specifically when
the scores reached fifteen points or higher out of thirty. When
comparing the Edinburgh against the Patient Health Questionnaire,
Zhong (2014) also found that there is a direct proportion of total score
to suicidal ideation.
Interestingly, Sit, Seltman, and Wisner (2011) found that
question ten is not the only item that is correlated with suicidal

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ideation. They noticed that item one (I have been able to laugh and
see the funny side of things), item two (I have looked forward with
enjoyment to things), and item seven (I have been so unhappy that I
have difficulty sleeping) are also related. It is possible that these
items are related because they comment on hopelessness, which has
been defined by Beck et al. (1990) as a predictor of eventual suicide.
Still, there is no preferred screening tool (Zhong et al., 2014).
Studies have compared the Edinburgh against different tools and have
found different results. For example, in Zhong et al.s study (2014), the
Patient Health Questionnaire found more participants with suicidal
ideation than the Edinburgh did with the same participants (15.8 vs.
8.8%). On the other hand, Mauri, Oppo, Borri, and Banti (2011) found
that the Edinburgh showed a higher prevalence of suicidality than the
Mood Spectrum Self Report tool (12.0 vs. 6.9%). A number of different
explanations may be relevant. For one, though Cox, Holden, and
Sagovsky (1987) defined 12/13 as cut off scores for the Edinburgh,
there is not a consensus among researchers on which point to use as a
cut off. Secondly, not all women are screened at the same time during
the peripartum period. The differing rate of prevalence may be due to
simply the change in a womans mental health state with the passage
of time. The Edinburgh also only asks about suicidal ideation using the
passive tone. The Patient Health Questionnaire, however, asks about
suicide in both the active and the passive tone, which may resonate

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differently with participants (Gavin et al., 2011). Finally, the Edinburgh

asks about experiences within the last seven days whereas other
measures use a different time period. Again, the passage of time could
be a significant contributor to the scores of these screening tools.
Perinatal depression and suicidal ideation affect a significant
number of new or expecting mothers. For the health and safety of
both the mother and her family, it is necessary that we screen for both
depression and suicidal ideation. Though there is no single preferred
screening tool, the Edinburgh Postnatal Depression Scale is worthwhile
for use. Use of the Edinburgh scale has a number of advantages such
as ease of use, timeliness, validity, and relevant application to women
in the peripartum period. Hopefully, future research will continue to
validate the use of this tool so that the overall mental health
professional community will use this screen routinely as a preventative
practice.

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10

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