Have a question about this calculator? Get a detailed answer.
The Edinburgh Postnatal Depression Scale (EPDS) is a 10-item self-report questionnaire developed in 1987 by Dr. John Cox, Dr. Jeni Holden, and Dr. Ruth Sagovsky at health centers in Livingston and Edinburgh, Scotland. It was specifically designed to screen for postnatal depression by excluding somatic symptoms (such as fatigue, appetite changes, and sleep disturbance) that are normal experiences in the postpartum period and would inflate scores on general depression scales like the Beck Depression Inventory or the PHQ-9. This deliberate design choice makes the EPDS uniquely suited for perinatal populations. The EPDS assesses mood, anxiety, and self-harm ideation over the past 7 days. Each of the 10 items is scored from 0 to 3, yielding a total score range of 0 to 30. Items 1, 2, and 4 are reverse-scored (the response indicating the least distress receives 3 rather than 0). A score of 13 or higher is the most widely used cutoff for probable major depression, while a score of 10 to 12 suggests possible depression warranting clinical follow-up. Item 10, which asks about self-harm thoughts, requires immediate clinical assessment regardless of the total score. Postnatal depression affects approximately 10 to 15 percent of women in high-income countries and up to 20 to 25 percent in low and middle income countries. Without screening, approximately 50 percent of postnatal depression cases go undetected in clinical practice. The EPDS has been validated in over 60 languages and across diverse cultural populations. At a cutoff of 13, it demonstrates sensitivity of approximately 86 percent and specificity of approximately 78 percent for major depressive disorder. Although originally developed for postnatal use, the EPDS has been validated for antenatal (prenatal) depression screening and is increasingly used throughout pregnancy. Research also supports its use in screening for perinatal anxiety, with items 3, 4, and 5 forming a three-item anxiety subscale. Some clinical guidelines now recommend the EPDS for screening fathers and non-birthing partners in the perinatal period as well, recognizing that paternal postnatal depression affects approximately 8 to 10 percent of fathers.
EPDS Total Score = Sum of all 10 items Scoring per item (0-3 scale): - Items 1, 2, 4: Reverse-scored (top response = 0, bottom = 3) - Items 3, 5, 6, 7, 8, 9, 10: Standard scoring (top response = 0, bottom = 3) Anxiety Subscale = Item 3 + Item 4 + Item 5 (range 0-9) Worked Example: A 6-week postpartum woman completes the EPDS: 1. I have been able to laugh and see the funny side of things: As much as I always could = 0 2. I have looked forward with enjoyment to things: As much as I ever did = 0 3. I have blamed myself unnecessarily when things went wrong: Yes, most of the time = 3 4. I have been anxious or worried for no good reason: Yes, very often = 3 (reverse-scored from response) 5. I have felt scared or panicky for no very good reason: Yes, quite a lot = 2 6. Things have been getting on top of me: Yes, most of the time I have not been able to cope at all = 3 7. I have been so unhappy that I have had difficulty sleeping: Yes, most of the time = 3 8. I have felt sad or miserable: Yes, most of the time = 3 9. I have been so unhappy that I have been crying: Yes, most of the time = 3 10. The thought of harming myself has occurred to me: Hardly ever = 1 EPDS Total = 0 + 0 + 3 + 3 + 2 + 3 + 3 + 3 + 3 + 1 = 21 Anxiety Subscale = 3 + 3 + 2 = 8 Interpretation: A score of 21 significantly exceeds the cutoff of 13 for probable major depression. The elevated anxiety subscale of 8 out of 9 suggests comorbid anxiety. The positive response on item 10 (self-harm ideation) requires immediate safety assessment. This patient needs urgent psychiatric referral and should not be left alone until safety is assured.
- 1Identify Appropriate Timing for Screening: The EPDS should be administered at multiple time points during the perinatal period. The American College of Obstetricians and Gynecologists recommends screening at least once during the perinatal period using a standardized validated tool. Many guidelines recommend screening at the first prenatal visit, during the third trimester, at the 6-week postpartum visit, and at the 3-month and 6-month well-baby visits. Postnatal depression can develop at any point during the first year postpartum, so a single negative screen does not rule out later onset. Some clinicians also screen during the second trimester when antenatal depression risk increases.
- 2Prepare the Patient and Setting: Administer the EPDS in a private, comfortable setting. Explain that the questionnaire asks about feelings over the past 7 days and that it is given to all perinatal patients as a routine part of care. Normalize the experience by stating that mood changes are common during pregnancy and after birth and that screening helps identify individuals who might benefit from additional support. The EPDS can be self-administered on paper, electronically (tablet or smartphone), or read aloud by the clinician for patients with low literacy. Ensure the questionnaire is available in the patient's preferred language.
- 3Score Each Item with Attention to Reverse Scoring: Each item has four response options scored from 0 to 3. For items 1, 2, and 4, the responses are ordered so that the option indicating the most positive mood receives 0 points. For example, item 1 ('I have been able to laugh and see the funny side of things') is scored: 'As much as I always could' = 0, 'Not quite so much now' = 1, 'Definitely not so much now' = 2, 'Not at all' = 3. Items 3 and 5 through 10 are scored with the response indicating the most distress receiving 3 points. This scoring ensures that higher total scores always indicate greater distress.
- 4Assess Item 10 Independently for Safety: Item 10 states 'The thought of harming myself has occurred to me' with responses: 'Never' (0), 'Hardly ever' (1), 'Sometimes' (2), or 'Yes, quite often' (3). Any response other than 'Never' requires immediate clinical follow-up regardless of the total EPDS score. When a patient endorses self-harm thoughts, the clinician should conduct a thorough suicide risk assessment, ask about the nature and frequency of these thoughts, whether there is intent or a plan, access to means, and protective factors. Depending on the assessment, immediate psychiatric referral, safety planning, or emergency intervention may be required.
- 5Calculate and Interpret the Total Score: Sum all 10 items for the total EPDS score (range 0-30). Interpret using established cutoffs: 0-9 indicates depression is unlikely, 10-12 indicates possible depression warranting monitoring and possible clinical follow-up, and 13 or higher indicates probable depression requiring comprehensive clinical assessment. Some guidelines use a lower cutoff of 10 for minor depression and 13 for major depression. For antenatal screening, some researchers recommend a higher cutoff of 15 due to slightly different psychometric properties during pregnancy. Also calculate the anxiety subscale (items 3, 4, 5) to assess the anxiety component.
- 6Consider Cultural and Individual Context: Interpret the EPDS score within the patient's cultural and individual context. Cultural norms around emotional expression, stigma associated with mental health concerns, expectations of motherhood, and social support structures all influence how patients respond to the EPDS. Some cultures discourage the expression of negative emotions, potentially leading to underreporting. Others may normalize significant distress as an expected part of motherhood. Additionally, consider situational factors such as infant health problems (NICU admission, colic), relationship difficulties, financial stress, and social isolation that may contribute to elevated scores without necessarily indicating clinical depression.
- 7Develop an Appropriate Care Plan: Based on the EPDS score and clinical assessment, develop an individualized care plan. For scores of 10-12, options include increased monitoring with repeat screening in 2 to 4 weeks, psychoeducation about perinatal mood disorders, referral to peer support groups, and lifestyle interventions (exercise, sleep hygiene, social support). For scores of 13 or higher, options include referral for clinical interview to confirm diagnosis, psychotherapy (cognitive behavioral therapy or interpersonal therapy are first-line), pharmacotherapy if indicated (sertraline and paroxetine are commonly used SSRIs compatible with breastfeeding), and in severe cases, referral to a perinatal psychiatrist. Always discuss the impact of untreated maternal depression on infant development and attachment.
This 4-week postpartum mother reports mild and transient mood fluctuations consistent with normal postpartum adjustment. The score of 3 is well below any clinical cutoff. Occasional sadness and crying in the early postpartum period are common and typically resolve by 2 weeks (baby blues). Positive reinforcement and routine follow-up are appropriate.
This 8-week postpartum mother scores 12, which falls in the borderline zone. She reports decreased pleasure, frequent sadness and crying, some self-blame, and mild coping difficulties. The anxiety subscale is low at 2 out of 9, and there is no self-harm ideation. The recommended approach is repeat screening in 2 weeks, psychoeducation about postnatal depression, connection with a mother-baby support group, and assessment of social support and practical stressors.
This 10-week postpartum mother scores 29 out of 30, indicating severe postnatal depression with significant anxiety (subscale 8 out of 9) and frequent self-harm ideation. This represents a psychiatric emergency requiring immediate safety assessment. The clinician must determine if the patient is safe to go home, whether there are concerns about infant safety, and whether inpatient psychiatric admission is needed. A perinatal mental health crisis team should be contacted. Treatment will likely require combined pharmacotherapy and psychotherapy, with consideration of a mother-baby psychiatric unit if inpatient care is needed.
Routine Perinatal Mental Health Screening in Obstetric Care: The EPDS is the most widely used perinatal depression screening tool globally. In the United Kingdom, the National Institute for Health and Care Excellence (NICE) recommends using the EPDS or the Whooley questions at every perinatal contact. In the United States, ACOG recommends screening at least once during the perinatal period, and many states have enacted legislation mandating perinatal depression screening. The EPDS has been integrated into electronic health records at major health systems, enabling systematic screening with automated scoring and clinical decision support alerts for elevated scores.
Pediatric Well-Child Visits as Maternal Depression Screening Opportunities: The American Academy of Pediatrics recommends that pediatricians screen mothers for postnatal depression at the 1, 2, 4, and 6-month well-baby visits. This recommendation recognizes that untreated maternal depression adversely affects infant development, attachment, breastfeeding, and vaccination adherence. Pediatric offices often have more frequent postpartum contact with mothers than obstetric practices after the 6-week visit. Studies show that administering the EPDS in pediatric settings identifies approximately 30 percent more cases of postnatal depression than obstetric screening alone.
Paternal Postnatal Depression Screening: Emerging research has validated the EPDS for screening paternal postnatal depression, which affects approximately 8 to 10 percent of fathers in the first year after their child's birth. Paternal depression is associated with increased behavioral problems in children, relationship conflict, and reduced father-infant bonding. The EPDS performs adequately in male populations with a recommended cutoff of 10 for fathers (lower than the 13 cutoff for mothers). Some healthcare systems now offer EPDS screening to both parents, recognizing that parental mental health affects the entire family unit.
Telehealth and Digital Perinatal Mental Health Screening: The shift toward telehealth during and after the COVID-19 pandemic has accelerated the adoption of digital EPDS administration. Studies show that electronic EPDS administration via smartphone apps, patient portals, and telehealth platforms produces scores comparable to paper-based administration. Digital platforms offer advantages including automatic scoring, longitudinal tracking of scores over time, integration with electronic health records, and the ability to screen patients between scheduled visits. Some digital platforms provide immediate psychoeducation and crisis resources based on the EPDS score.
When screening women who have experienced pregnancy loss (miscarriage,
When screening women who have experienced pregnancy loss (miscarriage, stillbirth, or neonatal death), the EPDS can be administered but must be interpreted with awareness that grief and depression have overlapping symptoms. A woman who has experienced a stillbirth may score very high on the EPDS due to appropriate grief rather than clinical depression. However, complicated grief that impairs functioning for an extended period may benefit from the same interventions as postnatal depression. In these cases, the EPDS serves as a starting point for clinical conversation rather than a definitive screening result. For women who have experienced a traumatic birth (emergency cesarean section, severe postpartum hemorrhage, NICU admission of the infant), the EPDS may underestimate distress because it does not specifically assess post-traumatic stress symptoms. These women may have clinically significant PTSD with relatively moderate EPDS scores. When a traumatic birth history is present, consider supplementing the EPDS with a PTSD screening tool such as the PC-PTSD-5 or PCL-5. In cases involving substance use during pregnancy, the EPDS should be administered with awareness that substance use, depression, and anxiety frequently co-occur in the perinatal period. Women in medication-assisted treatment for opioid use disorder have elevated rates of perinatal depression, and the EPDS may be confounded by substance-related mood symptoms. Integrated screening using the EPDS alongside the DAST-10 or AUDIT provides a more comprehensive picture.
| Score Range | Interpretation | Clinical Action | Follow-Up Timeline | Treatment Considerations |
|---|---|---|---|---|
| 0-9 | Depression unlikely | Positive reinforcement, routine monitoring | Next scheduled visit | Psychoeducation about warning signs |
| 10-12 | Possible depression | Clinical follow-up, repeat screening | 2-4 weeks | Supportive counseling, peer support, lifestyle interventions |
| 13-14 | Probable depression (mild) | Comprehensive clinical assessment | 1-2 weeks | Psychotherapy (CBT or IPT), consider medication |
| 15-19 | Probable depression (moderate) | Urgent clinical assessment | Within 1 week | Psychotherapy plus medication likely needed |
| 20-30 | Probable depression (severe) | Immediate assessment and intervention | Same day | Combined treatment, possible psychiatric referral, safety assessment |
| Item 10 > 0 | Self-harm ideation present | Immediate safety assessment | Before patient leaves | Suicide risk assessment, safety planning, crisis resources |
Can the EPDS be used during pregnancy, not just after birth?
Yes. Although originally developed for postnatal use, the EPDS has been extensively validated for antenatal (prenatal) depression screening. Multiple studies confirm its reliability and validity during pregnancy, with similar psychometric properties to postnatal use. Some researchers suggest using a slightly higher cutoff of 15 during pregnancy due to differences in symptom presentation. The EPDS is now widely recommended for screening at the first prenatal visit and again in the third trimester. Antenatal depression is a strong predictor of postnatal depression, so early identification allows for preventive intervention.
What should I do if a patient scores high on item 10 but low on the total score?
Item 10 (self-harm thoughts) requires immediate clinical attention regardless of the total EPDS score. A patient who scores 5 overall but endorses 'sometimes' on item 10 still needs a thorough suicide risk assessment. The clinical response should include asking directly about the nature, frequency, and intensity of self-harm thoughts; determining whether there is suicidal intent, a plan, or access to means; assessing protective factors (such as the infant and other children, supportive relationships); developing or updating a safety plan; and determining the appropriate level of care. Never assume that a low total score means the self-harm endorsement is clinically insignificant.
Is the EPDS valid for use with adoptive parents or parents via surrogacy?
Limited but growing research supports the use of the EPDS in non-birthing parents who are adjusting to parenthood through adoption, surrogacy, or other means. These parents experience many of the same psychological challenges as birthing parents, including sleep deprivation, role adjustment, anxiety, and mood changes, but without the hormonal fluctuations associated with childbirth. The EPDS items focus on psychological symptoms rather than physical postpartum experiences, making them broadly applicable. However, normative data and optimal cutoff scores have not been established specifically for these populations, so clinical judgment should supplement the numerical score.
How does the EPDS account for cultural differences in emotional expression?
The EPDS has been translated into over 60 languages, and each translation undergoes a rigorous process of forward translation, back translation, and validation in the target population. However, cultural differences extend beyond language. In some cultures, expressing negative emotions about motherhood is highly stigmatized, leading to underreporting. In others, somatic complaints may be the primary expression of psychological distress (which the EPDS may miss since it excludes somatic items). Cultural norms about help-seeking, the role of extended family, and expectations of motherhood all affect EPDS responses. Clinicians should consider cultural context when interpreting scores and may need to use supplementary clinical interview to achieve accurate assessment.
Can antidepressants be used safely during breastfeeding if the EPDS is high?
Yes, several antidepressants can be used during breastfeeding with appropriate risk-benefit analysis. Sertraline (Zoloft) has the strongest safety data during lactation, with minimal transfer to breast milk and no significant adverse effects in breastfed infants. Paroxetine (Paxil) also has favorable lactation data. The benefits of treating moderate to severe postnatal depression generally outweigh the small risks associated with antidepressant use during breastfeeding. Untreated maternal depression impairs breastfeeding success, mother-infant bonding, and infant development. The decision should be made collaboratively between the patient, prescribing clinician, and pediatrician.
What is the difference between baby blues and postnatal depression?
Baby blues affect approximately 50 to 80 percent of new mothers and typically begin within the first few days after delivery, peaking around days 3 to 5 and resolving spontaneously by 2 weeks postpartum. Symptoms include mood swings, tearfulness, irritability, and anxiety. Baby blues are considered a normal physiological response to the rapid hormonal changes after delivery. Postnatal depression, in contrast, is a clinical condition that typically develops between 2 weeks and 6 months postpartum (though it can occur anytime in the first year), persists for weeks to months without treatment, involves more severe symptoms including persistent sadness, loss of interest, guilt, worthlessness, and impaired functioning, and requires professional treatment. The EPDS can help distinguish between the two when administered after the first 2 weeks postpartum.
How does postnatal depression affect infant development?
Untreated postnatal depression has well-documented adverse effects on infant and child development. In infancy, it is associated with impaired mother-infant bonding, reduced responsiveness to infant cues, decreased breastfeeding duration, and disrupted infant sleep patterns. In early childhood, children of mothers with untreated postnatal depression show higher rates of behavioral problems, language delays, insecure attachment patterns, and cognitive development delays. Long-term follow-up studies have found effects persisting into adolescence, including increased rates of depression, anxiety, and behavioral disorders in the children. These findings underscore the importance of screening and treating postnatal depression not just for the mother's wellbeing but for the infant's developmental trajectory.
Pro Tip
When a postpartum patient scores between 10 and 12 on the EPDS, use the individual item responses rather than just the total score to guide your clinical conversation. A patient with elevated scores on items 3, 4, and 5 (the anxiety subscale) may be experiencing perinatal anxiety rather than or in addition to depression, which may respond better to anxiety-specific interventions. A patient with elevated scores on items 7 and 8 (sadness and sleep difficulty due to unhappiness) but low anxiety items has a different clinical profile. The pattern of responses tells a richer clinical story than the total score alone.
Did you know?
The Edinburgh Postnatal Depression Scale was developed because of a chance observation by Dr. John Cox during his work in Uganda in the 1970s. He noticed that the depression screening tools used in Western countries performed poorly in Uganda because symptoms like fatigue and appetite changes were so common among postpartum women (regardless of mood) that they could not distinguish depressed from non-depressed mothers. This experience led him to develop a scale that focused exclusively on emotional symptoms, which turned out to be equally advantageous in Western populations. The irony is that a tool designed for Scottish mothers was inspired by clinical work in East Africa.
References
- ›Detection of Postnatal Depression: Development of the 10-item Edinburgh Postnatal Depression Scale - Cox, Holden, and Sagovsky, British Journal of Psychiatry, 1987
- ›Screening for Perinatal Depression - ACOG Committee Opinion 757, American College of Obstetricians and Gynecologists, 2018
- ›Perinatal Depression: A Systematic Review of Prevalence and Incidence - Woody et al., Obstetrics and Gynecology, 2017
Get Weekly Math Tips
Join 12,000+ subscribers who get calculator tips every week.