The Edinburgh Postnatal Depression Scale: A Clinical Guide for Midwives, Health Visitors and Doulas
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Published by Circe | Postpartum Mental Health | Group Therapy for Women
The Edinburgh Postnatal Depression Scale has been a cornerstone of perinatal mental health screening for nearly four decades. Most birth workers are familiar with it. Fewer feel fully confident in what to do with a concerning score, how to raise the conversation with a client, or where the scale's limitations lie.
This guide covers the clinical foundations of the EPDS, how to administer and interpret it accurately, the conversations that need to happen around it, and the referral pathways available when a client needs more support than a single appointment can provide.
What the EPDS Is and Why It Matters
The Edinburgh Postnatal Depression Scale was developed in 1987 by John Cox, Jenifer Holden, and Ruth Sagovsky at the University of Edinburgh. It was designed specifically for the postpartum population, addressing a recognised limitation of general depression screening tools that include somatic symptoms, such as fatigue and appetite changes, which are normal features of the postpartum period and therefore poor discriminators of depression in new mothers.
The scale consists of ten self-report items. Women are asked to respond in relation to how they have felt over the past seven days, selecting the response that comes closest to how they have felt, not just on the day of completion.
Edinburgh Postnatal Depression Scale (Cox, Holden & Sagovsky, 1987. Reproduced with permission from the Royal College of Psychiatrists.)
1. I have been able to laugh and see the funny side of things
- As much as I always could
- Not quite so much now
- Definitely not so much now
- Not at all
2. I have looked forward with enjoyment to things
- As much as I ever did
- Rather less than I used to
- Definitely less than I used to
- Hardly at all
3. I have blamed myself unnecessarily when things went wrong
- Yes, most of the time
- Yes, some of the time
- Not very often
- No, never
4. I have been anxious or worried for no good reason
- No, not at all
- Hardly ever
- Yes, sometimes
- Yes, very often
5. I have felt scared or panicky for no good reason
- Yes, quite a lot
- Yes, sometimes
- No, not much
- No, not at all
6. Things have been getting on top of me
- Yes, most of the time I have not been able to cope at all
- Yes, sometimes I have not been coping as well as usual
- No, most of the time I have coped quite well
- No, I have been coping as well as ever
7. I have been so unhappy that I have had difficulty sleeping
- Yes, most of the time
- Yes, sometimes
- Not very often
- No, not at all
8. I have felt sad or miserable
- Yes, most of the time
- Yes, quite often
- Not very often
- No, not at all
9. I have been so unhappy that I have been crying
- Yes, most of the time
- Yes, quite often
- Only occasionally
- No, never
10. The thought of harming myself has occurred to me
- Yes, quite often
- Sometimes
- Hardly ever
- Never
Scoring Items 1, 2, and 4 are scored 0, 1, 2, 3 from top to bottom. Items 3 and 5 through 10 are reverse scored: 3, 2, 1, 0 from top to bottom. The maximum total score is 30.
A score of 13 or above indicates probable depression and warrants further assessment and referral.
Scores of 10 to 12 are clinically significant and require a careful follow-up conversation.
Any score above zero on item 10 requires immediate follow-up regardless of total score.
The anxiety subscale comprises items 3, 4, and 5. A combined score of 6 or above on these three items is associated with clinically significant anxiety.
The EPDS is validated for use during pregnancy as well as postpartum, and its use is recommended at multiple contact points in NICE guidelines on antenatal and postnatal mental health (CG192), which advise asking about mental health and emotional wellbeing at the first antenatal appointment, at the booking visit, postnatally at six to eight weeks, and at the new birth visit.
Importantly, the EPDS screens for anxiety as well as depression. Item four ("I have been anxious or worried for no good reason") and item five ("I have felt scared or panicky for no good reason") specifically capture anxiety symptoms, which are at least as prevalent as depressive symptoms in the perinatal period and are frequently the presenting feature that women themselves find most distressing.
How to Administer the EPDS Effectively
The EPDS is designed to be self-completed, but the context in which it is administered significantly affects its validity.
Create the conditions for honest responding.
A woman completing the EPDS in a busy clinic waiting room, with her partner present, or while managing a crying infant is less likely to respond honestly than one who completes it in a private, unhurried setting. Where possible, administer the scale at a point in the appointment where she has had time to settle, feels that you have time for her, and understands that her answers are confidential within the limits of clinical safeguarding.
Explain what the scale is and is not.
Framing matters. Introducing the EPDS as "just a standard questionnaire we do with everyone" normalises it and reduces the likelihood that a woman will underreport to appear well. It is worth adding: "There are no right or wrong answers. We ask everyone these questions because we know that the postpartum period can be difficult and we want to make sure you have the right support."
Be specific about the timeframe.
The EPDS asks about the past seven days. Women sometimes interpret questions in relation to how they feel right now, in the appointment, rather than across the previous week. A brief verbal reminder of the timeframe before she begins improves accuracy.
Do not skip item ten.
Item ten ("The thought of harming myself has occurred to me") is the most clinically significant item on the scale. Any score above zero on item ten requires immediate follow-up regardless of the total score. This is non-negotiable and should be protocol in every setting where the EPDS is used.
Interpreting Scores: Beyond the Threshold
The commonly cited threshold for probable depression is a score of thirteen or above. This figure comes from the original validation study and has been widely adopted, but applying it rigidly can both over- and under-identify women who need support.
What a score of thirteen or above indicates:
A score at or above this threshold is associated with a high probability of depressive illness and warrants further clinical assessment and referral. It is not a diagnosis. It is a signal that something needs follow-up.
What a score below thirteen does not mean:
A score below thirteen does not mean a woman is well. Scores in the range of ten to twelve are clinically significant and warrant a careful conversation. Women who are masking symptoms, who responded in relation to a particularly functional day, or who are experiencing predominantly anxiety rather than depression may score below threshold while still needing support.
Clinical judgment must sit alongside the numerical score. A woman who scores nine but breaks down during the appointment, who mentions she has not slept in days, or who makes a passing comment about not being able to go on, needs follow-up regardless of her number.
Anxiety scores:
Research published in the Journal of Affective Disorders has identified an anxiety subscale within the EPDS comprising items three, four, and five. A combined score of six or above on these three items is associated with clinically significant anxiety. This subscale is not universally used in clinical practice but is worth being aware of, particularly for women whose primary presentation is anxiety rather than low mood.
Cultural and linguistic considerations:
The EPDS has been translated and validated in numerous languages and is available in multiple translated versions through PANDAS Foundation and local NHS perinatal mental health teams. Cultural factors can affect how women interpret and respond to items, particularly those relating to emotional expression and help-seeking. Validated translated versions should always be used rather than informal interpretations.
Having the Conversation After a Concerning Score
This is where many birth workers feel least confident, and it is the most important part of the process.
A woman who has just disclosed significant distress through a screening tool needs the next five minutes of your time to feel safe, heard, and not judged. How that conversation goes will significantly affect whether she follows through with the support she is offered.
Lead with normalisation, not alarm.
"Thank you for being honest in your answers. Some of what you have described is something a lot of women experience, and it tells me that you could benefit from some extra support right now."
Avoid language that frames her score as a problem or a failure. Avoid clinical labels in the immediate follow-up unless she asks directly. The goal of this conversation is connection and next steps, not diagnosis.
Ask one open question before moving to referral.
"Can you tell me a little more about how you have been feeling?" gives her the opportunity to expand beyond the scale. It also gives you clinically important information that the scale cannot capture: how long symptoms have been present, what her support at home looks like, whether she has had previous episodes of depression or anxiety, and whether she has already tried to seek help.
Address item ten directly and calmly.
If she has scored above zero on item ten, this must be followed up directly and without panic. "I noticed you answered this question about thoughts of harming yourself. Can you tell me more about that?" Calm, direct inquiry is more likely to elicit an honest response than an alarmed reaction that causes her to minimise what she said.
For any active suicidal ideation or risk of harm, follow your organisation's safeguarding protocol and refer urgently. The National Confidential Enquiry into Patient Outcome and Death (NCEPOD) and MBRRACE-UK reports have consistently identified mental health as a leading cause of maternal death in the UK, with suicide the leading cause of direct maternal deaths in the year after birth. The clinical stakes of this conversation are high.
Do not leave the appointment without a clear next step.
Vague reassurance ("keep an eye on how you are feeling") is not a clinical plan. Before she leaves, she should know what happens next: whether you are making a referral, whether she should book with her GP and by when, what support is available to her in the interim, and when you will follow up.
Referral Pathways and What Is Available
GP referral The first point of contact for most women. GPs can prescribe, refer to NHS Talking Therapies, and refer to specialist perinatal mental health teams. Encouraging the woman to book promptly and offering to write a brief note summarising your clinical concern can improve the likelihood that the appointment results in adequate support.
NHS Talking Therapies (previously IAPT) Offers CBT and other evidence-based psychological therapies. Accepts self-referrals in most areas of England, which means you can signpost a woman to refer herself without waiting for a GP appointment. Find local services at nhs.uk/talking-therapies.
Specialist perinatal mental health teams For moderate to severe presentations. Referral is usually via GP. The Maternal Mental Health Alliance provides a directory of NHS specialist perinatal mental health services across the UK and is a useful resource to have to hand.
Peer support PANDAS Foundation offers a helpline and peer support groups specifically for perinatal mental health. For women waiting for clinical treatment or who need support between appointments, peer support can provide meaningful continuity of care.
Group therapy Clinically facilitated group therapy is an evidence-based intervention for postnatal depression that addresses both clinical symptoms and the isolation that characterises the condition. For women who are reluctant to engage with individual therapy, or who would benefit from peer connection alongside clinical facilitation, group therapy can be a particularly effective referral.
Circe offers an online postpartum mental health group facilitated by a qualified therapist with experience in perinatal mental health. It runs online, removing barriers of travel and childcare, and sits comfortably alongside GP care, NHS Talking Therapies, or specialist referral. If you would like to discuss whether Circe is an appropriate option for a client, or to find out more about the group, get in touch here or visit the group page here.
The Limitations of the EPDS
No screening tool is without limitations, and using the EPDS well means understanding where it falls short.
It does not screen for postpartum psychosis. Postpartum psychosis is a psychiatric emergency requiring urgent referral. Its symptoms, including confusion, hallucinations, rapid mood shifts, and disorganised behaviour, are not captured by the EPDS. Clinical vigilance for postpartum psychosis must operate independently of EPDS screening.
It can miss postnatal anxiety as the primary presentation. Women with predominantly anxious presentations may score below the depression threshold while experiencing significant clinical distress. The anxiety subscale and clinical observation are both important supplements.
It is a point-in-time measure. A single administration captures one week. Women whose symptoms fluctuate, who were having a better week, or who completed the scale during a more functional period may not be identified. Repeated administration at multiple contact points, as recommended by NICE, improves detection rates significantly.
Underreporting is common. Fear of judgment, concern about child protection involvement, and the stigma surrounding maternal mental illness all contribute to women minimising their responses. A low score in the context of clinical concern should not close the conversation.
Supporting Your Own Practice
Working with women in perinatal mental distress can be emotionally demanding, particularly for birth workers who carry significant relational investment in their clients' wellbeing.
The Royal College of Midwives provides guidance on supervision and support for midwives navigating complex perinatal mental health presentations. Regular clinical supervision, peer discussion, and clear escalation pathways within your organisation are all protective factors for both you and your clients.
Knowing your referral network well, including what is available locally, what the waiting times are, and which organisations offer timely support, means that when a client needs more than you can provide, you have somewhere confident to send her.
Circe offers online group therapy for women, including a postpartum mental health group. Birth workers are welcome to get in touch to discuss referrals or find out more about how we work. Contact us here.
Frequently Asked Questions
What is the Edinburgh Postnatal Depression Scale used for?
The EPDS is a ten-item self-report screening tool used to identify women who may be experiencing postnatal depression or anxiety. It is validated for use both during pregnancy and postnatally and is recommended by NICE at multiple contact points throughout the perinatal period. It is a screening tool, not a diagnostic instrument.
What is a concerning score on the EPDS?
A score of thirteen or above is associated with a high probability of depressive illness and warrants further assessment and referral. Scores between ten and twelve are clinically significant and require a careful follow-up conversation. Any score above zero on item ten, which relates to thoughts of self-harm, requires immediate follow-up regardless of the total score.
How often should the EPDS be administered?
NICE guidelines recommend asking about mental health and emotional wellbeing at the first antenatal appointment, the booking visit, the new birth visit, and the six to eight week postnatal check. More frequent administration may be appropriate for women with known risk factors or previous perinatal mental illness.
Can the EPDS detect postnatal anxiety as well as depression?
Yes, partially. The EPDS includes items that screen for anxiety symptoms, and a three-item anxiety subscale (items three, four, and five) has been identified in research. A combined score of six or above on these items is associated with clinically significant anxiety. However, the EPDS was primarily designed to screen for depression and should not be relied upon as a standalone anxiety screening tool.
What should I do if a client scores above zero on item ten of the EPDS?
Any score above zero on item ten requires direct, calm follow-up in the same appointment. Ask the woman to tell you more about the thought. Assess the nature and immediacy of any risk. Follow your organisation's safeguarding protocol. Do not leave the appointment without a clear safety plan and next steps in place.
What are the limitations of the EPDS?
The EPDS does not screen for postpartum psychosis, may miss predominantly anxious presentations, captures only a one-week window, and is subject to underreporting due to stigma and fear of judgment. Clinical observation and professional judgment must always operate alongside the numerical score.
How should I introduce the EPDS to a postnatal client?
Normalise it. Explain that it is a standard questionnaire completed with all postnatal women, that there are no right or wrong answers, and that the purpose is to make sure she has the right support. Administer it in a private, unhurried setting where possible and remind her that it covers the past seven days before she begins.
Where can I refer a client who scores high on the EPDS?
Referral options include the woman's GP, NHS Talking Therapies (which accepts self-referrals in most areas), specialist perinatal mental health teams via GP referral, PANDAS Foundation for peer support, and clinically facilitated group therapy such as that offered by Circe. The Maternal Mental Health Alliance provides a directory of NHS specialist perinatal mental health services across the UK.
Is the EPDS available in languages other than English?
Yes. The EPDS has been translated and validated in numerous languages. Translated versions are available through PANDAS Foundation and local NHS perinatal mental health teams. Validated translations should always be used rather than informal interpretations.
What is the difference between the EPDS and other depression screening tools?
General depression screening tools such as the PHQ-9 include somatic symptoms like fatigue and appetite changes, which are normal features of the postpartum period and therefore poor discriminators of depression in new mothers. The EPDS was specifically designed to avoid this limitation, making it more appropriate and accurate for perinatal populations than general adult depression scales.
This article is intended as a professional resource for birth workers and does not constitute clinical training or replace organisational safeguarding protocols. Always follow your organisation's guidelines when responding to concerning EPDS scores.