Abstract:

Objective:

To evaluate the sensitivity and specificity of the Two Whooley questions and the Arroll question, using the SCID, The Structured Clinical Interview (SCID-I) as the gold standard for detecting perinatal depression.

Materials and methods:

We interviewed 210 women during pregnancy and 6 months postpartum.

Results:

The criterion with the greatest sensitivity was responding positively to either Whooley question (pregnancy= 94.7 %; postpartum=100.0%), while the most specific criterion was responding positively to the two Whooley questions plus the Arroll question (Pregnancy=90.0% Postpartum = 85.7%).

Conclusion:

The Whooley and Arroll questions have adequate psychometric properties to detect possible cases of depression during the perinatal period. They can be applied during prenatal check-ups and postpartum consultations. Timely detection of women at risk of perinatal depression can contribute to their treatment for reducing their adverse consequences in mothers and infants.

Keywords:
depression postpartum; screening; sensitivity and specificity; primary healthcare

Resumen:

Objetivo:

Evaluar la sensibilidad y la especificidad de la Escala de las dos preguntas de Whooley y la pregunta de Arroll para detectar riesgo de depresión perinatal, usando la SCID como estándar de oro.

Material y métodos:

Se entrevistó a 210 mujeres durante el embarazo y 6 meses después del parto.

Resultados:

El criterio con mayor sensibilidad fue responder positivamente a cualquiera de las Preguntas de Whooley (embarazo = 94.7%; posparto = 100.0%) y, el más específico, responder positivamente a las preguntas de Whooley más la de Arroll (embarazo = 90.0% , Posparto = 85.7%).

Conclusiones:

Las preguntas de Whooley y Arroll tienen propiedades psicométricas adecuadas para detectar posibles casos de depresión durante el periodo perinatal. Pueden aplicarse durante las citas de control prenatal y consultas en el postparto. Detectar de manera oportuna a mujeres en riesgo de depresión perinatal puede ayudar a su atención para reducir sus consecuencias adversas en madres e infantes.

Palabras clave:
depresión posparto; sensibilidad y especificidad; primer nivel de atención

Introduction

Perinatal depression (depression in pregnancy and within the first year post-partum)¹1. O’Hara MW, McCabe JE. Postpartum depression: current status and future directions. Annu Rev Clin Psychol. 2013;9:379-407. https://doi.org/10.1146/annurev-clinpsy-050212-185612
https://doi.org/10.1146/annurev-clinpsy-... is a common disorder worldwide. Since it is a condition that casts a shadow over motherhood,²2. Beck CT. Postpartum depression: Stopping the thief that steals motherhood. AWHONN Lifelines. 1999;3(4):41-4. https://doi.org/10.1111/j.1552-6356.1999.tb01115.x
https://doi.org/10.1111/j.1552-6356.1999... causing a state of distress in women, its timely detection and treatment should be a priority. During pregnancy, between 2 and 21 % of women suffer major depression worldwide,³3. Bennett HA, Einarson A, Taddio A, Koren G, Einarson TR. Depression during pregnancy: overview of clinical factors. Clin Drug Invest. 2004;24(3):157-79. https://doi.org/10.2165/00044011-200424030-00004
https://doi.org/10.2165/00044011-2004240... ^,44. Fisher J, Mello MCD, Patel V, Rahman A, Tran T, Holton S, Holmes W. Prevalence and determinants of common perinatal mental disorders in women in low-and lower-middle-income countries: a systematic review. Bull World Health Organ. 2012;90(2):139-49. https://doi.org/10.2471/BLT.11.091850
https://doi.org/10.2471/BLT.11.091850... whereas in Mexico, between 9 and 14 % develop this condition.⁵5. Ocampo R, Heinze G, Ontiveros MP. Detección de depresión postparto en el Instituto Nacional de Perinatología. Psiquiatría. 2007;23:18-22.^,66. Gómez LME, Aldana CE. Alteraciones psicológicas en la mujer con embarazo de alto riesgo. Psicología y Salud. 2007;17(1):53-61.^,77. Lara MA, Navarrete L, Nieto L, Barba MJP, Navarro JL, Lara-Tapia H. Prevalence and incidence of perinatal depression and depressive symptoms among Mexican women. J Affect Disord. 2015;175:18-24. https://doi.org/10.1016/j.jad.2014.12.035
https://doi.org/10.1016/j.jad.2014.12.03... Postpartum depression (PPD) affects 10 to 19.8 % of women internationally⁴4. Fisher J, Mello MCD, Patel V, Rahman A, Tran T, Holton S, Holmes W. Prevalence and determinants of common perinatal mental disorders in women in low-and lower-middle-income countries: a systematic review. Bull World Health Organ. 2012;90(2):139-49. https://doi.org/10.2471/BLT.11.091850
https://doi.org/10.2471/BLT.11.091850... ^,88. O’Hara MW, Swain AM. Rates and risk of postpartum depression-a meta-analysis. Int Rev Psychiatry. 1996;8(1):1-52. https://doi.org/10.3109/09540269609037816
https://doi.org/10.3109/0954026960903781... and between 13.3 and 24.1% of those in Mexico.⁵5. Ocampo R, Heinze G, Ontiveros MP. Detección de depresión postparto en el Instituto Nacional de Perinatología. Psiquiatría. 2007;23:18-22.^,77. Lara MA, Navarrete L, Nieto L, Barba MJP, Navarro JL, Lara-Tapia H. Prevalence and incidence of perinatal depression and depressive symptoms among Mexican women. J Affect Disord. 2015;175:18-24. https://doi.org/10.1016/j.jad.2014.12.035
https://doi.org/10.1016/j.jad.2014.12.03... ^,99. Alvarado-Esquivel C, Sifuentes-Álvarez A, Estrada-Martínez S, Salas-Martínez C, Hernández-Alvarado AB, Ortiz-Rocha SG, et al. Prevalencia de depresión posnatal en mujeres atendidas en hospitales públicos de Durango, Mexico. Gac Med Mex. 2010;146:1-9.^,1010. Almanza-Muñoz JJ, Salas-Cruz CL, Olivares-Morales AS. Prevalencia de depresión posparto y factores asociados, en pacientes puérperas de Especialidades de la Mujer. Rev Sanid Milit Mex. 2011;65(3):78-86.^,1111. Álvarez EA, Ponce RER, Irigoyen CA. Frecuencia de depresión posparto en pacientes de dos clínicas de medicina familiar en México. Arch Med Fam. 2008;9(4):133-6.

Prenatal depression has been linked to an increased risk of emergency service use,¹²12. Field T. Postpartum depression effects on early interactions, parenting, and safety practices: a review. Infant Behav Dev. 2010;33(1):1-6. https://doi.org/10.1016/j.infbeh.2009.10.005
https://doi.org/10.1016/j.infbeh.2009.10... substance use by the mothers and premature birth, as well as insufficient fetal weight gain and late seeking of prenatal care services.¹³13. Marcus SM. Depression during pregnancy: rates, risks and consequences---Mother risk Update. Can J Clin Pharmacol. 2009;16(1):e15-22. There is evidence that PPD also has extremely negative consequences for both mother and infant. Untreated PPD affects the quality of the interaction between the mother and her baby, making it more likely for the infant to develop an insecure attachment pattern; it also affects the infant’s health and performance, as well as its cognitive, behavioral and emotional development.¹⁴14. Stein A, Pearson RM, Goodman SH, Rapa E, Rahman A, McCallum M, et al. Effects of perinatal mental disorders on the fetus and child. Lancet. 2014;384(9956):1800-19. https://doi.org/10.1016/S0140-6736(14)61277-0
https://doi.org/10.1016/S0140-6736(14)61... Low socioeconomic status increases the risk of PPD, since women with low resources are more likely to lack access to health services, infant care and information.¹⁵15. Goyal D, Gay C, Lee KA. How much does Low Socioeconomic Status Increase the Risk of Prenatal and Postpartum Depressive Symptoms in First Time Mothers? Womens Health Issues. 2010;20(2):96-104. https://doi.org/10.1016/j.whi.2009.11.003
https://doi.org/10.1016/j.whi.2009.11.00... In low-income countries, babies of depressed mothers have a higher risk of health problems such as more frequent bouts of diarrhea.¹⁶16. Rahman A, Iqbal Z, Bunn J, Lovel H, Harrington R. Impact of maternal depression on infant nutritional status and illness: a cohort study. Arch Gen Psychiatry. 2004;61(9):946-52. https://doi.org/10.1001/archpsyc.61.9.946
https://doi.org/10.1001/archpsyc.61.9.94... In Mexico, the only study on this issue showed that low-income women with children up to the age of 5 who suffered from depression were at an increased risk for never breastfeeding the baby, health problems, acute respiratory disease, accidents requiring child hospitalization, and food insecurity.¹⁷17. de Castro F, Place JM, Villalobos A, Rojas R, Barrientos T, Frongillo EA. Poor early childhood outcomes attributable to maternal depression in Mexican women. Arch Womens Ment Health. 2017;20(4):561-8. https://doi.org/10.1007/s00737-017-0736-7
https://doi.org/10.1007/s00737-017-0736-...

Despite the high prevalence of perinatal depression and its negative effects on maternal and infant health even in developed countries, it is estimated that between 75 and 90% of women suffering from this condition fail to be detected during the routine clinical check-ups delivered by primary healthcare.¹⁸18. Woolhouse H, Brown S, Krastev A, Perlen S, Gunn J. Seeking help for anxiety and depression after childbirth: results of the Maternal Health Study. Arch Womens Ment Health. 2009;12(2):75-83. https://doi.org/10.1007/s00737-009-0049-6
https://doi.org/10.1007/s00737-009-0049-... ^,1919. Goodman JH, Tyer-Viola L. Detection, treatment, and referral of perinatal depression and anxiety by obstetrical providers. J Women’s Health. 2010;19(3):477-90. https://doi.org/10.1089/jwh.2008.1352
https://doi.org/10.1089/jwh.2008.1352... ^,2020. Pereira AT, João-Soares M, Bos S, Marques M, Maia B, Valente J, et al. Why should we screen for perinatal depression? Ten reasons to do it. IJCNMH. 2014;1:10. https://doi.org/10.21035/ijcnmh.2014.1.10
https://doi.org/10.21035/ijcnmh.2014.1.1... This may be due to the lack of adequate tools at the primary care level for accurately identifying women at risk of depression,²¹21. Milgrom J, Gemmill AW. Screening for perinatal depression. Best Pract Res Clin Obstet Gynaecol. 2014;28(1):13-23. https://doi.org/10.1016/j.bpobgyn.2013.08.014
https://doi.org/10.1016/j.bpobgyn.2013.0... since the extremely high demand for health services prevents professionals from conducting lengthy diagnostic interviews.²²22. Austin MP. Marcé International Society position statement on psychosocial assessment and depression screening in perinatal women. Best Pract Res Clin Obstet Gynaecol. 2014;28(1):179-87. https://doi.org/10.1016/j.bpobgyn.2013.08.016
https://doi.org/10.1016/j.bpobgyn.2013.0...

Although there are several instruments for detecting perinatal depression in primary care settings, including the Edinburgh Postnatal Depression Scale (EPDS),²³23. Cox JL, Holden JM, Sagovsky R. Detection of postnatal depression. Development of the 10-item Edinburgh Postnatal Depression Scale. Br J Psychiatry. 1987;150(6):782-6. https://doi.org/10.1192/bjp.150.6.782
https://doi.org/10.1192/bjp.150.6.782... validated in Mexico by Juárez et al.²⁴24. Juárez IR, Santos R, Lara MA, Almanza JJ. Consistencia interna y análisis factorial de la Escala de Depresión Postparto de Edimburgo en mujeres mexicanas embarazadas y puérperas. Reporte preliminar. Neurol Neurocir Psiquiat. 2009;42(1-4):1-6. and by Alvarado-Esquivel et al.,²⁵25. Alvarado-Esquivel C, Sifuentes-Álvarez A, Salas-Martínez C. Validation of the Edinburgh Postpartum Depression Scale in a population of adult pregnant women in Mexico. J Clin Med Res. 2014;6(5):374-8. https://doi.org/10.14740/jocmr1883w
https://doi.org/10.14740/jocmr1883w... and the Center for Epidemiological Studies Depression-Scale (CES-D),²⁶26. Radloff LS. The CES-D scale: A self-report depression scale for research in the general population. Appl Psychol Meas. 1997;1(3):385-401. https://doi.org/10.1177/014662167700100306
https://doi.org/10.1177/0146621677001003... validated in Mexico by Lara and Navarrete,²⁷27. Lara MA, Navarrete L. Detección de depresión en mujeres embarazadas mexicanas con la CES-D. Salud Ment (Mex). 2012;35(1):57-62. these screening scales are not routinely used at healthcare centers. Among the reasons for not using them are the fact that, although there is an official standard for the detection of perinatal depression, it is not put into practice, since doctors prefer to ask a general question about their patients’ emotional state if they find any abnormal physical symptoms.²⁸28. Place JMS, Allen-Leigh B, Billings DL, Dues KM, de Castro F. Detection and care practices for postpartum depressive symptoms in public-sector obstetric units in Mexico: Qualitative results from a resource-constrained setting. Birth. 2017;44(4):390-396. https://doi.org/10.1111/birt.12304
https://doi.org/10.1111/birt.12304... In other countries, screening scales are often not used in primary health care either, partly due to the doctors’ belief that they are too long and reduce the time spent on patients during consultation.²⁹29. Thielke S, Vannoy S, Unützer J. Integrating mental health and primary care. Prim Care. 2007;34(3):571-92. https://doi.org/10.1016/j.pop.2007.05.007
https://doi.org/10.1016/j.pop.2007.05.00...

There is evidence from Australia³⁰30. Howell CA, Turnbull DA, Beilby JJ, Marshall CA, Briggs N, Newbury WL. Preventing relapse of depression in primary care: a pilot study of the “Keeping the blues away” program. Med J Aust. 2008;188(12):138-41. and the UK³¹31. National Collaborating Centre for Mental Health. Antenatal and Postnatal Mental Health: the NICE guideline on clinical management and service guidance. UK: The British Psychological Society, 2007 [cited 2016 Jan].Available from: Available from: http://www.nice.org.uk/nicemedia/pdf/CG45fullguideline.pdf
http://www.nice.org.uk/nicemedia/pdf/CG4... that brief instruments can accurately identify women at risk of PPD. The Whooley questions³²32. Whooley MA, Avins AL, Miranda J, Browner WS. Case-finding instruments for depression. Two questions are as good as many. J Gen Intern Med. 1997;12(7):439-45. https://doi.org/10.1046/j.1525-1497.1997.00076.x
https://doi.org/10.1046/j.1525-1497.1997... are a tool recommended by the NICE (National Institute for Health and Care Excellence) Guidelines on Clinical Management and Service Guidance³¹31. National Collaborating Centre for Mental Health. Antenatal and Postnatal Mental Health: the NICE guideline on clinical management and service guidance. UK: The British Psychological Society, 2007 [cited 2016 Jan].Available from: Available from: http://www.nice.org.uk/nicemedia/pdf/CG45fullguideline.pdf
http://www.nice.org.uk/nicemedia/pdf/CG4... for the detection of depressive symptoms during the perinatal period. The Whooley questions are an abridged version of the Primary Care Evaluation of Mental Disorders Procedure (PRIME-MD)³³33. Spitzer RL, Williams JB, Kroenke K, Linzer M, deGruy FV III, Hahn S, et al. Utility of a new procedure for diagnosing mental disorders in primary care. The PRIME-MD 1000 study. JAMA. 1994;272(22):1749-56. https://doi.org/10.1001/jama.1994.03520220043029
https://doi.org/10.1001/jama.1994.035202... consisting of a two-stage screening for five of the most common groups of disorders in primary care including depression. The two original Whooley questions include the two main criteria for diagnosing major depression according to the DSM-V³⁴34. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 5th ed. Arlington, VA: American Psychiatric Publishing, 2013. regarding depressed mood and loss of pleasure. Arroll et al.³⁵35. Arroll B, Goodyear-Smith F, Kerse N, Fishman T, Gunn J. Effect of the addition of a “help” question to two screening questions on specificity for diagnosis of depression in general practice: diagnostic validity study. BMJ. 2005;331(7521):884. https://doi.org/10.1136/bmj.38607.464537.7C
https://doi.org/10.1136/bmj.38607.464537... suggested adding a third one related to the need for help, in order to improve the specificity of these questions. The response options for the three items are yes or no.

A short instrument like this one might contribute to the detection of probable cases of perinatal depression if it were systematically used by the healthcare staff -nurses and social workers- who are more directly in contact with perinatal women³¹31. National Collaborating Centre for Mental Health. Antenatal and Postnatal Mental Health: the NICE guideline on clinical management and service guidance. UK: The British Psychological Society, 2007 [cited 2016 Jan].Available from: Available from: http://www.nice.org.uk/nicemedia/pdf/CG45fullguideline.pdf
http://www.nice.org.uk/nicemedia/pdf/CG4... in countries like Mexico, where this problem has been overlooked.

The Whooley questions have demonstrated adequate psychometric properties, both in the general population³²32. Whooley MA, Avins AL, Miranda J, Browner WS. Case-finding instruments for depression. Two questions are as good as many. J Gen Intern Med. 1997;12(7):439-45. https://doi.org/10.1046/j.1525-1497.1997.00076.x
https://doi.org/10.1046/j.1525-1497.1997... ^,3636. Arroll B, Khin N, Kerse N. Screening for depression in primary care with two verbally asked questions: cross sectional study. BMJ. 2003;327(7424):1144-46. https://doi.org/10.1136/bmj.327.7424.1144
https://doi.org/10.1136/bmj.327.7424.114... and in women in perinatal care.³⁷37. Darwin Z, McGowan L, Edozien LC. Identification of women at risk of depression in pregnancy: using women’s accounts to understand the poor specificity of the Whooley and Arroll case finding questions in clinical practice. Arch Womens Ment Health. 2015;19(1):1-9. https://doi.org/10.1007/s00737-015-0508-1
https://doi.org/10.1007/s00737-015-0508-... However, the psychometric properties of the Whooley questions for perinatal women in Latin America have not been assessed. Their validation is important since they constitute a viable and economic tool in terms of the time required for their administration.³⁸38. Rahman A. Challenges and opportunities in developing a psychological intervention for perinatal depression in rural Pakistan - a multi-method study. Arch Womens Ment Health. 2007;10(5):211-9. https://doi.org/10.1007/s00737-007-0193-9
https://doi.org/10.1007/s00737-007-0193-... Detection of depressive symptoms is a necessary initial step for implementing prevention strategies within prenatal care and for referring severe cases to specialized treatment, with the aim of reducing the negative consequences of untreated perinatal depression in both mother and child.

Accordingly, the purpose of this study is to evaluate the sensitivity and specificity of the Whooley³²32. Whooley MA, Avins AL, Miranda J, Browner WS. Case-finding instruments for depression. Two questions are as good as many. J Gen Intern Med. 1997;12(7):439-45. https://doi.org/10.1046/j.1525-1497.1997.00076.x
https://doi.org/10.1046/j.1525-1497.1997... and Arroll questions³⁵35. Arroll B, Goodyear-Smith F, Kerse N, Fishman T, Gunn J. Effect of the addition of a “help” question to two screening questions on specificity for diagnosis of depression in general practice: diagnostic validity study. BMJ. 2005;331(7521):884. https://doi.org/10.1136/bmj.38607.464537.7C
https://doi.org/10.1136/bmj.38607.464537... using the Structured Clinical Interview (SCID-I)³⁹39. First M, Spitzer R, Gibbon M, Williams J. Structured Clinical Interview for DSM-IV Axis I Disorders (SCID-I), Clinical Version. Washington, DC: American Psychiatric Press, 1996. as the gold standard for diagnosing perinatal depression in a sample of perinatal Mexican women.

Materials and methods

Sample

A non-probabilistic sample of 280 pregnant women receiving prenatal care agreed to participate in the research. All the women in the waiting room were invited to verify whether or not they met the inclusion criteria. Out of this total, 210 women (75.0%) were assessed during pregnancy and followed up at six months postpartum, and therefore they were included in the study. The women were selected at various healthcare institutions: 1) a secondary healthcare hospital offering comprehensive medical care for state workers and their dependents; women who come to this hospital simultaneously receive prenatal care at family clinics, from which they are referred to this hospital for periodic check-ups and medical studies that are unavailable at the family clinic; these health services are provided for state workers and their families; and 2) a community healthcare center that provides prenatal and other forms of medical care to the local population. Women are referred to secondary care hospitals for childbirth. This population is not covered by Social Security. Women were eligible if a screening checklist had determined that they were aged ≥ 20 years, ≥ 26 weeks pregnant, did not have a bipolar condition, and lived in the Mexico City Metropolitan Area. All the respondents were from an urban area.

Measures

Demographic data included age, educational attainment, monthly family income and marital status. For the purposes of this study, reported family income was divided into two categories: 1) low income (≤5 246 Mexican pesos), which corresponds to deciles 1-3, comprising families with the highest poverty level in Mexico, and 2) medium and high income (>5 246 Mexican pesos) corresponding to deciles 4-10, according to the statistics provided by the National Institute of Statistics and Geography (Instituto Nacional de Estadística y Geografía).⁴⁰40. Instituto Nacional de Estadística y Geografía, Encuesta Nacional de Ingresos y Gastos de los Hogares (ENIGH) 2012. Aguascalientes, México: INEGI, 2013. [cited 2015 February]. Available from: Available from: http://www.beta.inegi.org.mx/proyectos/enchogares/regulares/enigh/nc/2014/default.html
http://www.beta.inegi.org.mx/proyectos/e... ^,**These ranges were calculated based on the quarterly income per household of 2012 reported by the National Household Income and Expenditure Survey, 2014.

Depression was assessed by the mood disorders module of the Structured Clinical Interview (SCID-I).³⁹39. First M, Spitzer R, Gibbon M, Williams J. Structured Clinical Interview for DSM-IV Axis I Disorders (SCID-I), Clinical Version. Washington, DC: American Psychiatric Press, 1996. The SCID-I is a semi-structured interview for diagnosing current major depression according to DSM-IV criteria. The SCID-I has previously been used with perinatal Mexican women.⁴¹41. Lara MA, Navarro C, Navarrete L. Outcome results of a psycho-educational intervention in pregnancy to prevent PPD: A randomized control trial. J Affect Disord. 2010;122(1-2):109-17. https://doi.org/10.1016/j.jad.2009.06.024
https://doi.org/10.1016/j.jad.2009.06.02... The diagnostic assessment was carried out by psychologists who also conducted the general interview. They received 15 hours’ training in the SCID-I from a certified psychiatrist and met with her for supervision at four different points during the data collection.

Procedure

Interviews were conducted by graduate psychologists affiliated to the INP and psychology students doing their social service, trained to conduct the interviews. Interviews took place at ≥26 weeks of pregnancy and six months postpartum. The pregnancy interview was carried out at the clinic, while postpartum interviews were conducted at the respondents’ homes. The women’s participation was based on standard informed consent procedures. Data were collected between 2012 and 2013.The study was approved by the Institutional Review Board (IRB) of the Ramón de la Fuente National Institute of Psychiatry.

Data Analysis

Descriptive statistics were calculated for sociodemographic characteristics. Sensitivity, specificity, positive predictive value, positive likelihood ratio and confidence intervals were evaluated for each of the two Whooley questions,³²32. Whooley MA, Avins AL, Miranda J, Browner WS. Case-finding instruments for depression. Two questions are as good as many. J Gen Intern Med. 1997;12(7):439-45. https://doi.org/10.1046/j.1525-1497.1997.00076.x
https://doi.org/10.1046/j.1525-1497.1997... as well as for the Help question³⁵35. Arroll B, Goodyear-Smith F, Kerse N, Fishman T, Gunn J. Effect of the addition of a “help” question to two screening questions on specificity for diagnosis of depression in general practice: diagnostic validity study. BMJ. 2005;331(7521):884. https://doi.org/10.1136/bmj.38607.464537.7C
https://doi.org/10.1136/bmj.38607.464537... and for the different combinations of responses in order to determine which approach was most useful for detecting women at risk of depression, using the SCID-I as a gold standard in the two periods evaluated. Statistical analyses were conducted using STATA, version 12.

It is important to note that the term “sensitivity” indicates the percentage of respondents with depression detected by the test, in other words, the percentage of women with depression correctly classified as positive. Specificity indicates the percentage of respondents without depression correctly classified as negative. Positive predictive value refers to the probability that a participant with a positive result actually suffers from depression. Positive likelihood ratio shows how much more likely a respondent is to obtain a positive score if she has depression, compared with a person without it.⁴²42. González R, García J. Pruebas de detección masiva de enfermedades. En: Villa A, Moreno L, García G, eds. Epidemiología y estadística en salud pública. Ciudad de México: McGraw-Hill, 2012.

Results

The sample mean age was 29.5 years (SD=6.3); respondents had 13.0 (SD=3.8) years of schooling and most were married or living in a consensual union (80.5%). Almost half had a low family income (46.7%) (table I).

As can be seen from table II, about half the women responded affirmatively to the Depressed mood question at both pregnancy (59.0%), and postpartum (48.1%), while the percentage of women who responded affirmatively to the Loss of Pleasure criterion was higher in postpartum (37.6%) than during pregnancy (26.2%). Finally, in both periods, almost half the women (45.9 -52.2%) responded affirmatively to the Help question.

Sensitivity, specificity, predictive value and likelihood ratio of the Whooley and Arroll questions

The data showed that during pregnancy, the criterion with the greatest sensitivity was affirmatively answering either Whooley question (94.7%), while the criterion with the greatest specificity was affirmatively answering the two Whooley questions plus the Help question (90.0%). As for positive predictive values, all the criteria were below 40.0% (13.7-32.1), and the likelihood ratio for a positive test was moderate (4.7), while the criterion that most accurately diagnosed depression in pregnancy was the two Whooley questions plus the Help question (table III).

At six months postpartum, responding positively to either Whooley question showed perfect sensitivity (100%). The most specific criterion (85.7%) was responding positively to the two Whooley questions plus the Help question. The positive predictive value with a percentage above 40% was responding positively to the two Whooley questions plus the Help question (44.6%). The likelihood ratio for a positive test in this period was better than during pregnancy, and the criterion that most accurately diagnosed depression in pregnancy was the two Whooley questions plus the Help question (5.2) (table III).

Discussion

The aim of this study was to evaluate the sensitivity and specificity of the Whooley³²32. Whooley MA, Avins AL, Miranda J, Browner WS. Case-finding instruments for depression. Two questions are as good as many. J Gen Intern Med. 1997;12(7):439-45. https://doi.org/10.1046/j.1525-1497.1997.00076.x
https://doi.org/10.1046/j.1525-1497.1997... and Arroll questions³⁵35. Arroll B, Goodyear-Smith F, Kerse N, Fishman T, Gunn J. Effect of the addition of a “help” question to two screening questions on specificity for diagnosis of depression in general practice: diagnostic validity study. BMJ. 2005;331(7521):884. https://doi.org/10.1136/bmj.38607.464537.7C
https://doi.org/10.1136/bmj.38607.464537... for detecting perinatal depression in a sample of Mexican women using the Structured Clinical Interview (SCID-I)³⁹39. First M, Spitzer R, Gibbon M, Williams J. Structured Clinical Interview for DSM-IV Axis I Disorders (SCID-I), Clinical Version. Washington, DC: American Psychiatric Press, 1996. as a gold standard. The results show the ability of the three questions to discriminate between cases and non-cases of depression in pregnant and postpartum women.

During pregnancy and at six months postpartum, the most sensitive criterion was an affirmative response to either Whooley question.³²32. Whooley MA, Avins AL, Miranda J, Browner WS. Case-finding instruments for depression. Two questions are as good as many. J Gen Intern Med. 1997;12(7):439-45. https://doi.org/10.1046/j.1525-1497.1997.00076.x
https://doi.org/10.1046/j.1525-1497.1997... Thus, the number of women with perinatal depression not detected through these questions was very low (pregnancy= 5.3%; six months postpartum= 0.0%). Conversely, as often happens with highly sensitive instruments,⁴³43. Reitsma JB, Glas AS, Rutjes AW, Scholten RJ, Bossuyt PM, Zwinderman AH. Bivariate analysis of sensitivity and specificity produces informative summary measures in diagnostic reviews. J Clin Epidemiol. 2005;58(10):982-90. https://doi.org/10.1016/j.jclinepi.2005.02.022
https://doi.org/10.1016/j.jclinepi.2005.... specificity in the two-time points measured was low (pregnancy= 39.4%; six months postpartum= 52.5%). The most specific criterion at the two evaluation times was responding affirmatively to the two Whooley questions plus the Help question (pregnancy=90.0%; six months postpartum=85.7%).This means that the number of misdiagnosed women is low (pregnancy= 10.0%; six months postpartum= 14.3%). For this high level of specificity, sensitivity significantly decreased, particularly during pregnancy. This result differs from that previously reported by Arroll et al.,³⁵35. Arroll B, Goodyear-Smith F, Kerse N, Fishman T, Gunn J. Effect of the addition of a “help” question to two screening questions on specificity for diagnosis of depression in general practice: diagnostic validity study. BMJ. 2005;331(7521):884. https://doi.org/10.1136/bmj.38607.464537.7C
https://doi.org/10.1136/bmj.38607.464537... where both sensitivity and specificity were above 85%.

These findings confirmed Arroll et al.,³⁶36. Arroll B, Khin N, Kerse N. Screening for depression in primary care with two verbally asked questions: cross sectional study. BMJ. 2003;327(7424):1144-46. https://doi.org/10.1136/bmj.327.7424.1144
https://doi.org/10.1136/bmj.327.7424.114... assertion and coincide with the results obtained by Bosanquet et al.⁴⁴44. Bosanquet K, Bailey D, Gilbody S, Harden M, Manea L, Nutbrown S, McMillan D. Diagnostic accuracy of the Whooley questions for the identification of depression: a diagnostic meta-analysis. BMJ Open. 2015;5:e008913. https://doi.org/10.1136/bmjopen-2015-008913
https://doi.org/10.1136/bmjopen-2015-008... in that the Help question maintains good sensitivity and increases the specificity of the two Whooley questions.

Lastly, the criterion with the greatest balance in the two evaluation periods was an affirmative response to either Whooley question plus the Help question. However, at pregnancy, both sensitivity and specificity were less than 80%, which means that this criterion is less accurate in this period.

In order to determine which criteria to use, it is essential to consider the objective pursued by the healthcare professional applying the instrument.⁴⁵45. Hewitt CE, Gilbody SM, Brealey S, Paulden M, Palmer S, Mann R, et al. Methods to identify postnatal depression in primary care: an integrated evidence synthesis and value of information analysis. Health Technol Assess. 2009;13(36):1-145. https://doi.org/10.3310/hta13360
https://doi.org/10.3310/hta13360... Thus, since the main goal at primary and secondary care levels is prevention, a sensitive instrument is required to detect the largest number of women at risk of depression so that they can be included in preventive programs. Prevention strategies for women who attend antenatal check-ups in primary health care services could include providing information on perinatal depression and risk factors, as well as suggesting self-help strategies to prevent depressive symptomatology.⁴⁶46. Dennis CL, Dowswell T. Psychosocial and psychological interventions for preventing postpartum depression. Cochrane Database Syst Rev. 201328;(2):CD001134. https://doi.org/10.1002/14651858.CD001134.pub3
https://doi.org/10.1002/14651858.CD00113... In Mexico, there is evidence of the effectiveness of group interventions in the prevention of postpartum depression,⁴¹41. Lara MA, Navarro C, Navarrete L. Outcome results of a psycho-educational intervention in pregnancy to prevent PPD: A randomized control trial. J Affect Disord. 2010;122(1-2):109-17. https://doi.org/10.1016/j.jad.2009.06.024
https://doi.org/10.1016/j.jad.2009.06.02... while international studies show that postnatal home visits by health professionals help reduce the risk of postpartum depression.⁴⁶46. Dennis CL, Dowswell T. Psychosocial and psychological interventions for preventing postpartum depression. Cochrane Database Syst Rev. 201328;(2):CD001134. https://doi.org/10.1002/14651858.CD001134.pub3
https://doi.org/10.1002/14651858.CD00113... Conversely, at the tertiary care level, the goal is to provide treatment for people suffering from perinatal depression, in which case, a specific instrument is needed to select only women who are depressed and therefore require treatment. This reduces the cost of care and, among other things, prevents oversaturating third-level care services.⁴⁷47. Mitchell AJ, Coyne JC. Do ultra-short screening instruments accurately detect depression in primary care? Br J Gen Pract. 2007;57(535):144-51.

However, since these assessment tools consist of only three questions, they can be applied in full at no additional cost.

NICE⁴⁸48. National Collaborating Centre for Mental Health. Antenatal and Postnatal Mental Health: Clinical Management and Service Guidance. Leicester (UK): British Psychological Society, 2014[cited 2016 Nov].Available from: Available from: https://www.nice.org.uk/guidance/cg192/resources/antenatal-and-postnatal-mental-health-clinical-management-and-service-guidance 35109869806789
https://www.nice.org.uk/guidance/cg192/r... recommends that women who meet the risk criteria addressed by the Whooley questions (and in this case, Arroll’s questions) receive confirmation of the diagnosis from health personnel through self-report instruments such as the PHQ-9 or the EPDS. If the institution has trained personnel, clinical interviews such as the SCID-I³⁹39. First M, Spitzer R, Gibbon M, Williams J. Structured Clinical Interview for DSM-IV Axis I Disorders (SCID-I), Clinical Version. Washington, DC: American Psychiatric Press, 1996. or the MINI⁴⁹49. Sheehan DV, Lecrubier Y, Sheehan KH, Amorim P, Janavs J, Weiller E, et al. The mini international neuropsychiatric interview (M.I.N.I.): the development and validation of a structured diagnostic psychiatric interview for DSM-IV and ICD-10. J Clin Psychiatry. 1998;59(Suppl 20):22-33. can be applied to refer patients for treatment. This is not always feasible in low- and middle-income countries, since mental health care is generally not included in prenatal care.

It is essential to have instruments that have proven to be psychometrically adequate for detecting women at risk of depression. In this respect, the Whooley and Arroll questions meet the criteria for sensitivity and specificity. In Mexico, the clinical guidelines (the Official Health Norms) for treating women’s health during pregnancy were recently updated, taking into account the WHO (World Health Organization) recommendations for maternal and child health care, including the detection of postpartum depression.⁵⁰50. Centro Nacional de Excelencia Tecnológica en Salud. Prevención, diagnóstico y manejo de la depresión prenatal y posparto en el primero y segundo niveles de atención. México: Secretaría de Salud, 2014 [cited 2017 Mar]. Available from: Available from: http://www.cenetec.salud.gob.mx/descargas/gpc/CatalogoMaestro/SS-666-14-Depre-postparto/GRR_INTEGRACION_DPP_DEFINITIVA.pdf
http://www.cenetec.salud.gob.mx/descarga... ^,5151. Secretaría de Salud. Norma Oficial Mexicana NOM-007-SSA2-2016. Para la atención de la mujer durante el embarazo, parto y puerperio, y de la persona recién nacida. Diario Oficial de la Federación. México, 2016. Available from: http://www.cndh.org.mx/sites/all/doc/Programas/VIH/Leyes%20y%20normas%20y%20reglamentos/Norma%20Oficial%20Mexicana/NOM-007-SSA2-2016%20Embarazo,%20parto%20y%20puerperio.pdf
http://www.cndh.org.mx/sites/all/doc/Pro... However, the diagnosis and treatment of perinatal depression is not included within standard perinatal care, and only undertaken for at-risk populations, such as women diagnosed with HIV or victims of domestic violence, leaving a high percentage of women who also suffer from depression unattended.⁵²52. Place JM, Billings DL, Frongillo EA, Blake CE, Mann JR, de Castro F. Policy for Promotion of Women’s Mental Health: Insight from Analysis of policy on Postnatal Depression in Mexico. Adm Policy Ment Health. 2016;43(2):189-198. https://doi.org/10.1007/s10488-015-0629-x
https://doi.org/10.1007/s10488-015-0629-...

Moreover, identifying and providing care for women with depression or depressive symptoms in prenatal care is complicated by several factors: health professionals with a lack of information and awareness of perinatal mental health, the absence of standards to provide better, more timely care and a shortage of procedures for referring women to specialized staff.⁵³53. Dennis CL. Preventing and treating postnatal depression. BMJ. 2009;15(338):a2975.https://doi.org/10.1136/bmj.a2975
https://doi.org/10.1136/bmj.a2975... ^,5454. Lara MA, Navarrete L, Nieto L, Berenzon S. Acceptability and barriers to treatment for perinatal depression. An exploratory study in Mexican women. Salud Ment (Mex). 2014;37(4):293-301. https://doi.org/10.17711/SM.0185-3325.2014.034
https://doi.org/10.17711/SM.0185-3325.20...

The strategies suggested to address these problems in developing countries, where there are limited resources and supersaturated mental health services include optimizing the use of resources, particularly in primary health care.⁴4. Fisher J, Mello MCD, Patel V, Rahman A, Tran T, Holton S, Holmes W. Prevalence and determinants of common perinatal mental disorders in women in low-and lower-middle-income countries: a systematic review. Bull World Health Organ. 2012;90(2):139-49. https://doi.org/10.2471/BLT.11.091850
https://doi.org/10.2471/BLT.11.091850... ^,2222. Austin MP. Marcé International Society position statement on psychosocial assessment and depression screening in perinatal women. Best Pract Res Clin Obstet Gynaecol. 2014;28(1):179-87. https://doi.org/10.1016/j.bpobgyn.2013.08.016
https://doi.org/10.1016/j.bpobgyn.2013.0... The time women spend waiting for their prenatal check-ups could be used to apply the Whooley and Arroll questions to detect possible cases of depression, as well as to provide them with information on perinatal depression as an initial preventive strategy. These procedures could be carried out by nurses and social workers.

It is important to bear in mind that the detection of perinatal depression is the first step of a strategy that facilitates ways to provide proper care for women who need it.⁵⁵55. Buist AE, Barnett BE, Milgrom J, Pope S, Condon JT, Ellwood DA, et al. To screen or not to screen--that is the question in perinatal depression. Med J Aust. 2002;177(Suppl):S101-5.

It is essential to prevent or treat postpartum depression in order to reduce the negative consequences on both the mother and the infant. The depressed mother’s inability to detect the infant’s needs affects its emotional, social and cognitive development.¹⁴14. Stein A, Pearson RM, Goodman SH, Rapa E, Rahman A, McCallum M, et al. Effects of perinatal mental disorders on the fetus and child. Lancet. 2014;384(9956):1800-19. https://doi.org/10.1016/S0140-6736(14)61277-0
https://doi.org/10.1016/S0140-6736(14)61... ^,5656. Brummelte S, Galea LA. Postpartum depression: Etiology, treatment and consequences for maternal care. Horm Behav. 2016;77:153-66. https://doi.org/10.1016/j.yhbeh.2015.08.008
https://doi.org/10.1016/j.yhbeh.2015.08.... Limitations include the 25% attrition of the initial sample, which was not retained to complete the assessments. Women who failed to complete these assessments were younger, had fewer years of schooling and reported more depressive symptoms,⁷7. Lara MA, Navarrete L, Nieto L, Barba MJP, Navarro JL, Lara-Tapia H. Prevalence and incidence of perinatal depression and depressive symptoms among Mexican women. J Affect Disord. 2015;175:18-24. https://doi.org/10.1016/j.jad.2014.12.035
https://doi.org/10.1016/j.jad.2014.12.03... which may affect the performance evaluation of the Whooley and Arroll questions. The second limitation is that the sample is not probabilistic, meaning that caution should be exercised when results are generalized.

In conclusion, the Whooley and Arroll questions have adequate psychometric properties for detecting depressive symptoms during the perinatal period. They are an efficient instrument consisting of three questions that can be applied by non-mental health professionals during women’s regular prenatal check-ups and in the infant’s checkups and visits for immunization during the postpartum period. Referral and prevention strategies can be used to provide mental health care for this population. Systematic implementation of these strategies may contribute to reducing the adverse consequences for mothers and babies caused by perinatal depression.

Acknowledgements

This study was supported by the National Council of Science and Technology (Consejo Nacional de Ciencia y Tecnología, Conacyt, CB-2009-01 133923). We are grateful to the staff and patients of the Dr. Ángel BriosoVasconcelos Health Care Center (Centro de Salud Dr. Ángel BriosoVasconcelos) and of the ISSSTE Regional Hospital Lic. Adolfo López Mateos (Hospital Regional del ISSSTE Lic. Adolfo López Mateos), as well as to the research team: Yadira Ramos, Karla Alcántara, Valeria Zempoalteca, Lilian Delgado and Araceli Aguilar.

References

Publication Dates

History