Registered Nurses' Association of Ontario

Nursing Best Practice Guidelines

Administration and Interpretation of the EPDS

The EPDS can be administered to mothers anytime from birth to 52 weeks that have been identified with depressive symptoms either subjectively or objectively.

Instructions for the administration of the EPDS

  1. The EPDS may be administered in person.
  2. Efforts should be make to have the mother complete the scale by herself, where she feels she can answer the questions honestly.
  3. Mother’s may need assistance with the EPDS if they have limited reading skills or understanding of the English language.
  4. All 10 items on the questionnaire must be completed.
  5. The mother or health care professional should underline the response that best describes the mother’s feelings in the last week.
  6. The EPDS can be administered anytime from 0 to 52 weeks.

Sample lead in statements

Please be as open and honest as possible when answering these questions. It is not easy being a new mother and it is OK to feel unhappy at times. As you have recently had a new baby, we would like to know how you are feeling. Please state the answer which comes closest to how you have felt during the past several days, not just how you are feeling today.

Scoring of the EPDS

Each response is scored 0, 1, 2 or 3 based on the increased severity of the symptoms. Calculate the total score by adding together each of the 10 items.

Interpretation of the EPDS

  1. The EPDS score must be considered in combination with the assessment of the health care provider.
  2. A score of 13 or greater indicates the presence of depressive symptoms.
  3. The score does not reflect the severity of the symptoms.
  4. Use caution when interpreting the score of mothers who are non-English speaking and/or use English as a second language or are multicultural.
  5. If a mother scores positive (1, 2 or 3) on self-harm item number 10, further assessment should be done immediately for self-harm ideation
  6. Follow agency/institution protocol regarding scores.
  7. Remember that the EPDS is only a tool. If your clinical judgment indicates differently than the EPDS continue with the follow up as the assessment indicates.