Registered Nurses' Association of Ontario

Nursing Best Practice Guidelines

Confirming Depressive Symptoms

3.0 The Edinburgh Postnatal Depression Scale (EPDS) is the recommended self-report tool to confirm depressive symptoms in postpartum mothers.

4.0 The EPDS can be administered anytime throughout the postpartum period (birth to 12 months) to confirm depressive symptoms.

5.0 Nurses encourage postpartum mothers to complete the EPDS by themselves in privacy.

6.0 An EPDS cut-off score greater than 12 may be used to determine depressive symptoms among English-speaking women in the postpartum period. This cut-off criterion should be interpreted cautiously with mothers who:

  1.  are non-English speaking;
  2.  use English as a second language, and/or
  3.  are from diverse cultures.

7.0 The EPDS must be interpreted in combination with clinical judgment to confirm postpartum mothers with depressive symptoms.

8.0 Nurses should provide immediate assessment for self harm ideation/behaviour when a mother scores positive (e.g., from 1 to 3) on the EPDS self-harm item number 10