Abstract

Postpartum anxiety can be overlooked when clinicians focus on the total Edinburgh Postnatal Depression Scale (EPDS) score. This quality improvement project standardized EPDS administration and separately reviewed the 3-item anxiety subscale (EPDS-3A) in 100 postpartum women. Eight percent had an elevated EPDS-3A score without meeting the project’s total EPDS threshold. Deliberate review of anxiety-related responses may provide a practical cue for further assessment within an existing postpartum screening workflow.

Keywords: postpartum anxiety; Edinburgh Postnatal Depression Scale; EPDS-3A; postpartum screening; quality improvement

Background

Perinatal mental health care has traditionally emphasized depression, although anxiety disorders are also common during pregnancy and the postpartum period and can affect maternal functioning, maternal-infant interaction, and infant outcomes.^1,2 Current guidance recommends screening for both depression and anxiety during prenatal and postpartum care and emphasizes that screening should be connected to timely assessment, treatment, monitoring, and follow-up.³ NPWH likewise identifies perinatal mental health disorders as common complications that may go unrecognized and highlights the role of women’s health nurse practitioners and other APRNs in early recognition and intervention.⁴

The 10-item Edinburgh Postnatal Depression Scale (EPDS) was developed to screen for postnatal depression.⁵ Items 3, 4, and 5 have been described as an anxiety-related cluster, commonly called the EPDS-3A. Earlier studies suggested that separately reviewing these items may identify women with prominent anxiety symptoms who do not meet a total EPDS threshold.^6,7 More recent evidence supports a cautious interpretation: the EPDS-3A may provide an additional case-finding signal, but anxiety-specific instruments may perform better when the clinical goal is stand-alone anxiety screening.^8,9

Local Problem and Purpose

This project was conducted in a high-volume outpatient obstetric and gynecologic practice in a large Texas medical center. Before implementation, postpartum mental health screening was inconsistent. The EPDS was available in the electronic health record, but not every postpartum patient received a standardized screen, and clinicians often focused on the total EPDS score. Postpartum visits were typically scheduled for 10 to 15 minutes, making an efficient workflow essential.

This quality improvement project aimed to standardize postpartum mental health screening and evaluate whether separate review of EPDS items 3-5 identified women with elevated anxiety-related responses who did not meet the project’s total EPDS threshold and therefore warranted focused clinical assessment and referral.

Methods

The single-site quality improvement project used Lewin’s three-stage change model to support staff preparation, workflow change, and reinforcement. The implementation team included 3 medical assistants, 2 physicians, and 1 nurse practitioner who served as project director. A convenience sample of 100 postpartum women presenting after a live birth at 37 to 40 weeks’ gestation was included from June 1 through August 9, 2021. Women with fetal demise or miscarriage were excluded from the project dataset.

The intervention had three components: medical assistants standardized EPDS administration during rooming; clinicians scored the full EPDS and separately calculated the EPDS-3A from items 3-5; and the team used a defined response pathway so that concerning screening results led to clinician assessment and referral. Brief team check-ins were used to reinforce adherence and address workflow barriers.

The project used a total EPDS score of 10 or greater as the threshold for a positive overall screen and an EPDS-3A score of 6 or greater as the threshold for an elevated anxiety subscale, based on evidence available when the project was designed.^6,7 Neither threshold was considered diagnostic. Clinicians assessed symptoms and safety, including suicidal or homicidal ideation, and used screening results to guide referral. Data were summarized with descriptive statistics.

The Baylor University Louise Herrington School of Nursing institutional review process determined the evidence-based practice/quality improvement project eligible for exemption. The clinical site approved implementation. Project data were stored in a password-protected file.

Results

The sample included 100 postpartum women with a mean age of 31.7 years (SD, 3.8). Participants were non-Hispanic White (53%), Hispanic/Latina (30%), Asian (12%), and Black/African American (5%). Most had private insurance (84%), and 92% were screened at 6 weeks postpartum. Vaginal birth was the most common delivery route (52%), followed by cesarean birth (43%) and operative vaginal birth (5%) (Table 1).

Table 1. Participant Characteristics (N = 100)

Note. Values are n (%) unless otherwise indicated.

Twenty-two participants (22%) met the total EPDS threshold, the EPDS-3A threshold, or both. Seven (7%) met the total EPDS threshold without an elevated EPDS-3A score, 8 (8%) had an elevated EPDS-3A score without meeting the total EPDS threshold, and 7 (7%) met both thresholds. Overall, 15 participants (15%) had an elevated EPDS-3A score and 14 (14%) met the total EPDS threshold. One record was categorized as indeterminate in the original crosstabulation. All participants meeting either threshold were referred to the women’s mental health clinic for follow-up (Table 2).

Table 2. Postpartum Mental Health Screening Outcomes (N = 100)

Note. Positive total EPDS = score of 10 or greater. Elevated anxiety subscale = EPDS-3A score of 6 or greater. These thresholds indicate the need for further clinical assessment and do not establish a diagnosis.

The clinically important finding was the EPDS-3A-only group. Eight of the 15 participants with an elevated anxiety subscale, 53%, did not concurrently meet the project’s total EPDS threshold. Separate attention to items 3-5 therefore surfaced an additional group for focused assessment and referral within the existing screening workflow.

Discussion

Although the project was implemented in 2021, the practice question remains current: anxiety-related responses may be overlooked when postpartum screening is interpreted primarily through a total depression score. In this project, more than half of participants with an elevated anxiety subscale did not concurrently meet the total EPDS threshold. In a brief postpartum encounter, deliberate attention to anxiety-related responses can prompt focused questions about worry, panic, intrusive thoughts, sleep, functioning, and safety.

These findings do not establish that the EPDS-3A independently screens for or diagnoses an anxiety disorder. No structured diagnostic interview was used, and current psychometric evidence is mixed. Recent studies suggest that anxiety-specific tools such as the GAD-7 may outperform the EPDS-3A for stand-alone anxiety screening and that adding the anxiety subscale can increase detection while also increasing false-positive results.^8,9 The most defensible use of the EPDS-3A is therefore as an embedded clinical cue that prompts additional assessment, not as a diagnostic endpoint.

The strength of the intervention was not simply the subscale. It was the workflow: standardized administration, deliberate attention to anxiety-related responses, clinician assessment, safety evaluation, and a defined referral pathway. Every participant meeting either project threshold was referred. The project did not measure whether referrals were completed or whether treatment was initiated, so the results demonstrate improved workflow reliability rather than downstream clinical effectiveness.

Implications for NP Practice

For nurse practitioners and other clinicians providing postpartum care, the practical message is that anxiety should be assessed deliberately rather than inferred from the total score of a depression-focused screening instrument. When the EPDS is already used, reviewing items 3-5 can serve as a low-burden prompt to ask additional questions while the clinician determines whether an anxiety-specific tool or more comprehensive assessment is needed.

Workflow reliability matters as much as instrument choice. Practices should define who administers and scores screening, how they communicate concerning responses, how they escalate immediate safety concerns, where they send referrals, and how they confirm follow-up. The next step for quality improvement is to move beyond screening completion and track whether patients actually receive evaluation and treatment. This is especially important when access barriers may differ by insurance, geography, language, race/ethnicity, or other social determinants.

Limitations

This project was conducted at one private outpatient practice, and most participants had private insurance, limiting generalizability. The convenience sample was small; there was no concurrent comparison group or reliable pre-implementation detection rate, and no structured psychiatric diagnostic interview was used. The thresholds reflected evidence available when the project was implemented. The study did not measure referral attendance, treatment initiation, symptom response, or patient-reported outcomes. The project therefore supports a workflow observation, not diagnostic validation or causal inference.

Conclusion

Postpartum anxiety can be clinically important even when a patient does not meet a practice’s total EPDS threshold. In this project, separate review of EPDS items 3-5 identified an additional group of women with elevated anxiety-related responses who received focused assessment and referral. The enduring lesson is broader than any single subscale: postpartum screening should create multiple opportunities to notice anxiety, assess safety, and connect patients to care. A screen is only as meaningful as the clinical response that follows.

References

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