Objective To evaluate the Edinburgh Postnatal Depression Scale (EPDS) for screening to detect major depression in pregnant and postpartum women. Design Individual participant data meta-analysis. Data sources Medline, Medline In-Process and Other Non-Indexed Citations, PsycINFO, and Web of Science (from inception to 3 October 2018). Eligibility criteria for selecting studies Eligible datasets included EPDS scores and major depression classification based on validated diagnostic interviews. Bivariate random effects meta-analysis was used to estimate EPDS sensitivity and specificity compared with semi-structured, fully structured (Mini International Neuropsychiatric Interview (MINI) excluded), and MINI diagnostic interviews separately using individual participant data. One stage meta-regression was used to examine accuracy by reference standard categories and participant characteristics. Results Individual participant data were obtained from 58 of 83 eligible studies (70%; 15 557 of 22 788 eligible participants (68%), 2069 with major depression). Combined sensitivity and specificity was maximised at a cut-off value of 11 or higher across reference standards. Among studies with a semi-structured interview (36 studies, 9066 participants, 1330 with major depression), sensitivity and specificity were 0.85 (95% confidence interval 0.79 to 0.90) and 0.84 (0.79 to 0.88) for a cut-off value of 10 or higher, 0.81 (0.75 to 0.87) and 0.88 (0.85 to 0.91) for a cut-off value of 11 or higher, and 0.66 (0.58 to 0.74) and 0.95 (0.92 to 0.96) for a cut-off value of 13 or higher, respectively. Accuracy was similar across reference standards and subgroups, including for pregnant and postpartum women. Conclusions An EPDS cut-off value of 11 or higher maximised combined sensitivity and specificity; a cut-off value of 13 or higher was less sensitive but more specific. To identify pregnant and postpartum women with higher symptom levels, a cut-off of 13 or higher could be used. Lower cut-off values could be used if the intention is to avoid false negatives and identify most patients who meet diagnostic criteria. Registration PROSPERO (CRD42015024785).

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cause of disability worldwide by 2020, second only to ischemic heart disease, and the leading cause in developing regions. 1 The annual prevalence of major depressive disorder shows tremendous difference across different countries, nearly a 60-fold variation. 2 Based on the epidemiologic studies, societies with a high consumption of fish, which contains high amounts of omega-3 polyunsaturated fatty acids (PUFAs), appear to have a lower prevalence of major depressive disorder. 3-5 This result suggests a link between omega-3 PUFAs and the pathogenesis of depression. The PUFAs are classified into omega-3 (or n-3) and omega-6 (or n-6) groups. The parent essential fatty acid of omega-3 PUFAs is alpha-linolenic acid (ALA; C18: 3n-3), and that of the omega-6 group is linoleic acid (LA; C18:2n-6). In the central nervous system, neuronal cell membrane contains high concentrations of PUFAs, some of which cannot be synthesized and therefore must be obtained from the diet. The abnormalities in PUFA composition in cell membranes can alter membrane microstructure, cause abnormal signal transduction and immunologic dysregulation, and possibly increase the risk of developing depression. 6,7 There are studies revealing that PUFA composition may vary in different major psychiatric disorders. 8,9 Lower levels of omega-3 PUFAs, including eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA), have been reported in serum and red blood cell membranes in patients with major depressive disorder. 10-14