BMC Public Health 2006, 6:211 http://www.biomedcentral.com/1471-2458/6/211 Background In judging the utility of any health screening program, a central question is whether the condition is sufficiently common and sufficiently serious to justify the costs of screening. In practice, screening is only worthwhile for conditions that are both common enough and serious enough, for which identification leads to a benefit for those screened and for which affordable, acceptable, high- accuracy screening is available. Postnatal depression (PND) is a highly prevalent perina- tal mood disorder, with estimates around 10% in most Westernised countries [1,2]. Adverse consequences are significant and potentially far-reaching for mothers, infants and fathers: yet diagnosis rates are low and most cases go untreated [3]. Non-identification may prolong depression and leave women vulnerable to ongoing parenting difficulties [4]. Cost-effectiveness modelling has shown that active inter- ventions for depression, such as cognitive behavioural therapy or antidepressant medication, give value for money [5] and the cost-effectiveness of screening pro- grams for depression has also been quantified successfully [6]. Despite this, the utility of screening for PND in partic- ular remains the subject of some debate. A short, free, screening tool – the Edinburgh Postnatal Depression Scale (EPDS) – has been widely used for 20 years [7]. Whilst quantitative measurement of acceptability is common for other health screening and diagnostic tools [8-11] this has not been common for PND screening instruments. Although there is information on uptake rates in primary care [3] and on return rates in academic research [12], such statistics can tell us little about how women experi- ence the EPDS as a screening tool: – in the same way that attendance rates at any health appointment tell us little about the discomfort experienced by patients. A handful of small, qualitative reports on acceptability in postnatal populations also exist. In one interview-based study, the majority of respondents reported feelings of relief and appreciation that health professionals were interested in their well being [13]. More recently Shakespeare, Blake and Garcia [14] reported the qualitative results of 39 face- to-face interviews investigating women's experience of completing the EPDS in General Practice settings in the United Kingdom. Twenty one of these women (54%) found this screening process "unacceptable" and issues of fear of stigma as well as a perceived inappropriateness of the screening venue were raised. If generally true, such results could suggest that a majority of women are dis- tressed by the EPDS. Yet this rare study of screening acceptability was relatively small (n = 39 women in total) and the findings are un-replicated to date. There has been some study on acceptability among pregnant women (B. Leigh, unpublished manuscript) but to our knowledge, the only published study that has measured acceptability for the EPDS in a quantitative way in a sizeable popula- tion of postnatal women is that by Buist et al [15]. No existing acceptability study has included a large sample of postnatal women exhibiting elevated scores on the EPDS and/or a sizeable cohort of clinically depressed postnatal women. This is potentially important since any useful health screening instrument must have good acceptability not only in the general population that includes the much smaller target group, but specifically the acceptability must be high in that target group. In this paper we report on the results of a survey of newly delivered mothers in Australia about acceptability of the EPDS, their experiences and comfort/discomfort in being screened with the EPDS and their views on the desirability of routine screening. We structured the survey so that women with and without elevated EPDS scores and women with formal DSM-IV diagnoses of depression [16] were all well represented. Most surveys were administered by post and we also employed a face-to-face approach among a small sub-sample in an attempt to replicate something of Shakespeare at al's (2003) methodology. We thought this was worthwhile given that Shakespeare at al's results apparently run somewhat counter to the other existing indirect evidence on acceptability, and given the small numbers involved in that study. If different meth- ods of survey might give different estimates of comfort/ acceptability then this is important to know. For com- pleteness, we therefore also conducted a sub-sample of surveys by telephone. Methods Questionnaires Edinburgh postnatal depression scale The EPDS comprises 10 items and measures current mood disturbance for women in the perinatal period. It was developed as a screening device to assist health profes- sionals in detecting depressive symptoms in community samples of postnatal mothers [7]. Scores above a specified threshold are used in practice to judge the likelihood of depression and some researchers have suggested that scores above 9 indicate 'possible depression' while scores above 12 indicate 'probable depression' [17]. Complete Receiver Operating Characteristic curves (bivariate plots which illustrate the relationship of sensitivity versus spe- cificity across the entire range of possible scores) have been determined previously for the EPDS in a large Aus- tralian sample [18]. The analysis in that study pointed to a range of "optimal" cut-offs at around scores of 12 or 13. This was similar to some previous Australian research [19]. The screening reported in this current study used a cut-off score of ≥ 12. Specificity, sensitivity and overall Page 2 of 8 (page number not for citation purposes)