Category Archives: Edinburgh Postnatal Depression Scale

Sticks and Stones Will Break My Bones But Words….

I started this post the other day after a comment was left on a post I promoted on Facebook. Then I had to walk away because I started down a path I did not want to go down. This was a difficult post for me to write as it forces me to revisit a meeting which left me both enraged and shaken. I’ve calmed down quite a bit and the following is a much more polite response than the one I started the other day.

The post is a wonderful interview of Dr. Katherine Wisner by Walker Karraa. The interview, found here, focuses on Postpartum Mood Disorders, of course, but also addresses the challenge and controversy of screening mothers for the presence of Postpartum Mood Disorders.

Screening is a hot topic and has been for quite awhile. There are a lot of unknowns regarding when to screen, how to screen, what happens after a positive screen, liability for care of the patient, when to refer, etc. Bottom line, I feel, is that we need to screen in order to start the dialogue about Postpartum Mood Disorders with care providers in every field that comes in contact with both expecting and new mamas. We also need to work more diligently to create supportive nets of care for women in our communities – coalitions of OB’s, Midwives, Pediatricians, IBCLC’s, Psychiatrists, Psychologists, therapists, doulas, and other various caregivers for pregnant women and young children. It needs to be comprehensive.

Those of us who advocate for the care and support of families battling Postpartum Mood Disorders must be well-versed in all things relating to pregnancy and postpartum. Our scope of knowledge must include a basic grasp on the rights of the expectant woman and as a new mothers. This is in addition to the psychiatric knowledge we also hold and are constantly researching in order to better arm new and expectant mothers.

It is exhausting sometimes, to read all of this information. I myself have suffered from information overload. But, empowering new and expectant mothers to make healthy and better decisions for their care and therefore for their families, is what I have been called to do so read I must.

In the past couple of years I haven’t been reading as much, I’ll admit, but prior to that, I read voraciously. I dove into all things birth related. So when there was a chance to go see Henci Goer at a local get together on August 26, 2010, I went.

Henci, a well-known author and advocate for Lamaze birth and healthier women-empowered births, was someone I admired.

Until the night I met her and discussed my experiences which led to my own advocacy with her.

Henci, after discussing at length, her new project, completely shot down my experience with a very dismissive sentence, the gist of which was left in a comment at Karraa’s interview with Dr. Katherine Wisner I referenced above.

Here was a woman, who seemingly was all about empowering women and improving their birth experiences, failing to even acknowledge the difficulties I experienced after my own. I didn’t experience Postpartum Depression, according to Goer, my experiences were directly related to my birthing experience and therefore weren’t my fault but that of the system’s.

While I agree there are far too many interventions in the modern birthing realm for many mothers and it’s sad that organizations like Solace for Mothers even have to exist, to shoot down the experience of another and how she has worked through it in one dismissive sentence is almost as bad as what my first OB did to me.

PTSD QuoteTrauma is about perception. It’s not about what happened to you, it’s about how you perceive what happened to you. This perception is shaded by our own personal experiences and baggage. These experiences and this baggage also directly affects how we process our experience after our brush with trauma.

No one has the right to question a woman’s perception of her birth experience.

No one has the right to re-frame her experience FOR her. It is hers and hers alone to process. It is hers to share as she feels necessary, with whatever details she deems necessary.

The comment Henci left on Karraa’s interview with Dr. Wisner reads as follows:

I am extremely concerned that the focus on screening for postpartum depression using an instrument solely designed for this purpose will miss diagnosis of childbirth-related post-traumatic stress symptoms and full-blown PTSD altogether or will mislabel women experiencing post-traumatic distress as depressed. PTSD symptoms are fairly common–as New Mothers Speak Out found, 18% of women were experiencing symptoms and 9% met the diagnostic criteria for PTSD–and while some symptoms overlap with depression, the treatment differs.

Furthermore, on-site mental health services would be of little use to women suffering from childbirth-related emotional trauma because one of the prime protective responses is avoidance of environments and personnel that re-trigger traumatic memories.

I have as well a philosophical issue with making depression the preeminent postpartum mood disorder. Depression centers the problem in the woman, and therefore the cure is centered in her as well. PTSD, however, is centered in the system, and therefore its cure depends on systemic reforms. The incidence of emotional trauma can be minimized by reducing the overuse of cesarean surgery and other painful and invasive treatments, by implementing shared decision-making, and by providing physically and emotionally supportive care. So long as postpartum mood disorders are primarily seen as an issue of depression, little or no attention will be paid to the all too common glaring deficiencies of medical model management in this respect.

I have several issues with Henci’s comment.

She seemingly assumes that the Postpartum Mood Disorder community is unaware of the difference between Postpartum Depression and Postpartum Post-traumatic Traumatic Stress Disorder. I can assure her that we are indeed not unaware. Most providers and advocates I know work diligently to go beyond the EPDS to dig deeper for possible birth trauma. The EPDS, while yes, not designed to pick up specifically on PTSD, is a starting point for a conversation about emotional issues during the perinatal period. Henci’s issue with this illustrates exactly why we work to educate providers about the many aspects of Postpartum Mood and Anxiety Disorders.

The discussion with a mother who had a traumatic birth experience is wildly different than with one who did not. Not all mothers who experience a Postpartum Mood Disorder necessarily experience PPTSD. Nor are their issues rooted in an issue with the so-called system. May I remind you, Henci, that PMD’s have existed since the time of Hippocrates. It is not some new fangled “too-many interventions” kind of disorder.

Not all of us are not “victims” at the hand of the system as you would have us believe, Ms. Goer. I’ve held discussions with mothers who had home births or natural births in a birthing center and still gone on to experience a Postpartum Mood Disorder. While it’s certainly not as common and there is a seeming correlation to interventions during the birth experience, there simply isn’t enough evidence to claim interventions (particularly cesarean sections) are the definitive root of all Postpartum Mood & Anxiety Disorders as Henci claims in her comment. (See article “Is there a link between C-sections and Postpartum Mood Disorders?)

We, the advocates for care and empowerment of women who do experience emotional trauma during and after birth, are working diligently to bring to light the additional issues on the Postpartum Spectrum such as Postpartum Post-Traumatic Stress Disorder, Postpartum Obsessive Compulsive Disorder, Postpartum Anxiety, and others. We no longer focus solely on depression. If we do, it is only because Postpartum Depression has been used as a catch-all phrase for so very long.

In the past six years I have been blogging, the term has graduated from Postpartum Depression to Postpartum Mood Disorders to Perinatal Mood Disorders to Postpartum Mood and Anxiety Disorders. In fact, I’m often at a loss as to which one to use. Postpartum Mood and Anxiety Disorders covers it most thoroughly, I believe.

There are researchers who focus on nothing but birth trauma and Post-Traumatic Stress Disorders – such as Cheryl Tatano Beck. I had the pleasure of meeting Cheryl at the 2010 PSI Conference in Pittsburgh. That meeting was so much different than my meeting with Henci. Cheryl was warm, accepting, and thanked me for my work in bringing my experience to light and fighting for others who had been through the same thing.

I do not hide that my first birth was a rough one. I know there are other mothers out there who had even more horrific experiences. But I talk about it because negative birth experiences do happen. I talk about it so that other women will read it, and know that it’s okay to talk about their experiences. If I simply dismissed the experiences of all the women who reached out to me, well, I’d be doing a huge disservice to the community around me. To women in general. In essence, I’d be traumatizing them even further.

With wisdom and knowledge comes power. With that power, comes great responsibility. I hold that responsibility as if it were a fragile ball of glass. My goal is to keep it from shattering. My goal is to create a safe and soft space for it as it grows stronger.

If only Henci Goer saw the birthing world the same way.

Postpartum Depression formal screening not worth the cost, BMJ study says

According to a recently published study in the British Medical Journal (BMJ), Postpartum Depression Screening is not…. brace yourselves. Worth the cost.

That’s right.

NOT.WORTH.THE.COST.

In their cost effective analysis, the researchers used “A hypothetical population of women assessed for postnatal depression either via routine care only or supplemented by use of formal identification methods six weeks postnatally, as recommended in recent guidelines.”

The conclusion was that overall not using a formal screening method was much more cost effective as it eliminated false positives.

So the mental health of a woman which will then affect her child, her family, her community, the world at large, are just not worth it to the National Health System of the UK. The EPDS scored out at about $67,000 per quality adjusted life years while no screening method scored at a price tag of just $20 – $30,000. No value for the money was found to exist when using the formal identification methods.

Did these researchers not read Murray & Cooper’s Controlled trial of the short- and long-term effect of psychological treatment of post-partum depression which explores the effects of postpartum depression treatments on children?

There is SO much more at stake here than the dollar value to the National Health System.

There’s the potential for broken families. The potential for children growing into their own mental health issues, the potential for continued need for mental health treatment due to an undiagnosed episode of postpartum depression, potential for increased incarcerations due to untreated mental illness, continued sadness, the continued stigma, continued and perpetuated lack of education on the part of physicians in regards to Postpartum Mood Disorders.

The most interesting aspect of this study is that it focused on screening for Postpartum Depression in the Primary Care setting. Primary care physicians are not always comfortable or knowledgeable in screening for mental health issues. If a patient were to screen positive, that physician is then morally responsible for referring them to a specialist. Often times, at least here in the states, a Primary Care physician is unaware of where to refer a patient for help with a Postpartum Depression Disorder. Therefore, they become afraid of screening because they fear what will happen if a positive were to occur. What would they do with the patient? Where would they send them? How would they respond? Are they familiar enough with Postpartum Mood Disorders to recognize a false positive?

I think the key to the results of this study is not so much in blaming the high percentage of false positives but in urging that Primary Care physicians receive more training to enable them to recognize a false positive through more in depth questions after a positive is scored via the Edinburgh Postnatal Depression Scale.

original photo/graphic "Hand holding necklace" by K.Sawyer @flickr

A stronger safety net involving a stronger communication between midwives, Obstetricians, Pediatricians, and General Practitioners is so desperately needed to keep women from falling through the very big cracks which currently exist in the system.

Let’s think about this for a moment, shall we?

A woman gets pregnant. She sees a medical physician to get the pregnancy confirmed. Most mothers seek OB or midwife care for their entire pregnancy. Unless they’re depressed – depressed and mentally ill mothers are less likely to take good care of themselves during a pregnancy, making specialized care even more important even when baby is still in utero. Once mothers give birth, they are then shuttled off to the pediatrician’s office for the bulk of their medical contact. One six week or eight week visit to the midwife or OB to ensure mom is healing properly then an annual PAP visit unless something arises in between. Many Pediatricians focus on babies and not mother. But the tide is changing as more and more Pediatricians are taking into account the family lifestyle and well-being. My own Pediatrician does this and I absolutely adore her for it.

But overall, there is typically no continuity of care, no communication between physicians throughout the birth process. There should be. There needs to be. A woman deserves a team of support. She deserves to thrive. So do her children.

No matter what the cost.

Because once you fail woman and her children, you fail society.

Fail society and we fail to exist.

If we fail to exist….

Validation of the EPDS in Mainland China for antenatal women

Through research, the Mainland Chinese version of the Edinburgh Postnatal Depression Scale has been validated.

What does this mean?

It means the EPDS is now a valid tool practitioners available for use in the Chengdu region of China to identify pregnant mothers struggling with depression.

More research is needed to validate it for postnatal women. The overall prevalence of antenatal depression was at about 4.7%. Two studies were conducted: One to measure stability, the other to measure sensitivity. Both passed with flying colours.

To read more about this, click here.

National Institute for Health Care Management Foundation – Webinar: Identifying and Treating Maternal Depression

National Institute for Health Care Management Foundation – Webinar: Identifying and Treating Maternal Depression to take place on December 9, 2009 at 1:00pm -2:30pm EST. Registration is free. Please click on the previous link for information and to register for this event.

According to NIHCM’s website,This webinar will explore the prevalence of maternal depression and the current state of screening for perinatal and postpartum depression. It will include a discussion of the recent recommendations from the American College of Obstetricians and Gynecologists (ACOG) and the American Psychiatric Association (APA) for the treatment of women with depression during pregnancy. The role of primary care providers in identifying and managing postpartum depression will also be discussed and a web-based training program to educate providers on screening, diagnosis, treatment and referral for postpartum depression will be shared. Finally, the session will highlight a current health plan program to identify and manage depression during pregnancy and coordinate care following a depression diagnosis to ensure healthy pregnancies and deliveries.”

Please pass this information on to anyone you may know that will benefit from this important webinar. I am planning on attending myself because the information to be discussed sounds absolutely fascinating. I am particularly interested in the discussion of the role of the primary are providers in identifying and managing postpartum depression as so many patients often first seek help from their primary caregivers rather than a specialist.

Just Talkin’ Tuesday: The MOTHER’S Act

LegislationOn February 23, 2001, Melanie Stokes gave birth to a baby girl. Just three months later, she committed suicide. Melanie’s death gave birth to a very dedicated activist – her mother, Carol Blocker. Frustrated with the failure of physicians to appropriately care for her daughter, Carol worked endlessly to keep Melanie’s tragic death from becoming meaningless. Through Carol’s tireless advocacy and work with Representative Bobby Rush (IL), the Melanie Blocker Stokes Act has now become The MOTHER’S Act.

The MOTHER’S Act as it reads in the current version would provide funds for a public awareness campaign, education campaign for caregivers, increase availability of treatment options and entities as well as require the current Secretary of Health & Human Services to conduct a study regarding the validity of screening for Postpartum Mood & Anxiety Disorders.

More and more research is slowly uncovering potential underlying causes and risks related to Postpartum Mood & Anxiety Disorders. More and more women and caregivers are becoming educated as more of those who have survived a PMAD speak up to share our story.

If passed, The MOTHER’S Act would further reduce the stigma surrounding new mothers not ensconced in the Johnson & Johnson glow of infantdom. If passed, the MOTHER’S Act would increase funding for research and possibly open even more doors to understanding the cause and more importantly, the potential for truly preventing Postpartum Mood & Anxiety Disorders. If passed, the MOTHER’S Act has the potential to prevent tragic deaths like that of Melanie Blocker Stokes.

Much of the debate surrounding the MOTHER’S Act has centered on the word “medication.” Medication does not necessarily mean Anti-depressants. It does not mean this is the ONLY way to treat a PMAD. It is merely listed as an option for treatment. And frankly, if one has a doctor with a quicker draw on his/her prescription pad than Billy the Kidd, I’d run away. I’d run away faster than a cheetah.

Another key point of the opposition has been that the MOTHER’S Act mandates screening. In the current version, there is no mandate for screening. The only mention of screening is to require the Secretary of Health & Human Services to conduct a study regarding the validity of screening for Postpartum Mood & Anxiety Disorders. The current standard for screening is the Edinburgh Postnatal Depression Scale, which you can learn more about here.

You can read a copy of the current bill by clicking here.

Go read it. (Don’t worry – it’ll pop up in a new tab/window – I’m cool like that here)

Seriously. Read. The. Bill.

Then read it again.

And then come back here. Be honest.

Unlike this week’s TIME article which failed to present both sides, I promise to allow unedited comments in support of or opposing the bill as long as they are civil. (Any comments including personal attacks will NOT be allowed!)

So let’s get to Just Talkin’ Tuesday already!

TIME Magazine misfires debate on MOTHER’S Act

Awhile back, I was contacted by Catherine Elton regarding an article which was to examine Postpartum Depression and the Mother’s Act. The email somehow got buried and I did not get a chance to participate in the discussion.

It seems that it would not have mattered if I had been able to discuss my story with her.

Time published the story this week. While the online version has been modified to correct an error with Ms. Amy Philo’s story, you can still see the original version in the hard copy. (Which by the way, I am personally asking you to boycott – even asking if you can take the copy of TIME home from the doctor’s office in order to keep other moms from reading it! And make sure you ASK – because just taking it would be stealing and that’s illegal.)

The original version, entitled “The Melancholy of Motherhood” includes one quote from Carole Blocker, the mother of Melanie Blocker Stokes, a mother who tragically committed suicide after unsuccessful treatment for severe postpartum depression after the birth of her daughter. The quote reflects Ms. Blocker’s confusion as to how someone could oppose the MOTHER’S Act, a bill which is designed to increase public and professional education regarding Postpartum Mood & Anxiety Disorders. Frankly, I’m confused right along with Ms. Blocker.

The only survivor story featured in this article is that of Amy Philo, one of five recipients of an Outstanding Achievement for Mothers’ and Children’s Rights awards from the Citizens Commision on Human Rights or CCHR. CCHR was founded in 1969 by none other than the Church of Scientology, well-known to oppose the entire psychiatric field.

Amy has tirelessly worked against this bill for quite some time now but continues to be tragically misled. Few discussions with her have led to quite the round robin with Amy unable to come up with legitimate research to back up her claims. When asked for said research, Amy refers to her own websites instead of to specific research articles supporting her claims.

I happen to know that Ms. Elton did indeed interview fellow survivors who support the bill. One has to wonder then, why did their stories not make it into the article? Was it length? Was it editing? Or was it intentional? Regardless, the finished piece as published presents a very frightening and deceiptful picture of what new mothers face is this bill is passed. To begin with, the MOTHER’S Act no longer mandates screening. It requires a study to be completed by the Secretary of Health and Human Services (Kathleen Sebelius) as well as funds for an educational campaign for both caregivers and the general public.

I agree that just because a new mother shows emotion she should not immediately be diagnosed as having a PMAD. I also believe that a woman should have free choice when it comes to her treatment decisions and should NOT be judged for those choices. I chose to take Anti-depressants. My first prescription did not work out. But my second one did. Just as with any other medication, sometimes they don’t work so well with your system. So you try another one. You don’t suddenly take your own care into your hands – that’s ridiculous. Would you try to heal a broken leg or diabetes on your own? No? I didn’t think so. So why would you rely solely on self-care when it comes to mental illness? Self-care should be part of the picture but it shouldn’t be the ONLY part of the picture.

I am so tired of being judged and accused of not having informed consent. You know what? When I made my decision to go on Anti-Depressants, I had carried around an informational packet about AD’s & Breastfeeding given to me by the NICU Lactation Consultant with me for a week. I read that thing through and through. I was exclusively pumping for my daughter at the time and did not want to jeopardize her receiving my milk if I ended up having to take something. But I couldn’t function. I couldn’t take care of my family, I couldn’t take care of myself, and a lot of the same thoughts were coming back. Negative, scary thoughts about knives and hurting myself and my family. Yet I wasn’t on anti-depressants. I needed to be able to function. So I made a very informed decision to do so, one I do not regret to this day.

TIME – I am very disappointed in your lack of sharing both sides of this debate. Very very disappointed.

US Practitioners confident in use of EPDS; not charting results

A study entitled “Universal Screening for Postpartum Depression: an inquiry into provider attitudes and practice”, presented January 2009 at the 29th Annual Meeting of the Society for Maternal Fetal Medicine, January 2009, evaluated usage of the EPDS in an academic based clinical center and also evaluated the practitioner’s knowledge of and attitude towards the EPDS.

A total of 512 records were studied with a rather large difference between percentage of documented screens and reported rates of confidence and knowledge of screening. Only 39% of records included notated screens, 35% charted counseling with patients about their results,  even though 94% of practitioners reported they are responsible for and comfortable with making a diagnosis of a Postpartum Mood Disorder.

The study’s authors concluded that even though practitioners are confident they are not charting the results.

What does this mean?

Either practitioners are not as confident as they claim and really are not screening at a higher suspected level or they are truly confident and not documenting the patient’s complete visit. Whatever the case may be, something needs to change. Increased documentation of Postpartum Mood Disorders would allow for better understanding of how many women really do suffer. It also raises the question if more women than we think are seeking treatment and this information is just not making into the documentation. But at least these practitioners are asking the questions and not wording their way out of it much like a recent UK based study, right?

Therapy and the Postpartum Woman by Karen Kleiman

Karen Kleiman, a wonderfully dedicated therapist to the PPD world,  has authored yet another wonderful book, Therapy & the Postpartum Woman. Available for pre-order now,  this book will release in September and is written for the benefit of both clinicians and women with PPD to maximize the therapy experience on both sides. Click here to pre-order: Therapy & the Postpartum Woman

Here’s an excerpt of what Shari Lusskin, MD says in the foreword of the Therapy & the Postpartum Woman:

Ms. Kleiman presents a theoretical framework in which the therapist “mothers the mother” by acting as the “good” mother, who “must achieve that equilibrium between absolute support and appropriate boundaries.” Using compelling patient narratives, she demonstrates just how to achieve that balance in order to teach the patient how to develop confidence in her own skills as a mother. There is a treasure trove of “clinical pearls” in this eminently readable book, which even the most experienced clinician will be able to use right away. For those new to the field, and for patients and their loved ones, the book offers a wealth of information on the nature of postpartum depression as a medical illness and the psychosocial issues that arise when a woman is faced with caring for a baby. Ms. Kleiman describes how the medical community tends to minimize the complexity of these issues and use a “one size fits all” approach to treating depression. Readers will learn to be more effective advocates for proper treatment of perinatal depression. Therapists will also learn how to draw from their own experiences to facilitate the human connection between therapist and patient at a time when women feel isolated by shame and insecurity. Together, the therapist and the patient can work towards discovering the innate resilience that has allowed women to raise children even in the most extreme circumstances. Ms. Kleiman has developed a humanistic approach to psychotherapy for postpartum mood disorders that gives recognition to psychodynamic theory, but then uses many cognitive–behavioral techniques to reach well-defined goals. Therapy and the Postpartum Woman is an elegantly written book that not only offers practical advice but also does so in a way that will touch the lives of both patients and therapists. It is destined to become a classic for those experiencing or treating perinatal mood disorders.

Petition in Support of the MOTHER’S Act

Yes, we had a blog day.

Yes, we’ve called our Senators, written them, and speak out daily about the NEED for improved care for women just like us.

BUT… we’re not being heard. Instead, the voices of those who would argue that the MOTHER’S Act will force new mothers to take medication and submit to screening are the ones being heard. The MOTHER’S Act will not force medication on anyone – what it will do is provide the opportunity for every mother to have access to treatment for a PMD if she has one. The method of treatment is up to the mother and her physician (and frankly, if my physician wasn’t on the same page as I was or at least willing to back up his reasoning with some pretty strong fact, I’d find another physician!) and drugs may not be the best route for every mother – but EVERY MOTHER WHO SUFFERS DESERVES ACCESS TO TREATMENT.

Please sign the petition from the Depression & Bipolar Support Alliance in support of the MOTHER’S Act.

It’s urgent that your voice be heard NOW.

Mental Illness Awareness Week

In continued honour of mental illness awareness week, I am posting the EPDS (Edinburgh Postnatal Scale) here at Sharing the Journey. It is one of the standard screening tools for new mothers – and is not used often enough by practioners here in the States. 

If you are a new mother experiencing problems or know a new mother who is, please use this self screening tool or pass it on to someone who needs to use it by printing it for them. This particular version was found at www.wellmother.com.

Instructions for users:

  1. The mother is asked to underline the response which comes closest to how she has been feeling in the previous 7 days.
  2. All ten items must be completed.
  3. Care should be taken to avoid the possibility of the mother discussing her answers with others.
  4. The mother should complete the scale herself, unless she has limited English or has difficulty with reading.
  5. The EPDS may be used at 6-8 weeks to screen postnatal women. The child health clinic, postnatal check-up or a home visit may provide suitable opportunities for its completion.

Name: _______________________________
Address:  ___________________________________________________
Baby’s Age: __________________
As you have recently had a baby, we would like to know how you are feeling. Please UNDERLINE the answer which comes closest to how you have felt IN THE PAST 7 DAYS, not just how you feel today.

  1. I have been able to laugh and see the funny side of things.
    As much as I always could
    Not quite so much now
    Definitely not so much now
    Not at all
  2. I have looked forward with enjoyment to things.
    As much as I ever did
    Rather less than I used to
    Definitely less than I used to
    Hardly at all
  3. * I have blamed myself unnecessarily when things went wrong.
    Yes, most of the time
    Yes, some of the time
    Not very often
    No, never
  4. I have been anxious or worried for no good reason.
    No, not at all
    Hardly ever
    Yes, sometimes
    Yes, very often
  5. * I have felt scared or panicky for not very good reason.
    Yes, quite a lot
    Yes, sometimes
    No, not much
    No, not at all
  6. * Things have been getting on top of me.
    Yes, most of the time I haven’t been able to cope at all
    Yes, sometimes I haven’t been coping as well as usual
    No, most of the time I have coped quite well
    No, I have been coping as well as ever
  7. * I have been so unhappy that I have had difficulty sleeping.
    Yes, most of the time
    Yes, sometimes
    Not very often
    No, not at all
  8. * I have felt sad or miserable.
    Yes, most of the time
    Yes, quite often
    Not very often
    No, not at all
  9. * I have been so unhappy that I have been crying.
    Yes, most of the time
    Yes, quite often
    Only occasionally
    No, never
  10. * The thought of harming myself has occurred to me.
    Yes, quite often
    Sometimes
    Hardly ever
    Never

Response categories are scored 0, 1, 2, and 3 according to increased severity of the symptoms. Items marked with an asterisk are reverse cored (i.e. 3, 2, 1, and 0). The total score is calculated by adding together the scores for each of the ten items. Users may reproduce the scale without further permission providing they respect copyright by quoting the names of the authors, the title and the source of the paper in all reproduced copies.