We thank Dr Matthey and colleagues for their interest in our work, and for highlighting the impact of varying cut-off scores of the Edinburgh Postnatal Depression Scale (EPDS) and its implications for depression screening. The authors highlight the impact of using a higher cut-off score to screen positive for depression used in some earlier validation studies of the EPDS (ie, ≥13 rather than ≥12), as well as evidence suggesting different cut-off scores may be optimal for the antepartum and postpartum periods, and in women of different sociocultural backgrounds. We note that the authors have a recent publication indicating that in their population, they transitioned from using a cut-off of ≥10 to ≥13 for EPDS administered at the time of the first prenatal visit and found that they were able to decrease resource utilization without measuring a significant impact on patient care. We agree that with the implementation of any screening program, it is important to recognize the tradeoffs in sensitivity and specificity that are inherent in utilizing a specific threshold for further evaluation, and understanding the resources available in a particular clinical context helps to inform these decisions.

In the current study, we employed a cut-off score of ≥12 for further mental health evaluation to increase sensitivity both antepartum and postpartum, and to minimize missing women at risk. Women only underwent further treatment for depression following a formal psychological assessment after screening positive. Importantly, this study demonstrated the feasibility to implement a universal depression screening program within the context of existing clinical resources devoted to routine antepartum and postpartum obstetrical care. We agree that accurate scoring of the EPDS is critical to any screening program. Beyond routine implementation of EPDS administration, we agree that there is a need to enhance the efficacy, equity, and efficiency of screening by optimizing provider training and gaining a greater understanding of the best timing for administration as well as the optimal cut-offs for different populations.