Postpartum depression is depressive symptoms during the first year after delivery that last > 2 weeks and meet criteria for major depression.
Postpartum depression occurs in 7% of women during the first year after delivery (1). Although every woman is at risk, women with the following are at higher risk:
Postpartum blues (eg, rapid mood swings, irritability, anxiety, decreased concentration, insomnia, crying spells)
Prior episode of postpartum depression
Prior diagnosis of depression
Family history of depression
Significant life stressors (eg, relationship conflict, stressful events in the last year, financial difficulties, parenting with no partner, partner with depression)
Lack of support from partner or family members (eg, financial or child care support)
History of mood changes temporally associated with menstrual cycles or oral contraceptive use
Prior or current poor obstetric outcomes (eg, previous miscarriage, preterm delivery, neonate admitted to the neonatal intensive care unit, an infant with a congenital malformation)
Prior or continuing ambivalence about the current pregnancy (eg, because it was unplanned or termination was considered)
Problems with breastfeeding
The exact etiology of postpartum depression is unknown; however, prior depression is the major risk, and hormonal changes during the puerperium, sleep deprivation, and genetic susceptibility may contribute.
Transient depressive symptoms (baby blues) is very common during the first week after delivery. Postpartum blues typically lasts 2 to 3 days (up to 2 weeks) and is relatively mild; in contrast, postpartum depression lasts > 2 weeks and is disabling, interfering with activities of daily living.
General reference
1. Diagnostic and Statistical Manual of Mental Disorders, 5th ed, Text Revision (DSM-5-TR). American Psychiatric Association Publishing, Washington, DC, p 214
Symptoms and Signs of Postpartum Depression
Symptoms of postpartum depression are similar to those of major depression and may include
Extreme sadness
Mood swings
Uncontrollable crying
Insomnia or increased sleep
Loss of appetite or overeating
Irritability and anger
Headaches and body aches and pains
Extreme fatigue
Unrealistic worries about or disinterest in the baby
A feeling of being incapable of caring for the baby or of being inadequate as a mother
Fear of harming the baby
Guilt about her feelings
Suicidal ideation
Anxiety or panic attacks
Typically, symptoms develop insidiously over 3 months, but onset can be more sudden. Postpartum depression interferes with women’s ability to care for themselves and their baby.
Women may not bond with their infant, resulting in emotional, social, and cognitive problems in the child later.
Partners may also be at increased risk of depression, and depression in either parent may result in relationship stress.
Without treatment, postpartum depression can resolve spontaneously or become chronic depression. Risk of recurrence is about 1 in 3 to 4.
Other potential psychiatric disorders in the postpartum period include anxiety and, rarely, postpartum psychosis.
Untreated postpartum psychiatric disorders increase the risk of suicide and infanticide, which are the most severe complications.
Diagnosis of Postpartum Depression
Clinical evaluation
Criteria for major depressive disorder
Early diagnosis and treatment of postpartum depression substantially improve outcomes for women and their infant (1).
Postpartum depression is diagnosed based on the same criteria as major depressive disorder, which are ≥ 5 symptoms for > 2 weeks; symptoms include depressed mood and/or loss of interest or pleasure and (2)
Significant weight loss, loss of appetite, or weight gain
Insomnia or hypersomnia
Psychomotor agitation or retardation
Feeling of worthlessness or guilt
Diminished ability to concentrate
Suicidal or homicidal thoughts (women should be asked specifically about such thoughts)
Many women have postpartum "baby blues," which may include depressive symptoms but does not meet full criteria for postpartum depression.
Because of cultural and social factors, women may not report symptoms of depression, so clinicians should ask women about such symptoms before and after delivery. Also, women should be taught to recognize symptoms of depression, which they may mistake for the normal effects of new motherhood (eg, fatigue, difficulty concentrating).
All women should be screened at the postpartum visit for postpartum depression using a validated screening tool. Such tools include the Edinburgh Postnatal Depression Scale and the Postpartum Depression Screening Scale (2).
Depressive symptoms such as dysphoria, insomnia, fatigue, and impaired concentration can be present in both postpartum blues and postpartum depression. However, the diagnosis of postpartum blues does not require a minimum number of symptoms, whereas postpartum depression requires a minimum of 5 symptoms. In addition, the symptoms of postpartum blues are generally self-limited and resolve within 2 weeks of onset. By contrast, the diagnosis of postpartum depression requires that symptoms be present for > 2 weeks.
Patients should also be screened for anxiety disorders.
Patients with hallucinations, delusions, or psychotic behavior should be evaluated for postpartum psychosis.
Diagnosis references
1. American College of Obstetricians and Gynecologists (ACOG): Screening and Diagnosis of Mental Health Conditions During Pregnancy and Postpartum: ACOG Clinical Practice Guideline No. 4. Obstet Gynecol. 2023;141(6):1232-1261. doi:10.1097/AOG.0000000000005200
2. Diagnostic and Statistical Manual of Mental Disorders, 5th ed, Text Revision (DSM-5-TR). American Psychiatric Association Publishing, Washington, DC, pp 184-193
Treatment of Postpartum Depression
Other antidepressants
Psychotherapy
Treatment of postpartum depression includes antidepressants1, 2, 3).
If a woman has significant anxiety, she may be treated with anxiolytics (4).
Treatment of postpartum psychosis typically requires psychiatric hospitalization and antipsychotic medications.
Treatment of postpartum depression references
1. American College of Obstetricians and Gynecologists (ACOG)
2. Deligiannidis KM, Meltzer-Brody S, Gunduz-Bruce H, et al: Effect of Zuranolone vs Placebo in Postpartum Depression: A Randomized Clinical Trial [published correction appears in JAMA Psychiatry. 2022 Jul 1;79(7):740] [published correction appears in JAMA Psychiatry. 2023 Feb 1;80(2):191]. JAMA Psychiatry. 2021;78(9):951-959. doi:10.1001/jamapsychiatry.2021.1559
3. Epperson CN, Rubinow DR, Meltzer-Brody S, et al: Effect of brexanolone on depressive symptoms, anxiety, and insomnia in women with postpartum depression: Pooled analyses from 3 double-blind, randomized, placebo-controlled clinical trials in the HUMMINGBIRD clinical program. J Affect Disord. 2023;320:353-359. doi:10.1016/j.jad.2022.09.143
4. American College of Obstetricians and Gynecologists (ACOG): ACOG Clinical Practice Guideline No. 5: Treatment and Management of Mental Health Conditions During Pregnancy and Postpartum. Obstet Gynecol. 2023;141(6):1262-1288. doi:10.1097/AOG.0000000000005202
Key Points
Postpartum blues is very common during the first week after delivery, typically lasts 2 to 3 days (up to 2 weeks), and is relatively mild.
Postpartum depression occurs in 7% of women, lasts > 2 weeks, and is disabling (in contrast to postpartum blues).
Symptoms are similar to those of major depression and can also include anxiety.
Postpartum depression may result in adverse effects on the child or in relationship stress.
Teach all women to recognize the symptoms of postpartum depression, and ask them about symptoms of depression before and after delivery.
Formally screen all women for mood disorders during their postpartum visit.
For the best possible outcomes, identify and treat postpartum depression as early as possible.
