Postpartum depression is depressive symptoms that last 2 weeks after delivery and meet criteria for major depression.
Postpartum depression occurs in 10 to 15% of women after delivery. Although every woman is at risk, women with the following are at higher risk:
Baby 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, marital 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. Baby blues differs from postpartum depression because baby 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.
Symptoms and Signs of Postpartum Depression
Symptoms of postpartum depression are similar to those of major depression and may include
Baby blues (eg, rapid mood swings, irritability, anxiety, decreased concentration, insomnia, crying spells)
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 the 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.
Postpartum psychosis rarely develops; untreated postpartum depression and psychosis increase the risk of suicide and infanticide, which are the most severe complications.
Diagnosis of Postpartum Depression
Clinical evaluation
Criteria for major depression
Early diagnosis and treatment of postpartum depression substantially improve outcomes for women and their infant.
Postpartum depression (or other serious mental disorders) is diagnosed if women have ≥ 5 symptoms for > 2 weeks; symptoms include depressed mood and/or loss of interest or pleasure and
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)
Because of cultural and social factors, women may not volunteer symptoms of depression, so health care providers 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 (1).
Patients with hallucinations, delusions, or psychotic behavior should be evaluated for postpartum psychosis.
Diagnosis reference
1. American College of Obstetricians and Gynecologists (ACOG) Committee on Obstetric Practice: Committee Opinion No. 757: Screening for Perinatal Depression. Obstet Gynecol 130 (3): 132 (5):e208–e212, 2018. doi: 10.1097/AOG.0000000000002927
Treatment of Postpartum Depression
Antidepressants
Psychotherapy
Treatment of postpartum depression includes antidepressants and psychotherapy. If a woman has significant anxiety, she may be treated with anxiolytics.
Women who have postpartum psychosis may need to be hospitalized, preferably in a supervised unit that allows the infant to remain with them. Antipsychotic drugs may be needed as well as antidepressants.
Key Points
Baby 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 10 to 15% of women, lasts > 2 weeks, and is disabling (in contrast to baby blues).
Symptoms are be 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.
