Merck Manual

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Postpartum Depression

By

Julie S. Moldenhauer

, MD, Children's Hospital of Philadelphia

Last full review/revision May 2020| Content last modified May 2020
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Postpartum depression is depressive symptoms that last > 2 weeks after delivery and that interfere with activities of daily living.

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, unemployment of partner, 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 depression (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

Symptoms of postpartum depression may be 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 the baby.

Women may not bond with their infant, resulting in emotional, social, and cognitive problems in the child later.

Postpartum psychosis rarely develops; untreated postpartum depression and psychosis increase the risk of suicide and infanticide, which are the most severe complications.

Fathers are at increased risk of depression, and marital stress is increased.

Without treatment, postpartum depression can resolve spontaneously or become chronic depression. Risk of recurrence is about 1 in 3 to 4.

Diagnosis

  • Clinical evaluation

  • Sometimes formal depression scales

Early diagnosis and treatment of postpartum depression substantially improve outcomes for women and their infant.

Postpartum depression (or other serious mental disorders) should be suspected if women have the following:

  • Symptoms of depression for > 2 weeks

  • Symptoms that interfere with daily activities

  • Suicidal or homicidal thoughts (women should be asked specifically about such thoughts)

  • Hallucinations, delusions, or psychotic behavior

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).

Diagnosis reference

Treatment

  • Antidepressants

  • Psychotherapy

Treatment of postpartum depression includes antidepressants and psychotherapy. If a woman has significant anxiety, she may be treated with anxiolytics.

Exercise therapy, light therapy, massage therapy, acupuncture, and omega-3 fatty acid supplementation have shown some benefit in small studies.

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 may be similar to those of major depression and can also include worries and fears about being a mother.

  • Postpartum depression typically also affects other family members, often resulting in marital stress, depression in the father, and subsequent problems in the child.

  • 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 and anxiety disorders during their postpartum visit.

  • For the best possible outcomes, identify and treat postpartum depression as early as possible.

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NOTE: This is the Professional Version. CONSUMERS: Click here for the Consumer Version
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