Criteria

Neither the term nor the concept of postnatal depression are present in the two major diagnostic systems: the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM-5-TR) and the World Health Organization's International Classification of Diseases (ICD-11).

American Psychiatric Association: diagnostic and statistical manual of mental disorders, 5th edition, text revision (DSM-5-TR)[1]

DSM-5-TR does not recognise postnatal depression as a separate diagnosis; rather, patients must meet the criteria for a major depressive episode and the criteria for the peripartum-onset specifier. The definition is therefore a major depressive episode with an onset in pregnancy or within 4 weeks of delivery.

The DSM-5-TR criteria for a major depressive episode are as follows:

a) Five or more out of 9 symptoms (including at least one of depressed mood and loss of interest or pleasure) in the same 2-week period. Each of these symptoms represents a change from previous functioning, and needs to be present nearly every day:

  • Depressed mood (subjective or observed); can be irritable mood in children and adolescents, most of the day

  • Loss of interest or pleasure, in all, or almost all, activities most of the day

  • Change in weight or appetite. Weight: 5% change over 1 month

  • Insomnia or hypersomnia; nearly every day

  • Psychomotor retardation or agitation (observed by others, not subjective feelings of being slowed down or restlessness)

  • Loss of energy or fatigue

  • Feelings of worthlessness or excessive or inappropriate guilt

  • Diminished concentration or indecisiveness; or

  • Recurrent thoughts of death, recurrent suicidal ideation with or without a specific plan, or a suicide attempt.

b) Symptoms cause significant distress or impairment.

c) Episode is not attributable to a substance or medical condition.

d) Episode is not better explained by a psychotic disorder.

e) There has never been a manic or hypomanic episode. Exclusion e) does not apply if a (hypo)manic episode was substance-induced or attributable to a medical condition.

International classification of diseases 11 (ICD-11)[133]

The ICD-11 has a category for mental and behavioural disorders associated with pregnancy, childbirth and the puerperium that involves significant and mental and behavioural features, most commonly depressive symptoms, and defines a postnatal onset is considered to be within 6 weeks after delivery. It includes two categories within this, which differ depending on if the features include delusions, hallucinations, psychotic symptoms or not. If the symptomatic presentation also meets the diagnostic criteria for another specific ICD-11 mental health disorder that diagnosis is also applied.

Symptoms of depressive disorder in the ICD-11 include:

  • Depressed mood

  • Diminished interest/capacity for pleasure

  • Change in sleep

  • Psychomotor change

  • Reduced energy; fatigue

  • Feelings of worthlessness; excessive or inappropriate guilt

  • Hopelessness

  • Difficulty concentrating

  • Recurrent thoughts of death or suicide.

Mild depression is diagnosed when no symptom is present to an intense degree, and there is some, but not considerable functional impairment.

Moderate denotes several symptoms present to a marked degree and considerable but not complete functional impairment.

Severe depression is diagnosed when many or most of the characteristic symptoms of depression are present to a marked degree, and/or several are present to an intense degree, and there is complete or near-complete functional impairment.

Note: the presence of psychotic symptoms by definition defines an episode as moderate or severe.

Additionally, ICD-11 includes under the depressive disorder category, a diagnosis of dysthymic disorder, and a new one for mixed anxiety and depressive disorder.[133]

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