History and exam

Key diagnostic factors

common

presence of risk factors

Key risk factors include any history of depressed mood, depression, or anxiety, whether during the recent pregnancy or a previous pregnancy, or unrelated to pregnancy; recent stressful life events; violence and abuse; poor social support; preterm and low birth weight infants; and discontinuing psychopharmacological treatments.[131][132]

depressed mood

Depressed mood to a degree that is abnormal for the person, present for most of the day, and largely uninfluenced by circumstances.[1][133]

anhedonia

Anhedonia (loss of interest and pleasure in normally pleasurable activities) may be present.[1][133]

decreased energy or increased fatigability

Decreased energy or increased fatigability may be present.[123]

suicidal ideation

Suicidal ideation may occur.[123]

loss of confidence or self-esteem

Loss of confidence or self-esteem may be present.

unreasonable feelings of self-reproach or excessive and inappropriate guilt

Unreasonable feelings of self-reproach or excessive and inappropriate guilt may be present.[123]

poor concentration

Poor concentration may be present.[123]

Other diagnostic factors

common

change in psychomotor activity

Slowed activity or agitated activity may be present.[123]

sleep disturbance

Initial insomnia, middle insomnia, early morning waking, and/or excessive sleep may be present.[67][123]

change in appetite

Poor appetite or increased appetite may be present.[123]

change in weight

Change in appetite is usually, but not always, associated with a corresponding change in weight. Weight loss or weight gain may be present.[123]

obsessive/intrusive thoughts

Intrusive thoughts can occur in the absence of a mental health condition, but are also associated with perinatal depression (as well as perinatal anxiety and obsessive compulsive disorder).[4][119]​​ In one study of 37 women with postnatal depression, 57% reported obsessional thoughts, of whom 95% had aggressive thoughts. The most frequent content of the aggressive thoughts was causing harm to their newborns or infants. The presence or number of obsessional thoughts or compulsions was not related to severity of the depressive episode.[121] As a general guide, unwanted or intrusive thoughts associated with a higher risk to the baby are those where thoughts of harming the baby are comforting.​[4]

uncommon

significant self-harm or neglect or mistreatment of children

Must be elicited to assess the risk of self-harm or harm to the baby.

personal or family history of hypomania or mania

Postnatal depression most often occurs in the context of a unipolar depressive illness. However, episodes of mood disorder following childbirth are very common in women with bipolar disorder,[14] and a substantial minority of postnatal depressive episodes are bipolar.[6] ​One large US-based study conducted at an urban academic women’s hospital found that almost one quarter (22.6%) of women with a positive perinatal depression screen were later found to have bipolar disorder.[6]​ A higher score on a validated depression screening tool (e.g., EPDS >19) was found to convey a higher risk of bipolar disorder.[6]​

psychotic symptoms

These include hallucinations, delusions, confused and disturbed thoughts, and a lack of insight and self-awareness.

They substantially increase risk of self-harm or harm to the baby, particularly if the delusions or hallucinations relate to the baby.

Patients with psychotic symptoms require an emergency same-day detailed risk assessment by a psychiatrist.[82]​​

Risk factors

strong

history of depressed mood, depression, or anxiety

A past history of a mood or anxiety disorder (whether perinatal or not) is the strongest risk factor for postnatal depression.[6][37][38][39][40][41]

All psychiatric diagnoses including anxiety, panic disorders, bipolar disorder, obsessive-compulsive disorder, post-traumatic stress disorder, and eating disorders, confer an increased risk for postnatal depression.[42]

Women who experience antenatal depression have about a fivefold increased risk of developing postnatal depression, while women who experience antenatal anxiety have a threefold increased risk.[41]

A history of major depression at any time leads to a significantly increased risk of postnatal depression.​[37][38][41] The level of increased risk appears to be related to the severity and duration of the previous episode.

Postnatal blues, or 'baby blues', is common and transient, but has been associated with an increased risk of subsequent postnatal depression.​[11]

recent stressful life events

There is a strong association between recent negative life events and postnatal depression.​[46]​

poor social support

Social support can be defined variously as a source of support (spouse, friends, relatives) or a type of support (informational, instrumental, emotional).​[38]

Emotional and instrumental supports have been negatively correlated with depression in the postnatal period.[37][38][47][48] Perceived social isolation strongly predicted depression in the postnatal period in a sample of black women with low incomes.[49]

Marital problems during pregnancy and the lack of a supportive partner have been found to moderately increase the risk of postnatal depression.[38][50]​​

discontinuation of psychopharmacological treatments

Discontinuation of maintenance antidepressant medication in euthymic women before or during the first trimester of pregnancy increases the risk of postnatal depression when compared with women who remain on antidepressants throughout the pregnancy.[76]

In one longitudinal study of women with bipolar disorder, symptom recurrence increased sharply in the postnatal period after abruptly discontinuing lithium therapy.[43] The risk of recurrence was decreased by tapering the dose.

sleep deprivation

A strong association between infant sleep patterns, maternal fatigue, and new-onset depressive symptoms in the postnatal period has been suggested. Therapeutic interventions to reduce sleep deprivation in the early weeks postnatal have been tried,[69] but results are inconclusive.[70] Sleep changes in pregnancy are associated with depressive symptoms in the postnatal period, suggesting sleep timing may be a modifiable risk factor for developing postnatal depression.[67][68]

socioeconomic difficulties

Low income, financial strain, unemployment, and low social status are small but significant predictors of postnatal depression.[38][49]

Studies have also found differences in risk between ethnic groups, with black and Hispanic people having higher depression scores than white people.[47][49]

familial and genetic factors

Among women with a history of major depression, 42% of those with a family history of postnatal episodes experienced depression following their first delivery, as compared with 15% in women with no family history.[2]

Similar genes tend to be studied in postnatal depression as those already associated with major depression, and these genes have a similar pattern.[63] An Australian twin study[60] reported that genetic factors accounted for 26% to 49% of variance in postnatal depressive symptoms, while in a Swedish study the hereditability of perinatal depression was estimated between 44% and 54%, with 33% of the genetic variance unique for perinatal depression (i.e., not shared with depression at other times).[61] One study suggested that genetic variation on chromosomes 1q and 9p might increase susceptibility to broadly defined postnatal mood symptoms in one sample of women with both unipolar and bipolar disorder.[66] ​There is some genome-wide association study (GWAS) evidence that postnatal depression may have unique genetic components, which are distinct from those that increase susceptibility for major depressive disorder in the non-perinatal population.[65]​ 

physical, psychological, or sexual abuse by partner during pregnancy

Psychological, sexual, and physical violence against women by their intimate partner during pregnancy are all independently associated with postnatal depression.[51][52][53][54][55]​​ In one large Brazilian study, women reporting physical or sexual violence plus psychological violence had the highest risk of postnatal depression.[51]

weak

postnatal hypomania

Two longitudinal studies found that hypomanic symptoms at day 3 predicted depressive symptoms at 6 weeks after childbirth.[44][45] In the later study 40% of women with subclinical hypomanic symptoms in the first postnatal week became depressed at 6 weeks.[45]

personality traits

High neuroticism scores[38][39][57] and low self-esteem scores[37][57] have been found to be weak to moderate predictors of postnatal depression. There is no evidence, however, that any of these traits or styles confer a specific risk for the postnatal onset of episodes.[58]

pregnancy- and delivery-related complications

In general, pregnancy- and delivery-related complications have a small but significant effect on the onset of postnatal depression.[37][38] In particular, gestational diabetes and pre-eclampsia both appear to be associated with an increased risk of subsequent postnatal depression.[77][78]

A meta-analysis found no link between caesarean section and postnatal depression.[79]

age less than 16 years

Although maternal age has not emerged from most studies as a prominent risk factor, one study of mothers under 16 years of age found that they are at higher risk of postnatal depression.[39]

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