Approach

Clinicians should routinely check for the presence of depression in all women in the perinatal period.[4][5][92] Untreated postpartum depression is associated with profoundly negative consequences for both the mother and infant, underscoring the need for timely and effective diagnosis and treatment. In mothers, it is associated with reduced quality of life, poorer psychological health, poorer relationship quality, increased risk of suicidal thoughts, and impaired infant bonding. In infants, it is associated with reduced physical, behavioral, cognitive, and psychiatric outcomes, with greater risks for children in lower socioeconomic groups.[93][94][95][96][97][98] There is evidence that a proportional relationship exists between severity and duration of depressive symptoms and subsequent negative impact on outcomes in the child.[99]

There is no established consensus as to the length of the postpartum period, and definitions generally range from the first 3 to 12 months following birth.[4][5][100][101] This topic defines the postpartum period as up to 12 months after delivery, in keeping with a number of international guidelines.[3][4][5]

Postpartum 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 significant minority of postpartum depressive episodes are bipolar.[6]​ See Bipolar disorder in adults.

Service arrangements vary internationally, but suspected mild and moderate depression can often be assessed and managed in primary care. In the US, obstetricians play a key role in the initial assessment and management of perinatal mental illness, aided by Perinatal Psychiatry Access Programs where available.[82]​ Psychiatric referral may be necessary for patients whose symptoms do not improve with treatment. Urgent psychiatric assessment is warranted if there is a risk of self-harm or harm to the child at any time, or if a postpartum psychosis, or manic or mixed episode is suspected.[4][5] Consider whether or not is is appropriate to involve child protective services in such cases.[74]​​

During the assessment, it is also important to consider any psychosocial factors that might have increased the risk of depression and that require input and assistance, such as domestic abuse or violence, or a lack of psychosocial support.[102]

Presenting symptoms

Women with postpartum depression may have contact only with nonspecialists, so all health professionals who see pregnant and postpartum women need to be able to identify the illness. Postpartum depression is frequently missed or misdiagnosed; one study found that only 15% of 211 women with a mood disorder in the first year following childbirth had sought help, been prescribed drugs, or had hospital contact.[103] The results of one large UK-based survey of primary healthcare professionals and women with perinatal mental health problems found that the biggest barrier to better supporting women experiencing poor perinatal mental health was the low level of identification of need. Common barriers were identified, including a lack of focus on mother's and baby's well-being after the initial postpartum (6-8 week) checks, women feeling dismissed or overly reassured when discussing their problems with healthcare professionals, and a fear among women that their baby might be taken away from them if they admitted difficulties.[104] Voluntary disclosure of distress can be considered as a "red flag" moment for clinicians, and requires further active and compassionate investigation.

Ask sensitively about current symptoms of low mood, ideas of worthlessness and hopelessness about the future, and biologic symptoms such as severe insomnia, poor appetite, and weight loss.[1]​ Women with postpartum depression may present with a history of depressed mood, anhedonia, weight changes, sleep disturbance, psychomotor problems, low energy, excessive guilt, loss of confidence or self-esteem, poor concentration, or suicidal ideation. Depressed mood is defined as mood that is low to a degree that is abnormal for the person, present for most of the day, and largely uninfluenced by circumstances.

It is important to distinguish postpartum depression from a minor mood disturbance (postpartum blues or "baby blues"). Minor mood disturbance requires no treatment, but may indicate an increased risk of developing a clinically significant mood disorder later in the postpartum period.[11]​ In minor mood disturbance, the woman typically presents with mood swings ranging from elation to sadness, insomnia, tearfulness, crying spells, irritability, anxiety, and decreased concentration.[9] Symptoms develop within 2 to 3 days after childbirth, peak on the fifth day, and resolve within 2 weeks.

There is substantial heterogeneity in both the timing of onset and symptom presentation in postpartum depression.[34][105]​ ​A growing body of evidence suggests that many women develop onset of symptoms during pregnancy or even before pregnancy.[6][7]​​ Onset of depressive symptoms in the first 8 weeks after birth appears to be associated with more severe depression than onset during pregnancy or in the later postpartum period. Anxiety and anhedonia were found to be prominent symptoms in those with postpartum onset. Hormonal fluctuations occurring between pregnancy and the postpartum period have been postulated as one potential causative factor for depression developing in the early postpartum period within a subgroup of patients.[33][34][35]​​

Any psychotic symptoms substantially increase the risk of self-harm or harm to the baby, particularly delusions or hallucinations that relate to the baby. The core feature of postpartum psychosis is the acute onset of a manic or depressive psychosis in the immediate postpartum period. Postpartum psychosis is a psychiatric emergency and can develop rapidly into a very severe condition.

Screening for depression

US guidelines stress the importance of routinely assessing patients for depression during pregnancy and within the postpartum period.[4]​ The American College of Obstetricians and Gynecologists (ACOG) recommends that everyone receiving well-woman, pre-pregnancy, antepartum, and postpartum care be screened for depression at multiple timepoints using the same standardized, validated screening instrument. Examples given include the Edinburgh Postnatal Depression Scale (EPDS) or Patient Health Questionnaire (PHQ-9).[4]

In the UK (as in other countries, such as Canada), routine screening for postpartum depression is not currently recommended.​[106]​ However, the UK National Institute for Health and Care Excellence recommends that healthcare professionals (including midwives, obstetricians, health visitors, and primary care physicians) should consider asking two questions to identify possible depression, at the woman's first contact with primary care, at her first prenatal appointment (usually around week 10 of pregnancy), and postpartum (first year after childbirth):[5]

  • During the past month, have you often been bothered by feeling down, depressed, or hopeless?

  • During the past month, have you often been bothered by having little interest or pleasure in doing things?

If the woman answers "yes" to either of the initial questions, is at risk of developing a mental health problem, or there is clinical concern, consider:

  • Using the EPDS[107] or

  • Using the PHQ-9 as part of a full assessment or

  • Referring the woman to her primary care physician, or, if a severe mental health problem is suspected, to a mental health professional.[5]

The Bromley Postnatal Depression Scale (BPDS), the EPDS, and the Postpartum Depression Screening Scale (PDSS) are self-reported measures specifically designed to screen for depression in the postpartum period.[107][108][109] The EPDS had been most widely studied. It has been psychometrically tested extensively in postpartum women and used throughout the world. Sensitivity and specificity of cutoff points showed marked heterogeneity between different studies. Sensitivity results ranged from 34% to 100% and specificity from 44% to 100%.[110] The cutoff score of >12 has an overall positive predictive value of 57% and negative predictive value of 99%. Lower cutoff values (e.g., 10 or 11) may be used if the intention is to avoid false negatives.[4] ​In one large meta-analysis of studies comparing the PHQ-9 and EPDS, operating characteristics were nearly identical.[111]​ 

Other tools such as the Beck Depression Inventory may have value but require further research.[112][113] These screening tools should be used to identify women who need further clinical assessment.

When using screening tools, take into account the cultural background of the mother.[114] Primary care practices screening adults should have systems in place that ensure positive screening results are followed by accurate diagnosis, effective treatment, and careful follow-up.​[92][115]​​

Assessing risk of self-harm and/or harm to the baby

Exploring risk of harm to self

Some screening tools (e.g., EPDS, PHQ-9) contain a screening question on thoughts of self-harm and suicide. If a patient answers yes, the next step is to immediately assess for likelihood, acuity, and severity of risk of suicide attempt and then arrange for risk-tailored mitigation.[4]​ When discussing symptoms of low mood, sensitively ask whether the woman feels that life is not worth living and whether she has ever thought of harming her baby. This enables the clinician to find out more about the most serious aspects of risk (to the mother and to her child). There is no evidence that raising these issues with women increases the risk of self-harm or suicide.[90]

Women may be reluctant to disclose thoughts of self-harm or harm to the baby due to fear that their baby will be taken away. Be mindful of this, play close attention to verbal and non-verbal cues, and be careful about your choice of language; it may be appropriate to explain that the vast majority of women with postpartum depression will receive medical help without being separated from their baby.[116]

In some countries such as the UK, suicide has been identified as the leading cause of maternal death in the first year after childbirth.[28] Ask compassionately about suicidal thoughts and intent, Everymind: Life in Mind initiative (Australia) Opens in new window including:

  • Suicidal thoughts: if suicidal thoughts are present, how frequent and persistent are they?

  • Plan: if the woman has a plan, how detailed and realistic is it?

  • Lethality: what method has the woman chosen; how lethal is it?

  • Means: does the woman have the means to carry out the chosen method?

Consider:

  • Risk factors: these remain uncertain, and the absence of risk factors does not mean an absence of suicide risk. According to one 15-year UK study, a diagnosis of psychiatric illness, presence of substance misuse, intimate partner violence, neonatal complications (especially perinatal death), medical comorbidity, and young maternal age (e.g., teenager) all seem to be associated with an increased risk of perinatal suicide.[117] The most predictive factors for imminent suicide are the presence of a suicide plan and immediate access to lethal means.[118]

  • Protective factors: ask about what is important to the woman. Is there anything (e.g., people, places, activities, or achievements) that makes her feel hopeful? Is there anything else you should know about her?

  • Mental state: hopelessness, despair, psychosis, agitation, shame, anger, guilt, impulsivity.

  • History of suicidal behavior.

  • Family history of suicidal behavior.

  • Substance use: current misuse of alcohol or other drugs.

  • Strengths and supports: availability, willingness, and capacity of supports.

Although it is important to explore self-harm and suicidal thoughts fully as described above, be aware that suicide risk cannot be predicted accurately in any given individual at a single point in time. When a woman discloses suicidal thoughts, the next step is to work collaboratively with her to establish a plan to prevent her from harming herself now, and also in the coming days and weeks. This involves a decision about the most appropriate site of care, to consider whether there is a need for hospital admission (e.g., if there is psychosis, diagnostic uncertainty, imminent risk to self or others, and/or inadequate social support). ACOG recommends that emergency psychiatric evaluation is always warranted for those with suicidal ideation with an intent and plan, and for those who are unable to state reasons why they would not proceed with a suicide attempt.[4]

For more information, see  Suicide risk mitigation. 

Exploring risk of harm to the infant

Expressions of fear of harming the baby are common and may be the result of unwanted or intrusive thoughts related to anxiety rather than intent, but always assess this further. Intrusive thoughts may take the form of unwanted thoughts about infant-related harm, including thoughts of harming the baby on purpose.[119]​ 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]​​​ ACOG notes that most women experiencing intrusive thoughts as distressing will not act on them. As a general guide, unwanted or intrusive thoughts are associated with a higher risk to the baby if they include thoughts of harming the baby that are experienced as comforting.[4]

There is evidence of a relationship between postpartum depression and obsessive-compulsive symptoms, particularly unwanted intrusive thoughts of hurting the baby.[120] In one study of 37 women with postpartum 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] In another study, of the 41% of women with postpartum depression who reported aggressive obsessive thoughts, 5% had actually acted in an aggressive way toward their child. 

The prevalence of aggressive thoughts among postpartum women without depression was 6.5%.[122]

Psychotic symptoms occurred in 4% of episodes in one study.[123] These include hallucinations, delusions, confused and disturbed thoughts, and a lack of insight and self-awareness. They can substantially increase the risk of self-harm or harm to the baby, particularly if the delusions or hallucinations relate to the baby. 

Other important points to consider are whether there is impaired bonding with the baby, a lack of feeling of attachment toward them, and/or a sense of emotional numbness. Postpartum depression can interfere with maternal-infant bonding. If there are any concerns about the risk to a child, in addition to arranging urgent assessment by a psychiatrist, follow the relevant local or national guidance on safeguarding children; in the first instance it may be helpful to discuss the situation with an experienced colleague, named or designated doctor for child protection, and/or professional or regulatory body.[5] Consider involving child protection services in these cases.[74]​​

Screening for undiagnosed bipolar disorder

The consequences of missing a diagnosis of bipolar disorder can be particularly serious, as treatment with antidepressants may precipitate mania, a mixed state, or rapid cycling, and thereby increase the risk for admission to a psychiatric hospital.[15]

Because bipolar disorder and depression both include depressive symptomatology, a bipolar disorder diagnosis may be missed and symptoms mistakenly attributed to perinatal depression. 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 >13) was found to convey a higher risk of bipolar disorder.[6]​ Women with a first-time psychiatric contact during the first postpartum month are significantly more likely to go on to receive a diagnosis of bipolar disorder within 15 years than those with an onset later in the postpartum period or those with a first psychiatric episode unrelated to childbirth.[124][125]

​Many experts endorse screening for bipolar disorder in the perinatal period. US guidance from ACOG recommends routinely screening all pregnant women for bipolar disorder on at least one occasion in the perinatal period, using a standardized, validated instrument that asks about lifetime symptomatology, such as the Mood Disorder Questionnaire (MDQ) or Composite International Diagnostic Interview (CIDI​).[4]​ If screening for bipolar disorder hasyet to take place, it is imperative to screen for undiagnosed bipolar disorder before offering pharmacologic treatment for depression, given the risk of iatrogenic preciptation of bipolar symptoms such as mania and psychosis, with subsequent increased risk of self-harm and/or harm to the baby or others.[4] ​Screening should include questions about past and current symptoms of mania and hypomania, as well as an enquiry about any family history of bipolar disorder.

​Atypical features (mood reactivity, weight/appetite increase, hypersomnia, leaden paralysis, and interpersonal rejection sensitivity), racing thoughts, and psychotic symptoms during a depressive episode should raise suspicion of a bipolar disorder.[1][15] 

In addition to asking questions about high mood and related symptoms in the history, questionnaires can also be used to screen for past history or current symptoms of mania/hypomania. The Highs is a self-reported questionnaire to detect hypomanic features in the postpartum period. About 10% of women experience hypomanic features in the first 5 days postpartum. A score of 8 or higher on the Highs scale within 3 days postpartum is associated with postpartum depression.[126] Other self-reported measures used to screen for bipolar disorder in the general population include the Altman Self-Rating Mania Scale (ASRM) for symptoms in the past week, the MDQ for lifetime history, and the Screening Assessment of Depression-Polarity (SAD-P).[127][127][128]​ Although no screening tool has been shown to be superior, the MDQ​​ and Highs are the most promising tools studied in perinatal populations.[15][126]​​ The MDQ incorporates all pertinent information included in the other scales with the addition of an assessment of irritability and impulsive behavior.

If bipolar disorder is suspected, urgent consultation with or referral to a mental health professional for further assessment, management, and treatment is required, due to the complexities of diagnosis and management, and associated risk to mother and baby. Immediate psychiatric input is required on an emergency (immediate/same day) basis if there is suspicion of postpartum psychosis, and the woman should not be left alone and should not be left unattended with the baby.​[4][5]

Physical exam

Carry out a physical exam to assess the patient's general medical status, although this may not reveal any specific features of depression. Most patients will have a depressed affect. Conditions that are frequently confused with depression may be identified (e.g., hypothyroidism). Examination of the skin may reveal stigmata of trauma, self-injury, or drug use. In rare cases, organic brain disease may mimic depression (see the Differential diagnosis section); consequences of misdiagnosis can be serious and life-threatening.[129]

Investigations

There are no specific guidelines about which tests should be done routinely. Investigations are not required to diagnose postpartum depression. It is important to have a clear rationale for ordering tests; consider each patient individually. Tests that may be done are those that:

  • Detect or rule out the presence of a medical disorder or condition (examples include a urine screen for substance use disorders, brain imaging to ascertain the presence of a structural neurologic abnormality, a complete blood count to rule out anemia, and thyroid function tests)

  • Determine the relative safety and appropriate dose of potential pharmacologic treatments

  • Monitor blood levels of medications when indicated (e.g., for effectiveness, toxicity, or adherence).

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