Postpartum Major Depression

Aka: Postpartum Major Depression, Postpartum Depression, Postpartum Blues, Postnatal Depression, Peripartum Depression, Puerperal Depression, Antidepressants in Lactation, Antidepressants in Breast Feeding

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II. Definitions

  1. Peripartum Depression
    1. Depression during pregnancy or in the 12 months following delivery that lasts longer than 2 weeks
  2. Postpartum Blues
    1. Onset of depressed mood within a few days of delivery
    2. Depressed mood lasts <10 days (contrast with more than 2 weeks for depression)

III. Epidemiology

  1. Postpartum Blues: 50-80% of post-partum women
  2. Postpartum Depression: 7-15% of post-partum women (within first 3 months of delivery)
  3. Postpartum Major Depression: 5-7% of post-partum women (within first 3 months of delivery)
  4. Postpartum Psychosis: 1-2 per thousand postpartum women

IV. Risk Factors

  1. History of Major Depression is greatest risk factor (OR 29)
    1. Postpartum Depression with a prior pregnancy (recurrence in 25-50% of women)
    2. Antepartum Depression
    3. Prior history of Major Depression
  2. Prior history of other psychiatric disorder (e.g. Anxiety Disorder)
  3. Emotional stress or maternal anxiety
  4. Fear of child birth
  5. History of physical or sexual abuse
  6. Unplanned or Unwanted Pregnancy
  7. Pregnancy complications
    1. Pregnancy loss
    2. Preterm delivery
    3. Traumatic birth
  8. Breast Feeding difficulties
  9. Lack of Social Support
  10. Single parent
  11. Lower socioeconomic status
  12. Gesational Diabetes (or pre-Gestational Diabetes)
  13. Tobacco use
  14. Age extremes
    1. Teen Mothers
    2. Age over 40 years old
  15. References
    1. Milgrom (2008) J Affect Disord 108(1-2):147-57 [PubMed]

V. Symptoms

  1. Depression symptoms last >2 weeks (contrast with Postpartum Blues)
  2. Comorbid anxiety and Agitation
  3. Most common symptoms
    1. Sadness is less commonly reported than in non-Postpartum Major Depression
    2. Guilt
    3. Worthlessness
    4. Anhedonia
    5. Decreased energy
    6. Difficulty sleeping when the baby is sleeping
    7. Poor concentration
  4. High risk symptoms (emergent mental health evaluation indications)
    1. Homicidal Thoughts
      1. Intrusive thoughts of hurting the newborn (may present as avoidance of the infant)
    2. Psychosis
      1. Hallucinations
      2. Delusions
      3. Rambling or pressured speech
    3. Suicidal thoughts
      1. Active Suicidal Ideation with a plan requires emergent psychiatric evaluation
      2. Passive Suicidal Ideation (e.g. no plan, but a wish go to sleep and not wake up) is more common
        1. Risk for progression to active Suicidal Ideation

VI. Labs

  1. Not routinely indicated
  2. Thyroid Stimulating Hormone (TSH)
    1. Consider if indicated by additional findings
  3. Hemoglobin
    1. Consider if not recently obtained postpartum

VII. Diagnosis

  1. See Major Depression Diagnosis
  2. Peripartum Depression
    1. Depression diagnosed during pregnancy or within 12 months postpartum
    2. Persistent symptoms >2 weeks

VIII. Differential Diagnosis

  1. Baby Blues
    1. Lasts <10 days (contrast with more than 2 weeks for depression)
    2. Onset within a few days of delivery
    3. Mild to no dysfunction (compared with moderate to severe dysfunction in depression)
  2. Bipolar Disorder
    1. Exclude mania
  3. Postpartum autoimmune Thyroiditis

IX. Evaluation: Depression Screening Tools

  1. See Depression Screening Tools
  2. Screening Intervals
    1. AAP: Screen at perinatal visits and Well Child Visits (2, 4 and 6 months)
    2. USPTF: Screen starting in second trimester for those with Peripartum Depression risk factors
    3. Also screen for Suicidality and homicidality
  3. Edinburgh Postnatal Depression Scale
    1. http://www.fresno.ucsf.edu/pediatrics/downloads/edinburghscale.pdf
    2. 10 item, free tool, completed in <5 minutes, with good efficacy (>75% sensitive, >76% specific)
    3. Preferred first-line screening for Postpartum Depression over PHQ-9
  4. Patient Health Questionaire 9 (PHQ-9)
    1. Free tool, completed in <5 minutes, with good efficacy (>75% sensitive, 90% specific)
  5. Postpartum Depression Screening Scale (PDSS)
    1. Commercial product with 35 items, available for a fee
    2. Good efficacy (>91% sensitive, >72% specific)

X. Management: Non-Medication

  1. Psychotherapy (esp. Cognitive Behavioral Therapy)
  2. Adjust social situation
    1. Longer maternity leave
    2. Return part-time

XI. Management: Standard Medications

  1. Approach
    1. Typically taper off Antidepressants after 6-12 months of depression remission (esp. if first depression episode)
  2. Women not Breast Feeding
    1. Selective Serotonin Reuptake Inhibitors (SSRI)
  3. Women who are Breast Feeding
    1. Safest agents in Lactation (undetectable in Breast Milk, L2 Risk)
      1. Sertraline (Zoloft) - preferred agent
      2. Paroxetine (Paxil)
        1. Safe in Lactation, but NOT in pregnancy
        2. Teratogenic if patient becomes pregnant again (therefore generally avoided)
    2. Agents with acceptably low levels in Breast Milk (L3 Risk)
      1. Escitalopram (Lexapro) - preferred agent
      2. Citalopram (Celexa)
      3. Venlafaxine (Effexor)
    3. Agents that are safe in Lactation, but excessive sedation or other side effects
      1. Nortriptyline
      2. Mirtazapine (Remeron)
      3. Fluvoxamine (Luvox)
    4. Agents to avoid in Lactation due to infant risks
      1. Fluoxetine (Prozac)
        1. Low levels in milk, but still more adverse effects in infants
        2. Teratogenic if patient becomes pregnant again (therefore generally avoided)
      2. Bupropion
        1. Risk of Seizures in newborns
  4. Avoid ineffective agents or those with insufficient evidence to support
    1. Avoid low dose Estrogen Replacement (also increases VTE Risk)
    2. Insufficient evidence for any supplement (e.g. St John's Wort, Folate, Vitamin D)

XII. Management: Medications for Refractory Postpartum Depression

  1. Zuranolone (Zurzuvae)
    1. Indicated in Postpartum Depression starting in third trimester or first month postpartum
    2. Like IV Brexanolone, mimics Allopregnanolone (GABA Receptor agent), known to decrease peripartum
    3. Schedule IV Controlled Substance
    4. Taken orally with a fatty meal in the evening for 14 days
      1. Started within 12 months of delivery, at a cost of $14,000/course
    5. Adverse effects include drowsiness and confusion
      1. Avoid driving for 12 hours after each dose
      2. Avoid with other CNS Depressants (e.g. Opioids, Alcohol)
    6. Drug Interactions include CYP3A4 Inducers (e.g. Phenytoin)
    7. Unknown safety in Lactation (may cause sedation in the nursing infant)
    8. Avoid in pregnancy (use Contraception)
    9. (2024) Presc Lett 31(2): 10-11
    10. Fang (2025) Am Fam Physician 111(3): 265-6 [PubMed]
  2. Intravenous Brexanolone (Zulresso)
    1. Mimics Allopregnanolone (GABA Receptor agent) which normally decreases in peripartum period
    2. Intravenous infusion over 60 hours with onset of action by 24-48 hours
    3. Used in addition to standard SSRI agents
    4. Risk of sedation and loss of consciousness (REMS program)
      1. Monitor for excessive sedation and apnea (e.g. Pulse Oximetry)
    5. Schedule IV Controlled Substance
    6. Astronomically expensive ($34,000)
    7. Unknown safety in Lactation
    8. (2019) Presc Lett 26(5)

XIII. Complications

  1. Infant
    1. Failure to Thrive or Growth Faltering
    2. Attachment disorder
    3. Developmental Delay (at one year old)
  2. Mother
    1. Typical Major Depression symptoms (low energy, Insomnia, decreased concentration)
    2. Maternal Suicide
      1. Postpartum Suicide accounts for 20% of postpartum deaths
      2. Second only to Pulmonary Embolism as most common cause of postpartum death

XIV. Resources

  1. Patient Education materials form Minnesota Department of Health
    1. http://www.health.state.mn.us/divs/fh/mch/fhv/strategies/ppd/index.html
  2. Mothers and Babies Program (CBT Approach to counseling)
    1. http://www.mothersandbabiesprogram.org/
  3. Reach Out, Stand Strong, Essentials (ROSE) for New Mothers (interpersonal therapy approach to counseling)
    1. Taught as a part of some prenatal classes
    2. {https://www.publichealth.msu.edu/flint-research/the-rose-sustainment-study]

XV. Prevention

  1. See Evaluation above for screening tools
    1. Perform at perinatal visits and Well Child Visits (esp. with risk factors present)
  2. Consider home health visits, peer support for high risk mothers
    1. First-time mothers
    2. Teen Mothers
    3. Traumatic delivery
  3. Counseling is effective and recommended by USPTF in the prevention of perinatal depression for those at risk
    1. See Risk Factors above
    2. Consider starting to screen for risk factors and Peripartum Depression in the second trimester of pregnancy
    3. See Evaluation Tools above for the diagnosis of perinatal depression
    4. Refer for Cognitive Behavioral Therapy (or interpersonal therapy) for those at risk
      1. Also see Resources above (e.g. Mothers and babies, ROSE Program)
  4. Other measures
    1. Single postpartum dose of Esketamine in those at risk for Postpartum Depression reduced risk
      1. Wang (2024) BMJ 385:e078218 [PubMed]

XVI. References

  1. (2017) Presc Lett 24(4): 20
  2. (2019) Am Fam Physician 100(6): 364A-C [PubMed]
  3. Ahokas (2000) J Clin Psychiatry 61:166-9 [PubMed]
  4. Hirst (2010) Am Fam Physician 82(8): 926-33 [PubMed]
  5. Justesen (2023) Am Fam Physician 108(3): 267-72 [PubMed]
  6. Langan (2016) Am Fam Physician 93(10):852-8 [PubMed]
  7. Wisner (2002) N Engl J Med 347(3): 194-99 [PubMed]

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Ontology: Depression, Postpartum (C0221074)

Definition (CHV) depression in women occurring usually shortly after childbirth
Definition (CHV) depression in women occurring usually shortly after childbirth
Definition (CHV) depression in women occurring usually shortly after childbirth
Definition (CHV) depression in women occurring usually shortly after childbirth
Definition (CHV) depression in women occurring usually shortly after childbirth
Definition (CHV) depression in women occurring usually shortly after childbirth
Definition (CHV) depression in women occurring usually shortly after childbirth
Definition (CHV) depression in women occurring usually shortly after childbirth
Definition (CHV) depression in women occurring usually shortly after childbirth
Definition (CHV) depression in women occurring usually shortly after childbirth
Definition (MEDLINEPLUS)

Many women have the baby blues after childbirth. If you have the baby blues, you may have mood swings, feel sad, anxious or overwhelmed, have crying spells, lose your appetite, or have trouble sleeping. The baby blues most often go away within a few days or a week. The symptoms are not severe and do not need treatment.

The symptoms of postpartum depression last longer and are more severe. You may also feel hopeless and worthless, and lose interest in the baby. You may have thoughts of hurting yourself or the baby. Very rarely, new mothers develop something even more serious. They may have hallucinations or try to hurt themselves or the baby. They need to get treatment right away, often in the hospital.

Postpartum depression can begin anytime within the first year after childbirth. The cause is not known. Hormonal and physical changes after birth and the stress of caring for a new baby may play a role. Women who have had depression are at higher risk.

If you think you have postpartum depression, tell your health care provider. Medicines, including antidepressants and talk therapy can help you get well.

Dept. of Health and Human Services Office on Women's Health
Definition (NCI) A type of clinical depression that occurs after childbirth.
Definition (CSP) depression in women occurring usually shortly after the delivery of a child; degree of depression ranges from mild transient depression to neurotic or psychotic depressive disorders.
Definition (MSH) Depression in POSTPARTUM WOMEN, usually within four weeks after giving birth (PARTURITION). The degree of depression ranges from mild transient depression to neurotic or psychotic depressive disorders. (From DSM-IV, p386)
Concepts Mental or Behavioral Dysfunction (T048)
MSH D019052
ICD10 F53
SnomedCT 268753005, 154889000, 192475007, 147016002, 191740008, 58703003
English Postpartum Depression, Depression, Post-Natal, Depression, Post-Partum, Depression, Postnatal, Depression, Postpartum, Post Natal Depression, Post-Natal Depression, Post-Partum Depression, Postnatal Depression, Postnatal depression, Postnatal depressive disorder, DEPRESSION PUERPERAL, postpartum depression, postpartum depression (diagnosis), Depression puerperal, Depression, Postpartum [Disease/Finding], depression postnatal, Depression;postnatal, Depression;puerperal, post partum depression, post-partum depression, postnatal blues, depression postpartum, post natal depression, post-natal depression, Post Partum Depression, Depression postpartum (excl psychosis), [X]Postnatal depression NOS, [X]Postpartum depression NOS, Depression - postnatal, Postnatal depressive disorder (disorder), Postnatal blues, Postnatal depression (excl psychosis), Postpartum depression, Puerperal depression, Postpartum depression (disorder), depression; postnatal, depression; postpartum, postnatal; depression, postpartum; depression, Puerperal Depression, Depression postpartum (excluding psychosis), Postnatal depression (excluding psychosis), postnatal depression, puerperal depression
Portuguese DEPRESSAO PUERPERAL, Depressão pós-parto (excl. psicose), Depressão puerperal, Depressão Pós-Natal, Depressão pós-parto, Depressão Pós-Parto, Depressão Puerperal
Dutch puerperale depressie, postnatale blues, postnatale depressie (excl. psychose), depressie; post partum, depressie; postnataal, post partum; depressie, postnataal; depressie, postpartumdepressie, Depressie, postpartum-, Postnatale depressie, Postpartumdepressie
French Dépression post-partum (excl psychose), Cafard postnatal, Dépression postnatale (excl psychose), Dépression à la suite des couches, DEPRESSION DU POST-PARTUM, Dépression postnatale, Dépression post-natale, Dépression du post-partum, Dépression du postpartum, Dépression puerpérale
German postnataler Baby-Blues, postnatale Depression (ausschl Psychose), Postpartum Depression (ausschl Psychose), Wochenbettdepression, Depression, postpartale, Postnatale Depression, Postpartale Depression
Italian Depressione puerperale, Depressione postpartum (psicosi esclusa), Depressione postnatale, Depressione post-partum, Depressione post-natale, Depressione postpartum
Spanish Tristeza postparto, Depresión postparto (excl psicosis), Depresión puerperal, Depresión Postparto, Depresión Puerperal, Depresión Posparto, depresión posparto, depresión postparto (trastorno), depresión postparto, Depresión postparto, Depresión Postnatal
Japanese 産後うつ病（精神病を除く）, 産後うつ病, 産褥期うつ病, マタニティーブルーズ, ﾏﾀﾆﾃｨｰﾌﾞﾙｰｽﾞ, ｻﾝｼﾞｮｸｷｳﾂﾋﾞｮｳ, ｻﾝｺﾞｳﾂﾋﾞｮｳ, ｻﾝｺﾞｳﾂﾋﾞｮｳｾｲｼﾝﾋﾞｮｳｦﾉｿﾞｸ, うつ病-分娩後, 出生後鬱病, 分娩後鬱病, 出生後うつ病, 分娩後うつ病, 鬱病-分娩後
Swedish Postpartumdepression
Czech deprese poporodní, Poporodní deprese, Poporodní deprese (vyjma psychózy), Deprese poporodní (vyjma psychózy), Deprese puerperální, Puerperální deprese
Finnish Synnytyksenjälkeinen masennus
Russian DEPRESSIIA POSLERODOVAIA, POSTNATAL'NAIA DEPRESSIIA, POSLERODOVAIA DEPRESSIIA, ДЕПРЕССИЯ ПОСЛЕРОДОВАЯ, ПОСЛЕРОДОВАЯ ДЕПРЕССИЯ, ПОСТНАТАЛЬНАЯ ДЕПРЕССИЯ
Polish Depresja poporodowa
Hungarian Postpartum depressio (kivéve psychosis), Puerperalis depressio, Gyermekágyi depressio, Postnatalis depressio, Postpartum depressio, Postnatalis depressio (kivéve psychosis)
Norwegian Post partum-depresjon, Fødselsdepresjon
Derived from the NIH UMLS (Unified Medical Language System)

Ontology: Postpartum blues (C2909477)

Concepts Mental or Behavioral Dysfunction (T048)
ICD10 O90.6
English Postpartum blues
Derived from the NIH UMLS (Unified Medical Language System)

Related Topics in Obstetrics

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