Postpartum depression (PPD) is a condition that includes a range of emotional and physical changes experienced by women after having a baby. It can occur anytime within the year after the baby is born, but usually happens from three days to six weeks after delivery.

PPD should not be confused with postpartum blues (“baby blues”), which is a common condition that usually starts within a few days after birth and can last for a few weeks, or postpartum psychosis (PPP), a condition characterized by more severe symptoms, such as delusions and paranoia. PPD is a form of clinical depression.

Exactly why PPD develops is not fully understood, but risk factors include a past history of depression (personal or family), as well as previous diagnoses of PPD. Other risk factors include the stress of caring for a new baby, a lack of support from family and friends and sleep deprivation. Hormonal changes associated with pregnancy may also play a role.

Patients with PPD can experience a variety of symptoms, many of which are identical to those experienced by patients with other types of depression. Some examples are anger, sadness and anxiety. PPD can also occur with other anxiety disorders, including obsessive-compulsive disorder and panic disorder.

PPD is usually diagnosed following a physical examination. A depression-screening questionnaire, such as the Edinburgh Postnatal Depression Scale, may be used to help identify mothers experiencing PPD. In some cases, the obstetrician-gynecologist (ObGyn) may refer the woman to a qualified mental health specialist, such as a psychologist or psychiatrist for a complete mental health evaluation.

All new mothers, including those with PPD, may benefit from taking certain steps, such as eating a proper diet and getting adequate rest. PPD is typically treated with antidepressant medications and psychotherapy. Women experiencing PPD also may benefit from joining a support group to help cope with their depression.

Postpartum depression (PPD) is a mood disorder characterized by feelings of sadness, anxiety and restlessness experienced by women after childbirth. PPD sometimes occurs with panic disorder or obsessive-compulsive disorder (OCD), sometimes provoking undiagnosed OCD or reigniting old cases.

It typically occurs from three days to six weeks after the baby is delivered, but can develop anytime within the first year. PPD can last for months or longer if untreated. It can occur after the birth of any infant, not just a first-born. It may also result from the birth of a stillborn infant or a late-term miscarriage.

PPD is a form of clinical depression, which means that patients experience a range of physical and emotional characteristics that meet criteria accepted by mental health clinicians. Generally, PPD is very similar to other types of depression in that patients tend to have many of the same risk factors and present similar symptoms as depressed individuals who have not recently given birth. However, depression that occurs during the postpartum period is unique because of many factors, including:

• The degree of hormonal fluctuation in the mother following childbirth
• The special stresses and adjustments involved in caring for a new child
• The impact of breastfeeding on treatment choices
• The impact of a history of PPD on family planning

PPD may interfere with a woman’s ability to care for herself or her baby. In addition, women with PPD have an increased risk of adopting negative parenting skills because the mother’s ability to recognize and respond to the baby’s needs is impaired. PPD also interferes with mother-child bonding and affects the social, cognitive, emotional and behavioral development of the infant.

Babies who nurse from depressed mothers tend to gain less weight, possibly because the mother’s condition negatively affects:

• The nutrition and quality of the breast milk
• The mother’s breastfeeding habits
• The mother’s sensitivity to the infant’s cries of hunger

Children of mothers with PPD may also demonstrate reduced self-esteem, increased aggression towards others, helpless behaviors and poorer social skills in early childhood.

PPD affects women of all ages, races, socioeconomic classes and education levels. According to the American College of Obstetricians and Gynecologists (ACOG), about 10 percent of women experience PPD within the first year after birth. This essentially matches the rate of depression in non-pregnant women.

There are other postpartum conditions that are often confused with PPD. They include:

• Postpartum blues. Also referred as the “baby blues,” it is a common condition that affects between 70 to 85 percent of new mothers, according to the ACOG. It usually starts within three days of birth and can last up to 14 days. Postpartum blues usually does not require medical treatment.
• Postpartum psychosis (PPP). This condition affects about 1 in every 1,000 women, according to the ACOG. It most often appears during the first four weeks after delivery. Patients with PPP may experience paranoia, mood shifts or hallucinations and delusions about the baby dying or being demonic. Hallucinations may command the patient to hurt herself, her child or others. PPP requires immediate medical attention and, usually, hospitalization.

No clear cause has been identified for the postpartum blues, postpartum depression (PPD) or postpartum psychosis (PPP). There is evidence, however, that physical changes may play a role in the development of these conditions.

Immediately after childbirth, the hormone levels in the body fluctuate. Estrogen and progesterone levels, which increase during pregnancy, decrease dramatically. This can trigger depression, although the reason for this is not completely understood. Hormones produced in the thyroid (a gland located at the base of the neck that regulates metabolism) drop sharply, which may result in feelings of fatigue, sluggishness and depression. Other changes in the amount of blood in the body, blood pressure, immune system and metabolism can cause fatigue or mood swings.

Risk factors for PPD include a personal or family history of depression and/or conditions such as bipolar disorder, severe premenstrual syndrome (PMS) and premenstrual dysphoric disorder (PMDD). About half of women diagnosed with PPD have a history of depression. Women who have had PPD with prior children are also at greater risk for developing the condition again. Other risk factors include:

• Emotional changes. The demands of caring for a baby coupled with sleep deprivation can lead to frustration and depression. Other emotional influences that may contribute to depression include:
  
  
• • Identity crisis. Some women have difficulty reconciling their new role as mother with their identity prior to giving birth.
  • Childbirth difficulties. Medical complications and other factors can make it difficult to care for a baby.
  • Unrealistic expectations. Some women worry about being perfect mothers.
    
  • Feelings of being unattractive, overwhelmed or out of control.
    
• Lifestyle changes. Some circumstances following birth can lead to anxiety and depression, such as:
  
  
• • Baby with greater than average needs
  • Medical problems following childbirth
  • Fatigue from caring for a baby or multiple children
  • Poor education about childrearing techniques
  • Financial problems
  • Childcare concerns
  • Lack of support from family and friends
  • Difficulty with breastfeeding
  • Relationship problems
  • Major life changes (e.g., changes in career, moving)

Other factors that may increase the risk of PPD include:

• History of pregnancy or delivery complications
• Marital conflict
• Lack of perceived support from family, friends and others
• Living without a partner
• Stress related to childcare issues
• Unplanned pregnancy
• Previous miscarriage
• Lack of emotional or financial support from a spouse or partner

Signs and symptoms of the postpartum blues (“baby blues”) and postpartum depression (PPD) are often similar to those experienced with other kinds of depression. They vary among patients, but may include:

• Anger
• Uncontrollable crying
• Feelings of worthlessness, inadequacy, failure or guilt
• Irritability
• Restlessness
• Sadness
• Apathy
• Excessive tiredness or fatigue
• Mood swings
• Anxiety or panic attacks
• Obsessive thoughts about harming herself or the baby
• Insomnia or sleeping too much
• Poor concentration
• Loss of interest or motivation to perform normal activities

The signs and symptoms of the postpartum blues are usually milder and disappear on their own. Patients experiencing PPD typically experience more severe symptoms that typically last up to 12 months. PPD patients may also experience the following:

• A sense of emotional numbness
• Fear of harming oneself or the baby
• Loss of interest in living
• Loss of interest in sex
• Significant weight loss or gain
• Withdrawal from family and friends

Patients with PPD may experience headaches, chest pains, heart palpitations, numbness or hyperventilation, although they are not symptoms unique to depression.

Patients with postpartum psychosis may experience any of the above symptoms accompanied by more severe symptoms, such as:

• Confusion and disorientation
• Thoughts of harming oneself or the baby
• Hallucinations or delusions
• Paranoia

Postpartum depression (PPD) may be overlooked in many cases because attention is typically directed toward the infant rather than the mother. To counter this risk, screening for PPD is becoming much more common, and may take place anytime between the initial postpartum follow-up visit and the six-week postpartum follow-up visit.

Some women may be diagnosed with PPD following a physical examination that includes a complete medical history. A blood test may also be performed to determine whether a patient has a disorder of the thyroid (a gland that produces the thyroid hormone, which regulates growth and metabolism). An underactive thyroid may make the patient feel tired, sluggish or depressed. An overactive thyroid may cause depression, anxiety or psychosis.

In other cases, a review of signs and symptoms experienced during the postpartum period may be sufficient for diagnosis of PPD or the postpartum blues, a more common and transient condition. Patients experiencing symptoms of depression may also be referred to a psychiatrist (mental health physician) for a mental health evaluation. 

There are screening instruments that may aid physicians in detecting PPD. Among these is the Edinburgh Postnatal Depression Scale, a diagnostic tool developed in 1987 that contains 10 questions pertaining to emotions experienced in the previous week. This tool may be used in the six to eight weeks following childbirth.

Some questions that are usually asked during the Edinburgh Postnatal Depression Scale include:

• How often have you been able to laugh and see the funny side of things?
• How often have you looked forward with enjoyment to things?

Women experiencing symptoms of PPD and/or confusion or agitation may be screened for postpartum psychosis (PPP), an extreme form of PPD that is often accompanied by hallucinations and delusional thinking. To determine whether a patient is experiencing PPP, the physician may ask questions such as:

• Have you heard voices or seen things that others do not see or hear?
• Have you had thoughts of harming the baby or others?

Physicians typically recommend the following treatments for postpartum depression (PPD):

• Antidepressant medications. These medications are often indicated for the management of PPD. There are a number of different antidepressants available, including selective serotonin reuptake inhibitors (SSRIs), which regulate the levels of serotonin (a chemical linked to mood) in the brain and serotonin-norepinephrine reuptake inhibitors (SNRIs), which regulate level of both serotonin and another chemical called norepinephrine in the brain. People with depression often have low levels of serotonin and norepinephrine. It is safe for women who are breastfeeding to take certain types of SSRIs or SNRIs. Although antidepressants are excreted in breast milk, research has shown that certain types pose little risk to babies. However, no long-term studies of infants exposed to SSRIs or SNRIs have been conducted.
  
  Antidepressants are a complex class of medications. A physician may need to adjust the dosage or completely change the prescription to find a medication that provides optimal results with minimal side effects. In addition, certain patients cannot take antidepressants. The Food and Drug Administration (FDA) has advised that antidepressants may increase the risk of suicidal thinking in patients under age 25 and all people being treated with them should be monitored closely for unusual changes in behavior. Treatment might continue for up to a year after symptoms abate.
• Psychotherapy. Psychotherapy is often the first treatment for PPD and may be the only therapy available to women who refuse antidepressants. During psychotherapy, patients are encouraged to discuss their condition and any related issues with a mental health professional such as a psychiatrist. The length of time patients with PPD receive psychotherapy varies, but typically ranges from 6 to 12 one-hour sessions. Sometimes, the new mother may be given “homework” assignments between sessions. There are several different types of psychotherapy:
  
  
• • Cognitive behavioral therapy (CBT). Combines cognitive therapy, which focuses on thoughts, assumptions and beliefs, and behavioral therapy, which teaches people to learn how to change their behaviors. This can help patients modify thoughts and behaviors that contribute to depression.
  • Interpersonal psychotherapy (IPT). A short-term therapy aimed at addressing interpersonal issues. This can help patients whose depression is linked to problems with relationships and other interpersonal issues.
  • Group therapy. A type of therapy in which patients meet with a therapist in a group setting. During the session, patients typically decide the topics of discussion. This is particularly effective with patients who are feeling socially isolated.
  • Family and marital therapy. A type of therapy in which the patient attends counseling sessions with a partner or other family member. Women with PPD recover more quickly with the support of a partner or other family member.

Women experiencing PPD also may benefit from joining a support group to help cope with their depression. There are various support groups formed by patients that offer support and education to women with PPD or other conditions. Meetings are held to discuss PPD issues and educational information is available through these groups. A woman’s physician may refer her to a support group for postpartum depression.

In many cases, patients benefit from a combination of antidepressants and psychotherapy.

Massage therapy and relaxation training for the mother and infant may help to improve the mood of a new mother with PPD, and may also improve mother-infant interaction and infant health. However, these therapies tend to be more effective when combined with psychotherapy or other treatments.

If impaired thyroid gland function is detected, medications are administered. In such cases, depression often improves without the need for psychotherapy or antidepressants.

Patients with postpartum psychosis (PPP) may require hospitalization and treatment with antipsychotic medications (used to treat psychotic disorders, such as schizophrenia), antidepressant medications or lithium carbonate (medication used to treat bipolar disorder, which is characterized by mood swings between mania and depression).

Women with PPD that does not respond to medication and/or psychotherapy may also receive electroconvulsive therapy (ECT) in which a small amount of electrical current is delivered to the brain through electrodes. The electrical current results in a 30- to 60-second seizure that alters brain functioning. When administered on a regular basis, ECT can reduce symptoms. Although often reserved for severe cases, ECT may be a safe option for breastfeeding mothers because there are no effects on the infant. Women suspected of having PPD or PPP should receive immediate medical attention.

Antidepressants or psychotherapy may be started in the first couple of days after delivery as preventive measures. This issue must be discussed with a physician, preferably an obstetrician-gynecologist (ObGyn).

The postpartum blues (“baby blues”) and postpartum depression (PPD) cannot be prevented. However, all new mothers can benefit from the following:

• Eating a proper diet.  
• Getting adequate rest. Resting or sleeping at the same time the baby sleeps can help new mothers avoid fatigue.
• Making time for oneself. Spending time alone, with a friend or with a partner can help alleviate stress.
• Avoiding isolation. New mothers may benefit from sharing feelings and concerns with friends, family members and others. A variety of support groups are also available for new mothers.
• Having realistic expectations. New mothers are encouraged to scale back expectations of being the perfect mother or keeping the perfect house. They are instructed to ask for assistance with childcare or household duties when necessary.
• Asking for assistance when necessary.

Preparing questions in advance can help patients have more meaningful discussions with their physicians regarding their conditions. Patients may wish to ask their doctor the following questions about postpartum depression (PPD):

1. What are the chances that I will develop postpartum depression?
2. How will I know if I’m at risk for the condition?
3. Why do some women develop postpartum depression and others do not?
4. What should I do if I feel I am getting PPD?
5. How will I know if I have postpartum blues or a more serious condition?
6. What are the best ways for me to avoid developing this condition?
7. What is the best treatment for my PPD?
8. Is it safe for me to breastfeed while on antidepressant medications?
9. Can you refer me to support groups for PPD?
   
   
10. What is the likelihood that I will experience PPD again with future pregnancies?
11. Can you recommend a support group for people with PPD?