For most women, having a baby is a very exciting, joyous, and often anxious time. But for women with peripartum (formerly postpartum) depression it can become very distressing and difficult. Peripartum depression refers to depression occurring during pregnancy or after childbirth. The use of the term peripartum recognizes that depression associated with having a baby often begins during pregnancy.
Peripartum depression is a serious, but treatable medical illness involving feelings of extreme sadness, indifference and/or anxiety, as well as changes in energy, sleep, and appetite. It carries risks for the mother and child.
An estimated one in seven women experiences peripartum depression.1
Pregnancy and the period after delivery can be a particularly vulnerable time for women. Mothers often experience immense biological, emotional, financial, and social changes during this time. Some women can be at an increased risk for developing mental health problems, particularly depression and anxiety.
Up to 70 percent of all new mothers experience the “baby blues,” a short-lasting condition that does not interfere with daily activities and does not require medical attention. Symptoms of this emotional condition may include crying for no reason, irritability, restlessness, and anxiety. These symptoms last a week or two and generally resolve on their own without treatment.
Peripartum depression is different from the “baby blues” in that it is emotionally and physically debilitating and may continue for months or more. Getting treatment is important for both the mother and the child.
In January 2016, the U.S. Prevention Services Task Force (USPSTF) updated its recommendation for depression screening in adults to include screening pregnant and postpartum women.2 In February 2019, the USPSTF recommended that clinicians provide or refer pregnant and postpartum women at increased risk of perinatal depression to counseling interventions.
Untreated peripartum depression is not only a problem for the mother’s health and quality of life, but can affect the well-being of the baby who can be born prematurely, with low birth weight. Peripartum depression can cause bonding issues with the baby and can contribute to sleeping and feeding problems for the baby. In the longer-term, children of mothers with peripartum depression are at greater risk for cognitive, emotional, development and verbal deficits and impaired social skills.3,4 It should not be ignored that gestational carriers and surrogates are also at risk of developing peripartum depression.
Symptoms of Peripartum Depression
Symptoms of Peripartum Depression include:5
- Feeling sad or having a depressed mood
- Loss of interest or pleasure in activities once enjoyed
- Changes in appetite
- Trouble sleeping or sleeping too much
- Loss of energy or increased fatigue
- Increase in purposeless physical activity (e.g., inability to still still, pacing, handwringing) or slowed movements or speech [these actions must be severe enough to be observable by others]
- Feeling worthless or guilty
- Difficulty thinking, concentrating, or making decisions
- Thoughts of death or suicide
- Crying for “no reason”
- Lack of interest in the baby, not feeling bonded to the baby, or feeling very anxious about/around the baby
- Feelings of being a bad mother
- Fear of harming the baby or oneself
A woman experiencing peripartum depression usually has several of these symptoms, and the symptoms and their severity may change. These symptoms may cause new mothers to feel isolated, guilty, or ashamed. To be diagnosed with peripartum depression, symptoms must begin during pregnancy or within four weeks following delivery.
Many women with peripartum depression also experience symptoms of anxiety. One study found that nearly two-thirds of women with peripartum depression also had an anxiety disorder.6
While there is no specific diagnostic test for peripartum depression, it is a real illness that should be taken seriously. Any pregnant woman or new mother who experiences the symptoms of peripartum depression should seek evaluation by a medical professional – an internal medicine doctor or an OB-GYN, who can make referrals to a psychiatrist or other mental health professional. Assessment should include a psychiatric evaluation and a medical evaluation to rule out physical problems that may have symptoms similar to depression (such as thyroid problems or vitamin deficiencies).
You should contact your doctor if:
- You are experiencing several of the symptoms above for more than two weeks
- You have thoughts of suicide or thoughts of harming your child
- Your depressed feelings are getting worse
- You are having trouble with daily tasks or taking care of your baby
Who Is at Risk?
Any new mother (or gestational carrier/surrogate) can experience symptoms of peripartum depression or other mood disorder. Women are at increased risk of depression during or after pregnancy if they have previously experienced (or have a family history of) depression or other mood disorders, if they are experiencing particularly stressful life events in addition to the pregnancy, or if they do not have the support of family and friends.
Research suggests that rapid changes in sex and stress hormones and thyroid hormone levels during pregnancy and after delivery have a strong effect on moods and may contribute to peripartum depression. Other factors include physical changes related to pregnancy, changes in relationships and at work, worries about parenting and lack of sleep.
Fathers: Pregnancy/childbirth and Depression
New fathers can also experience symptoms of peripartum depression. Symptoms may include fatigue and changes in eating or sleeping. An estimated 4% of fathers experience depression in the first year after their child’s birth. Younger fathers, those with a history of depression and fathers with financial difficulties are at increased risk of experiencing depression.1
Many women may suffer in silence, dismissing their struggles as a normal part of pregnancy and childbirth and fail to seek care. Treatment for depression during pregnancy is essential. Greater awareness and understanding can lead to better outcomes for women and their babies.
Like other types of depression, peripartum depression can be managed with psychotherapy (talk therapy), medication, lifestyle changes and supportive environment or a combination of these. Women who are pregnant or nursing should discuss the risks and benefits of medication with their doctors. In general, the risk of birth defects to the unborn baby are low. the decision should be made based on careful consideration of the potential risk-benefit ratio of treatment vs. no treatment affecting the health of the mother, the unborn child, and/or the nursing newborn/infant.
APA guidelines for treating women with major depressive disorder who are pregnant or breastfeeding recommend psychotherapy without medication as a first-line treatment when the depression or anxiety is mild. For women with moderate or severe depression or anxiety, antidepressant medication should be considered as a primary treatment.6
Antidepressant options during pregnancy:
- Selective serotonin reuptake inhibitors (SSRIs): Consult with your physician, but note that some SSRIs have been associated with a rare but serious lung problem in newborn babies (persistent pulmonary hypertension of the newborn).
- Serotonin and norepinephrine reuptake inhibitors (SNRIs)
- Bupropion (Wellbutrin)
- Tricyclic antidepressants (TCAs)
For more information on pregnancy/depression and psychiatric medications, see MotherToBaby from the Organization of Teratology Information Specialists, and Breastfeeding and Psychiatric Medications from the Massachusetts General Hospital, Center for Women’s Mental Health.
With proper treatment, most new mothers find relief from their symptoms. Women who are treated for peripartum depression should continue treatment even after they feel better. If treatment is stopped too soon, symptoms can recur.
Self-help and Coping
The support of family and friends, joining a mom’s support group, and good nutrition and exercise can be helpful. Other suggestions for helping to cope with peripartum depression include resting as much as you can (sleep when your baby sleeps) and make time to go out or visit friends.
How Partners, Family and Friends Can Help
Strong support from partners, family and friends is very important. Here are some suggestions from Moms’ Mental Health Matters, a National Institutes for Health initiative, for how loved ones can help:
- Know the Signs. Learn to recognize the symptoms of depression and anxiety and if you see signs, urge her to see a health care provider.
- Listen to Her. Let her know you want to hear her concerns. For example, "I notice you are having trouble sleeping, even when the baby sleeps. What's on your mind?"
- Give Her Support. Let her know she's not alone and you are here to help. Try offering to help with household tasks or watching the baby while she gets some rest or visits friends.
- Encourage her to seek help if needed. She may feel uncomfortable and not want to seek help. Encourage her to talk with a health care provider. Share some information on peripartum conditions. Offer to make an appointment for her talk with someone.
National Suicide Prevention Lifeline at 1-800-273-TALK (8255) for free and confidential emotional support—they talk about more than just suicide.
Related Conditions during Pregnancy and after Childbirth
Peripartum anxiety – Although estimates vary, a 2013 study found that about 16% of women experience an anxiety disorder during pregnancy and about 17% experience it during the postpartum period.7 After giving birth, some women develop intense anxiety, with rapid heart rate, a sense of impending doom and irrational fears and obsessions. Feeling guilty and blaming oneself when things go wrong, and worrying and feeling panicky for no good reason are signs of anxiety in the peripartum period.8
Treatment may include medication and therapy, alone or in combination.
Peripartum bipolar disorder – Bipolar disorder has two phases, the depression phase (the ‘lows’) and the manic phase (the ‘highs’). When the ‘lows’ and ‘highs’ happen at the same time, it is considered a ‘mixed’ episode. Bipolar illness can emerge during pregnancy or the postpartum period. Risk factors include a previous mood disorder and family history of mood disorders.
Symptoms of depression and mania:
- Severe sadness and irritability
- Elevated mood
- Rapid speech and racing thoughts
- Little or no sleep and high energy
- Impulsive decisions and poor judgment
- Delusions that can be grandiose or paranoid
- Hallucinations – seeing or hearing things that are not present
Treatment can include mood stabilizers and antipsychotic medications9 along with therapy.
Peripartum Psychosis: Peripartum psychosis is an extremely rare but serious condition — it occurs in only one or two out of every 1,000 deliveries. The symptoms of peripartum psychosis are extreme and may include insomnia, excessive energy, agitation, hearing voices, and extreme paranoia or suspiciousness. Many women with peripartum psychosis have a personal or family history of bipolar disorder. Symptoms of peripartum psychosis can be a serious medical emergency and require immediate attention.
- Davé S1, Petersen I, Sherr L, Nazareth I. Incidence of maternal and paternal depression in primary care: a cohort study using a primary care database. Arch Pediatr Adolesc Med. 2010 Nov;164(11):1038-44.
- 2. Siu AL, Bibbins-Domingo K, Grossman DC, et al; US Preventive Services Task Force (USPSTF). Screening for depression in adults: US Preventive Services Task Force recommendation statement. JAMA. 2016;315(4):380-387.
- Field, T. Postpartum depression effects on early interactions, parenting, and safety practices. Infant Behav Develop. 2010; 33:1-6.
- Brand, SR, Brennan, PA. Impact of antenatal and postpartum maternal mental illness: How are the Children? Clin Obstet Gynecol 2009; 53:441-55
- Diagnostic and Statistical Manual of Mental Disorders (DSM-5). 2013. American Psychiatric Association.
- Wisner, KL, et al. Onset Timing, Thoughts of Self-harm, and Diagnoses in Postpartum Women With Screen-Positive Depression Findings. JAMA Psychiatry/ Vol. 70 (No. 5), May 2013.
- Fairbrother, et al. Perinatal anxiety disorder prevalence and incidence. J Affect Disord. 2016 Aug; 200:148-55.
- Screening for Peripartum Anxiety Disorders: What Are the Best Screening Tools? Massachusetts General Hospital Center for Women's Mental Health.
- Yonkers, K. et al. Management of bipolar disorder during pregnancy and the postpartum period. Am J Psychiatry 161:4, 2004 April; 607-620.
Felix Torres, M.D., MBA, DFAPA