What Is Postpartum Depression?

There are multiple organizations that categorize perinatal depression, each with a varying definition.

According to the American College of Obstetricians and Gynecologists (ACOG), perinatal depression, also commonly called postpartum depression (PPD), includes major and minor depressive episodes that occur during pregnancy or in the first 12 months after delivery.1

The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) states that a major depressive episode or major depression qualifies as peripartum if onset occurs during pregnancy or in the 4 weeks following delivery.2

When does PPD start?

Expert opinions vary as to the timing of the onset of PPD. For example, symptoms of PPD can begin:

•   During pregnancy or following childbirth up to 4 weeks (DSM-5 definition)2

•   During pregnancy or following childbirth up to 12 months (ACOG definition)1

Causes of PPD

While the exact cause of PPD is unknown, below are key risk factors/triggers that may play a role.

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Biological changes

Changes in reproductive hormones during and after pregnancy have been closely linked to depressive symptoms and mood dysregulation.3-6 Women with PPD may have an impaired ability to regulate neuronal function due to perinatal changes in hormone levels.3,7 Additional acute biological changes can also contribute to PPD, such as inflammatory factors and sleep disturbances.8-14

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Social and psychological risk factors

Various social risk factors, such as chronic stress and a history of depression or trauma, have been identified for women experiencing PPD.15-20

  1. Screening for Perinatal Depression. ACOG Committee Opinion No. 757. American College of Obstetricians and Gynecologists. Obstet Gynecol. 2018;132:e208-212.
  2. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. Arlington, VA: American Psychiatric Association Publishing; 2013.
  3. Bloch M, Schmidt PJ, Danaceau M, Murphy J, Nieman L, Rubinow DR. Effects of gonadal steroids in women with a history of postpartum depression. Am J Psychiatry. 2000;157(6):924-930.
  4. Paoletti A, Romagnino S, Contu R, et al. Observational study on the stability of the psychological status during normal pregnancy and increased blood levels of neuroactive steroids with GABA-A receptor agonist activity. Psychoneuroendocrinology. 2006;31(4):485-492.
  5. Pearson Murphy BE, Steinberg SI, Fen-Yun HY, Allison CM. Neuroactive ring A-reduced metabolites of progesterone in human plasma during pregnancy: elevated levels of 5(alpha)-dihydroprogesterone in depressed patients during the latter half of pregnancy. J Clin Endocrinol Metab. 2001;86(12):5981-5987.
  6. Nappi RE, Petraglia F, Luisi S, Polatti F, Farina C, Genazzani AR. Serum allopregnanolone in women with postpartum “blues”. Obstet Gynecol. 2001;97(1):77-80.
  7. Deligiannidis KM, Sikoglu EM, Shaffer SA, et al. GABAergic neuroactive steroids and resting-state functional connectivity in postpartum depression: a preliminary study. J Psychiatr Res. 2013;47(6):816-828.
  8. Groer MW, Morgan K. Immune, health and endocrine characteristics of depressed postpartum mothers. Psychoneuroendocrinology. 2007;32(2):133-139.
  9. Cassidy-Bushrow AE, Peters RM, Johnson DA, Templin TN. Association of depressive symptoms with inflammatory biomarkers among pregnant African-American women. Am J Reprod Immunol. 2012;94(2):202-209.
  10. Boufidou F, Lambrinoudaki I, Argeitis J, et al. CSF and plasma cytokines at delivery and postpartum mood disturbances. J Affect Disord. 2009;115(1-2):287-292.
  11. Maes M, Lin AH, Ombelet W, et al. Immune activation in the early puerperium is related to postpartum anxiety and depressive symptoms. Psychoneuroendocrinology. 2000;25(2):121-137.
  12. Fransson E, Dubicke A, Byström B, Ekman-Ordeberg G, Hjelmstedt A, Lekander M. Negative emotions and cytokines in maternal and cord serum at preterm birth: Am J Reprod Immunol. 2012;67(6):506-514.
  13. Bränn E, Papadopoulos F, Fransson E, et al. Inflammatory markers in late pregnancy in association with postpartum depression: a nested case-control study. Psychoneuroendocrinology. 2017;79:146-159.
  14. Bhati S, Richards K. A systematic review of the relationship between postpartum sleep disturbance and postpartum depression. J Obstet Gynecol Neonatal Nurs. 2015;44(3):350-357.
  15. Robertson E, Grace S, Wallington T, Stewart DE. Antenatal risk factors for postpartum depression: a synthesis of recent literature. Gen Hosp Psychiatry. 2004;26(4):289-295.
  16. Silverman ME, Reichenberg A, Savitz DA, et al. The risk factors for postpartum depression: a population-based study. Depress Anxiety. 2017;34(2):178-187.
  17. Howard LM, Oram S, Galley H, Trevillion K, Feder G. Domestic violence and perinatal mental disorders: a systematic review and meta-analysis. PLoS Med. 2013;10(5):e1001452 [epub May 28, 2013].
  18. Biaggi A, Conroy S, Pawlby S, Pariante CM. Identifying the women at risk of antenatal anxiety and depression: a systematic review. J Affect Disord. 2016;191:62-77.
  19. Yim IS, Tanner Stapleton LR, Guardino CM, Hahn-Holbrook J, Dunkel Schetter C. Biological and psychosocial predictors of postpartum depression: systematic review and call for integration. Annu Rev Clin Psychol. 2015;11:99-137.
  20. Goyal D, Gay C, Lee KA. How much does low socioeconomic status increase the risk of prenatal postpartum depressive symptoms in first-time mothers? Womens Health Issues. 2010;20(2):96-104.