Recognizing postpartum depression (PPD)
Recognizing postpartum depression (PPD)
Insights to aid in the differential diagnosis of PPD.
Early distinction between PPD—the most common medical complication of childbirth—and the “baby blues”—a milder, transient form of symptoms—is important.1-9
Differentiating PPD from the baby blues.
Onset of PPD symptoms may occur during pregnancy or after delivery. Opinions of experts vary as to the timing of occurrence of symptoms in PPD after delivery. For example:
- According to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), PPD symptoms can begin during pregnancy or in the 4 weeks following childbirth12
- ACOG, World Health Organization (WHO), and the Centers for Disease Control and Prevention (CDC) state that PPD symptoms can occur during pregnancy and up to 1 year after giving birth13-15
- Frequent crying
- Mood swings
Note: While symptoms of the baby blues overlap with those of PPD, they are typically less severe, go away on their own, and do not interfere with daily activities.1,10,16
According to the National Institute of Mental Health, symptoms include18:
- Feeling sad, hopeless, empty, or overwhelmed
- Crying more often than usual or for no apparent reason
- Worrying or feeling overly anxious
- Feeling moody, irritable, or restless
- Insomnia or hypersomnia
- Trouble concentrating
- Experiencing anger or rage
- Losing interest in activities that are usually enjoyable
- Physical aches and pains
- Changes in appetite
- Withdrawing from friends and family
- Trouble bonding with her baby
- Persistently doubting her ability to care for her baby
- Thoughts of harming herself or her baby
Symptoms of PPD may vary.
Commonly reported symptoms include the following: feeling sad, hopeless, empty, or overwhelmed; crying more often than usual or for no apparent reason; worrying or feeling overly anxious; feeling moody, irritable, or restless; Insomnia or hypersomnia; trouble concentrating; experiencing anger or rage; losing interest in activities that are usually enjoyable; physical aches and pains; changes in appetite; withdrawing from friends and family; trouble bonding with her baby; persistently doubting her ability to care for her baby; thoughts of harming herself or her baby.18
Anxiety can be a prominent component of PPD. This may manifest as intrusive and or obsessive thoughts about the newborn.20
The American College of Obstetricians and Gynecologists (ACOG) recommends screening patients at least once during the perinatal period using a standardized, validated tool.14
Some examples of these tools include the Edinburgh Postnatal Depression Scale (EPDS) and the Patient Health Questionnaire-9 (PHQ-9).
Very rarely, a new mother may develop postpartum psychosis.3,10
Women with postpartum psychosis may show symptoms of paranoia, hallucinations, confusion, and extreme agitation, and are a danger to themselves and their children. They should never be left alone.
Patients exhibiting signs of postpartum psychosis require immediate admission to an emergency department for evaluation and care.
1. Moses-Kolko EL, Roth EK. Antepartum and postpartum depression: healthy mom, healthy baby. J Am Med Womens Assoc. 2004; 59(3):181-191. 2. Sit DK, Wisner KL. Identification of postpartum depression. Clin Obstet Gynecol. 2009; 52(3)456-468. 3. Beck CT. Postpartum depression: it isn’t just the blues. Am J Nurs. 2006; 106(5);40-50. 4. Ko JY, Rockhill KM, Tong VT, Morrow B, Farr SL. Trends in postpartum depressive symptoms – 27 states, 2004, 2008, and 2012. MMWR Mor Mortal Wkly Rep. 2017;66(6):153-158. 5. DeSisto CL, Kim SY, Sharma AJ. Prevalence estimates of gestational diabetes mellitus in the United States, Pregnancy Risk Assessment Monitoring System (PRAMS), 2007-2010. Prev Chronic Dis. 2014;11:E104. 6. Data on Selected Pregnancy Complication in the United States. 2017. Centers for Disease Control and Prevention website. https://www.cdc.gov/reproductivehealth/maternalinfanthealth/pregnancy-complications-data.htm. Accessed May 8, 2017. 7. Centers for Disease Control and Prevention. Pregnancy-related mortality surveillance. 2017. Available at: https://www.cdc.gov/reproductivehealth/MaternalInfantHealth/PMSS.html. 8. Knight M, Callaghan WM, Berg C, et al. Trends in postpartum hemorrhage in high resource countries: a review and recommendations from the International Postpartum Hemorrhage Collaborative Group. BMC Pregnancy Childbirth. 2009;9:55. 9. Reddy UM, Rice MM, Grobman WA, et al; the Eunice Kennedy Shriver National Institute of Child Health and Human Development Maternal-Fetal Medicine Units Network. Serious maternal complications after early perterm delivery (24-33 weeks’ gestation). Am J Obstet Gynecol. 2015;213(4):538.e1-9. 10. Earls MF; Committee on Psychological Aspects of Child and Family Health, American Academy of Pediatrics. Incorporating recognition and managegment of perinatal and postpartum depression into pediatric practice. Pediatrics. 2010;126(5):1032-1039. 11. Gavin NI, Gaynes BN, Lohr KN, Meltzer-Brody S, Garthlehner G, Swinson T. Perinatal depression: a systematic review of prevalence and incidence. Obstet Gynecol. 2005; 106(5 Pt 1):1071-1083. 12. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. Arlington, VA: American Psychiatric Association; 2013. 13. World Health Organization. mhGAP intervention guide for mental, neurological and substance use disorders in non-specified health settings. Geneva, Switzerland: World Health Organization; 2010. 14. The American College of Obstetricians and Gynecologists. Committee Opinion: screening for perinatal depression. 2015:630. 15. Centers for Disease Control and Prevention. Prevalence of self-reported postpartum depressive symptoms–17 states, 2004-2005. https://www.cdc.gov/mmwR/preview/mmwrhtml/mm5714a1.htm. Accessed November 2, 2017. 16. As reviewed in Thurgood S, Avery DM, Williamson L. Postpartum depression (PPD). Am J Clin Med. 2009;6(2):17-22. 17. As reviewed in Goodman JH. Postpartum depression beyond the early postpartum period. J Obstet Gynecol Neonatal Nurs. 2004;33(4):410-420. 18. National Institute of Mental Health website. Postpartum depression
facts. https://www.nimh.nih.gov/health/publications/postpartum-depression-facts/index.shtml. Accessed April 3, 2018. 19. Posmontier B. Functional status outcomes in mothers with and without postpartum depression. J Midwifery Womens Health. 2008;53(4):310-318. 20. Abramowitz JS, Meltzer-Brody S, Leserman J, et al. Obsessional thoughts and compulsive behaviors in a sample of women with postpartum mood symptoms. Arch Womens Ment Health. 2010;13(6):523-530. 21. Byatt N, Simas TA, Lundquist RS, Johnson JV, Ziedonis DM. Strategies for improving perinatal depression treatment in North American outpatient obstetric settings. J Psychosom Obstet Gynaecol. 2012;33(4):143-161. 22. Goodman JH. Women’s attitudes, preferences, and perceived barriers to treatment for perinatal depression. Birth. 2009;36(1):60-69.