Postnatal depression

Postnatal depression may present with symptoms of depressed mood, anhedonia, weight changes, sleep disturbance, psychomotor problems, low energy, excessive guilt, loss of confidence or self-esteem, poor concentration, or suicidal ideation.

Recognition and effective treatment is vital; untreated postnatal depression causes substantial impairment for the woman, and may also result in impaired behavioural, emotional, and cognitive outcomes for the baby.

Exclude postnatal psychosis and bipolar disorder in all patients.

Treatment is with psychological therapy and/or medication. Antidepressants are recommended for more severe episodes if the woman declines psychological therapy or if psychological therapy is either ineffective or unavailable.

Psychiatric referral may be necessary for patients who do not respond to treatment. Urgent psychiatric assessment is warranted if there is a risk of self-harm or harm to the child at any time, or if a postnatal psychosis, or manic or mixed episode, is suspected.

Episodes of postnatal depression last 3 to 6 months on average, but may last for months or even years.

Postnatal depression refers to the development of a depressive illness following childbirth and may form part of a bipolar or, more usually, a unipolar illness. Postnatal depression is not recognised by current classification systems as a condition in its own right, but the onset of a depressive episode within 4 weeks of childbirth can be recorded via the peripartum-onset specifier in the Diagnostic and Statistical Manual of Mental Disorders, fifth edition, text revision (DSM-5-TR).[1]American Psychiatric Association. Diagnostic and statistical manual of mental disorders, 5th ed., text rev (DSM-5-TR). Washington, DC: American Psychiatric Publishing; 2022. There is evidence that the DSM-5-TR specifier is too narrow.[2]Forty L, Jones L, Macgregor S, et al. Familiality of postpartum depression in unipolar disorder: results of a family study. Am J Psychiatry. 2006 Sep;163(9):1549-53. http://ajp.psychiatryonline.org/doi/full/10.1176/ajp.2006.163.9.1549 http://www.ncbi.nlm.nih.gov/pubmed/16946179?tool=bestpractice.com Hence, in common usage, depressive episodes occurring within 6 to 12 months of delivery may be considered to be postnatal depression. This topic defines the postnatal period as up to 12 months after delivery, in accordance with several international guidelines.​[3]Austin MP; Marcé Society Position Statement Advisory Committee. Marcé International Society position statement on psychosocial assessment and depression screening in perinatal women. Best Pract Res Clin Obstet Gynaecol. 2014 Jan;28(1):179-87. http://www.ncbi.nlm.nih.gov/pubmed/24138943?tool=bestpractice.com [4]American College of Obstetricians and Gynecologists. ACOG clinical practice guideline no. 4: screening and diagnosis of mental health conditions during pregnancy and postpartum. Jun 2023 [internet publication]. https://www.acog.org/clinical/clinical-guidance/clinical-practice-guideline/articles/2023/06/screening-and-diagnosis-of-mental-health-conditions-during-pregnancy-and-postpartum [5]National Institute for Health and Care Excellence. Antenatal and postnatal mental health: clinical management and service guidance. Feb 2020 [internet publication]. http://www.nice.org.uk/guidance/cg192 ​Symptom onset in pregnancy (and before pregnancy) is not uncommon; therefore, the term ‘perinatal depression’ may be strictly more accurate.​[6]Wisner KL, Sit DK, McShea MC, et al. Onset timing, thoughts of self-harm, and diagnoses in postpartum women with screen-positive depression findings. JAMA Psychiatry. 2013 May;70(5):490-8. http://www.ncbi.nlm.nih.gov/pubmed/23487258?tool=bestpractice.com [7]Biaggi A, Conroy S, Pawlby S, et al. Identifying the women at risk of antenatal anxiety and depression: a systematic review. J Affect Disord. 2016 Feb;191:62-77. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4879174 http://www.ncbi.nlm.nih.gov/pubmed/26650969?tool=bestpractice.com

This topic focuses on postnatal depression within a unipolar illness. For more information on postnatal depression in the context of a bipolar illness, see  Bipolar disorder in adults. For information on depression during pregnancy, see  Depression in adults. 

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