Postpartum Psychiatric Disorders — Blues vs Depression vs Psychosis, EPDS Screening and Treatment

Childbirth is a major physical, emotional and social stressor, and the weeks after it carry a spectrum of mood disturbance. StatPearls describes three clinical entities along a severity gradient: postpartum (maternity) blues — mild and transient; postpartum (perinatal) depression — a major depressive episode; and postpartum psychosis — the most severe, with loss of touch with reality, delusions and hallucinations.

Terminology matters. In the DSM-5-TR there is no separate 'postpartum depression'. A major depressive episode that begins during pregnancy or within 4 weeks after delivery is coded with the specifier 'with peripartum onset', and the term replaces 'postpartum depression' because about 50% of postpartum major depressive episodes actually begin before delivery. Most experts, however, count symptoms up to 12 months postpartum.

Postpartum blues (maternity or baby blues) are mild, transient depressive symptoms and dysphoria in the first days to weeks after delivery: tearfulness, crying spells, mood swings, irritability, insomnia, anxiety, poor appetite and fatigue. Symptoms usually develop within 2 to 3 days of delivery and resolve within 2 weeks. They do not cause significant functional impairment and are not considered a mental disorder — no treatment is needed beyond support and reassurance.

• Cause: unclear; rapid fall in oestrogen and progesterone after delivery, sleep deprivation and the stress of caring for a newborn.
• Risk: in one study, 27.7% of women with postpartum blues went on to develop perinatal depression, versus 16.4% of those without blues — so severe or persistent blues need follow-up.
• Blues also affect some fathers (17.5% in a French study).

Diagnosis follows major depressive disorder criteria: at least 5 of 9 symptoms for at least 2 weeks, including depressed mood or anhedonia. The nine symptoms are low mood, loss of interest, sleep disturbance, psychomotor change, worthlessness or guilt, fatigue, suicidal ideation, poor concentration and appetite or weight change. There must be no prior manic or hypomanic episode, and the episode must not be due to a psychotic disorder, substance use or a medical condition.

• Depression is the commonest psychiatric condition of the peripartum period. Suicide is the second most common cause of postpartum mortality.
• Risk factors: previous depression or anxiety, family psychiatric history, high-risk pregnancy, traumatic delivery, lack of social support, domestic violence, young age, premature infant, vitamin B6 deficiency and sleep loss.
• Complications: poor mother-infant bonding, breastfeeding failure, and adverse child emotional, behavioural and cognitive development.
• Pathogenesis is multifactorial: reproductive hormone changes, HPA-axis dysregulation and GABA imbalance.
• Rule out thyroid disease (check TSH), anaemia, substance use, adjustment disorder, PTSD from a traumatic birth and bipolar disorder — consider it if irritability is prominent or symptoms are severe.

For the general framework of depression and bipolar disorder, see mood disorders: depression and bipolar.

The EPDS is the most frequently used screening tool for perinatal depression: a 10-item questionnaire completed by the patient within a few minutes. The highest possible score is 30. A score of 13 or more is associated with an increased risk of perinatal depression and is the basis for further assessment, while many institutions refer for mental-health assessment above 9 or 10, or if there is any suicidal ideation.

• ACOG, the AAP and the AAFP recommend screening every patient with the EPDS, during pregnancy and postpartum.
• Other tools: PHQ-9 (depression), GAD-7 (anxiety) and the Mood Disorder Questionnaire (MDQ) to pick up mania in at-risk populations.
• A screening score is not a diagnosis — a clinical evaluation is needed to confirm depression, assess suicide and homicide risk and exclude other illness.
• Use the same tool to track response: a 50% or greater improvement defines a treatment response.
• NICE advises being alert for postpartum psychosis in the first 2 weeks after childbirth in women with past or family severe mental illness, and immediate specialist assessment (within 4 hours of referral) for sudden-onset symptoms.

• Benefit may start within a week but takes 4 to 8 weeks; continue treatment for 6 to 12 months after remission to prevent relapse.
• Prior successful antidepressant treatment should be resumed. Avoid abrupt discontinuation; taper SSRIs and SNRIs over 2 to 4 weeks.
• Fluoxetine and paroxetine may be used if previously effective, despite a risk of neonatal adaptation syndrome.
• Both brexanolone and zuranolone cause sedation; zuranolone can reduce driving ability.

Postpartum (puerperal) psychosis is the most severe postpartum disorder: extreme confusion, loss of touch with reality, paranoia, delusions, disorganised thought and hallucinations, occurring in 1 to 2 per 1,000 women. It typically begins within days to 6 weeks (usually 3 to 10 days) with an acute onset of manic or depressive psychosis. It is a psychiatric emergency: the risk of suicide and infanticide is real, and symptoms can include command hallucinations to kill the infant or beliefs that the infant is possessed.

• Strongest risk factor: bipolar I disorder — a first pregnancy in a woman with a personal or family history is the single most important risk. Others: previous postpartum psychosis, schizoaffective disorder, schizophrenia and stopping psychiatric medication during pregnancy.
• About half of cases in first-time mothers occur without prior psychiatric hospitalisation.
• Work-up to exclude organic causes: CBC, electrolytes, glucose, calcium, thyroid and liver function, B12, folate, urine drug screen and imaging when indicated (eclampsia-related stroke, thyroid storm, infection).
• Management: immediate hospitalisation if the mother or baby is at risk; antipsychotics (quetiapine, olanzapine), mood stabilisers (lithium, valproate, carbamazepine) and benzodiazepines; ECT is safe and effective for acute postpartum psychosis.
• Prophylaxis: restart lithium soon after delivery in women with bipolar disorder or earlier postpartum psychosis (target level 0.8 to 1 mmol/L, checked twice weekly for at least 2 weeks). Avoid breastfeeding on lithium; SSRIs, carbamazepine, valproate and short-acting benzodiazepines are relatively safe with breastfeeding.

• Blues vs depression: blues resolve in 2 weeks and keep function; depression lasts longer, impairs function and meets MDD criteria.
• Depression with psychotic features exists: delusions and hallucinations, such as voices telling her to harm the infant, can occur in perinatal depression — the DSM-5-TR uses the specifier 'with psychotic features'.
• Organic mimics: before labelling psychosis, exclude metabolic, thyroid, infective and substance causes, and stroke in women with pre-eclampsia or eclampsia.
• Postpartum anxiety, adjustment disorder, PTSD: excessive worry, a less severe stress response, and trauma symptoms after a traumatic birth respectively.
• Hypo- and hyperthyroidism cause mood disorders and should be excluded with a TSH.

For legal and ethical context on admitting a patient who lacks capacity, see Mental Healthcare Act 2017. For obstetric emergencies in the same period, see postpartum haemorrhage and pre-eclampsia and eclampsia.