Postpartum Mental Health Problems
Postpartum mental health problems include:
- Postpartum blues (maternity blues / baby blues)
- Postpartum depression / postnatal depression
- Postpartum psychosis
Postpartum Blues (Maternity Blues / Baby Blues)
Definition
Postpartum blues is a common, mild, transient and self-limiting postpartum mood disturbance characterised by mood lability and other mild depressive symptoms developing shortly after childbirth [Ref]
It is NOT classified as a distinct mental disorder
Clinical Features and Recognition
| Timing | Usually develops within the first few days after delivery, commonly around days 3-4
Usually resolves spontaneously within ~10 days and should resolve within 2 weeks |
| Clinical features | Possible mood changes include:
|
Postpartum blues can be recognised by:
- Mild mood changes (no obvious functional impairment) beginning within the first few days after childbirth
- Symptoms that spontaneously resolve within 2 weeks (without treatment)
Postpartum blues is associated with an increased risk of subsequent postpartum depression
Management
No specific treatment is usually required as postpartum blues is temporary and self-limiting [Ref1][Ref2]
Provide reassurance, rest and practical / emotional support
Postpartum Depression
Clinical Features and Recognition
Disclaimer:
DSM-5 criteria do not classify postpartum depression as a separate disorder. Instead, the specifier “with peripartum onset” can be applied to a major depressive episode that begins during pregnancy or within 4 weeks after delivery
However, the clinical term “postpartum depression / postnatal depression” is still used for depression occurring after childbirth.
| Timing | Onset: often begins within the first 1-2 months after childbirth, but may develop several months later
Duration: depressive symptoms persist for ≥2 weeks Symptoms may also begin during pregnancy and continue after delivery |
| Clinical features | Key features:
|
Postpartum depression should be suspected if:
- Depressive symptoms persist for ≥2 weeks, particularly when apparent postpartum blues fails to resolve
- Symptoms can cause significant distress and/or functional impairment
Unlike postpartum blues, postpartum depression is more persistent and clinically significant
Management
Management depends on the severity of depression:
| Depression severity | Recommended management |
|---|---|
| Subthreshold / mild / moderate | Facilitated self-help
If mild depression + history of severe depression → consider an antidepressant (TCA / SSRI / SNRI) |
| Moderate to severe | High-intensity psychological intervention (e.g. CBT)
Consider an antidepressant (TCA / SSRI / SNRI) if the patient:
Consider combined psychological therapy + antidepressant if there is limited response to either alone |
Choice of antidepressants:
- NICE recommends considering a TCA, SSRI or SNRI when antidepressant treatment is indicated
- NICE does NOT name a single ‘preferred’ antidepressant, instead emphasises personalised prescribing principles based on safety and past efficacy
- A primary factor in choosing a drug is the woman’s previous response to the medication. If a drug has worked well for her in the past, clinicians must weigh the risks of switching or stopping that previously effective medication
- The lowest effective dose and a single drug are preferred
- Specific drug warnings: the guideline noted paroxetine and venlafaxine are particularly associated with discontinuation symptoms in the mother and neonatal adaptation syndrome in the baby
- As per NHS SPS: [Ref]
- Sertraline or paroxetine are the preferred SSRIs during breastfeeding
- Imipramine or nortriptyline are the preferred TCAs during breastfeeding
Postpartum Psychosis
Definition
Postpartum psychosis is a psychiatric emergency with sudden onset after childbirth, characterised by psychotic symptoms, often accompanied by manic and/or depressive symptoms
Clinical Features and Recognition
Postpartum psychosis can occur in women with no previous psychiatric history [Ref]
Important risk factors include: [Ref]
- Bipolar I disorder (postpartum psychosis is strongly associated with bipolar)
- Previous postpartum psychosis
- Close family history of postpartum psychosis
| Timing | Usually develops within the first 2 weeks after childbirth, often within the first few days |
| Clinical features | Core symptom: psychosis
Other symptoms:
|
Management
Postpartum psychosis is a psychiatric emergency
Immediate referral to secondary mental health service (preferably perinatal specialist)
- Patients often require inpatient care
- If inpatient care is necessary → admit in a specialist mother and baby unit
Pharmacological treatment is specialist-led and usually involves: [Ref]
- Antipsychotics
- Mood stabiliser
- Combination treatment may be required