Support and Training to Enhance Primary Care for Postpartum Depression

Spectrum of Postpartum Adjustment

In the first hours and days following the birth of a baby, a woman may feel exhilarated, exhausted, overwhelmed, and overjoyed. Women receive many important health-related instructions during this time, covering topics such as breastfeeding, general infant care, and recognizing signs of maternal and infant distress. As the postpartum period progresses beyond the first days, it is also important for providers to address issues related to maternal mental health and emotional adjustment.

Postpartum emotional adjustment is unique to every woman; some women are unaffected while, for others, the impairment varies in severity from normal postpartum blues to acute postpartum psychosis:

Postpartum or “baby” blues Postpartum depression (PPD) and anxiety disorders Postpartum psychoses
Least severe SEVERITY OF IMPAIRMENT Most severe

While these disorders are not completely independent of one another, each syndrome is qualitatively distinct and should not be conceptualized as a progression from one disorder to the next. This spectrum simply illustrates the differences in the severity of illness with relation to one another (i.e., postpartum blues are the least severe and cause the least amount of impairment while postpartum psychoses are the most severe and cause the greatest amount of impairment.)


Postpartum Depression 23 35 50 53

Approximately 10-15 percent of new mothers experience PPD. This condition occurs in women of all cultures, races, geographic locations, and socioeconomic strata. PPD occurs as often as pregnancy-related hypertension and 5-10 times as often as gestational diabetes. Rates are higher for women with high levels of stress or women who have had previous episodes of depression or anxiety disorders particularly if they have occurred within 12 months of previous pregnancies. The DSM-IV-TR criteria require onset within the first 4 weeks postpartum, but expert consensus is that PPD can develop any time within the first 12 months after delivery. The peak onset of PPD is between 2 and 3 months postpartum.

The symptoms of PPD are listed below. These include diagnostic criteria for major depressive disorder (APA, DSM-IV-TR), as well as symptoms identified in the literature as common among postpartum depressed women.

  • Tearfulness, feelings of sadness
  • Irritability
  • Decreased interest in usual activities
  • Changes in appetite, inability to eat
  • Sleep disturbances: inability to sleep when the baby is sleeping, nightmares, restless sleep
  • Low energy or fatigue
  • Poor concentration
  • Feelings of guilt or shame
  • Anxiety
  • Obsessive thoughts (i.e., about the baby’s safety)
  • Ambivalent or negative feelings toward the baby, wanting to flee
  • Doubts or feelings of inadequacy about caring for the baby
  • Somatic complaints 63 65 100 115
  • Suicidal ideation
  • Thoughts of harming the baby

Pharmacological, psychological, and other treatments are available for the treatment of PPD. However, stigma and other factors may hinder help-seeking. Symptomatic women are most likely to seek help from their own or their baby’s primary care provider.


Perinatal Depression

Major depression during pregnancy, known as antenatal depression, affects approximately 8-10 percent of women. While assessing women for depression in all stages of pregnancy is critical, this program focuses specifically on PPD. As such, some of the information presented will not be relevant or suitable for use with women experiencing depression during pregnancy. Please see the Resources section to find more information on proper assessment and treatment for perinatal depression.

Differential Diagnoses

To make accurate diagnoses of PPD, an understanding of other disorders related to maternal adjustment is needed. Ruling out other diagnoses is important, as is recognizing symptoms of anxiety disorders and psychoses.

Below are signs and symptoms of an array of maternal adjustment disorders women sometimes face in the first postpartum year. As the focus of this program is on PPD, these other disorders are covered only briefly here. For more information about these other maternal adjustment problems, see the Resources section to learn where to go for additional information.