Key Facts

Postnatal depression is a depressive illness occurring in the first year after childbirth. It is common, frequently underdiagnosed, and can have significant effects on the mother, her relationship with her baby, and the child's development.

Epidemiology

• Prevalence: 10-15% of women in the first postnatal year
• Onset typically within first 3 months but can occur up to 12 months postpartum
• Baby blues: affects 50-80% of women, onset day 3-5, resolves within 2 weeks
• Paternal PND: affects approximately 5-10% of fathers
• Recurrence risk: 30-50% in subsequent pregnancies

Aetiology

• Biological: hormonal changes (rapid fall in oestrogen and progesterone), HPA axis dysregulation, thyroid dysfunction, genetic predisposition
• Psychological: previous mental health problems, personality factors, unrealistic expectations of parenthood
• Social: lack of social support, relationship difficulties, domestic violence, financial stress, adverse life events, unplanned pregnancy

Pathophysiology

• Rapid decline in reproductive hormones postpartum affects serotonergic and GABAergic neurotransmission
• HPA axis hyperactivity and elevated cortisol levels
• Inflammatory markers (IL-6, TNF-α) are elevated in PND
• Sleep deprivation and disrupted circadian rhythms contribute
• Neuroimaging shows altered activity in prefrontal cortex, amygdala, and anterior cingulate cortex

Core Symptoms

• Persistent low mood (most of the day, nearly every day for ≥2 weeks)
• Anhedonia (loss of interest or pleasure)
• Fatigue and reduced energy

Associated Symptoms

• Sleep disturbance (beyond normal infant-related sleep disruption)
• Appetite changes (usually decreased)
• Poor concentration and indecisiveness
• Feelings of guilt, worthlessness, or inadequacy as a mother
• Anxiety (often prominent - worry about baby's health, own competence)
• Reduced bonding with baby
• Social withdrawal
• Irritability

Red Flags

• Suicidal ideation or plans
• Thoughts of harming the baby
• Self-neglect or neglect of baby
• Psychotic symptoms (hallucinations, delusions) → consider puerperal psychosis
• Rapidly escalating symptoms
• Previous history of bipolar disorder or psychosis

Bedside

• Edinburgh Postnatal Depression Scale (EPDS): score ≥13 suggests depression; question 10 specifically asks about self-harm
• PHQ-9: alternative screening tool
• GAD-7: assess co-morbid anxiety
• Risk assessment: suicidality, thoughts of harming baby, safeguarding concerns

Bloods

• TFTs: exclude hypothyroidism (postpartum thyroiditis)
• FBC: exclude anaemia (common postpartum)
• Ferritin: iron deficiency can mimic or exacerbate depression

Imaging

• Not routinely indicated

Special Tests

• Formal psychiatric assessment if severe or psychotic features
• Social assessment (housing, finances, support network)

Non-pharmacological

• Guided self-help (computerised CBT, self-help books): first-line for mild PND (NICE CG192)
• CBT: first-line for moderate PND; 8-12 sessions
• Interpersonal therapy (IPT): evidence-based for PND
• Peer support and mother-and-baby groups
• Practical support: help with childcare, sleep strategies
• Exercise (moderate regular exercise has evidence for improving mood)
• Partner and family involvement

Pharmacological

• Mild-moderate: psychological therapy preferred first
• Moderate-severe or failed psychological therapy: SSRI antidepressant
  • Sertraline 50-200mg OD (first-line in breastfeeding - lowest milk transfer)
  • Alternative: fluoxetine 20mg OD, paroxetine 20mg OD (higher milk transfer)
• Continue antidepressant for ≥6 months after remission, then gradual withdrawal
• If previous PND: consider prophylactic antidepressant in third trimester or immediately postpartum
• Severe/psychotic depression: specialist perinatal mental health team; may need antipsychotic, lithium

Surgical/Interventional

• Not applicable

Referral Criteria

• Specialist perinatal mental health team: severe depression, psychotic features, significant risk, history of bipolar
• Mother and Baby Unit (MBU): if inpatient admission needed (keeps mother and baby together)
• Crisis team: suicidal ideation, acute safety concerns
• Safeguarding: if concerns about baby's safety
• Health visitor: ongoing community monitoring and support

• With treatment, majority of women recover fully
• Untreated PND: 50% still depressed at 6 months, 25% at 12 months
• Recurrence risk in subsequent pregnancy: 30-50%
• Impact on child: impaired bonding, delayed cognitive and emotional development, behavioural problems
• Increased risk of chronic depression: 40% of women with PND develop recurrent depression
• Paternal PND associated with poorer child outcomes
• Early identification and treatment significantly improves outcomes for mother and baby

Differentiating Postnatal Mood Disorders

Edinburgh Postnatal Depression Scale