Postpartum depression is clinically defined as depression following the birth of a child that lasts at least two weeks and interferes with a parent's ability to go about their daily tasks. About 14% of mothers and 4% of fathers experience postpartum depression, according to a 2010 study published in the journal Archives of Pediatrics and Adolescent Medicine.
Having a baby is physically grueling and can also be emotionally difficult. It's not uncommon for parents to feel anxious, depressed and upset soon after giving birth. This is often called the "baby blues." Symptoms may include crying for no obvious reason, having trouble eating and sleeping, and questioning their parenting ability. The baby blues usually disappear on their own within two weeks following the birth of a child even without treatment, according to the American College of Obstetricians and Gynecologists (ACOG).
But if those blue moods become more dominant, start interfering with the ability to go about daily tasks, and last longer than two weeks, they may be a sign of postpartum depression. "Depression or postpartum depression doesn't resolve by itself. Typically, people need treatment to get better," said Dr. Nancy Byatt, a professor and postpartum depression expert at University of Massachusetts Medical School in Worcester.
People who are depressed, whether generally or postpartum, "can feel worthless, they can feel hopeless, they can feel helpless. They can also feel bad about themselves; they can feel guilty about things they have or haven't done," Byatt said. In postpartum depression, those feelings tend to be focused on or related to the baby, Byatt said. A parent with postpartum depression may feel like they're a bad parent or that the baby would be better off with someone else. They may have to push to take care of the baby. They may even consider suicide, Byatt said.
People with the baby blues, in contrast, "can still function, they're still able to do things. They're not feeling bad about themselves. They don't have suicidal thoughts," she said.
For 2 out of 3 mothers who experience postpartum depression, the depression starts before the baby is born, Byatt said. One-third of mothers with postpartum depression are depressed before they become pregnant, and one-third of mothers with postpartum depression develop depression during pregnancy. For that reason, Byatt considers postpartum depression to fall under the umbrella of perinatal depression, which is depression that occurs at any point during pregnancy and up to one year after birth of the baby, she said.
How does postpartum depression affect the baby and the mother?
Postpartum depression can make it harder for the parent and baby to bond, said Dr. Simone Vigod, a perinatal health researcher and chief of psychiatry at Women's College Hospital in Toronto, Ontario. There's also some evidence that having a mother with untreated postpartum depression is associated with developmental delays and social-emotional problems in children, she added.
However it's important that parents with postpartum depression don't blame themselves for the potential harms that could result from the illness, Vigod told Live Science. "Depression is a medical illness. If people could just snap their fingers and snap out of it, I wouldn't have a practice. Nobody chooses this, and nobody is just not working hard enough to make it better," she said.
Postpartum depression affects the parent, first and foremost. "Having a depressive episode means that her mental health and well-being is impacted; it means that the experience of parenthood is impacted," Vigod said. "And it opens the door, especially if it's not treated, for having continued mental health issues or continued depression across the lifespan."
Although suicide in mothers is rare, it's one of the leading causes of death during pregnancy and the postpartum period in the U.S. and Canada, Vigod said. A 2017 study led by Vigod and published in the Canadian Medical Association Journal found that from 1994 to 2008, 1 out of every 19 women in Canada who died during pregnancy or up to one year after giving birth died by suicide, and that maternal suicide occurred at a rate of 2.58 suicides per 100,000 live births. From 2003 to 2007 in the U.S., maternal suicide during pregnancy or in the first year postpartum occurred at a rate of 2 suicides per 100,000 live births, according to a 2011 report published in the journal Obstetrics & Gynecology.
Mental health conditions are the seventh most common cause of pregnancy-related death among mothers during or within one year of pregnancy, in at least nine U.S. states according to a 2018 report from those states' Maternal Mortality Review Committees. According to the same report, 6.5% of maternal deaths during pregnancy or in the first year following the birth of a child are by suicide. Deaths related to mental health conditions that are not classified as suicide include non-suicidal drug overdoses or fatal injuries during psychotic episodes.
What causes postpartum depression?
The hormones estrogen and progesterone are significantly elevated throughout pregnancy, then within hours after delivery, levels of those hormones plummet, according to the ACOG. Experts believe the rapid and dramatic changes in hormone levels during pregnancy and after birth could be what triggers mental health issues in mothers, Vigod said. "But clearly, some women's brains probably are more sensitive than others," she added. Some evidence suggests that the same women who are sensitive to the hormonal changes associated with menstruation and menopause are also more sensitive to the changes that occur postpartum, Vigod said.
Other factors that increase the risk of postpartum depression include a history of depression and anxiety, financial stress, lack of social support, being a first time mother, or very young or older mother, and having a baby with special needs, according to the American Psychological Association (APA). Postpartum depression also has a genetic component, Byatt said, because having a family history of postpartum depression increases a person's risk of developing it.
Fathers can also get postpartum depression, Byatt said. It's treated the same way as maternal postpartum depression but can have different symptoms in fathers, she said. For example, parental postpartum depression could present more as increased irritability, aggression, isolation or even substance abuse.
Can postpartum depression be prevented?
In a 2019 report, the U.S. Preventive Services Task Force concluded that for pregnant or postpartum women at increased risk for perinatal depression, meeting with a therapist had an overall "moderate" benefit for preventing perinatal depression. The task force didn't assess the potential benefits or harms of non-counseling interventions, such as medication, on preventing perinatal depression, the report said.
Implementing preventative therapy for postpartum depression could be hard, Byatt said. "People working in clinical settings are so busy meeting the needs of the people who have identified depression or any sort of perinatal mood or anxiety disorder that giving those resources to folks to prevent it is just really challenging," she said.
However, mothers can decrease their risk of postpartum depression by getting treatment for depression that exists before the baby is born, Byatt said. Sometimes such treatment involves medication, including during pregnancy. Mothers may decide not to take antidepressants during pregnancy out of fear that the drugs could harm the baby, but the harm caused by depression is greater than the potential harm caused by antidepressants. "Antidepressants in pregnancy have been very, very well studied," Byatt said. "We have data on millions of women, and overall, they [antidepressants] are a reasonable option."
Although there are many studies examining the effects of antidepressants on pregnant women and their babies, none of those studies were randomized, controlled clinical trials — the highest scientific standard for testing a hypothesis. That's because doctors can't randomly assign women with depression to stop taking antidepressants, Vigod explained. Nonetheless, the risk of adverse effects reported in these clinical trials is small, she said.
Indeed, a 2015 study by the Centers for Disease Control and Prevention concluded that the increased risk of 14 birth defects associated with a common class of antidepressants called selective serotonin reuptake inhibitors (SSRIs) was incredibly small. For instance, the agency found that the risk for a particular heart defect could increase from 10 in 10,000 births to 24 in 10,000 births for women taking the SSRI paroxetine (Paxil) during early pregnancy. Overall, the absolute risks for these birth defects is low, the agency concluded.
What's more, having major depression during pregnancy has been associated with greater risk of "premature birth, low birth weight, decreased fetal growth or other problems for the baby," according to the Mayo Clinic. "I think the thing to remember is that we're not weighing taking these medications against nothing, we're weighing it against 'What's the risk of the maternal mental illness going going untreated?'" Vigod said.
"The best thing a pregnant or postpartum individual can do for themselves and their baby and family is to get the mental health support that they need," Byatt said. "People absolutely do not have to stop their antidepressants because they become pregnant."
How is postpartum depression diagnosed?
Postpartum depression may be detected and diagnosed during a routine doctor's visit. A 2018 committee opinion by the ACOG recommends that doctors providing obstetric care screen mothers at least once during pregnancy and/or within the year following the birth of a child. The American Academy of Pediatrics recommends that pediatricians continue to screen mothers for postpartum depression during their babies' one-, two-, four-, and six-month checkups.
If the parent's responses to screening questions suggest that they are depressed, doctors will follow up with a more thorough assessment, in which the clinician asks more questions about the person's experience before making a diagnosis and recommending treatment, Byatt said.
How is postpartum depression treated?
Interpersonal therapy, which is short-term psychotherapy focused on a person's relationships, and cognitive behavioral therapy, which focuses on changing emotions and behaviors that cause problems for the individual by addressing and questioning the thoughts behind them, are two types of therapy that have been shown to work as a treatment for postpartum depression, Byatt said. (These are also the types of therapy that the U.S. Preventive Services Task Force reported to be effective in preventing postpartum depression in its 2019 report.)
For a person with mild depression, therapy might be enough to resolve it, Byatt said. But usually, therapy is accompanied by treatment with antidepressants. If a patient has not previously taken antidepressants, that person would likely start with an SSRI, such as sertraline (Zoloft), citalopram (Celexa) or fluoxetine (Prozac).
Sertraline is often considered as a first-line treatment, especially if someone has never taken antidepressants, because it doesn't transfer to breast milk as much as some of the other antidepressants, Byatt said.
Brexanolone (Zulresso) is the first and only drug approved by the U.S. Food and Drug Administration (FDA) specifically for postpartum depression, Live Science previously reported. Brexanolone is a neurosteroid, which is a steroid that affects neuronal activity. It works by counteracting some of the changes triggered by the postpartum drop in estrogen and progesterone, Byatt said. The drug doesn't necessarily increase hormone levels, but it interacts with the signaling pathways involving those hormones in such a way as to relieve women's symptoms, she explained.
"The great thing about brexanolone is that it works quickly. Most antidepressants take about a month to work, approximately. With brexanolone, people experience a relief in symptoms within 48 hours," Byatt said.
A challenge with the drug is that it is administered by continuous intravenous infusion for 60 hours (2.5 days), and one of brexanolone's most common side effects is loss of consciousness. Those factors mean that patients receiving the drug must stay at an inpatient facility and be monitored throughout the infusion. Healthcare facilities administering the drug must become certified to do so by enrolling in a special program (called a Risk Evaluation and Mitigation Strategy), which ensures that they will train their staff to prescribe, dispense and administer the drug, counsel patients about its risks and monitor patients appropriately, according to the FDA. The drug's manufacturer, Sage Therapeutics, lists certified facilities on its website. As of July, 2021, there were 100 U.S. facilities certified to dispense the drug, according to the manufacturer's website. The need for certification currently limits access to brexanolone, but access is increasing as more and more healthcare facilities become certified to provide the drug, Byatt said.
Brexanolone is indicated for any adult with postpartum depression, according to its prescribing information. Contrary to what some people may believe, it is not a treatment of last resort, Byatt said. "A lot of times people think that it's for moderate to severe depression. It's not," she said.
Brexanolone may cause fetal harm, according to the drug's label, so it should not be used during pregnancy. It also should not be used in people with end stage renal disease.
Other ways to treat postpartum depression
There are a few things mothers can do at home to ease postpartum depression, such as getting as much rest as possible, asking for help when they need a break, and sharing their feelings with family and friends, the Office on Women's Health recommends. Obstetricians may also be able to recommend support groups for new mothers.
"I often recommend deep breathing, other exercises, [physical] exercise, nutrition, things like that — a lot of other adjunctive interventions to sort of enhance people's self care, enhance their wellness overall, and also their social connectedness," Byatt said. Doing these sorts of things can complement treatment with medication and therapy, she said.
How to get help
For people who fear they may hurt themselves or their baby, the APA recommends puting the baby in a safe place, such as a crib, and calling a suicide hotline or visiting the emergency room, and calling a friend or family member for help.
For people with depression whose symptoms are less severe, the APA recommends getting in touch with an OB-GYN or primary care physician who can then refer the person to a mental health professional. Another option is to call a support service such as Postpartum Support International (PSI), Byatt said. PSI is a nonprofit mental health organization that has a helpline people can call to get help accessing resources, ranging from support groups for mothers with postpartum depression to clinicians.
No matter the severity of the symptoms, people experiencing depression shouldn't wait to ask for help, Byatt said.