Postpartum depression symptoms:
When is it more than the "baby blues"?

© 2018-2019 Gwen Dewar, Ph.D., all rights reserved

black and white photo of mother lying in bed with newborn

Postpartum depression symptoms overlap with symptoms of the "baby blues," the mood swings that mothers experience in the first few days after childbirth.

But when symptoms persist beyond two weeks — or take a more severe turn — it's time to get screened for depression.

Here's what to look for.

Baby blues — also called "maternity blues" — are
a common experience in the first few days after childbirth. All around the
world — from Brazil to Hong Kong to Nigeria to Germany — between 33 to 55% of
women report feeling moody, vulnerable and stressed in the first few days after
childbirth (Faisal-Cury et al 2008; Hau and Levy 2003; Adewuya 2005; Reck et al 2015).

Is this postpartum depression?

The psychiatric profession tends to view baby blues as something different. Maybe that's because the baby blues are closely linked with the physical exhaustion and rapid hormonal changes that follow childbirth, and because women often experience improvements by two weeks postpartum.

But if you dig deeper, several points are clear.

1. The symptoms of the baby blues and postpartum depression
are pretty much the same, and largely overlap with the symptoms of depression
that women experience outside the context of childbirth (Hoertel et al 2015).

2. Some women experience severe postpartum depression
symptoms during the first two weeks — symptoms that seriously impact their
ability to function (Gonidakis et al 2007).

3. Women who experience baby blues during the first two
weeks are more likely, at a later time point, to get diagnosed with postpartum
depression (Reck et al 2009).

So it seems that the baby blues and postpartum depression are part of a continuum, with the term "baby blues" implying, "We think there's a good chance your symptoms will improve soon, as your body recovers from the chemical and physical effects of childbirth."

This happens for some women with the baby blues, but not for others. Their symptoms persist. And for some mothers, postpartum depression doesn't have baby blues as a prequel. Although they don't report experiencing the baby blues in the early days postpartum, they end up developing postpartum depression months later (Wisner et al 2013).

So what are the key symptoms?

Postpartum depression symptoms

  • sadness
  • fatigue, or a decrease of energy
  • impaired concentration and decision making
  • the inability to feel pleasure
  • a tendency to blame yourself, to feel guilty or worthless
  • sleep disturbances
  • agitation or restlessness
  • appetite disturbances or weight loss
  • recurring thoughts of self-harm

These are the nine symptoms of depression recognized by the American
Psychiatric Association (2013). This organization stipulates that you need to
experience at least 5 of them, on a nearly daily basis, to rate a diagnosis of
depression.

In addition, some researchers also add that sufferers might
experience

  • feelings of being overwhelmed or unable to cope well,

and studies indicate that postpartum women also tend to suffer from

  • increased anxiety or worry.

This last symptom isn't associated with depression in general (as defined by the American Psychiatric Association). But it very frequently accompanies postnatal depression.

Does sleep deprivation cause postpartum depression?

It certainly seems to be a contributing factor.

For example, when researchers reviewed 31 relevant studies, they found evidence that women who perceive poor sleep are more likely to develop symptoms of postpartum depression (Lawson et al 2015).

And research using objective measures of sleep are suggestive.

In one study, researchers monitored the sleep of 112 new mothers using wrist actigraphs — "fitbit"-like devices that provide an objective estimate of time spent sleeping.

The researchers found that the total number of hours slept didn't predict who would develop postpartum depression. But two other things did — naps, and whether or not parents got enough sleep between the crucial hours of midnight and 6 a.m.

Women who slept less than 4 hours between 12:00 p.m. and 6 a.m. were at increased risk for depression at 3 months postpartum.

In addition, new mothers were at increased risk if napped for less than 60 minutes during the day.

How can you judge the frequency and severity of your symptoms?

A quick and easy way is to use the Edinburgh Postnatal
Depression Scale, a 10 item multiple-choice questionnaire that asks you to think back
over the past week (Cox et al 1987; Wisner et al 2002).

Each item in the
questionnaire presents a statement that you quantify with an answer — choosing
whichever comes closest to representing your feelings over the last 7 days.

For example, if you were presented with a statement like
this:

"I have felt worthless or hopeless."

You would choose whichever of the following answer choices
came closest to representing your feelings over the last 7 days:

0 No,
not at all

1 Hardly ever

2 Yes, sometimes

3 Yes,
very often

As you can see, each answer choice is associated with a
certain number of points. After you have answered all the questions, you tally
up the points and see if they exceed a given threshold.

If they do, you have screened positive for postpartum
depression. This isn't the same as a diagnosis. A diagnosis is made by a
qualified physician or therapist, using information that goes beyond the
questionnaire. But it's an indication that you have many of the signs.

Below, you will find a reproduction of the scale that you can use to test yourself. When calculating your score, please note that some questions are reverse-scored (with the top answer choice scored as a 3 and the bottom answer choice scored as a 0).

The Edinburgh Postnatal Depression Scale

In the past 7 days:

1. I have been able to laugh and see the funny side of
things

0 As much
as I always could

1 Not
quite so much now

2 Definitely
not so much now

3 Not at
all

2. I have looked forward with enjoyment to things

0 As much
as I ever did

1 Rather
less then I used to

2 Definitely
less than I used to

3 Hardly
at all

3. I have blamed myself unnecessarily when things went wrong

3 Yes,
most of the time

2 Yes,
some of the time

1 Not very
often

0 No,
never

4. I have been anxious or worried for no good reason

0 No, not
at all

1 Hardly
ever

2 Yes,
sometimes

3 Yes,
very often

5. I have felt scared or panicky for no very good reason

3 Yes,
quite a lot

2 Yes,
sometimes

1 No, not
much

0 No, not
at all

6. Things have been getting on top of me

3 Yes,
most of the time I haven't been able to cope at all

2 Yes,
sometimes I haven't been coping as well

1 No, most
of the time I have coped quite well

0 No, I
have been coping as well as ever

7. I have been so unhappy that I have had difficulty
sleeping

3 Yes,
most of the time

2 Yes,
sometimes

1 Not very
often

0 No, not
at all

8. I have felt sad or miserable

3 Yes,
most of the time

2 Yes,
quite often

1 Not very
often

0 No, not
at all

9. I have been so unhappy that I have been crying

3 Yes,
most of the time

2 Yes,
quite often

1 Only
occasionally

0 No,
never

10. The thought of harming myself has occurred to me

3 Yes,
quite often

2 Sometimes

1 Hardly
ever

0 Never

So what score is required to screen positive for postpartum depression?

There isn't any universally accepted, magic number.

Suggested cutoffs have ranged between 9 and
13 points, but a doctor may diagnose you with PPD even if you have a lower
score. The Edinburgh Postnatal Depression Scale isn't intended as a complete
inventory of postnatal depression symptoms. Your doctor may decide you have
additional symptoms or risk factors, and make his or her diagnosis accordingly.

And one question it does ask merits a closer look no matter
what: Thoughts of violence or self-harm
warrant a follow-up regardless of your overall score.

What about men? Can fathers get postpartum depression?

Fathers are subjected to many of the same stressful life changes that cause postpartum depression in women, so it's not unusual for them to get depressed too.

The latest studies suggest that somewhere between 7 and 10% of men experience symptoms depression during the transition to parenthood (Cameron et al 2016).

When do postpartum depression symptoms go away?

That varies from person to person, but we know there are certain risk factors for prolonged bouts of depression.

In a recent study, Sheehan Fisher and her colleagues tracked more than 500 women with postpartum depression, beginning at 4-8 weeks after childbirth.

Approximately half the women experienced gradual improvements over time, reaching full remission by 12 months postpartum.

But about 40% of the women were still at least mildly depressed at 12 months. And the remaining 8% showed a pattern of chronic, severe depression: Their symptoms worsened between childbirth and 3 months postpartum, and remained severe at 12 months postpartum.

Were there any systematic differences between these women — risk factors that marked them from the beginning? Fisher's team identified several.

Risk factors for postpartum depression symptoms lasting beyond 12 months (Fisher et al 2019)

Depression combined with anxiety. Women whose early symptoms included anxiety had about twice the odds of remaining depressed throughout the first year.

Physical abuse in adulthood. The odds were also doubled for women who had survived physical abuse as an adult. Childhood abuse was not linked with a heightened risk for long-term postpartum depression.

Chronic illness. Women struggling with chronic illness were more likely to suffer from postpartum depression at 12 months.

Having more than one child. For each additional child that a woman had, her risk of long-term depression was increased.

Global functioning (handling daily tasks, work, social relationships). The more difficulty women had with global functioning at the beginning of the study, the more likely they were to experience postpartum depression symptoms at 12 months.

Severity of symptoms. Sadly, severe postpartum depression symptoms in the early weeks increased the likelihood that a woman would experience continued, severe symptoms at 12 months.

But it's crucial to understand that all of these risk factors don't mean you're helpless. If you take action, and get help, you can improve. And the sooner the better.

For example, the news about severe postpartum depression seems disheartening. But when Fisher and her colleagues delved deeper, they identified a telling pattern: Women who experience early, severe symptoms take longer to seek help (Fisher et al 2019).

More information about coping during the postpartum phase

See my articles about postpartum stress and childbirth trauma.

References: Postpartum depression symptoms

The Edinburgh Postnatal Depression Scale was designed by John Cox and Jenni Holden and is discussed in these papers:

Cox JL, Holden JM, and Sagovsky R. 1987. Detection of
postnatal depression: Development of the 10-item Edinburgh Postnatal Depression
Scale. British Journal of Psychiatry 150: 782-786.

Wisner KL, Parry CM, and Piontek CM. 2002. Postpartum
Depression. New England Journal of Medicine 347: 194-199.

Other research cited in this article about postpartum depression symptoms follows.

Adewuya AO. 2005. The maternity blues in Western Nigerian
women: prevalence and risk factors. Am J Obstet Gynecol. 193(4):1522-5.

American Psychiatric Association. 2013. Diagnostic and
statistical manual of mental disorders, 5th ed., (DSM-5). Washington, DC:
American Psychiatric Publishing.

Bernstein IH, Rush AJ, Yonkers K, Carmody TJ, Woo A,
McConnell K, Trivedi MH. 2008. Symptom features of postpartum depression: are
they distinct? Depress Anxiety. 25(1):20-6.

Cameron EE, Sedov ID, Tomfohr-Madsen LM. 2016. Prevalence of
paternal depression in pregnancy and the postpartum: An updated meta-analysis. J
Affect Disord. 206:189-203.

Faisal-Cury A, Menezes PR, Tedesco JJ, Kahalle S, Zugaib M.
2008. Maternity "blues": prevalence and risk factors. Span J
Psychol. 11(2):593-9.

Fisher SD, Sit DK, Yang A,
Ciolino JD, Gollan JK, Wisner KL. 2019. Four maternal
characteristics determine the 12-month course of
chronic severe postpartum depressive symptoms.
Depress Anxiety. 2019 Jan 15. doi: 10.1002/da.22879.

Gonidakis F, Rabavilas AD, Varsou E, Kreatsas G,
Christodoulou GN. 2007. Maternity blues in Athens, Greece: a study during the
first 3 days after delivery. J Affect Disord. 99(1-3):107-15.

Goyal D, Gay C, Lee K. 2009. Fragmented maternal sleep is
more strongly correlated with depressive symptoms than infant temperament at
three months postpartum. Arch Womens Ment Health. 12(4):229-37.

Hau FW and Levy VA. 2003.
The maternity blues and Hong Kong Chinese women: an exploratory study. J
Affect Disord. 75(2):197-203.

Hoertel N, López S, Peyre H, Wall MM, González-Pinto A,
Limosin F, Blanco C. 2015. Are symptom features of depression during pregnancy,
the postpartum period and outside the peripartum period distinct? Results from
a nationally representative sample using item response theory (IRT). Depress
Anxiety. 32(2):129-40.

Lawson A, Murphy KE, Sloan E, Uleryk E, Dalfen A. 2015. The
relationship between sleep and postpartum mental disorders: A systematic review.
J Affect Disord. 176:65-77.

O'Hara MW and McCabe JE. 2013. Postpartum depression: current
status and future directions. Annu Rev Clin Psychol. 9():379-407.

O'Keane V, Lightman S, Patrick K, Marsh M, Papadopoulos AS,
Pawlby S, Seneviratne G, Taylor A, Moore R. 2011. Changes in the maternal
hypothalamic-pituitary-adrenal axis during the early puerperium may be related
to the postpartum 'blues'. J Neuroendocrinol. 23(11):1149-55.

Myers S, Johns SE. 2018. Postnatal depression is associated
with detrimental life-long and multi-generational impacts on relationship
quality. PeerJ. 6:e4305.

Pearson RM, Bornstein MH, Cordero M, Scerif G, Mahedy L,
Evans J, Abioye A, Stein A 2016. Maternal perinatal mental health and offspring
academic achievement at age 16: the mediating role of childhood executive
function. J Child Psychol Psychiatry. 57(4):491-501.

Reck C, Stehle E, Reinig K, Mundt C. 2009. Maternity blues
as a predictor of DSM-IV depression and anxiety disorders in the first three
months postpartum. J Affect Disord. 113(1-2):77-87.

Surkan PJ, Kennedy CE, Hurley KM, Black MM. 2011. Maternal
depression and early childhood growth in developing countries: systematic
review and meta-analysis. Bull World Health Organ. 89(8):608-15.

Taraban L, Shaw DS, Leve LD, Natsuaki MN, Ganiban JM, Reiss
D, Neiderhiser JM. 2018. Parental Depression, Overreactive Parenting, and Early
Childhood Externalizing Problems: Moderation by Social Support. Child Dev. 2018
Feb 20. doi: 10.1111/cdev.13027. [Epub ahead of print]

Wisner KL, Sit DK, McShea MC, Rizzo DM, Zoretich RA, Hughes
CL, Eng HF, Luther JF, Wisniewski SR, Costantino ML, Confer AL, Moses-Kolko EL,
Famy CS, Hanusa BH. 2013. Onset timing, thoughts of self-harm, and diagnoses in
postpartum women with screen-positive depression findings. JAMA Psychiatry.
70(5):490-8.

Content of "Postpartum depression symptoms" last modified 1/2019

Title image of mother with newborn by Matt Johnson/flickr

Tired mother peering at newborn's face by george ruiz /flickr


Original Article