Postpartum blues, a mild and transient depression in the immediate postpartum period, occur in up to 70% to 85% of new mothers [3,132]. The condition is characterized by mild dysphoria, with symptoms such as tearfulness, fatigue, sleep disturbances, and physical exhaustion, that lasts a few days following delivery. The majority of women experiencing postpartum blues recover spontaneously within three to five days [3,4,132].

PPD occurs in approximately 10% to 20% of new mothers [3,5,93,132]. According to multiple studies, PPD occurs at the same rate in new mothers around the world [6]. There is little evidence to suggest that any country or class of persons is not at risk for PPD. Symptoms usually occur shortly after childbirth but may occur as late as one year after delivery. PPD is a serious, long-lasting type of depression in women that can have harmful consequences for the mother and child if undetected and untreated [3].

The third type of postpartum mental disturbance, postpartum psychosis, occurs in 1 to 2 of every 1,000 new mothers [8,9]. If undetected and untreated, postpartum psychosis presents a danger to both the life of the mother and her infant. Infanticide is rare but does occur in 1 of 250,000 women with postpartum psychosis [10]. Among patients with postpartum psychosis, an estimated 4% will attempt infanticide and 5% will attempt suicide [9].

Documentation of PPD can be traced to the writings of Hippocrates in the fourth century B.C.E. Hippocrates described melancholia as a state of "aversion to food, despondency, sleeplessness, irritability, and restlessness" [6]. Galen (131–201 C.E.) described melancholia as "fear and depression, discontent with life, and hatred of all people" [6]. Greco-Roman medicine recognized melancholia in the form of fear, suspicion, aggression, and suicidal thoughts. In 1436, the life story of a young mother was published and described how she felt "insane" and despaired of her life and survival after the birth of her first child [11].

In the last decade, greater emphasis has been placed on the role of a woman's brain chemistry in the development of depression in the postpartum period. As noted, the DSM-5-TR, published by the American Psychiatric Association, does not recognize PPD as a distinct entity. Instead, patients must meet the criteria for a major depressive episode and the criteria for the peripartum-onset specifier (onset during pregnancy or in the four weeks following delivery) [14,15,47]. Limiting the onset of symptoms of depression to within four weeks postpartum has been considered too restrictive by some researchers and clinicians [2]. Postpartum Support International has argued that the timeframe should be extended to six months postpartum. Debate continues regarding how PPD fits into the larger classification of depressive disorders [16,17,47].

Although PPD occurs worldwide, cultural differences can influence the perception of depression in women. Culture influences the expression and interpretation of symptoms, the definition of stressors, the nature of the social support system, and the relationship between healthcare provider and patient. Culture also dictates whether certain expressions of symptoms are socially acceptable. An individual's view of illness and health is also culturally bound. Displays of emotion may be encouraged in some cultures and discouraged in others [27].

PPD affects women of all ages, economic statuses, and racial/ethnic backgrounds. Any woman who is pregnant or has given birth can develop PPD. Whether the birth is a first child or one of multiple births has not been shown to affect the incidence of PPD. However, women with a history of depressive episodes have a greater risk for developing PPD than women with no prior history of depression. The risk of PPD is highest in women younger than 25 years of age with a prior history of mood instability. Among these women, it is estimated that 30% to 40% will have a postpartum episode of depression [30,70]. There are additional risk factors evident prior to pregnancy that may increase the chances of developing PPD, including [5,30,70]:

Treating depression during pregnancy is a challenge because the vast majority of antidepressants cross the placenta and can have negative effects on fetal development. Psychiatrists, family practice physicians, and obstetricians may find themselves in a dilemma when diagnosing and treating depression in pregnant patients. As previously noted, the onset of depression may not become evident until symptoms become severe due to the similarity of depressive symptoms and neurovegetative signs during pregnancy [33]. Although diagnosis and treatment pose a serious challenge, early recognition, diagnosis, and treatment are warranted [33]. Indication of certain risk factors that may contribute to depression during pregnancy can be helpful in a prenatal assessment. Risk factors for an onset of depression during pregnancy include [5,33,70]:

Risk factors for PPD following the birth of a baby are similar to those present prior to conception and during pregnancy. Any combination of the following factors should be considered concerning, as it indicates a potential to develop PPD [5,34,70]:

The areas of the brain affected by female reproductive hormones (i.e., estrogen and progesterone) are the same as those known to regulate mood stability and behavior. Therefore, it may be concluded that different hormonal circumstances can alter mood and anxiety in a woman [13]. There are several events associated with a woman's reproductive cycle that provoke mood instability in predisposed individuals, including the use of oral contraceptives, phases of the menstrual cycle, pregnancy and the postpartum period, and menopause. The vulnerability of women for mood instability bears some relationship to the fluctuation of ovarian steroids during specific phases of the reproductive cycle [36,37].

The areas of the brain associated with anxiety and mood disorders are the limbic brain and the cortex. The paralimbic cortex is the first layer of the cortex that surrounds the limbic brain. The cingulate gyrus is a part of the limbic brain that is believed to be involved in autonomic motor function, mood regulation, and the maternal bonding process. It works collaboratively with other structures of the limbic brain. The instinct for mothering, nurturing, and the emotional responses of the mother toward her infant emanate from the cingulate gyrus area of the brain. This area has evolved to allow for the development of bonding behavior between mother and infant, thus assuring the attachment process [13].

Every significant event in life is accompanied by emotions. These events are thus emotional experiences that are "recorded" in the brain. The "emotional brain" is thought to consist of the prefrontal cortex, which is the area located directly above the eyes, and the frontal cortex. The prefrontal cortex is significantly involved with developing judgment [13]. Sichel and Driscoll refer to the connections between the limbic brain, the paralimbic brain, and the prefrontal cortex as the "prefrontal limbic complex" [13]. This complex has a large role in processing emotions, regulating mood, and storing memories. The memories of powerful life experiences, both stressful and pleasurable, are stored in this area of the brain.

Although there are numerous neurotransmitters, those that primarily affect anxiety and mood are dopamine, serotonin, norepinephrine, gamma-amino butyric acid (GABA), and glutamate. Together, these neurotransmitters regulate thinking, emotions, and behavior. Dopamine is involved in learning, memory, and emotional arousal. Norepinephrine is a hormone similar to adrenaline that is released during stress. A lack of norepinephrine may be associated with depression [38]. An excess of norepinephrine can produce agitation or irritability, which also frequently accompanies depression. GABA regulates how fast messages are sent along the nerve cells and helps to maintain a steady rhythm. Excessive stimulation of nerve cells produces a sense of anxiety [34].

Serotonin is a neurotransmitter known to be involved in mood and anxiety disorders. It is one of the major classes of chemical messengers known as monoamines and is associated with the induction of emotional calmness and the perception and regulation of pain, restful sleep, sexual behavior, and appetite control. A person's general level of well-being depends largely on his or her levels of serotonin [19].

Women have a greater lifetime risk than men for depression, with two times the incidence of depressive episodes or recurrent depression [43,44]. Because higher risk is correlated with gender, it is highly likely that reproductive hormones in women play a role in mood instability [43,44].

Sichel and Driscoll believe that estrogen may act within the brain as a natural antidepressant and mood stabilizer [13]. When estrogen levels drop, as they do after childbirth, this effect would presumably be reversed. Fluctuations of estrogen levels at any point during a woman's reproductive cycle can disrupt the delicate balance of neurotransmitters and affect a woman's mood stability. Thus, under normal circumstances, estrogen could be regarded as protecting women against depression [46].

Progesterone is produced during the second phase of the menstrual cycle and functions to dismantle the nerve connections established by estrogen, decreasing the number of available estrogen receptors [13]. Like estrogen, progesterone is also available in large quantities during pregnancy and drops significantly after childbirth.

In pregnant patients, placental hormones stimulate the production of cortisol, the level of which remains high until the placenta is delivered. There is conflicting evidence regarding the role of cortisol levels in PPD [52,53,54]. Discrepancies in the studies of cortisol and PPD may result from the lack of control for variables that influence cortisol levels, such as stressful life events. However, it is possible that the sustained high levels, and subsequent drop, of cortisol may have an effect on mood stability in the postpartum period. Some have suggested that women for whom cortisol levels remain higher after delivery of the placenta may have a greater risk of developing PPD [52].

Approximately 5% to 7% of postpartum women have abnormal thyroid levels [55,56]. Thyroid dysfunction is associated with depressed mood, and in one study, having a thyroid-stimulating hormone (TSH) level greater than 4.0 mU/L at delivery was associated with increased risk for depressive symptoms at six months postpartum [42,57,58,59]. Thyroid dysfunction has not been consistently identified in PPD; however, there may be a subgroup for whom it does play a role.

Some families appear to be more prone to depressive illness than others [13]. Therefore, a woman's genetic makeup may be a risk factor for PPD. A detailed family history specifically documenting incidences of depression or mental illness is useful in any PPD assessment.

With this in mind, certain traits are possible indicators of disturbances in brain chemistry and mood instability in some individuals [30]. Some important traits that may become evident when taking a patient's history include:

The brain's mood pathways can presumably be restored to normal following one depressive event without any further episodes, assuming that the depression is treated aggressively and appropriately. However, research has shown that 70% of those who become depressed will have another depressive episode [13,62].

It is observed that women with PPD do not experience the initial stages of motherhood as they had fantasized; consequently, their disappointments are more intense and severe. Women with postpartum blues or depression may seem unable to deal with disappointments with equanimity. When a woman is already biochemically predisposed to depression, unfulfilled expectations, unanticipated losses, and/or lack of social support create the potential for PPD to develop. For a woman with PPD, disappointments will be felt more intensely and with a greater degree of emotional sensitivity and self-criticism [63].

The psychologic impact of infertility may also play a role in the development of depression in some women. Impaired fertility affects approximately 13.4% of women of childbearing age in the United States [67]. Studies of women receiving fertility treatments have shown that these women generally had less satisfaction with life, higher levels of anxiety, and tested higher on the depression scores than women who were fertile [19]. Infertility had an impact on sexuality and self-esteem, and women being treated for infertility were likely to blame themselves and to avoid contact with friends [68]. Women receiving, or who have received, fertility treatments require compassion, understanding, and support. Treatments can take considerable time and require a woman to deal with the emotional and mental consequences of hope and loss. Fertility medications themselves, which generally act on the pituitary gland, may disrupt mood stability [19].

Postpartum blues, also referred to as "baby blues," is the most common type of postpartum mood disturbance, occurring in approximately 70% to 85% of all new mothers [3,70,132]. Its onset is usually shortly after birth, and it generally resolves within 10 days [2,3]. A study by Iles et al. indicated a characteristic pattern of mood changes that peaked on day 5 after delivery and declined by day 10, perhaps best described as a period of emotional upheaval following birth [71]. Incessant crying and tearfulness are the most common emotional expressions of postpartum blues [2,3].

Postpartum blues, also referred to as "baby blues," is the most common type of postpartum mood disturbance, occurring in approximately 70% to 85% of all new mothers [3,70,132]. Its onset is usually shortly after birth, and it generally resolves within 10 days [2,3]. A study by Iles et al. indicated a characteristic pattern of mood changes that peaked on day 5 after delivery and declined by day 10, perhaps best described as a period of emotional upheaval following birth [71]. Incessant crying and tearfulness are the most common emotional expressions of postpartum blues [2,3].

As discussed, incessant crying and tearfulness are the most common emotional expressions of the postpartum blues. The tearfulness is not necessarily linked to sadness, but occurs in response to numerous environmental triggers, such as insufficient milk production, too much or too little attention from nurses, or a sarcastic remark [10]. Essentially, an emotional oversensitivity exists. All of the emotions associated with childbirth are normal and healthy so long as they are not excessive and resolve within one to two weeks [10]. The signs and symptoms of postpartum blues include [10,13,72]:

Emotional Symptoms

Physical Symptoms

An estimated 10% to 25% of women experiencing the transient state of postpartum blues will subsequently become seriously depressed [2,3,78]. The development of a more serious depression involves psychologic and psychosocial factors that are not prevalent in the development of the postpartum blues. An early warning sign for more serious depression is feeling overwhelmed combined with suicidal ideation; this should not be ignored. Feeling overwhelmed is normal after childbirth, but feeling suicidal is not. Being overwhelmed and/or distressed for longer than two weeks should be a warning signal that the patient requires an evaluation for depression.

With an annual live birth rate of nearly 3.7 million in the United States each year, an estimated 555,000 women experience PPD in the United States [79]. Women who miscarry or whose children are stillborn are also susceptible to PPD. When this group is included in the figures, an estimated 830,000 women suffer from PPD each year [51,80]. Several studies have shown that PPD occurs with greater frequency in the first 3 months following childbirth than in the 6 or 12 months following [81]. Although exact percentages vary, it has been reported that between 40% to 90% of PPD cases occur within three months after childbirth. Nonetheless, women should be carefully assessed throughout the first year after childbirth, as PPD can occur up to one year postpartum [66,70].

Women for whom PPD is their first incidence of depression tend to experience a shorter duration of symptoms, be significantly less likely to experience recurrent depression outside the postpartum period and be more likely to experience subsequent PPD [66]. Whether PPD is determined to be the first episode of depression may depend upon the clinician's history-gathering skills. Many women who are diagnosed with PPD as a first episode of depression may realize, upon careful examination, that they have experienced depressive symptoms in the past, although the symptoms may never have been diagnosed as depression [13,82].

The physical manifestations of PPD are diverse and include [2,3,5,13,82]:

When PPD affects cognitive abilities, it may present as [2,3,10,82]:

Irritability is one of the main mood changes most women experience with PPD. This type of irritability is characterized by emotional swings from anger to distress. Frequently, attacks of irritability end with uncontrollable sobbing. Mothers find that this irritability is out of their control, which adds to the distress [3,10]. If the irritability continues, it can make dealing with the tasks of caring for an infant very difficult and can damage other relationships. Irritability may be expressed either verbally or through physical violence. Mothers may describe themselves as intolerant, impatient, jittery, short-tempered, spiteful, or quarrelsome. Irritability varies in its intensity among women with PPD and may develop in the weeks to months after childbirth.

All new mothers experience a change in sleep patterns. Due to the baby's presence and the need for feedings during the night, most new mothers suffer from some degree of sleep deprivation. There is a different quality to sleep problems in women with PPD. These women have difficulty getting to sleep, have disturbed sleep, and/or wake early and are unable to go back to sleep. Insomnia is a common complaint. Even when they do sleep, it is never enough; the sleep is not refreshing. Five hours of solid sleep is often recommended; however, women with PPD are rarely able to sleep for that length of time. It is usual for new mothers to have their sleep interrupted by a crying baby, but women with PPD report that they cannot go to sleep even when the baby is settled and goes to sleep. They may lie awake worrying. Although rare, some women with PPD report sleeping too much [2,82].

One of the most prominent features that a woman with PPD experiences is that somehow she is not worthy of having a child; she may feel that because of the depressive symptoms, she is a bad mother. These thoughts may cause an individual to detach herself, in an effort to hide perceived inadequacies from others. Women who believe that they are "bad mothers" also have significant feelings of guilt. There is an accompanying loss of self-confidence in other areas of life that is difficult to shake. These women may have excessive guilt about any minor wrongs committed in the past [2,69].

Postpartum psychosis is an extreme condition that can occur during the postpartum period. The term "psychosis" is defined as a mental state characterized by being out of touch with reality [2]. Postpartum psychosis affects approximately 1 or 2 in 1,000 first-time mothers [3,15]. For women who experience psychosis after the birth of their first child, the risk increases by 50% for subsequent deliveries [15]. The major risk factors for postpartum psychosis are a personal history of PPD or psychosis, a family history of depression, or the presence of bipolar disorder [3,15,43,69]. One study found that nearly 10% of women hospitalized for psychiatric conditions before delivery went on to develop postpartum psychosis after their first child was born [83]. When it does occur, psychosis in a new mother constitutes a psychiatric emergency, requiring immediate treatment and, in many cases, psychiatric hospitalization.

Postpartum psychosis is an extreme condition that can occur during the postpartum period. The term "psychosis" is defined as a mental state characterized by being out of touch with reality [2]. Postpartum psychosis affects approximately 1 or 2 in 1,000 first-time mothers [3,15]. For women who experience psychosis after the birth of their first child, the risk increases by 50% for subsequent deliveries [15]. The major risk factors for postpartum psychosis are a personal history of PPD or psychosis, a family history of depression, or the presence of bipolar disorder [3,15,43,69]. One study found that nearly 10% of women hospitalized for psychiatric conditions before delivery went on to develop postpartum psychosis after their first child was born [83]. When it does occur, psychosis in a new mother constitutes a psychiatric emergency, requiring immediate treatment and, in many cases, psychiatric hospitalization.

Women are seven times more likely to be hospitalized for a psychotic episode during the first month after delivery than at any other time before or after childbirth [69]. For women with a history of postpartum psychosis, the risk of psychiatric hospitalization after childbirth is increased [8]. One-half of all patients with psychosis are admitted to a psychiatric hospital within 14 days of delivery [13]. In one study, 90% of women with postpartum psychosis had an onset of symptoms within four weeks of delivery [83]. In most women, symptoms develop within the first two weeks postpartum [3].

Postpartum psychosis is characterized by hallucinations, delusions, confusion, extreme agitation, inability to carry on a coherent conversation, and inability to sleep or eat [3,69]. Moods may swing from euphoria to homicidal or suicidal ideation in a short period of time without warning. The risk of suicide or infanticide requires immediate attention. Safeguards should be established to protect the mother from harming herself or her baby until psychiatric intervention becomes available [13]. Irrationality is the hallmark of postpartum psychosis, and a mother's behavior may be peculiar or described as bizarre. She may engage in frenzied activities, as though in response to stimuli not apparent to anyone other than herself [10].

Another symptom of psychosis is confusion or disorientation [69]. Confusion is defined by a lack of awareness of identity, surroundings, or time. Disorientation, on the other hand, is characterized by forgetfulness from one moment to the next. If confusion and disorientation are present, organic brain conditions should be ruled out. An acute organic brain condition is a medical emergency and should be diagnosed and treated immediately. Generally, when the condition is corrected, the symptoms will resolve [2]. As with the onset of any psychotic or delirious symptoms, toxic, metabolic, and neurologic causes should be ruled out. Toxic delirium and psychosis may present with similar symptomatology [8,86].

Relatives and friends should be warned of the possibility of psychosis returning even if a mother is treated in a psychiatric hospital and released. There is a danger of psychosis returning at the resumption of menstruation, even if the mother is undergoing continuous psychiatric outpatient treatment. Twenty-four hour surveillance is necessary at this vulnerable time [3,10].

In general, healthcare professionals should be alert for early signs of psychosis, such as agitation, hyperactivity, or restlessness following delivery [69]. Suspicious, paranoid ideations might manifest as a certainty that there is something seriously wrong with the baby or that nurses are hurting or trying to poison the baby. These symptoms are usually indicators that the mother is in the early phases of a psychosis; they should be reported immediately to facilitate a psychiatric consultation [10].

Data from the Centers for Disease Control and Prevention (CDC) and other studies indicate that 10% to 20% of new mothers suffer from PPD, and up to 85% experience postpartum blues [92,93,94,95]. A 2017 study found a decline in PPD from 14.8% in 2004 to 9.8% in 2012 [230]. The rate of depressive disorders diagnosed at the time of delivery increased from 4.1 per 1,000 hospitalizations in 2000 to 28.7 per 1,000 hospitalizations in 2015 [231]. The CDC has therefore recommended that healthcare providers address the issue of PPD during prenatal visits, preferably during the third trimester [92]. Other sources, including the U.S. Preventive Services Task Force (USPSTF), recommend assessing for depression throughout the prenatal period [94,96]. The USPSTF has stated that screening pregnant and postpartum women for depression may reduce depressive symptoms in women and that screening instruments can identify pregnant and postpartum women who need further evaluation and who may need treatment [94]. The screening should be implemented with adequate systems in place to ensure accurate diagnosis, effective treatment, and appropriate follow-up [94,97].

Both the USPSTF and the American College of Obstetricians and Gynecologists recommend that assessment for depression using a standardized, validated tool occur at least once during the perinatal period [94,97]. Women with current depression or anxiety, a history of perinatal mood disorders, or risk factors for perinatal mood disorders should receive close monitoring, evaluation, and assessment [97]. Women most likely to suffer from PPD often describe pregnancy as "one of the worst times of my life" or a "very hard time" [98]. In order to avoid a delay in learning about a woman's problems caring for the baby or herself, a plan for early detection of women at risk for PPD should be in place [94,97].

The EPDS is limited to certain depressive symptoms and does not evaluate a woman's exhaustion, irrational irritability, or thoughts of harming her baby. These symptoms should be examined during a clinical assessment by asking specific questions relevant to these areas. Nonetheless, the EPDS is the most widely used screening tool available to detect PPD [10]. Given prenatally, the EPDS has been shown to effectively identify women at risk for PPD [102]. The EPDS may be accessed online at http://www.fresno.ucsf.edu/pediatrics/downloads/edinburghscale.pdf.

The test yields an overall severity score falling into three ranges:

The occurrence of PPD raises concerns about the quality of the mother-infant relationship and the potential impact of a mother's depression on the infant. One important aspect of the mother-infant relationship is a mother's adjustment to her baby and her understanding of her infant's needs and communications. When a mother's depression interferes with her sensitivity to her baby, their interactions can have a negative effect on the child [106,107].

Bonding, in actuality, is a process of closeness, comfort, and familiarity that develops over time [19]. When the process of bonding with an infant is disrupted, it can have long-term consequences for the future relationship between mother and child. The delay in developing attachment may be unusually prolonged and delayed with a clinically depressed mother. This attachment difficulty may take different forms. The mother may not be nurturing to the infant, or she may have limited interaction with the infant. In some cases, the depressed mother may reject her baby emotionally and refuse to have anything to do with the infant. The mother may have an adverse sentiment towards the baby and handle the baby with irritability. Depressed mothers may also be outwardly angry or resentful toward the infant. Some mothers are so consumed with fears of harming their child that they avoid even touching him or her. All of these emotions and attitudes toward the child affect the process of attachment [2,109].

Klier and Muzik describe the role of perinatal psychiatry in maternal-infant bonding issues [110]. They classify the disorders of mother-infant bonding into three groups [110]:

Researchers of infant behavior have come to acknowledge that the establishment of social relationships is a primary process of development. When a child successfully accomplishes communication with others, normal development occurs. A child who does not engage the world successfully will not develop normally, regardless of the source of the failure. Success or failure depends upon three critical processes [112]:

These processes make up what is called "mutual regulation," which is the capacity of both the mother (or other caregiver) and infant to express their intentions, appreciate the intentions of the other, and allow each other to achieve their goals [112].

Studies have shown that when the mother is depressed, a break in the mutual regulatory system occurs [114]. Depressed mothers disrupt the interaction in two distinct ways: intrusiveness and withdrawal. It has been reported that intrusive mothers with PPD engaged in rough handling, spoke in an angry tone of voice, and interfered with their infants' activities. Withdrawn mothers, by contrast, were disengaged, unresponsive, and affectively flat and did little to support their infants' activities.

Both disruptions have a deleterious effect on the infant's development [112]. The infants of intrusive mothers eventually adopt an angry and protective style of coping, which is used defensively in anticipation of the mother's behavior. Infants of withdrawn mothers attempt to regulate their own emotional states. They may fail at social connectedness due to the mother's lack of response. Eventually, the infant will attempt to regulate their affective states, resulting in passivity and withdrawal [115]. Infants of either intrusive or withdrawn mothers develop a negative affective core characterized by anger and sadness, a representation of the mother as unresponsive and untrustworthy, and a representation of themselves as ineffective and helpless. This does not lead to successful normal development unless some intervention changes the mother's interaction style [112,115,116].

A mother's unresponsiveness or inappropriate parenting during infancy may prevent the child from achieving the developmental goals of social interaction and object exploration. If an infant learns that a parent is unavailable and unreliable, it interferes with the infant's development of a sense of mastery and control over events; the infant develops a sense of helplessness and hopelessness [112]. Infants eventually become aware of their mothers' anger, sadness, or hostility and begin to react to their parents' state of mind. Infants also must cope with their own sadness, anger, and apprehensiveness. Tronick and Weinberg speculate that infants become hypervigilant of their mothers' emotional state in order to protect themselves [112]. They must also protect themselves from their mother's responses by disallowing a high level of emotional arousal. Therefore, they become emotionally constricted. One study has indicated that, at the end of the first year, infants of depressed mothers express less intense emotional reactions to stressful situations and are less emotionally responsive than infants of nondepressed mothers. These early patterns can lead to the development of pathologic methods of coping [112,115].

Kurstjens and Wolke found that long-term effects may be present when a mother's depression is chronic [123]. In the postpartum period, chronic depression in mothers may make infants more vulnerable to negative outcomes; short-lived depressions may have fewer consequences for the quality of the mother-infant relationship and for infant development. It is thought that short-lived PPD with an onset in the first few weeks postpartum and resolution by four to five months should have less of an impact on the quality of the attachment than depressions lasting six months or longer [123]. A longitudinal study of 296 mother-child dyads found that maternal depression at 30 to 90 days postpartum and at 12 months was significantly associated with the language development of infants at 12 months of age, with the impact correlated with the duration of the mother's depression [95].

A study has been completed assessing the long-term effects on the children of mothers who were depressed three months postpartum [126]. In a community sample from two general practices in London, 149 women were given psychiatric interviews at three months after childbirth, and 89% of their children were assessed at 11 years of age. The children of women who were depressed at three months postpartum suffered attention deficit problems, difficulty with mathematics, and were more likely than other children to have special educational needs. The cognitive deficits present at 11 years of age may be a result of the quality of the infant's social environment in the first three months of life. Problems were noted in the children whether or not the mothers' depression continued beyond three months. Boys were more severely affected than girls. These effects on cognitive development were not altered by the parent's intelligence quotient (IQ) or socioeconomic status, or by the mother's later mental health problems. In this study, PPD was a risk factor for children's subsequent cognitive and behavioral problems. These findings demonstrate a long-term legacy of PPD that continues to affect children's intellectual development into adolescence [126]. Subsequent studies have reported similar findings [127,128,129].

PPD puts a strain on marital relationships. According to Dalton and Horton, PPD is a significant medical cause of marital and relationship breakdown [10]. This is especially true when a woman's depression is untreated and/or chronic. Marital conflict and dissatisfaction are generally common in the first year after childbirth; PPD intensifies stress on the relationship during this period. Support from the baby's other parent or a partner is critical to a woman's recovery from PPD and may act as a buffer to the mother-infant interaction. Most partners do offer support to women coping with PPD. However, as the effects of depression multiply, they may become impatient or frustrated by the extra burden. In some cases, husbands or partners may be unsupportive or become verbally abusive, intentionally or unintentionally. Even when a husband or partner is supportive, the woman may feel, due to her depression and feelings of being overwhelmed, that it is not enough [63]. Lack of communication and misunderstandings of feelings, behavior, and attitudes are common occurrences. Each partner perceives the other as being uninterested in his or her activities. Given that women with PPD are often preoccupied and withdrawn, these problems may not be resolved, and miscommunication can grow. Women may feel ashamed to ask for help, which can create a strain in the relationship [63].

Three areas have been identified as the most affected: the need for practical support, emotional needs, and sexuality. These are complex issues that should be dealt with, and most couples struggle to resolve conflicts in these areas. Assistance from health or mental health professionals may be needed and has shown to be helpful to women with PPD and their husbands or partners [63].

Statistics show that psychiatric disorders, and specifically suicide, account for 20% to 30% of all maternal deaths [93,130]. A study of Danish women published in 2016 indicated that unnatural maternal causes of death (e.g., suicides, accidents, homicides) accounted for 40.6% of fatalities among women with identified psychiatric illness within one year of childbirth [131]. In the United States, suicide is considered the greatest cause of maternal mortality in the year following childbirth [93,130].

Eight out of ten suicidal persons give some sign of their intentions [138]. Persons who talk about suicide, threaten to attempt suicide, or call suicide crisis centers are 30 times more likely to attempt suicide than those that do not [138]. Although not all suicidal individuals indicate their plans, nearly three-fourths of all persons who die by suicide have visited a physician in the four months before their deaths [138]. It is therefore advisable that mental status and signs of suicidal ideation be assessed at every contact with postpartum women [139].

If a mother with PPD or postpartum psychosis tells any family member or healthcare professional that she is having thoughts of harming her baby, she should be taken seriously and immediate help should be forthcoming. If she is not already being treated for depression or psychosis, she should be referred immediately for psychiatric consultation and treatment. A mother who expresses concern that thoughts of harming her baby are becoming strong and she is afraid she might act on them should be supervised when she is with her baby. Alternatively, she may require hospitalization. A mother with PPD or postpartum psychosis who indicates that she has thought about harming or wants to harm her baby should never be dismissed.

Postpartum blues produce symptoms of increased emotionality and sensitivity in new mothers. These symptoms are transitory and usually resolve within 5 to 10 days without the necessity of formal treatment. However, there is no clear evidence that women recover spontaneously from PPD [141]. Mothers who are breastfeeding may appear to have recovered from depression when, in fact, they have not. Some women may breastfeed their children for months to years, during which time they may be protected from depression by the production of prolactin. Depression may appear in these women after they stop breastfeeding [19]. Other studies of PPD and breastfeeding practices suggest that a mother's breastfeeding self-efficacy can both put her at risk for PPD and can predict a change in symptoms of currently experienced PPD [142,143]. This should all be taken into account when assessing women for recovery and symptom resolution, and it should also reinforce the need for early screening for PPD [143]. It has been suggested that there may be a possibility for spontaneous recovery in depressed women with milder symptoms and a shorter duration [144]. Unfortunately, withholding treatment while waiting for a spontaneous recovery may put women at risk for a more chronic or severe depressive episode [145,146].

If possible, a spouse or other caregiving partner can alternate nights getting up to take care of the baby, allowing the mother to sleep at least five hours at a time. Knowing in advance that arrangements for nighttime feedings and attention to the baby can be made, mothers may ask for help without feelings of guilt or inadequacy [5]. Because women with PPD often complain of insomnia, a safe sedative may be prescribed to allow patients to obtain enough sleep.

Although it may be difficult to do, a woman should be encouraged to discuss her feelings with her partner/husband, close family members, and intimate friends. Hiding feelings due to shame and embarrassment contributes to isolation and loneliness. Therefore, although it may be difficult, it will ultimately help a depressed woman to have companionship. Isolation can lead to a sense of detachment from others, which may make depressive symptoms worsen. The depressed woman should avoid spending all of her time alone. Whenever possible, she should be encouraged to get dressed and leave the house.

There is some evidence that men may experience a form of PPD following the birth of their child [151,152]. The strongest predictor of paternal PPD in one study was the presence of maternal depression, with symptoms tending to arise after those of the mother [152]. Therefore, fathers should also be assessed for signs and symptoms of depression in the postpartum period, particularly when their partner is depressed. Educating both parents can assist them to work together for mutual benefit and for the benefit of the baby, and may alleviate possible marital discord. In one analysis, fathers reported fewer depressive symptoms if they received support from midwives, child health nurses, and their partners (mothers) [194].

A reduction in hormones after delivery is thought to be a major factor in the etiology of PPD in predisposed women. Therefore, the use of hormonal treatment as prophylaxis or a treatment component seems plausible. Since 1970, several studies were carried out investigating the efficacy of either estrogen or progesterone in the management of PPD. There are several problem areas in these studies, both in regards to methodologic issues and in the use of different hormones in the studies [153]. More structured research is necessary in order to ascertain efficacy.

One problem with the use of progesterone is that it cannot be given successfully by mouth or as a skin patch but must be administered by injection or vaginal or rectal suppository. According to Dalton and Horton, 400-mg suppositories administered twice daily are the minimum effective dose [10]. However, empirical data has not found progesterone to be effective in the treatment of PPD and it may intensify depressive symptoms in some patients [157].

The U.S. Food and Drug Administration (FDA) has alerted healthcare professionals and the public regarding a potentially life-threatening condition called serotonin syndrome. Serotonin syndrome, or serotonin toxicity, results from an excess of serotonergic activity in the central nervous system. It is seen only rarely in postpartum women, usually when multiple antidepressants, such as TCAs, MAOIs, St. John's wort, or opioids are combined. Serotonin syndrome is a medical emergency that requires immediate treatment. Symptoms and signs of this syndrome include [167,168]:

Studies have shown that SSRIs peak in the breast milk seven to nine hours after maternal dosing. The highest concentrations are found in the hindmilk [163,176,232]. The best time to nurse is one hour before taking the SSRIs. If a mother must breastfeed during the peak concentration, she may nurse for a brief period and discard the hindmilk, which will help to reduce the amount of medication the baby receives [177].

Fluoxetine produces the highest proportion of infant levels (22%), elevated more than 10% above the average maternal level, and fluoxetine has a longer half-life than either sertraline or paroxetine [166]. Two case reports of nursing infants whose mothers were taking fluoxetine related instances of increased irritability, colic, increased crying, decreased sleep, increased vomiting, and watery stools [176]. The long-term neurobehavioral development of infants exposed to fluoxetine has not been investigated. It is a drug "of concern" and should be used with caution in nursing mothers [163].

There are a variety of factors that contraindicate the use of TCAs. TCAs should not be prescribed to anyone with a history of heart disease, as they may cause cardiovascular problems. There have also been cases of TCAs triggering manic episodes in patients with a personal or family history of bipolar disorder [190,191]. It is also important not to prescribe TCAs with any of the following medications or other items, as there are risks of dangerous interactions [189]:

Often, individual therapy and antidepressant medications are combined in a treatment regimen. However, some women with PPD will respond well to psychotherapy alone [63]. The decision of whether to use a medication is based on a complex combination of factors that include the severity of symptoms, the individual's preferences, the response to other treatments or changes in support, and the risk of side effects. In many cases, support and education alone are not effective treatments for PPD, and medication must be added. The presence of certain symptoms, such as loss of concentration, severe insomnia, confusion, extreme indecisiveness, and severe feelings of guilt, indicate that psychotherapy alone will not be a sufficient treatment option. It is important to remember that in severe cases of PPD, medications may contribute to a quicker, fuller, and longer-lasting recovery [63,196].

Success has been reported with the use of interpersonal psychotherapy [66,196]. However, it is unclear whether individual psychotherapy is effective prophylaxis to prevent recurrence of PPD in the five years after the initial onset of depression. Individual psychodynamic psychotherapy and cognitive behavioral therapy have also been effective in the treatment of PPD [196,197,198]. All women with PPD should be offered psychosocial treatment, and this is of particular urgency for women with severe symptoms or psychosis. Some women, however, may refuse treatment.

The advantages of group therapy are that it is cost effective, reduces isolation, and offers support and empathy from others with similar problems. The disadvantages are that there is no one-on-one interaction between the therapist and each individual, and the group is not specifically tailored to meet each individual's particular needs [34]. Additionally, some mothers' childcare responsibilities may interfere with their ability to attend and participate in group therapy sessions [199]. A feasibility study on the effects of telecare therapy (i.e., a combination of cognitive-behavioral therapy, relaxation techniques, and problem-solving strategies) indicated that this may be an effective treatment option for women with PPD who are unable to attend group therapy sessions or support groups [200].

Prevention of PPD is of utmost interest to researchers and clinicians, and it is clear that preventing severe depression would have clear benefits for mothers and children. Two barriers to effective and efficient postpartum care in the United States have been identified: the lack of parity between insurance coverage for mental and physical illnesses decreases access to care, and the current model of postpartum care fails to incorporate screening and follow-up. In developing a prevention model in the United States, these concerns should be taken into account. The types of prevention strategies employed should be determined by the risk factors with which a woman presents. Early detection and treatment are keys to a full recovery [207]. Healthcare professionals involved in childbirth education are in an excellent position to offer pregnant patients anticipatory information about postpartum complications, including PPD [124].

An effort to place greater emphasis on identifying any previous psychiatric illness in pregnant patients and their families, combined with the continuous observation of the psychologic well-being of women during pregnancy, will enable potential sufferers of PPD to receive treatment at the earliest possible stage. In addition to screening for PPD during pregnancy, screening at six weeks, three months, and six months postpartum should become routine. It remains the primary responsibility of physicians treating women of childbearing age to ensure that all healthcare professionals involved in prenatal care have a full knowledge of the devastating effects of PPD and actively work to detect women at risk as early as possible [10]. As noted, the EPDS is the most accepted and widely used screening tool available today and takes only a few minutes to administer. Having a standardized mechanism of screening available for all pregnant patients should become the standard of care. Without a formal assessment, most depressive symptoms will remain undetected by primary care health professionals [201].

For all women who have given birth, prevention planning should consist of an unstructured debriefing in the postpartum ward by a nurse, midwife, or someone functioning in a similar capacity. Studies show that providing women the opportunity to talk about their feelings following delivery allows them to integrate and make sense of their birth experiences. One study of postpartum debriefing, which is regularly utilized in many British and Australian hospitals, showed that unstructured debriefing resulted in a significant decrease in the likelihood of depressive symptoms [207]. These results indicate that even a short meeting with a nurse or similar professional involving listening, support, counseling, and explanations may be sufficient to prevent PPD in some first-time mothers. Evidence in support of formal, structured debriefings is inconclusive [208,209,210].

A single, brief cognitive behavioral therapy session taking place prior to being discharged from the hospital has also been shown to be effective in preventing PPD in at-risk women. In this study, women were considered to be at-risk if they were experiencing elevated depressive symptoms shortly after birth. The therapy given was a one-hour, individual session consisting of education, support, empathetic listening, and a cognitive-behavioral approach to dealing with ideas of perfectionistic standards. The researchers concluded that a single, brief intervention provided to high-risk women focusing on education, support, and modification of maladaptive thoughts can help to reduce the incidence of PPD [207]. While long-term effectiveness remains unclear, psychosocial and psychologic interventions (i.e., professionally based postpartum home visits, telephone-based peer support, interpersonal psychotherapy) have been found to significantly reduce the number of women who develop PPD [201].

Prevention studies involving care by midwives or other healthcare professionals suggest that the incidence of PPD in the general population may be reduced by providing personalized care to women in the hospital and at home after childbirth [201]. Continuity of care is ensured if the same professional provides personalized care during home visits. Ideally, the same nurse or midwife would provide care throughout the antepartum and postpartum periods, tailoring the care to the individual woman's needs rather than to a standardized care plan. A program focused on continuity of care, individualization, and emotional support has the potential to prevent or minimize the effects of PPD and could be implemented for many pregnant patients [201,207,221,222]. Home visits should become the standard of care of at-risk women [201].

If utilized, it is advised that, upon completion of labor, the patient is given 100 mg of progesterone by injection daily for seven days, followed by a 400 mg suppository twice daily until the return of menstruation. The dosage of suppositories may be increased if the mother experiences a return of mild early symptoms. Each woman should also be equipped with information about the symptoms of PPD [10]. At the end of two months, if menstruation has not begun and no symptoms appear, the number of suppositories may be reduced and then discontinued. If menstruation has begun and symptoms appear, progesterone should be given from day 14 of the cycle until the next menstruation. Natural progesterone should only be given in the prescribed method of administration. Studies have been conducted on progesterone preventive treatment in 1985, 1989, 1994, and 1995 [10]. In these studies, the prevention of symptom recurrence was 90% to 92% successful.