Guideline Note:
This article is anchored to NICE CG192 and Royal College of Psychiatrists CR232. Where UK guideline definitions are insufficient, DSM-5 criteria and a NEJM review are used to supplement.
Postpartum Blues (Maternity Blues)
Definition
Postpartum blues is NOT considered a mental disorder, characterised by sudden changes in mood that do NOT cause functional impairment.
It is likely to be caused by physiological changes after delivery.
Clinical Features and Recognition
Postpartum blues are common, affecting ~70% of new mothers
| Timing | Sudden onset that peaks between days 2-5 after delivery
Spontaneously resolves within 2 weeks |
| Clinical features | Possible mood changes include:
|
Postpartum blues can be recognised by:
- Mood changes that do NOT cause functional impairment, and
- Spontaneously resolves within 2 weeks (without treatment)
However, some cases can progress to postpartum depression
Management
Postpartum blue does NOT require treatment – it is temporary and self-limiting.
Postpartum Depression
Definition
A major depressive episode with peripartum onset if mood symptoms occur during pregnancy or within 4 weeks following delivery.
Disclaimer:
The formal DSM-5 criteria define postpartum depression as “major depressive episode with peripartum onset“, while peripartum is defined as “during pregnancy or in the 4 weeks following delivery“.
However, in clinical practice, the term “postpartum depression” typically refers to a major depressive episode occurring after delivery.
Clinical Features and Recognition
| Timing | Onset during pregnancy or <4 weeks after delivery
Lasts for >2 weeks |
| Clinical features | Key features:
Co-existing anxiety and obsessive-compulsive symptoms are common |
Postpartum depression should be suspected if:
- Mood changes persist beyond 2 weeks, and
- Functional impairment is present
These features differentiate postpartum depression from postpartum blues, which is NOT a mental disorder.
Management
Management depends on the severity of depression:
| Depression severity | Recommended management |
|---|---|
| Subthreshold / mild / moderate | Facilitated self-help
If the patient has mild depression and a history of severe depression → consider prescribing an antidepressant (TCA / SSRI / SNRI) |
| Moderate to severe | High-intensity psychological intervention (e.g. CBT)
An antidepressant (TCA / SSRI / SNRI) should be offered if the patient:
|
Choice of antidepressants:
- UK guidelines (NICE and RCP) specifically recommend TCAs, SSRIs, and SNRIs for the treatment of postpartum depression
- However, the guidelines do NOT name any specific “preferred” antidepressant, but emphasise personalised prescribing principles based on safety and past efficacy
- A primary factor in choosing a drug is the woman’s previous response to the medication. If a drug has worked well for her in the past, clinicians must weigh the risks of switching or stopping that previously effective medication
- The lowest effective dose and a single drug are preferred
- Specific drug warnings: the guideline noted paroxetine and venlafaxine carry a particular risk of discontinuation symptoms in the mother and neonatal adaptation syndrome in the baby
NICE CKS:
- Paroxetine and sertraline are generally the SSRIs of choice for treatment initiated in breastfeeding women
- TCAs are less commonly used due to concerns about maternal toxicity. If necessary and appropriate, imipramine and nortriptyline are preferred
Postpartum Psychosis
Definition
Postpartum psychosis is a severe mental illness characterised by psychosis, often with mania and/or depressive symptoms, occurring in the immediate postnatal period.
Clinical Features and Recognition
Postpartum psychosis is often a manifestation of bipolar disorder
- 1 in 5 women with bipolar disorder experience postpartum psychosis
- Postpartum psychosis often occurs in women with a history of severe mental illness or a family history of severe perinatal mental illness
- However, it can also occur in women with no previous psychiatric history
| Timing | Sudden onset within the first 2 weeks after childbirth |
| Clinical features | Core symptom: psychosis
Often accompanied by:
|
Management
IMMEDIATE emergency referral to secondary mental health service (preferably perinatal specialist)
- Patients often require inpatient care
- If inpatient care is necessary → specialist mother and baby unit (mother admitted together with their baby – as separating them causes great maternal distress, prevents breastfeeding and can harm the development of relationships between the mother and baby)
Pharmacological interventions:
- Offer an antipsychotic if the patient is NOT currently taking psychotropic medications
- If necessary, consider rapid transquillisation with an antipsychotic (e.g. haloperidol) or benzodiazepine (e.g. lorazepam)
References
NICE guideline Antenatal and postnatal mental health: clinical management and service guidance