Post natal depression

Definition

  • A depressive disorder occurring within the postnatal period, typically within the first 4 to 12 weeks postpartum, though it may develop anytime in the first 12 months after birth
  • Associated with low mood, anxiety, fatigue, sleep disturbance, and impaired maternal-infant bonding
  • Can occur in both mothers and fathers

DSM-5 Criteria

  • Major depressive episode with onset during pregnancy or within 4 weeks postpartum
  • At least 5 of the following symptoms present nearly every day for ≥2 weeks, including at least one of depressed mood or anhedonia:
    • Depressed mood
    • Anhedonia
    • Appetite or weight changes
    • Sleep disturbances
    • Psychomotor agitation or retardation
    • Fatigue or loss of energy
    • Feelings of worthlessness or guilt
    • Poor concentration
    • Recurrent thoughts of death or suicide

ICD-10 Classification

  • F53.0: Mild to moderate mental and behavioural disorders associated with the puerperium, not elsewhere classified
  • F32.x: Depressive episode (used if criteria for MDD are met, with postpartum specifier)

Epidemiology (Australia)

  • Affects 10–15% of mothers within 12 months postpartum
  • Around 5–10% of fathers may also experience postnatal depression
  • Higher rates among women with psychosocial stress, limited support, or past psychiatric history

Risk Factors

  • History of depression or anxiety
  • Antenatal depression or anxiety
  • Poor social support
  • Marital or relationship conflict
  • Birth trauma or complications
  • Premature or unwell infant
  • Sleep deprivation
  • Isolation, financial stress, or housing insecurity
  • History of abuse or trauma

Clinical Features

  • Persistent low mood or tearfulness
  • Fatigue, low energy, or exhaustion
  • Irritability or anger
  • Anxiety, often about baby’s health or self-doubt as a parent
  • Sleep disturbances unrelated to infant
  • Appetite changes
  • Loss of interest in previously enjoyed activities
  • Feelings of inadequacy, shame, guilt, or hopelessness
  • Difficulty bonding with baby
  • Intrusive thoughts, including fear of harming baby (non-psychotic)
  • Suicidal thoughts or behaviour

Screening Tools

  • Edinburgh Postnatal Depression Scale (EPDS), validated in Australia
  • Administer at 6-week postnatal check and during pregnancy
  • Score ≥13 suggests probable depression
  • Ask directly about suicidal ideation regardless of score

Differential Diagnoses

  • Baby blues (transient, resolves within 2 weeks)
  • Postpartum psychosis
  • Postnatal anxiety disorder
  • Thyroid dysfunction (postpartum thyroiditis)
  • Anaemia
  • Sleep deprivation-related mood change
  • Bipolar disorder

Investigations

  • TSH (to exclude hypothyroidism or postpartum thyroiditis)
  • Full blood count (to exclude anaemia)
  • Vitamin B12 and folate if dietary restriction or fatigue
  • Further tests if other medical symptoms present

Complications

  • Impaired maternal-infant bonding
  • Delayed child development
  • Marital strain or relationship breakdown
  • Suicide or infanticide (rare but serious)
  • Long-term maternal mental illness if untreated
  • Increased risk of future depression or anxiety

Psychoeducation

  • Normalise that PND is common and treatable
  • Discuss that it is not a sign of failure or poor parenting
  • Involve partner or support persons
  • Provide credible resources such as COPE, PANDA, and Beyond Blue

Lifestyle Management

  • Encourage rest and sleep optimisation where possible
  • Promote social support and connection
  • Encourage physical activity (e.g., walking with baby)
  • Support with breastfeeding if stress-related
  • Screen for domestic violence and ensure safety

Psychological Therapies

  • First-line for mild to moderate depression
  • Cognitive Behavioural Therapy (CBT)
  • Interpersonal Therapy (IPT)
  • Acceptance and Commitment Therapy (ACT)
  • Available through GP Mental Health Treatment Plan via Medicare
  • Referral to perinatal psychologist or mental health nurse where available

Pharmacological Treatment

  • Indicated in moderate to severe depression, suicidality, or significant functional impairment
  • First-line: SSRIs with low infant exposure via breast milk (e.g., sertraline, escitalopram)
  • Discuss risks and benefits with breastfeeding mothers
  • Monitor both mother and infant
  • Avoid antipsychotics unless for psychosis (specialist referral)

Follow-Up and Monitoring

  • Review within 1–2 weeks of starting treatment
  • Reassess EPDS score and clinical features
  • Monitor mental state, safety, medication side effects, and bonding
  • Provide longer-term follow-up (at least 6–12 months postpartum)
  • Watch for recurrence in future pregnancies

Referral and Escalation

  • Refer to perinatal psychiatrist if severe, psychotic, suicidal, or treatment-resistant
  • Involve Child and Family Health Services
  • Urgent referral for postpartum psychosis or suicidal ideation with intent
  • Inpatient mother–baby units available in major centres

Patient Support and Resources

  • PANDA (Perinatal Anxiety & Depression Australia)
  • COPE (Centre of Perinatal Excellence)
  • Beyond Blue – Perinatal Mental Health Programs
  • Raising Children Network
  • Lifeline: 13 11 14
  • GP mental health nurse (if available)
  • Family support, parenting groups, mother–baby programs
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