Postpartum Blues

Article Editor: Raman Marwaha (thatsraman@gmail.com)

Assigned Author: Kripa Balaram (kbalaram@metrohealth.org)

Updated: 6/7/2022 9:25:50 AM

Introduction
Psychiatric illnesses that are non-psychotic are one of the most common morbidities of pregnancy and
the perinatal period. These disorders include depressive disorders (postpartum blues, postpartum
depression), anxiety, post-traumatic stress disorder (PTSD), and personality disorders. Postpartum
“blues” are defined as low mood and mild depressive symptoms that are transient and self-limited.
[1] The depressive symptoms include sadness, crying, exhaustion, irritability, anxiety, decreased sleep,
decreased concentration, and labile mood. These symptoms typically develop within two to three days
of childbirth, peak over the next few days, and resolve by themselves within two weeks of their onset.

Etiology
Several risk factors can lead to the development of postpartum blues. These include a history of
menstrual cycle-related mood changes or mood changes associated with pregnancy, a history of major
depression or dysthymia, a larger number of lifetime pregnancies, or a family history of post-partum
depression.[1][2] The factors that, when present, do not predispose a patient to the development of
postpartum blues: low economic status, ethnic or racial background, gravidity status (primiparous vs.
multiparous), planned vs. unplanned pregnancy, spontaneous pregnancy vs. IVF, type of delivery
(vaginal vs. cesarean), family history of mood disorders, or history of postpartum depression in the
past.[1]
Pathogenesis is largely unknown. However, hormonal changes have long been suggested as one of the
primary causative factors in developing postpartum mood changes. Typically, there is a drastic
decrease in estradiol, progesterone, and prolactin in the time following delivery. The decrease in these
hormones is also noted in the mood changes that occur during the various phases of the menstrual
cycle, such as those noted in premenstrual dysphoric disorder.[3]
According to one particular study, the three predisposing factors most often found in women who
developed postpartum blues were higher levels of depressive symptoms during pregnancy, at least one
previous episode of diagnosed depression, and a history of premenstrual depression or other
menstrual-related mood changes.[3]
Other studies have also proposed that elevated monoamine oxidase levels or decreased serotoninergic
activity in the immediate postpartum period are also significant risk factors or etiological characteristics
that could predispose a woman to the development of postpartum blues.[4][5]

Epidemiology
Postpartum blues are extremely common and are estimated to occur in about 50% or more of women
within the first few weeks after delivery.[1] Postpartum major depression is approximately 4 to 11
times more common among women who have postpartum blues.

History and Physical

As with all psychiatric diagnoses, the most important diagnostic tool is the interview. In the setting of a
female patient who presents immediately after or within two weeks of delivery, a low mood and
depressive symptoms that do not meet the major depressive disorder criteria can point to a diagnosis
of postpartum blues. If the criteria for major depressive disorder are met or if the mood disturbances
persist beyond two weeks after delivery, a diagnosis of postpartum blues should not be made.

Evaluation
Symptoms of postpartum blues include crying, dysphoric affect, irritability, anxiety, insomnia, and
appetite changes.[3] These symptoms, when present, should not meet the criteria for major depressive
disorder or, when occurring in the postpartum period, of postpartum depression. To fully meet the
criteria for a diagnosis of postpartum blues, the symptoms usually develop within two to three days of
delivery and resolve within two weeks. If the symptoms persist beyond two weeks, the diagnostic
criteria for postpartum depression are then fulfilled. A clinical tool that can be useful to screen for
postpartum depression is the Edinburgh Postpartum Depression Scale, which has been validated to
have adequate sensitivity and specificity across population groups, even when assessing changes in
depression over time.[6]
Under the updates proposed in the fifth edition of the new Diagnostic and Statistical Manual of Mental
Disorders, postpartum depression is re-defined as “depressive disorder with peripartum onset.”[7] In
rare cases, psychotic features may accompany the primary symptoms of depression. This symptomatic
presentation used to formerly be referred to under its own diagnostic classification as postpartum
psychosis. Postpartum depression and postpartum psychosis are now classified as one diagnosis,
namely "depressive disorders with peripartum onset" and differentiated with the classifier “with
psychotic features” if psychotic features are present. This DSM-5 does not recognize postpartum blues
as its own separate diagnosis. Instead, it is clinically differentiated from the depressive disorder with
peripartum onset by being labeled either "adjustment disorder with depressed mood" or "depressive
disorder not otherwise specified." For coding purposes, it is recognized by the ICD-10 diagnostic
manual as "postpartum depression, not otherwise specified."

Treatment / Management
Peripartum mood disorders can be viewed as occurring on a spectrum of severity, with postpartum
“blues” being milder and self-limited and postpartum depression more disabling. By its diagnostic
criteria, postpartum blues are transient and self-limited. Therefore, it resolves on its own and requires
no treatment other than validation, education, reassurance, and psychosocial support.[8] Patients
diagnosed with postpartum blues should be carefully evaluated to see if the diagnostic criteria for
postpartum depression are met. This would entail ensuring both that symptoms do not meet the
criteria for a depressive episode at the time of presentation and that symptoms do not persist beyond
two weeks. If a diagnosis of postpartum depression, or depression with peripartum onset, is finalized,
the clinician should initiate a treatment regimen with supportive psychotherapy and antidepressants.
Concurrently, with a diagnosis of postpartum depression, antipsychotics should be considered if
psychotic features are present. 
While postpartum blues symptoms are mild, transient, and self-limited, patients should still be
carefully screened for suicidal ideation, paranoia, or homicidal ideation towards the infant. Moreover,
home help should be sought to help the patient in getting enough sleep. If insomnia persists, cognitive
therapy and/or pharmacotherapy can be recommended.

Differential Diagnosis
Sleep disturbances decreased energy, and some mood changes can normally occur in the peripartum
period. These can be differentiated from postpartum blues by assessing if the mood and activity levels
are normal peripartum-related changes or determining if the symptoms cause impairment or distress
in the individual’s life.
Postpartum blues requires differentiation from postpartum depression or, in concordance with the
new DSM-5, a depressive disorder with peripartum onset. In the latter case, symptoms must meet the
criteria for a depressive episode, and mood disturbances must persist beyond two weeks. According to
the DSM-5, the criteria for a depressive disorder include depressed mood, anhedonia, weight or
appetite changes, sleep disturbances or insomnia, psychomotor agitation or retardation, fatigue or loss
of energy, feelings of worthlessness or guilt, difficulty concentrating, and recurrent thoughts of death or
suicidal ideation. The diagnosis for depressive disorder with a peripartum onset uses the same
diagnostic criteria but with the added criteria that symptoms must occur in the context of pregnancy or
within four weeks after delivery.

Prognosis
Postpartum blues involve mood changes that are typically mild, transient, and self-limited. However, a
diagnosis of postpartum blues can predispose an individual to postpartum depression or postpartum
anxiety disorders. According to the DSM-5, the risk of postpartum depression developing in an
individual with “baby blues” significantly increases in those who had mood or anxiety symptoms during
pregnancy.

Complications
Individuals who are diagnosed with postpartum blues are at increased risk for developing postpartum
depression or postpartum psychosis. One particular study completed in Africa demonstrated that
women diagnosed with “postpartum blues” on the fifth day after delivery were twelve times more likely
to be diagnosed with postpartum depression one month after delivery and ten times more likely to be
diagnosed with postpartum depression two months after delivery.[9]
While postpartum depression, which is the most common and widely recognized complication of
postpartum “blues,” has many of the same characteristics and is diagnosed using the same criteria as
major depressive disorder, women with postpartum depression tend to have higher levels of co-
morbid anxiety. These women are also more likely to convert to bipolar disorder in the future than
women with major depressive disorder without a peripartum onset.[10]
According to the DSM-5, psychotic features are estimated to occur in 0.1% to 0.2% of women in the
peripartum period. The DSM further states that this risk is more common in primiparous women, those
with a prior history of depressive or bipolar disorders, and those with a family history of bipolar
disorder. The DSM further states that once an individual has had one peripartum-onset depressive
episode with psychotic features, the risk of recurrent with subsequent pregnancies and deliveries is
30% to 50%.

Deterrence and Patient Education

Like all psychiatric disorders, the prevention of postpartum blues would involve mediation of the major
risk factors. Unlike most other psychiatric disorders, however, most of the risk factors for postpartum
blues – such as parity, delivery status, history of depression or bipolar disorder, or history of
menstrual-related mood changes – are nonmodifiable. However, the most important factor in
managing postpartum blues is the early identification of symptoms, prompt intervention, facilitation of
open discussions with patients and their families, and access to mental health resources and
professionals. It is also important that patients are screened for suicidal ideation, homicidal ideation
towards the infant, paranoia, or psychotic features. It is also essential if symptoms were to develop and
be identified that resources are in place to ensure that new mothers feel adequately supported.

Enhancing Healthcare Team Outcomes

Postpartum “blues,” though not formally recognized as a diagnosis by the DSM-5, is a phenomenon
that is extremely prevalent in the immediate time period after delivery. As postpartum blues are, by
definition, mild, transient, and self-limited, they do not cause significant distress or disability in an
individual’s life. However, the need for prompt identification and intervention, namely the access to
social support systems and other mental health resources like counseling, is underscored by the
significant risk of developing postpartum depression or psychosis in those with postpartum blues.
As with most mental health disorders, the primary care setting is usually the predominant location in
which these symptoms are brought to healthcare providers' attention. Therefore, primary care
providers, including obstetricians, must be knowledgeable in the symptoms of postpartum blues and
adept in its diagnosis and treatment. Obstetric nurses should watch for signs and symptoms of the
disorder and provide patient education. If the patient requires antidepressant therapy, a pharmacist
consult is to verify agent selection, appropriate dosing, and medication reconciliation to preclude drug-
drug interactions. Both nursing and pharmacy need to report any concerns to the prescriber/treating
clinician. Employing these interprofessional strategies will optimize patient outcomes. [Level 5]
It is also of extreme importance that individuals diagnosed with postpartum blues are screened for
suicidal ideation, paranoia, para- or pre-psychotic thoughts, or homicidal ideation towards the infant.
Though all mental health diagnoses are most effectively managed through a comprehensive and inter-
disciplinary model, peripartum mood disorders are naturally predisposed to this modality of
management. According to a review article published in the American Journal of Obstetrics and
Gynecology, a combination of various hormonal, biologic, and psychologic factors are responsible for
many perinatal and postnatal complications, including preterm delivery, low birth weight in the infant,
and mood disorders. Therefore, an interprofessional process that allows healthcare providers to
collaborate on mitigating these interrelated risk factors would be most effective in reducing the rates of
these outcomes.[11]

References
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[2] Bloch M,Rotenberg N,Koren D,Klein E, Risk factors associated with the development of postpartum mood disorders.
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[3] O'Hara MW,Wisner KL, Perinatal mental illness: definition, description and aetiology. Best practice & research. Clinical
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[4] Sacher J,Wilson AA,Houle S,Rusjan P,Hassan S,Bloomfield PM,Stewart DE,Meyer JH, Elevated brain monoamine
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[5] Doornbos B,Fekkes D,Tanke MA,de Jonge P,Korf J, Sequential serotonin and noradrenalin associated processes
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[6] Cox JL,Holden JM,Sagovsky R, Detection of postnatal depression. Development of the 10-item Edinburgh Postnatal
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[8] Seyfried LS,Marcus SM, Postpartum mood disorders. International review of psychiatry (Abingdon, England). 2003 Aug
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[9] Zanardo V,Volpe F,de Luca F,Giliberti L,Giustardi A,Parotto M,Straface G,Soldera G, Maternity blues: a risk factor for
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