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Postpartum
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depression:
Beyond the “baby blues”
By screening all pregnant and postpartum women for mood and
anxiety disorders, we can promptly identify PPD—a significant health
problem that threatens the safety of mothers and their families.
By Michele M. McKelvey, PhD, RN, and Jill Espelin, DNP, APRN, CNE, PMHNP-BC
Postpartum depression (PPD) is a serious of Mental Disorders, Fifth Edition added a

perinatal complication and a common peripartum onset to the psychiatric mood
concern for many mothers. The World disorder category. This refers to a major
Health Organization reported that in de- depressive episode with an onset during
veloping countries, approximately 19.8% pregnancy or following childbirth. The
of pregnant women develop depression APA proposes that postpartum psychiatric
following childbirth. According to the disorders be considered as one condition
CDC, about one in every nine women with three subclasses: adjustment reac-
experience depression after childbirth. tion with depressed mood, postpartum
The ramifications of PPD are widespread major mood episodes, and postpartum
and significantly affect the health of mood episodes with psychotic features.
mothers and families. Although the focus
of this article is on PPD, it’s important Adjustment reaction
to be aware that PPD represents only with depressed mood
one aspect of perinatal mood disorders. Adjustment reaction with depressed
Depression and anxiety can begin dur- mood is the mildest manifestation of
ing pregnancy and may take place at any postpartum mood disorder. This tran-
time within the first year after childbirth. sient mood disturbance is commonly
In this article, we present information referred to as “postpartum blues” or
HIGHWAYSTARZ-PHOTOGRAPHY / THINKSTOCK
about postpartum mood disorders, with “baby blues.” Recent studies show that
a focus on PPD, including risk factors, approximately 50% to 85% of all mothers
possible causes, signs and symptoms, experience postpartum blues. First-time
complications, screening, treatment, and mothers can experience more severe
nursing care. postpartum blues because they may have
unrealistic expectations of themselves
Types of postpartum mood disorders as mothers. This commonly develops
Women may experience many types of between 2 and 4 days after birth, and
psychiatric problems after childbirth. typically resolves within 14 days.
The American Psychiatric Association’s Mothers experience an emotional let-
(APA) Diagnostic and Statistical Manual down after childbirth, as well as physical
www.NursingMadeIncrediblyEasy.com May/June 2018 Nursing made Incredibly Easy! 29

discomfort, fatigue, and uncertainty about Postpartum psychosis is a medical emer-

their maternal role. Mothers commonly gency, with risk of suicide and infanticide.
feel overwhelmed, anxious, fatigued, sen- Major risk factors include a history of
sitive, and irritable. Although postpartum PPD, postpartum psychosis, depression,
blues is categorized as adjustment reaction or bipolar disorder, as well as a family his-
with depressed mood, it frequently occurs tory of these disorders. Clinical symptoms
in new mothers and doesn’t require medi- progress rapidly and include inability
cal treatment. Assistance with self and to sleep; depersonalization; confusion;
infant care, family support, peer support, disorganized thinking; hallucinations;
rest, and healthy nutrition usually enables delusions; and psychomotor disturbances,
mothers to recover from postpartum blues. such as stupor, agitation, and incoherent
Although the vast majority of postpar- speech. These clinical features appear
tum blues cases resolve within approximate- within the first few days after childbirth.
ly 2 weeks, some women go on to develop Women with postpartum psychosis
PPD. If women continue to experience post- need referrals for immediate psychiatric
partum blues beyond 2 weeks, they should care. Treatment of postpartum psychosis
seek medical attention and be evaluated for is aimed at the specific symptoms of each
a more severe postpartum mood disorder. patient. Treatment may consist of antide-
pressants, antipsychotics, mood stabilizers,
Postpartum major mood episodes and possibly electroconvulsive therapy
Postpartum major mood episodes are also (ECT), along with psychotherapy. Infants
known as PPD, which consists of clinical may need to be removed from their moth-
depression occurring within the first year ers’ care to maintain safety. If mothers are
of childbirth. Mothers are most vulner- breastfeeding their infants, medication
able to PPD at approximately the fourth risks must be considered. Parents need to
week after childbirth, just before the re- consider the risks and benefits of treatment
turn of their menses, and at the time of while maintaining the safety of their entire
weaning their infants from breastfeeding. family.
Postpartum mood episodes with Risk factors

psychotic features According to the APA, women with a per-
Commonly referred to as postpartum sonal or family history of PPD, depression,
psychosis, this is the most serious post- anxiety, or bipolar disorder are particularly
partum mood disorder. Although it at risk for PPD. Other risk factors for PPD
remains rare—affecting approximately include:
1 to 2 in every 1,000 mothers—this dis- • stressful life events
order has gained a great deal of media • financial, employment, or environmental
attention. In 2001, while suffering from stress
postpartum psychosis, Andrea Yates tragi- • infertility or complicated childbirth
cally drowned her • difficulty breastfeeding
five children in a • loss of a loved one
Postpartum psychiatric cheat bathtub. This well- • burden of caring for a newborn
disorder subclasses • social isolation
sheet
known tragedy il-

• Adjustment reaction with depressed lustrates the depth • adolescent or older mothers.
mood of postpartum
• Postpartum major mood episodes psychosis and the Possible causes
(also known as PPD)
urgent need for Although there’s no one particular cause
• Postpartum mood episodes with
early identifica- of PPD, both emotional and physical
psychotic features
tion and referral. factors play a part in this disorder. A
30 Nursing made Incredibly Easy! May/June 2018 www.NursingMadeIncrediblyEasy.com

combination of these factors likely contrib-

utes to the onset of PPD. Signs and symptoms of PPD cheat
Women who have negative thoughts • Hopelessness, sadness, and mood swings
sheet
about themselves as mothers are more • Irritability, anger, and feelings of being overwhelmed
likely to develop PPD. And some mothers • Isolation
• Sleep impairment
place unrealistic expectations on them-
• Poor appetite
selves to be perfect. New mothers often
• Inability to concentrate or make decisions
lack personal time; they may feel unat- • Loss of interest in pleasurable activities
tractive and struggle to find their own • Disinterest in caring for the baby
identity. These overwhelming feelings can • Difficulty maintaining relationships
cause mothers to become sleep deprived. • Physical pain and muscle aches
With an inadequate amount of sleep or
poor sleep, new mothers may have dif- depression, according to the Mayo Clinic.
ficulty coping with even simple problems. Mothers may have difficulty bonding
They may feel like they’ve lost control of with their infants. These newborns are at
their lives and ultimately question their risk for excessive crying, poor nutrition,
ability to care for their newborns. deficient sleep, developmental delays,
Drops in the following hormone levels and failure to thrive. Untreated PPD can
may also contribute to depressive episodes: also result in suicide, infanticide, and
• estrogen (decreases serotonin and may physical harm to newborns.
mimic signs of depression) Children of mothers with PPD are more
• progesterone (may cause anxiety and likely to have attention-deficit hyperactivity
poor sleep) disorder, emotional problems, behavioral
• thyroid (may cause lethargy and fatigue). problems, and language delays.
Fathers/partners also face an emo-
Signs and symptoms tional strain from PPD. Although they
According to the National Institute of don’t experience the perinatal hormone
Mental Health, signs and symptoms of changes, they’re exposed to the demands
PPD include: of becoming a new parent. Partners of
• hopelessness, sadness, and mood swings women with PPD may become over-
• irritability, anger, and feelings of being whelmed with the practical burdens of
overwhelmed caring for their newborns and families.
• isolation It can also be difficult to witness their
• sleep impairment partner experiencing PPD; the couple’s
• poor appetite relationship will likely be strained. It may
• inability to concentrate or make decisions be especially difficult to integrate a new-
• loss of interest in pleasurable activities born into the family if the father/partner
• disinterest in caring for the baby subsequently experiences depression
• difficulty maintaining relationships and/or anxiety. Older siblings may also
• physical pain and muscle aches. be negatively affected by PPD and at risk
Mothers experiencing PPD frequently for depression and anxiety.
question their ability to care for their According to the literature, mothers
babies. In extreme circumstances, they with female partners may be more at risk
can have thoughts of harming themselves for PPD. Lesbian mothers may face het-
and/or their babies. erosexist attitudes and homophobia from
healthcare providers. Confronting stigma
Complications and even rejection from their own families
If mothers with PPD don’t receive places these mothers at an increased risk
treatment, they may develop chronic for PPD.

Screening questionnaires that assess for depressive

The Association of Women’s Health, symptoms, as well as suicidal ideation.
Obstetric and Neonatal Nurses (awhonn), The EPDS also addresses anxiety.
American College of Obstetricians and The Postpartum Depression Screening
Gynecologists, and the American Academy Scale (PDSS) is also a useful, valid, evidence-
of Pediatrics recommend that all pregnant based screening instrument to detect PPD.
and postpartum women be screened for The PDSS is a self-administered question-
mood and anxiety disorders. The awhonn naire that screens women for PPD and
recommends that all healthcare institutions evaluates the presence of suicidal ideation.
caring for obstetric, neonatal, and pediat- Nurses should continuously assess for
ric patients utilize screening for perinatal decline or stability in maternal mood during
mood and anxiety disorders. the first 24 to 48 hours after birth. If mothers
Postpartum Support International recom- show signs of declining mood, nurses should
mends universal screening of all mothers for refer them for immediate evaluation and
prenatal depression and postpartum mood treatment of PPD. All postpartum patients
and anxiety disorders using evidence-based may benefit from referrals to lactation con-
measurements at the following intervals: sultants, breastfeeding support groups, and
• first prenatal visit new mother peer support groups.
• at least once during the second trimester
• at least once during the third trimester Treatment
• first postpartum visit The most effective treatment for PPD is a
• 6 months after delivery with the primary combination of antidepressants and mood
care provider stabilizers with psychotherapy (including
• 12 months after delivery with the pri- individual therapy, group therapy, and/
mary care provider. or family therapy). This combination is
It’s also recommended that women are usually associated with positive results
screened in the pediatric setting at the in women with mild-to-moderate PPD.
3-month, 6-month, and 9-month appoint- Women diagnosed with PPD typically
ments. This comprehensive and collabora- continue taking antidepressants for a year
tive screening approach between obstetric after their symptoms subside.
and pediatric providers increases the like- Antidepressants may take up to 6 weeks
lihood of identifying postpartum mood to alleviate symptoms of depression. Because
and anxiety disorders, particularly PPD. ECT is often effective within 1 week, it may
Both the Edinburgh Postnatal Depres- be used for mothers with severe PPD, those
sion Scale (EPDS) and the Patient Health who don’t respond to medications, or those
Questionnaire (PHQ-9) are validated who are at high risk for suicide.
for use with pregnant and postpartum Selective serotonin reuptake inhibitors
women. These are brief, self-administered (SSRIs), such as sertraline, are commonly
used to treat PPD, as well as mood stabilizers
such as valproate. When SSRIs aren’t effec-
key points tive, tricyclic antidepressants, such as ami-
Mothers typically go to their first postpartum follow-up visit at 6 weeks triptyline, may be used. These medications
after delivery. If the mother is at risk for PPD, this follow-up appointment
may transfer into the mother’s breast milk.
should be scheduled sooner, ideally at 2 to 3 weeks after delivery. During
The FDA recommendation is to either stop
this visit, the mother should be formally evaluated for PPD. Although
PPD may develop within a year of childbirth, there’s an elevated risk at
the medication or stop breastfeeding. Moth-
approximately 4 weeks’ postpartum. Planning for an earlier postpartum ers may consider feeding alternatives, such as
follow-up visit enables nurses to identify women with PPD sooner and formula or the use of donated breast milk.
promptly refer them for appropriate care. Pharmacologic treatment for mothers
who are breastfeeding must be carefully

considered. Although some of the antide- Maria’s pregnancy and labor/delivery were did you know?
pressant medication is excreted into breast physically uneventful. She worried about
Prolactin levels
milk, most SSRIs and mood stabilizers possibly having another miscarriage and
remain elevated
are considered safe for breastfeeding but describes being very sad during the pregnancy in breastfeeding
need to be closely monitored. If the baby because of the loss of her first two babies. women throughout
shows signs of irritability, sedation, feeding Maria states that she loves her baby, but she the course of lacta-
difficulty, or sleep disturbance, the medica- just doesn’t feel like a good mother. Maria tion. Prolactin can
tion may need to be discontinued. Mothers comes to the postpartum clinic for her routine have a relaxing,
should communicate with their healthcare follow-up appointment. calming effect on
providers to choose the best treatment for lactating mothers.
themselves and their families. The poten- Assessment Evidence suggests
tial benefits and risks of treatments must First, complete a thorough health history that breastfeeding
may offer some pro-
be carefully considered. Other modali- and identify any risk factors for PPD. Ide-
tection against the
ties, such as yoga, exercise, meditation, ally, this should begin at the first prenatal
development of PPD.
and relaxation, can also be encouraged visit and continue throughout all prenatal Formula feeding
to enhance psychological and physical care visits. Ask Maria open-ended ques- mothers may, there-
well-being. tions and use active listening to determine fore, be at increased
Psychotherapy may be used alone or in if she’s at risk for PPD. Use a nonjudgmen- risk for PPD.
combination with medication. There are tal approach because Maria may be embar-
several psychotherapy approaches that may rassed to admit her feelings of sadness.
be employed, such as interpersonal therapy Motherhood and pregnancy are general-
or talk therapy. Both types allow the mother ly expected to be happy occasions; be aware
to speak openly about personal feelings that there may be a stigma associated with
and concerns with a qualified individual, PPD. Mothers with PPD may avoid seeking
such as a psychologist, social worker, or help and obtaining treatment because they
advanced practice RN, who’s nonjudgmen- fear judgment and being labeled as an inade-
tal and neutral. The therapist and mother quate mother. For this reason, PPD is under-
identify specific problems, plan goals, and reported. Mothers with PPD often experience
work to accomplish these goals. The mother shame over their depressive symptoms.
also gains new skills in problem solving. They may be reluctant to reveal that they’re
unhappy after the birth of their babies. That’s
Nursing care why all mothers must be formally screened
The following case study will utilize the for PPD with a reliable, valid instrument,
nursing process to provide therapeutic, such as the EPDS, PHQ-9, or PDSS.
evidence-based, family-centered care for Maria presents with many risk factors
a patient with PPD. for PPD, including:
Maria is a 39-year-old woman who gave • history of depression and anxiety
birth to her first baby daughter 6 weeks ago • past miscarriages and infertility
after a long history of infertility treatment treatment
and two miscarriages. She’s having difficulty • financial stress
breastfeeding and her baby wakes up hourly • social isolation
throughout the night to feed. Even when the • poor sleep and appetite
baby is asleep, Maria says that she can’t rest • difficulty breastfeeding
and she feels exhausted. She has a poor appe- • older first-time mother.
tite and feels sad most of the time. If Maria admits to thoughts of wanting
Maria’s husband is supportive, but he to hurt herself or the baby, it’s critical to con-
works two jobs to pay for medical expenses duct a thorough risk assessment, including:
from their fertility treatments. She’s alone • suicidal or homicidal ideation (thoughts
most of the time and feels overwhelmed. of harming self or baby)

on the web Offer anticipatory guidance to Maria

and her husband as new parents. Because
American Academy of Pediatrics: Maria will be at home with her newborn
www.aap.org/en-us/advocacy-and-policy/aap-health-initiatives/
while her husband works long hours,
Screening/Pages/Maternal-Depression.aspx
she may become isolated. It’s beneficial
CDC: www.cdc.gov/features/maternal-depression/index.html to assist Maria with identifying support
March of Dimes: www.marchofdimes.org/pregnancy/postpartum-
systems. You may suggest community
depression.aspx
resources, including a peer support group
Mayo Clinic: www.mayoclinic.org/healthy-lifestyle/pregnancy-week-by- or parenting group. You should also
week/in-depth/depression-during-pregnancy/art-20237875
encourage Maria to identify family mem-
National Institute of Mental Health: bers and friends to help her through her
www.nimh.nih.gov/health/publications/postpartum-depression-facts/ transition to motherhood.
index.shtml#pub9
Educate Maria and her husband about
Postpartum Support International: the signs and symptoms of PPD to antici-
www.postpartum.net pate and report to her healthcare provider.
U.S. Department of Health and Human Services: Maria should be screened for PPD using
www.womenshealth.gov/mental-health/illnesses/ an instrument such as the PDSS and
postpartum-depression.html referred to a provider who specializes in
World Health Organization: treating postpartum mood disorders. It
www.who.int/mental_health/maternal-child/maternal_mental_health/en may also be beneficial for Maria to be seen
by a home care nurse for further support
• specific plan for how to carry out and monitoring.
suicide/homicide
• means to carry out the plan, including Evaluation
access to weapons. Evaluate and revise the care plan as
needed. If the care plan is effective, PPD
Plan and implementation will be identified and promptly treated.
Use a proactive approach to develop a Maternal, infant, and family safety will
care plan for Maria. The plan should be be maintained. Maria’s medications may
collaborative and include a dialogue with need to be adjusted by her healthcare
Maria and her husband to set goals. provider if PPD doesn’t resolve. Because
Nursing interventions should include: antidepressants may take a few weeks
• Provide anticipatory guidance regard- to become effective, supportive care and
ing the realistic demands and lifestyle closer monitoring may be necessary, such
changes associated with parenthood. as home visits with a community health
• Encourage Maria to identify personal nurse. Maria’s care plan should be evalu-
support systems. ated on an ongoing basis and adjusted
• Educate Maria and her husband about regularly to meet her healthcare needs
signs and symptoms of PPD. and keep Maria and her family safe.
• Teach them how to recognize suicidal
ideation. Supporting healthy families
• Instruct them about the prescribed Nurses are in a key position to perform
medication regime. routine screening for PPD, provide
• Provide emotional support for Maria education, and ensure appropriate
and her family. treatment referrals. Educating women
• Make a referral for home visits and and their families about PPD helps cre-
individual or group therapy. ate a healthy perinatal and postpartum
• Maintain communication through period, and contributes to a healthy
regularly scheduled phone calls. family dynamic. ■

REFERENCES week/in-depth/depression-during-pregnancy/art-20237875.
American Academy of Pediatrics. Maternal depression. McKelvey MM. The other mother: a narrative analysis of
www.aap.org/en-us/advocacy-and-policy/aap-health- the postpartum experiences of nonbirth lesbian mothers.
initiatives/Screening/Pages/Maternal-Depression.aspx. ANS Adv Nurs Sci. 2014;37(2):101-116.
American College of Obstetricians and Gynecologists. National Institute of Mental Health. Postpartum depres-
Screening for perinatal depression. www.acog.org/Clinical- sion facts. www.nimh.nih.gov/health/publications/
Guidance-and-Publications/Committee-Opinions/Committee- postpartum-depression-facts/index.shtml#pub9.
on-Obstetric-Practice/Screening-for-Perinatal-Depression. Schiller CE, Meltzer-Brody S, Rubinow DR. The role of
American Psychiatric Association. Diagnostic and reproductive hormones in postpartum depression. CNS
Statistical Manual of Mental Disorders. 5th ed. Arlington, Spectr. 2015;20(1):48-59.
VA: American Psychiatric Publishing; 2013. Stahl SM. Prescriber’s Guide: Stahl’s Essential Psychopharmacology.
American Psychological Association. Understanding psy- 6th ed. New York, NY: Cambridge University Press; 2017.
chotherapy and how it works. www.apa.org/helpcenter/ Postpartum Support International. Screening recommen-
understanding-psychotherapy.aspx. dations. www.postpartum.net/learn-more/screening.
Association of Women’s Health, Obstetrical and Neonatal U.S. Department of Health and Human Services.
Nurses. Mood and anxiety disorders in pregnant and postpar- Postpartum depression. www.womenshealth.gov/mental-
tum women. J Obstet Gynecol Neonatal Nurs. 2015;44(5):687-689. health/illnesses/postpartum-depression.html.
CDC. Maternal depression. www.cdc.gov/features/ U.S. Food and Drug Administration. Pregnancy and lac-
maternal-depression/index.html. tation labeling (drugs) final rule. www.fda.gov/Drugs/
Cunningham FG, Leveno KJ, Bloom SL, et al. Williams DevelopmentApprovalProcess/DevelopmentResources/
Obstetrics. 24th ed. New York, NY: McGraw Hill; 2014. Labeling/ucm093307.htm.
Davidson M, London M, Ladewig P. Olds’ Maternal- World Health Organization. Maternal mental health.
Newborn Nursing and Women’s Health Across the Lifespan. www.who.int/mental_health/maternal-child/maternal_
10th ed. Boston, MA: Pearson; 2016. mental_health/en.
Department of Psychiatry Center for Women’s Mood
Disorders at The University of North Carolina School of At Central Connecticut State University in New Britain, Conn.,
Medicine. Perinatal mood and anxiety disorders. www. Michele M. McKelvey and Jill Espelin are Assistant Professors
of Nursing. Michele M. McKelvey is also a Maternal/Newborn
med.unc.edu/psych/wmd/mood-disorders/perinatal#md_ RN at St. Francis Hospital in Hartford, Conn. Jill Espelin is also a
postpartum. Psychiatric Mental Health NP.
March of Dimes. Postpartum depression. www.march
The authors and planners have disclosed no potential conflicts of
ofdimes.org/pregnancy/postpartum-depression.aspx. interest, financial or otherwise.
Mayo Clinic. Depression during pregnancy: you’re not alone.
www.mayoclinic.org/healthy-lifestyle/pregnancy-week-by- DOI-10.1097/01.NME.0000531872.48283.ab
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www.NursingMadeIncrediblyEasy.

Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.

Postpartum depression (PPD) is a serious of Mental Disorders, Fifth Edition added a

www.NursingMadeIncrediblyEasy.com May/June 2018 Nursing made Incredibly Easy! 29

Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.

discomfort, fatigue, and uncertainty about Postpartum psychosis is a medical emer-

Postpartum mood episodes with Risk factors

known tragedy il-

30 Nursing made Incredibly Easy! May/June 2018 www.NursingMadeIncrediblyEasy.com

Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.

combination of these factors likely contrib-

www.NursingMadeIncrediblyEasy.com May/June 2018 Nursing made Incredibly Easy! 31

Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.

Screening questionnaires that assess for depressive

32 Nursing made Incredibly Easy! May/June 2018 www.NursingMadeIncrediblyEasy.com

Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.

www.NursingMadeIncrediblyEasy.com May/June 2018 Nursing made Incredibly Easy! 33

Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.

on the web Offer anticipatory guidance to Maria

34 Nursing made Incredibly Easy! May/June 2018 www.NursingMadeIncrediblyEasy.com

Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.

For more than 128 additional continuing-education articles related to

Earn CE credit online:

www.NursingMadeIncrediblyEasy.com May/June 2018 Nursing made Incredibly Easy! 35

Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.

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