Introduction
Postnatal depression is a mood (affective) disorder that occurs after childbirth, affecting up to one in 10 women.1 Although it most commonly affects mothers, it can also impact partners.
The term “postnatal” refers to the period following delivery, typically lasting up to one year, although specialist perinatal mental health services can support patients for up to two years.
Postnatal depression is characterised by persistent sadness, hopelessness, fatigue and a lack of interest in daily activities. It is important to distinguish postnatal depression from the “baby blues,” which are transient and usually resolve within a week. Postnatal depression, however, can have lasting consequences for both the parent and the child.
Common misconceptions include the belief that it resolves on its own, that it occurs only in the early postnatal months, or that it is purely due to hormonal changes. Others assume pregnancy or childbirth will improve pre-existing mental health issues.
Many individuals may avoid seeking help due to stigma, fear of judgement, or concerns about losing custody of their child. As a result, postnatal depression is frequently underreported. Early identification and treatment are crucial for both parent and child.
Aetiology
The exact cause of postnatal depression remains unclear, but it is generally thought to involve an interaction between hormonal, biological, psychological and social factors:2,3
- Hormonal changes: post childbirth, a decline in oestrogen and progesterone levels is thought to play a role in altering mood, which can trigger the onset of depression
- Biological factors: genetics can affect susceptibility to postnatal depression, with individuals who have a first-degree relative with a history of depression being at higher risk
- Social stressors: financial pressures, relationship problems, and/or limited social support can increase risk, and the demands of caring for a newborn on top of these stressors may trigger postnatal depression
- Psychological vulnerability: a history of psychiatric illness before pregnancy, such as anxiety or mood disorders, is considered the strongest risk factor for developing postnatal depression
Risk factors
Many factors are associated with a greater risk of developing postnatal depression.2 These can be broadly categorised as biological, psychological, and social factors:
Table 1. Summary of risk factors for postnatal depression
| Category | Risk factors |
|
Biological risk factors |
|
|
Psychological risk factors |
|
|
Social risk factors |
|
Clinical features
History
Typical symptoms of postnatal depression include:
- Persistent low mood, sadness, feelings of worthlessness or excessive guilt
- Fatigue and lethargy
- Sleep disturbance (insomnia or hypersomnia)
- Appetite or weight changes
- Poor concentration and intrusive or negative thoughts
- Loss of interest or pleasure in usual activities
- Thoughts of self-harm or suicide
Other important areas of the history to cover include:
- The impact of symptoms on daily functioning and the ability to care for the baby
- Past psychiatric history, including depression, anxiety, or other mental illness
- The quality of the mother-baby bond or attachment
- Presence of any risk factors, such as psychosocial stressors or lack of support (see Table 1)
Clinical examination
The clinical examination should include a full mental state examination. Typical findings may include:
- General appearance: signs of self-neglect, self-harm, tiredness, poor self-care or hygiene and/or signs of emotional distress
- Mood and affect: depressed mood, melancholy, flat affect, or tearfulness
- Thought content: confused or disorganised thoughts, impaired insight, or lack of awareness. These features may occur in severe cases
A physical examination may be needed to identify or exclude organic causes of symptoms, such as anaemia or hypothyroidism.
If the baby is present, observe the mother-infant interaction. Limited eye contact, irritability, emotional withdrawal or lack of engagement may indicate impaired bonding.
Risk assessment
A thorough risk assessment is essential and should include perinatal-specific questions, asked sensitively. Parents may feel stigmatised, embarrassed, or reluctant to discuss their mental health or concerns about their baby’s safety.
| Risk domain | What to assess | How to ask |
| Risk to self |
Assess for thoughts of self-harm or suicidal ideation, protective factors, access to means, history of self-harm or suicidal behaviour, self-neglect, and substance misuse |
“Sometimes new parents feel overwhelmed. Have you had thoughts of harming yourself or wishing you weren’t here?” “Have you ever felt you might act on these thoughts?” |
| Risk to others |
Assess for thoughts, plans, or behaviours that could harm the baby or others, including delusions, hallucinations, or intrusive thoughts, as well as feelings of aggression, hostility, estrangement, or parental inadequacy. |
“How are your feelings towards your baby?” “Have you ever had thoughts that you might hurt your baby or someone else?” “Have you ever felt you might act on these thoughts?” “Have you ever felt guilty or that you are letting your baby down?” “Have you experienced seeing or hearing anything unusual that makes you worried about your or your baby’s safety?” “Do you feel connected to your baby?” “Do you feel liked or responded to by your baby?” |
|
Risk from others |
Assess for any domestic violence, abuse or threats from others |
“Do you feel safe?” “Has anyone ever threatened or harmed you or your baby?” |
In addition, consider both adult and child safeguarding concerns in your assessment.
For more information, see the Geeky Medics guide to suicide risk assessment.
Differential diagnoses
Several conditions may present with similar symptoms to postnatal depression and should be considered in the differential diagnosis:4
- Baby blues: transient mood changes in the first week postpartum, characterised by tearfulness, insomnia, irritability and mood swings. Unlike postnatal depression, these symptoms are less severe, do not impair functioning and resolve without treatment.
- Postpartum psychosis: a rare but severe psychiatric emergency with hallucinations, delusions and disorganised behaviour. It usually develops within six weeks of childbirth.
- Bipolar disorder: should be considered if there is a history of mania or hypomania. Depression in this context may be misdiagnosed as postnatal depression.
- Anxiety disorders: such as GAD, PTSD or OCD may occur postpartum and can mimic or coexist with depression.
- Organic causes: medical conditions such as anaemia, thyroid dysfunction or vitamin deficiencies can contribute to symptoms that mimic depression.
Investigations
Screening questionnaires
Routine appointments with midwives, GPs or health visitors offer opportunities for mental health screening.
Tools such as the Edinburgh Postnatal Depression Scale (EPDS) can be used to screen patients. A score of 10 or more indicates the need for further assessment, but a high score alone does not confirm a diagnosis of postnatal depression.
Other tools include the PHQ-9 for depression and the GAD-7 for anxiety.
Physical investigations
Physical health investigations are not routinely required but may be useful to exclude underlying conditions that can mimic symptoms of postnatal depression.
Baseline blood tests can also support safe prescribing and ongoing monitoring where indicated. These may include:
Additional endocrine tests are rarely required and should be guided by clinical presentation. Female hormone screening (e.g. AMH, FSH, LH, oestradiol, progesterone, testosterone) may help identify ovarian or perimenopausal changes affecting mood.
Raised prolactin (hyperprolactinaemia) can also contribute to mood disturbance. Cortisol testing may be useful if Addison’s or Cushing’s disease is suspected.
Diagnosis
Postnatal depression meets the same diagnostic criteria as a depressive episode, but the key difference is timing: symptoms begin after childbirth.
Severity
Postnatal depression can be classified as mild, moderate or severe:
- Mild postnatal depression: some disturbance in mood and functioning, but daily life and caregiving responsibilities are maintained
- Moderate postnatal depression: several symptoms present to a significant degree. Considerable but not complete impairment in functioning. Outpatient treatment is usually required.
- Severe postnatal depression: most symptoms of depression are present to a marked or an intense degree. Complete difficulty in daily functioning with possible risk to self or baby. They would likely require intensive psychological treatment and/or inpatient admission for safety.
Postnatal depression with psychotic features vs. postnatal psychosis
In the severe stages, postnatal depression can sometimes be accompanied by psychotic features, such as delusions or hallucinations. This is referred to as ‘postnatal depression with psychotic features‘
It is important to distinguish this from postnatal psychosis (a separate psychiatric disorder).
While both may include psychotic symptoms, postnatal depression with psychotic features tends to have a more gradual onset. In contrast, postnatal psychosis typically develops suddenly and severely, often within the first few weeks postpartum, and usually requires immediate medical intervention.
Management
A holistic biopsychosocial approach should be tailored to symptom severity:
- Mild postnatal depression: managed with self-help strategies, psychoeducation, and cognitive behavioural therapy (CBT), without the need for medication
- Moderate postnatal depression: treated with psychological therapy (e.g. CBT) alongside antidepressants such as SSRIs
- Severe postnatal depression: requires intensive intervention, which may include hospital admission, psychotropic medication (e.g. SSRIs, antipsychotics), and structured psychological support
Any concerns for adult or child safety must be escalated appropriately.
Acute intervention
A thorough risk assessment should guide the level of monitoring, which must be reviewed regularly. If a patient is considered high risk and cannot be safely managed in the community, inpatient admission may be required.
Where possible, admission should be to a Mother and Baby Unit (MBU) to avoid separation and support the mother–infant bond. Treatment in an MBU can be provided for up to 12 months postpartum.
Biological management
SSRIs (e.g. sertraline) are first-line and considered safe in breastfeeding. Other antidepressants (e.g. SNRIs, mirtazapine, tricyclic antidepressants) may be used if SSRIs are not tolerated, but these are second-line due to varying safety levels in breastfeeding.
In patients with significant sleep disturbances, sedatives and sleep aids should be used cautiously and at the lowest effective dose, as these can pass into breastmilk.
Antipsychotics (e.g. quetiapine, olanzapine, risperidone) may be required for postnatal depression with psychotic symptoms or treatment-resistant cases.
Electroconvulsive therapy (ECT) is reserved for severe, refractory or high-risk cases where the health of the mother or safety of the baby is at significant risk.
Transcranial direct current stimulation (tDCS) is a newer, safe and non-invasive treatment option in the perinatal period.6,7
Safety of medications in breastfeeding
Information about the safety of medicines (e.g. antidepressants, antipsychotics) in pregnancy and breastfeeding can be found on the UKTIS and Bumps websites.
Psychological management
Options include CBT, interpersonal therapy (IPT), mindfulness and EMDR for birth trauma. Psychoeducation and self-help strategies can be useful.
Signposting to activities such as baby massage groups can also help strengthen the bond between mother and baby.
Social management
Support from partners, family and local groups is vital. Parenting support may involve practical help and guidance from professionals such as midwives, health visitors or nursery nurses.
Occupational therapy may assist with adjusting to parental roles and returning to work.
Follow-up and ongoing monitoring
Regular follow-up is essential to assess treatment response and to check for medication side effects.
The initial review should occur within 2 weeks of starting medication. Further reviews are typically at six weeks, three months and six months postpartum.
Referral to specialist perinatal services is advised for complex or severe cases.
Complications
Complications of postnatal depression include:
- Maternal or infant death: in severe cases, there is an increased risk of maternal death due to suicide or declining physical health. Infant death or infanticide may occur, particularly when psychotic symptoms are present. Early recognition and urgent intervention are vital.
- Impaired bonding and attachment: low mood, fatigue, and emotional withdrawal can make it difficult for parents to form a secure bond with their baby. Persistent bonding difficulties may lead to attachment disorders and, in severe cases, child neglect.
- Impact on infant development: infants of parents with postnatal depression are at higher risk of developmental delay, behavioural and emotional difficulties, and problems with language and social skills. They are also more likely to experience anxiety or depression later in life.
Reviewer
Dr Jamila Carey
Consultant Perinatal Psychiatrist
References
- National Institute for Health and Care Excellence (NICE). (2025). Postnatal depression: Management (NICE Clinical Guideline CG192). Available from: [LINK]
- Leigh, B., & Milgrom, J. (2008). Risk factors for antenatal depression, postnatal depression and parenting stress. BMC Psychiatry, 8(1), 24.
- Hutchens, B. F., & Kearney, J. (2020). Risk factors for postpartum depression: An umbrella review. Journal of Midwifery & Women’s Health, 65(1), 96–108.
- World Health Organization. (2025). Maternal mental health. Available from: [LINK]
- McAllister-Williams, R. H. et al. (2017). British Association for Psychopharmacology consensus guidance on the use of psychotropic medication preconception, in pregnancy and postpartum 2017. Journal of Psychopharmacology, 31(5), 519–552.
- Royal College of Psychiatrists. (2025). Postnatal depression: Key facts. Available from: [LINK]
- Vigod, S. et al. (2014). Transcranial direct current stimulation (tDCS) for treatment of major depression during pregnancy: Study protocol for a pilot randomized controlled trial. Trials, 15, 366.
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