Postpartum depression symptoms: 
When is it more than the "baby blues"?

© 2018 Gwen Dewar, Ph.D., all rights reserved

Postpartum depression symptoms overlap with symptoms of the "baby blues," the mood swings that mothers experience in the first few days after childbirth. 

But when symptoms persist beyond two weeks -- or take a more severe turn -- it's time to get screened for depression.

Here's what to look for.

Baby blues -- also called "maternity blues" -- are a common experience in the first few days after childbirth. All around the world -- from Brazil to Hong Kong to Nigeria to Germany -- between 33 to 55% of women report feeling moody, vulnerable and stressed in the first few days after childbirth (Faisal-Cury et al 2008; Hau and Levy 2003; Adewuya 2005; Reck et al 2015).

Is this postpartum depression?

The psychiatric profession tends to view baby blues as something different. Maybe that's because the baby blues are closely linked with the physical exhaustion and rapid hormonal changes that follow childbirth, and because women often experience improvements by two weeks postpartum.

But if you dig deeper, several points are clear.

1. The symptoms of the baby blues and postpartum depression are pretty much the same, and largely overlap with the symptoms of depression that women experience outside the context of childbirth (Hoertel et al 2015).

2. Some women experience severe postpartum depression symptoms during the first two weeks -- symptoms that seriously impact their ability to function (Gonidakis et al 2007).

3. Women who experience baby blues during the first two weeks are more likely, at a later time point, to get diagnosed with postpartum depression (Reck et al 2009).

So it seems that the baby blues and postpartum depression are part of a continuum, with the term "baby blues" implying, "We think there's a good chance your symptoms will improve soon, as your body recovers from the chemical and physical effects of childbirth."

This happens for some women with the baby blues, but not for others. Their symptoms persist. And for some mothers, postpartum depression doesn't have baby blues as a prequel. Although they don't report experiencing the baby blues in the early days postpartum, they end up developing postpartum depression months later (Wisner et al 2013).

So what are the key symptoms?

Postpartum depression symptoms

  • sadness
  • fatigue, or a decrease of energy
  • impaired concentration and decision making
  • the inability to feel pleasure
  • a tendency to blame yourself, to feel guilty or worthless
  • sleep disturbances
  • agitation or restlessness
  • appetite disturbances or weight loss
  • recurring thoughts of self-harm

These are the nine symptoms of depression recognized by the American Psychiatric Association (2013). This organization stipulates that you need to experience at least 5 of them, on a nearly daily basis, to rate a diagnosis of depression.

In addition, some researchers also add that sufferers might experience

  • feelings of being overwhelmed or unable to cope well,

and studies indicate that postpartum women also tend to suffer from

  • increased anxiety or worry.

This last symptom isn't associated with depression in general (as defined by the American Psychiatric Association). But it very frequently accompanies postnatal depression.

Need help judging the frequency or severity of your symptoms?

A quick and easy way is to use the Edinburgh Postnatal Depression Scale, a 10 item  multiple-choice questionnaire that asks you to think back over the past week (Cox et al 1987; Wisner et al 2002).

Each item in the questionnaire presents a statement that you quantify with an answer -- choosing whichever comes closest to representing your feelings over the last 7 days.

For example, if you were presented with a statement like this:

"I have felt worthless or hopeless."

You would choose whichever of the following answer choices came closest to representing your feelings over the last 7 days:     


0 No, not at all                    

1 Hardly ever                        

2 Yes, sometimes                               

3 Yes, very often                

 

As you can see, each answer choice is associated with a certain number of points. After you have answered all the questions, you tally up the points and see if they exceed a given threshold.

If they do, you have screened positive for postpartum depression. This isn't the same as a diagnosis. A diagnosis is made by a qualified physician or therapist, using information that goes beyond the questionnaire. But it's an indication that you have many of the signs.

Below, you will find a reproduction of the scale that you can use to test yourself. When calculating your score, please note that some questions are reverse-scored (with the top answer choice scored as a 3 and the bottom answer choice scored as a 0).


The Edinburgh Postnatal Depression Scale

In the past 7 days:

1. I have been able to laugh and see the funny side of things

0 As much as I always could

1 Not quite so much now

2 Definitely not so much now

3 Not at all

 

2. I have looked forward with enjoyment to things

0 As much as I ever did

1 Rather less then I used to

2 Definitely less than I used to

3 Hardly at all

 

3. I have blamed myself unnecessarily when things went wrong

3 Yes, most of the time

2 Yes, some of the time

1 Not very often

0 No, never

 

4. I have been anxious or worried for no good reason

0 No, not at all

1 Hardly ever

2 Yes, sometimes

3 Yes, very often

 

5. I have felt scared or panicky for no very good reason

3 Yes, quite a lot

2 Yes, sometimes

1 No, not much

0 No, not at all

 

6. Things have been getting on top of me

3 Yes, most of the time I haven't been able to cope at all

2 Yes, sometimes I haven't been coping as well

1 No, most of the time I have coped quite well

0 No, I have been coping as well as ever

 

7. I have been so unhappy that I have had difficulty sleeping

3 Yes, most of the time

2 Yes, sometimes

1 Not very often

0 No, not at all

 

8. I have felt sad or miserable

3 Yes, most of the time

2 Yes, quite often

1 Not very often

0 No, not at all

 

9. I have been so unhappy that I have been crying

3 Yes, most of the time

2 Yes, quite often

1 Only occasionally

0 No, never

 

10. The thought of harming myself has occurred to me

3 Yes, quite often

2 Sometimes

1 Hardly ever

0 Never


So what score is required to screen positive for postpartum depression?

There isn't any universally accepted, magic number. 

Suggested cutoffs have ranged between 9 and 13 points, but a doctor may diagnose you with PPD even if you have a lower score. The Edinburgh Postnatal Depression Scale isn't intended as a complete inventory of postnatal depression symptoms. Your doctor may decide you have additional symptoms or risk factors, and make his or her diagnosis accordingly. 

And one question it does ask merits a closer look no matter what: Thoughts of violence or self-harm  warrant a follow-up regardless of your overall score.

More information about coping during the postpartum phase

See my articles about postpartum stress and childbirth trauma.


References: Postpartum depression symptoms

The Edinburgh Postnatal Depression Scale was designed by John Cox and Jenni Holden and is discussed in these papers:

Cox JL, Holden JM, and Sagovsky R. 1987. Detection of postnatal depression: Development of the 10-item Edinburgh Postnatal Depression Scale. British Journal of Psychiatry 150: 782-786.

Wisner KL, Parry CM, and Piontek CM. 2002. Postpartum Depression. New England Journal of Medicine 347: 194-199.

Other research cited in this article about postpartum depression symptoms follows.

Adewuya AO. 2005. The maternity blues in Western Nigerian women: prevalence and risk factors. Am J Obstet Gynecol. 193(4):1522-5.

American Psychiatric Association. 2013. Diagnostic and statistical manual of mental disorders, 5th ed., (DSM-5). Washington, DC: American Psychiatric Publishing.

Bernstein IH, Rush AJ, Yonkers K, Carmody TJ, Woo A, McConnell K, Trivedi MH. 2008. Symptom features of postpartum depression: are they distinct? Depress Anxiety. 25(1):20-6.

Faisal-Cury A, Menezes PR, Tedesco JJ, Kahalle S, Zugaib M. 2008. Maternity "blues": prevalence and risk factors. Span J Psychol.  11(2):593-9.

Gonidakis F, Rabavilas AD, Varsou E, Kreatsas G, Christodoulou GN. 2007. Maternity blues in Athens, Greece: a study during the first 3 days after delivery. J Affect Disord. 99(1-3):107-15.

Hau FW and Levy VA. 2003.  The maternity blues and Hong Kong Chinese women: an exploratory study. J Affect Disord. 75(2):197-203.

Hoertel N, López S, Peyre H, Wall MM, González-Pinto A, Limosin F, Blanco C. 2015. Are symptom features of depression during pregnancy, the postpartum period and outside the peripartum period distinct? Results from a nationally representative sample using item response theory (IRT). Depress Anxiety. 32(2):129-40.

O'Hara MW and McCabe JE. 2013. Postpartum depression: current status and future directions. Annu Rev Clin Psychol. 9():379-407.

O'Keane V, Lightman S, Patrick K, Marsh M, Papadopoulos AS, Pawlby S, Seneviratne G, Taylor A, Moore R. 2011. Changes in the maternal hypothalamic-pituitary-adrenal axis during the early puerperium may be related to the postpartum 'blues'. J Neuroendocrinol. 23(11):1149-55.

Myers S, Johns SE. 2018. Postnatal depression is associated with detrimental life-long and multi-generational impacts on relationship quality. PeerJ. 6:e4305.

Pearson RM, Bornstein MH, Cordero M, Scerif G, Mahedy L, Evans J, Abioye A, Stein A 2016. Maternal perinatal mental health and offspring academic achievement at age 16: the mediating role of childhood executive function. J Child Psychol Psychiatry. 57(4):491-501.

Reck C, Stehle E, Reinig K, Mundt C. 2009. Maternity blues as a predictor of DSM-IV depression and anxiety disorders in the first three months postpartum. J Affect Disord. 113(1-2):77-87.

Surkan PJ, Kennedy CE, Hurley KM, Black MM. 2011. Maternal depression and early childhood growth in developing countries: systematic review and meta-analysis. Bull World Health Organ. 89(8):608-15.

Taraban L, Shaw DS, Leve LD, Natsuaki MN, Ganiban JM, Reiss D, Neiderhiser JM. 2018. Parental Depression, Overreactive Parenting, and Early Childhood Externalizing Problems: Moderation by Social Support. Child Dev. 2018 Feb 20. doi: 10.1111/cdev.13027. [Epub ahead of print]

Wisner KL, Sit DK, McShea MC, Rizzo DM, Zoretich RA, Hughes CL, Eng HF, Luther JF, Wisniewski SR, Costantino ML, Confer AL, Moses-Kolko EL, Famy CS, Hanusa BH. 2013. Onset timing, thoughts of self-harm, and diagnoses in postpartum women with screen-positive depression findings. JAMA Psychiatry. 70(5):490-8.

Content of "Postpartum depression symptoms" last modified 4/2018

Title image of mother with newborn by Matt Johnson/flickr 

Tired mother peering at newborn's face by george ruiz /flickr