Peripartum depression: Early recognition improves outcomes

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Depression is highly prevalent in women of childbearing age, especially during the postpartum period. Early recognition and treatment improve outcomes for mother, developing fetus, and infant. Caution is warranted when prescribing antidepressants to pregnant and breastfeeding mothers, but evidence is mounting that the risks of untreated maternal depression outweigh those of pharmacologic treatment for it.


  • Depression occurs in up to 13% of pregnant women, a prevalence similar to that in nonpregnant women, but the incidence rises postpartum.
  • Depressed pregnant women are more likely to engage in behaviors that pose a risk to the fetus.
  • Depression in pregnancy is associated with adverse pregnancy outcomes such as preterm birth, low birth weight, gestational diabetes, and hypertensive disorders of pregnancy.
  • Risk factors for depression in pregnancy include past episodes of depression, poor social support, unwanted pregnancy, and domestic violence.



Contrary to common belief, pregnancy does not confer protection against depression.1,2 In fact, pregnant women are just as likely as nonpregnant women to become or remain depressed, and up to 12.7% of pregnant women meet criteria for depression.1

In the postpartum period, women are particularly vulnerable to a major depressive episode, whether a first episode or a recurrence. The estimated prevalence of a depressive episode in the first 3 postpartum months is 19.2%,2 making postpartum depression the most common complication of childbearing.2 At the same time, peripartum depression remains largely underrecognized and undertreated.3

As evidence mounts regarding the deleterious impact of untreated mental illness on the mother, the developing fetus, and the infant, early detection and intervention for peripartum depression are paramount.3


Although the rates of depression in pregnant and nonpregnant women are similar, depression in pregnancy carries additional significant consequences. Further, many depressed pregnant women believe their depression will lift once their baby is born, though it is well documented that depression during pregnancy is the strongest predictor of postpartum depression and that if left untreated it can be devastating for mother, infant, and family.4

Compared with nondepressed pregnant women, depressed pregnant women have poorer overall health status,5 are more likely to engage in behaviors that pose risk to the developing fetus such as smoking,5 alcohol consumption, and substance use,6 and have poor nutrition and inadequate weight gain.7,8

Pregnant women who are depressed and are also experiencing domestic violence are especially at risk for poor prenatal care as they tend to miss more prenatal appointments.9 Evidence also suggests that depressed pregnant women are less attached to the fetus and more likely to have elective terminations.10,11

Depression in pregnancy is associated with higher rates of adverse pregnancy outcomes such as preterm birth, low birth weight, operative delivery, and longer predelivery hospital stay.3,12 Depression and anxiety during pregnancy have been associated with prenatal hypertension,13 gestational diabetes,14 preeclampsia,15 and HELLP syndrome (ie, hemolysis, elevated liver enzymes, and low platelet count).15 Depression and anxiety during pregnancy are associated with subsequent poorer infant attachment16,17 and an overall unfavorable impact on infant and child development.18

Risk factors for depression during pregnancy include past episodes of depression, current anxiety, poor social support, unintended pregnancy, life stress, being single, domestic violence, and being on Medicaid.19

Undoubtedly the most devastating consequence of severe depression during pregnancy is suicide. Rates of suicide are lower in peripartum women,20 but when suicide does occur, pregnant women tend to use more violent means than nonpregnant women. Pregnant adolescents represent a particularly high-risk group.21


Postpartum depression is the most common complication of childbearing. Although the precise pathogenesis is undetermined, there is converging evidence of a subset of women particularly sensitive to dramatic fluctuations in levels of estradiol and progesterone that occur during childbirth.22,23 There is also evidence that dysregulation of the hypothalamic-pituitary-adrenal axis contributes to the development of postpartum depression in certain women.24 Further, women who have depression or anxiety during pregnancy are much more likely to experience postpartum depression than those who are not symptomatic during pregnancy.4 A history of peripartum depression or other lifetime depressive episodes, poverty, conflict with a primary partner, poor social support, stressful life events, and low self-esteem are strongly associated with postpartum depression.25

When unrecognized and untreated, postpartum depression can have profound and persistent effects on the mother and the developing infant.18,26 Mothers with postpartum depression are much more likely than mothers without depression to have impaired bonding,27 to be less responsive to their infant’s needs,17 and to be more likely to miss well-baby checkups.28

Postpartum depression’s effects on maternal-infant interactions can include maternal withdrawal, disengagement, intrusion, and hostility and can lead to long-term effects on child development, including poor cognitive functioning, emotional maladjustment, and behavioral inhibition.29,30 Infants and children of mothers with untreated postpartum depression have been shown to exhibit a higher incidence of colic, excessive crying, sleep problems, and irritability.31,32 Women with postpartum depression may be less likely to initiate or maintain breastfeeding, and depressive symptoms have been noted to precede the discontinuation of breastfeeding.33–35

Risk factors for postpartum depression

Characteristics to look for in the prenatal care of pregnant women include the following:

  • Depression during pregnancy
  • History of postpartum or other depressive episode
  • Poverty
  • Conflict with primary partner
  • Poor social support
  • Low self-esteem
  • Single status.

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