What is Maternal Depression?

The term maternal depression encompasses a range of conditions that can affect women during pregnancy and up to one year postpartum. This spectrum of conditions includes prenataldepression, the "baby blues," postpartumdepressionand postpartum psychosis. The table below provides an overview and comparison of these conditions.

Types, Prevalence, and Symptoms of Maternal Depression and Related Conditions

Type Onset Prevalence Symptoms
Prenatal Depression During pregnancy 10 to 20 percent of pregnant mothers
  • Crying, weepiness
  • Sleep problems
  • Fatigue
  • Appetite disturbance
  • Anhedonia (loss of enjoyment of activities)
  • Anxiety
  • Poor fetal attachment
  • Irritability
Baby Blues Begins during the first few weeks after delivery (usually in first week, peaking at 3 to 5 days). Symptoms usually resolve by two weeks after delivery. As high as 80 percent of new mothers
  • Crying, weepiness
  • Sadness
  • Irritability
  • Exaggerated sense of empathy
  • Anxiety
  • Mood lability ("ups" and "downs")
  • Feeling overwhelmed
  • Insomnia; trouble falling or staying asleep; Fatigue/exhaustion
  • Frustration
Postpartum Depression Usually within the first two to three months post-partum, though onset can be immediate after delivery (distinguishable from "baby blues" as it lasts beyond two weeks post-partum) 10 to 20 percent of new mothers
  • Persistent sadness
  • Frequent crying, even about little things
  • Poor concentration or indecisiveness
  • Difficulty remembering things
  • Feelings of worthlessness, inadequacy or guilt
  • Irritability, crankiness
  • Loss of interest in caring for oneself
  • Not feeling up to doing everyday tasks
  • Psychomotor agitation or retardation
  • Fatigue, loss of energy
  • Insomnia or hyperinsomnia (excessive daytime sleepiness)
  • Significant decrease or increase in appetite
  • Anxiety manifested as bizarre thoughts and fears, such as obsessive thoughts of harm to the baby
  • Feeling overwhelmed
  • Somatic symptoms (headaches, chest pains, heart palpitations, numbness and hyperventilation)
  • Poor bonding with the baby (no attachment), lack of interest in the baby, family or activities
  • Loss of pleasure or interest in doing things one used to enjoy (including sex)
  • Recurrent thoughts of death or suicide
Postpartum Psychosis Usually starts within 2 to 4 weeks of delivery, but can start as early as 2 to 3 days after delivery (and can occur anytime in the first year). 1-2 per 1,000 new mothers
  • Auditory hallucinations and delusions (often about the baby and often of a religious nature)
  • Visual hallucinations (often in the form of a seeing or feeling a presence of darkness)
  • Insomnia
  • Hopelessness
  • Feeling agitated, angry
  • Anxiety
  • Paranoia, distrusting of others
  • Delirium
  • Confusion
  • Mania (hyperactivity, elated mood, restlessness)
  • Suicidal or homicidal thoughts
  • Bizarre delusions and commands to harm the infant

Source: National Institute for Health Care Management, 2010.

Postpartum psychosis (PPP)

Postpartum psychosis (PPP) is a severe mental disorder that occurs in 1-2/1,000 deliveries. Rates of PPP in women with bipolar disorder are ~25-50%; rates increase to over 70% if there is also a family history of PPP. PPP often strikes abruptly in the first two weeks after delivery, or it may develop slowly over months if early postpartum depression is untreated. It is important to differentiate PPP from postpartum depression, which is a non-psychotic condition that occurs in 10 – 20 percent of childbearing women.

PPP presents a complex picture of mood cycling, cognitive impairment, and psychosis and includes rapidly shifting moods, agitation, bizarre hallucinations, and delusions; the delusions may be organized around the infant.

The cognitive disorganization and ever changing moods add to the unpredictable nature of this condition, which has a significant risk of suicide and infanticide. The safety of mother and baby is paramount. As such, this illness is a psychiatric emergency that requires immediate hospitalization, resulting in separation of the infant from the mother. On admission, the patient should receive a thorough physical examination, standard blood tests, a metabolic workup, and drug testing.

Preventive strategies are warranted in the prenatal period; these include screening for mood disorders, particularly bipolar disorder in the patient or family. Research suggests that the use of mood stabilizers (primarily lithium) and antipsychotics are the treatments of choice, though electroconvulsive therapy (ECT) may be indicated in certain cases. While the prognosis is good and there are rare episodes between pregnancies, there is a 50% recurrence rate with subsequent childbirth. Recurrence can be reduced with mood stabilizer and antipsychotic medication given before childbirth.

Postpartum psychosis has a unique precipitant, namely childbirth. At this time, an abrupt drop in hormones alters brain neurotransmitters. Recent research suggests an immune system dysregulation similar to that of bipolar disorder, suggesting that PPP is an episode of bipolar disorder complicated by dysregulation of the immune system and an altered neuroendocrine axis.

Prevalence of Maternal Depression

Survey data collected from new mothers between 2004-2008 through the CDC's Pregnancy Risk Assessment Monitoring Systems (PRAMS) indicate that approximately 14.5% of women reported symptoms of postpartum depression within three months after the birth of a child (CDC 2011). Data were collected in 22 states, with the highest prevalence (21.3%) reported in Tennessee and the lowest (9.8%) reported in Minnesota. In New York State, 12.7% of mothers reported symptoms of postpartum depression. 2011 NYS PRAMS data showed 3.1% of women reported feeling sad, 1.3% reported feeling hopeless, and 5% reported feeling slowed down – all in the months after childbirth. Note that the questions for the two surveys were different, and so data cannot be compared

In 2011, the New York State Department of Health (NYSDOH) partnered with the Island Peer Review Organization (IPRO) to conduct a Medicaid Perinatal Care Study to assess prenatal and postpartum care services provided to women enrolled in Medicaid, as related to statewide Medicaid Prenatal Care standards. The study found that 18% of women screened at an initial prenatal visit, 21% of women screened at a third trimester visit, and 12% of women screened at a postpartum visit, had symptoms of depression.

Depression among Fathers

Just as a new baby can introduce factors that contribute to maternal depression, the same can apply to new fathers. Paternal depression, though not as frequently investigated as maternal depression, occurs in approximately 4.8 to 13%t of new fathers within the first 12 months after delivery. By the time the child is 12 years old, 21% of fathers will have experienced one or more episodes of depression. Symptoms include: higher levels of irritability, frustration and anger; isolation from family and friends; impulsiveness and risk taking;, lack of concentration and motivation; and, loss of interest in work, hobbies and sex. Factors that contribute to paternal depression include: a partner with maternal depression, younger age, lower education and income. Like maternal depression, paternal depression can have negative impacts on the partner and children. Fathers suffering from paternal depression are more likely to have unhappy relationships with their partners, and are more critical and negative towards their partners. As with maternal depression, paternal depression, independent of the mother's mood, negatively affects the child's development.

Risk Factors for Maternal Depression

The most common risk factor for maternal depression is a previous episode of prenatal or postpartum depression. . Other factors associated with maternal depression include:

  • personal or family history of anxiety, depression or other mood disorders, including prenatal or postpartum depression;
  • current or past history of alcohol or other substance abuse;
  • life stress, poor quality or no relationship with the baby's father, lack of social support or absence of a community network;
  • unplanned or unwanted pregnancy;
  • difficult pregnancy or delivery, including preterm birth, multiple births, miscarriage or stillbirth, birth defects or disabilities or other pregnancy complications;
  • white race and non-Hispanic ethnicity;
  • maternal age <24 years of age;
  • lower maternal socioeconomic status.

While the above factors have been associated with a higher risk for maternal depression, depression also occurs among women without these risk factors.

Health Risks of Maternal Depression to Mother and Infant/ Partner/ Family

Maternal depression affects the entire family, and may have significant adverse effects on the health of both the mother and infant. Strong and consistent evidence indicates that a mother's untreated depression undercuts young children's development, and can affect learning, academic success, and success later in life.. Maternal depression can cause "lasting effects on [children's] brain architecture and persistent disruptions of their stress response systems."

A thorough review of this research by the National Research Council and Institute of Medicine finds that maternal depression endangers young children's cognitive, socio-emotional and behavioral development, as well as their learning, and physical and mental health over the long term. Depression disproportionately affects low-income mothers, putting their children at the highest risk for poor developmental outcomes. For low-income mothers, depression is embedded in an array of risk factors including financial and housing instability, lack of social supports and limited resources. Mothers of young children living in poverty and deep poverty are particularly affected by depression. Rates of depression for mothers of young children go up as income goes down. About one in nine infants living in poverty has a mother who is severely depressed, and more than half have a mother experiencing some level of depression. Homeless mothers also experience disproportionately high rates of depression, often compounded by their circumstances.

Maternal depression can significantly affect the ability of mothers and infants to form healthy and secure emotional bonds and reduce the quality of maternal-infant interactions, which in turn can have serious and permanent impacts on children's health and development. Children born to mothers with maternal depression are at higher risk for:

  • delays in social, emotional, cognitive and physical development;
  • long-term mental health problems;
  • reduced utilization of preventive health care services (such as immunizations) and higher use of emergency rooms and other medical services;
  • lack of breastfeeding and early discontinuation of breastfeeding.

Maternal depression can also impact overall family functioning, and increase the risk for paternal depression.