Pathophysiology & Risk Factors

Postpartum mood disorders fall on a severity spectrum: self-limiting baby blues (up to 80% of mothers, onset 2-3 days, resolves by day 10-14) -> postpartum depression (10-15%, persists beyond 2 weeks with functional impairment) -> postpartum psychosis (1-2 per 1,000 births, a psychiatric emergency with a break from reality). Risk factors overlap across the spectrum.

Baby blues vs PPD vs postpartum psychosis

Baby bluesPPDPsychosis

Onset2-3 daysWithin weeks; up to 12 months48-72h to 2 weeks

DurationResolves day 10-14Persists >2 weeksAcute, rapid

Reality testingIntactIntactLost

Key featuresTearful, labile, irritablePersistent sadness, guilt, impaired functionHallucinations, delusions, disorganized

TreatmentNone (self-limiting)Therapy + medsPsychiatric emergency

Baby blues

Onset: 2-3 days
Duration: Resolves day 10-14
Reality testing: Intact
Key features: Tearful, labile, irritable
Treatment: None (self-limiting)

PPD

Onset: Within weeks; up to 12 months
Duration: Persists >2 weeks
Reality testing: Intact
Key features: Persistent sadness, guilt, impaired function
Treatment: Therapy + meds

Psychosis

Onset: 48-72h to 2 weeks
Duration: Acute, rapid
Reality testing: Lost
Key features: Hallucinations, delusions, disorganized
Treatment: Psychiatric emergency

Signs & Symptoms

EarlyProgresses →

Tearfulness and mood swings

Baby blues; self-limiting, no impairment

Irritability

Late / Severe

Persistent sadness

PPD; beyond 2 weeks

Feelings of worthlessness or guilt

Inability to care for the infant Hallmark

Sleep disturbance

Unrelated to newborn care

Appetite disturbance

Difficulty bonding with infant

Hallucinations Hallmark

Postpartum psychosis

Delusions about the infant Hallmark

Disorganized or incoherent thinking Hallmark

Severe insomnia and agitation

Diagnostics & Labs

Diagnostic

Edinburgh Postnatal Depression Scale Hallmark

Validated postpartum-specific tool; preferred over PHQ-9

EPDS score >= 10EPDS >= 10

Threshold warranting further evaluation

EPDS question 10 endorsement

Any self-harm response triggers immediate safety assessment regardless of total

Monitor

Direct suicidal ideation assessment

Interventions & Priorities

Assess suicidal and infanticidal ideation

Frequency, intent, plan

Separate infant from psychotic client Hallmark

Never leave alone with the newborn

Activate 911 for active psychosis

Acute delusions = psychiatric emergency, not an office visit

Administer EPDS screening

After immediate safety is ensured; objective severity score

Refer for mental health evaluation

Provide therapeutic, nonjudgmental support

Provide crisis resources to all clients

Treatments & Medications

SertralinePrototype

First-line for PPD; breastfeeding-compatible

Psychotherapy

Inpatient psychiatric stabilization

Postpartum psychosis

Patient Teaching

Blues resolving by 2 weeks is normal

Symptoms past 2 weeks need evaluation

PPD is treatable, not a personal failing

Guilt keeps mothers from self-reporting

Activate support and screen high-risk clients early

Report Nowescalate immediately

Hallucinations Hallmark

Postpartum psychosis = psychiatric emergency

Delusions Hallmark

Disorganized behavior with infant

Thoughts of self-harm

Thoughts of harming the infant

Endangering behavior toward newborn

e.g., holding infant near open window

Clinical Pearl

If it lasts past two weeks, it's not the blues — and if reality breaks, it's an emergency, not severe depression.

Postpartum Depression & Psychosis