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Am Fam Physician. 2023;108(3):267-272

Patient information: See related handout on depression during and after pregnancy.

This clinical content conforms to AAFP criteria for CME.

Author disclosure: No relevant financial relationships.

Peripartum depression is one of the most common disorders of pregnancy. It has a higher morbidity and mortality risk than any other condition affecting pregnant people. The American Academy of Family Physicians, the American College of Obstetricians and Gynecologists, the American Academy of Pediatrics, and the U.S. Preventive Services Task Force recommend that pregnant patients be screened for depression with one of several validated tools and offered treatment with psychotherapy and medication. There are no validated tools available to identify who is at increased risk of peripartum depression. Risk factors for peripartum depression include a history of depression, a history of physical or sexual abuse, carrying an unplanned or unwanted pregnancy, and traumatic birth. The U.S. Preventive Services Task Force recommends offering psychotherapy to patients at increased risk of depression because it can decrease the development of peripartum depression by up to 39%. Untreated peripartum depression increases the risk of adverse pregnancy outcomes and mortality for the patient, as well as negative outcomes for the newborn, including growth faltering, developmental delay, and attachment disorder. Cognitive behavior therapy and interpersonal psychotherapy are the mainstay of treatment for peripartum depression; physicians should consider selective serotonin reuptake inhibitors for those with moderate to severe depression. The benefits of selective serotonin reuptake inhibitors generally outweigh the risks; however, fluoxetine and paroxetine should be avoided during pregnancy because they can cause an increased risk of birth defects.

Peripartum depression refers to depression experienced during pregnancy or in the 12 months following childbirth; it affects up to 1 in 7 pregnant patients.1 Symptoms of peripartum depression persist for more than two weeks and include anhedonia, decreased energy, reduced appetite, and poor concentration. Peripartum depression is one of the most common disorders of pregnancy, and mortality from mental health conditions is higher than mortality from any other condition in the peripartum period, accounting for 22.7% of pregnancy-related deaths from 2017 through 2019.2 Peripartum depression can also have negative impacts on the child, including growth faltering, developmental delay, and attachment disorder.3 The etiology of peripartum depression is not known.

Mental health conditions accounted for 22.7% of pregnancy-related deaths from 2017 through 2019, a higher mortality than that from any other condition in the peripartum period.
A systematic review showed no consistent changes in thyroid-stimulating hormone, prolactin, or cortisol levels in patients with peripartum depression.

Incidence and Prevalence

In different studies, rates of peripartum depression ranged from 12.4% to 14.3%.1,4 During the COVID-19 pandemic, one study noted a depression rate that was more than twice as high in people who were pregnant during the pandemic compared with those whose pregnancy occurred before the pandemic, with 40% of all patients experiencing symptoms of depression during the pandemic.5 Recurrence rates are as high as 25% if a patient had depression with a previous pregnancy and 56% if depression occurred in two past pregnancies.6 Peak point prevalence of peripartum depression is at three months postpartum.1

Risk Factors

There are many risk factors for peripartum depression (Table 1).4,710 Notably, patients with a history of depression outside of the peripartum period have a twofold risk of recurrence during pregnancy.4

Adolescent pregnancy
Breastfeeding difficulties
Comorbid anxiety
History of depression
History of physical or sexual abuse
Lack of financial support
Lack of social support
Low socioeconomic status
Ongoing stressful life event
Preexisting diabetes mellitus or gestational diabetes
Traumatic birth
Unplanned or undesired pregnancy

Screening, Evaluation, and Diagnosis

Family physicians have the opportunity to screen patients during prenatal, postpartum, and infant clinic visits. The U.S. Preventive Services Task Force recommends depression screening for adults, including those who are pregnant or in the postpartum period.11,12 The American College of Obstetricians and Gynecologists recommends screening for depression at least once during the peripartum period and again postpartum if the initial screening took place during pregnancy.13

Family physicians often provide care to the birthing parent and child after delivery. The American Academy of Pediatrics recommends screening the birthing parent for depression at the one-, two-, four-, and six-month well-child visits.14 In 2016, the Centers for Medicare and Medicaid Services directed state Medicaid agencies to allow billing for depression screening of the birthing parent at well-child visits.15

Several validated screening tools are available. The most widely used are the Edinburgh Postnatal Depression Scale (EPDS) and the Patient Health Questionnaire-9 (PHQ-9); both are recommended by the U.S. Preventive Services Task Force, American College of Obstetricians and Gynecologists, American Academy of Family Physicians, and American Academy of Pediatrics to screen patients for peripartum depression. These tools take less than five minutes to complete and have no more than 10 questions each. The PHQ-9 includes questions about constitutional symptoms, such as fatigue and change in appetite, that are common in postpartum patients without depression, so the specificity of this test may be lower than that of the EPDS. Table 2 provides resources for each tool.16

TestNumber of itemsTime to self-administer (minutes)Sensitivity (%)Specificity (%)
Edinburgh Postnatal Depression Scale10< 575 to 100* 76 to 97*
Patient Health Questionnaire-99< 57590

The diagnosis of peripartum depression can be made using the Diagnostic and Statistical Manual of Mental Disorders, 5th ed. (DSM-5).17 The DSM-5 criteria require the onset of depression to occur within the first four weeks after delivery; however, most experts in the field define peripartum depression as having an onset anytime during pregnancy or up to 12 months postpartum.18 Peripartum depression must be differentiated from the baby blues. Although the baby blues typically occur within two to three days of delivery and recede by 10 days postpartum, peripartum depression lasts for more than two weeks.

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