Postpartum Depression

What it is

Perinatal depression includes depression that occurs during pregnancy, called prenatal depression, and in the weeks and months after childbirth, called postpartum depression [1]. It is a medical condition, not a character problem, and it is treatable.

Why this guide is written for Black patients

One in 8 new mothers reports experiencing symptoms of postpartum depression in the year after childbirth [2].

The disparity that has been measured most clearly is not in who has it, but in who gets named as having it. In a study across a large health system, about 11 percent of women had a positive depression screen, and Black women were less than half as likely as white women to receive a diagnosis in adjusted models during pregnancy, an adjusted odds ratio of 0.40 [3]. That difference disappeared after delivery, with no significant difference in diagnosis rates postpartum [3].

That is a specific, fixable failure. A screening questionnaire is only useful if a positive answer turns into a diagnosis and a plan. If you fill in a form and nobody comes back to you about the score, the screening did not happen in any way that matters.

What to ask a clinician

• What was my score on the screening questionnaire, and what does it mean?
• If it was positive, what is the diagnosis, and what is the plan, in writing?
• Which treatment do you recommend, and can I do it while breastfeeding [2]?
• Who is checking on me between now and the postpartum visit?
• What do I do at 2am if it gets worse?

What good care looks like

Good care starts by separating this from the baby blues. Baby blues are mild, short-lasting mood changes in the first 2 weeks after giving birth [1]. Postpartum depression symptoms are severe or last longer than 2 weeks, and generally need treatment from a professional [1]. Symptoms include persistent sadness or anxiety, hopelessness, irritability, fatigue, sleep problems, difficulty concentrating, and thoughts of death or of harming oneself or the baby [1].

Treatment usually includes therapy, medicine, or a combination of the two [1]. Cognitive behavioral therapy and interpersonal therapy are used, along with antidepressants, and the medicines brexanolone and zuranolone are approved for severe cases [1]. Antidepressants can relieve symptoms of depression and some can be taken while breastfeeding [2]. Support groups, practical help and rest are part of the plan rather than a substitute for it [2].

Hormones are part of the picture: after delivery, hormone levels drop quickly back to pre-pregnancy levels, and low thyroid hormone can also produce depressive symptoms [2], which is why a thyroid test is a reasonable thing to ask for.

Good care follows up. Ask who is calling you, and when, and hold them to it.

When it is urgent

Call 911 immediately for symptoms of postpartum psychosis, which is a severe condition [1]. Those symptoms include seeing or hearing things that are not there, confusion, rapid mood swings, paranoia, or beliefs that do not match reality.

Call or text the 988 Suicide and Crisis Lifeline at 988 for thoughts of suicide, or for thoughts of harming the baby [1]. Having those thoughts does not mean the baby will be taken from you, and it does mean the situation needs help today rather than next week. The line is free, confidential and open at any hour.

Sadness that lasts more than two weeks is a reason to see a doctor rather than wait for the postpartum visit [2].

What to do next

Tell someone today. A partner, a relative, a friend, and then a clinician.

Bring it to the OB-GYN who delivered you, since they can screen, prescribe and refer. See Black OB-GYNs. For talking therapy, see Black therapists, and ask for someone who works with new parents. Take a written list of your symptoms, because the appointment is short and the words go missing.