Review Article
Postpartum Depression: An Essential Overview
for the Practitioner
Sarah J. Breese McCoy, PhD
Abstract: Postpartum depression (PPD) is a cross-cultural form of
major depressive disorder that affects some 13% of women and can
have serious health consequences for both the mother and her child.
Easy-to-use, reliable, self-administered screening tools are available.
PPD may have a variety of etiologies, which include changing plasma
levels of estrogen and progesterone, postpartum hypothyroidism,
sleep deprivation, or difficult life circumstances. Standard treatments
for PPD include psychotherapy and antidepressants. However, treat-
ment of a thyroid condition or insomnia, or even regular exercise or
massage may also be beneficial. PPD is underdiagnosed, therefore
more screening is needed. Obstetricians and pediatricians have a
unique opportunity to test women for PPD, but general practitioners
may encounter patients with undiagnosed PPD, too. These physi-
cians could positively impact the lives of depressed mothers and
their children by identifying them, then treating or providing refer-
rals for care as appropriate.
Key Words: diagnosis of postpartum depression, etiology of post-
partum depression, treatment of postpartum depression
A lthough the majority of women have a transient period
of mood dysphoria within about two weeks after giving
birth, about 13% of new mothers actually experience a true
form of major depressive disorder (MDD) know as postpar-
tum depression (PPD).1,2 The strictest criteria for designation
of MDD as PPD place the onset of the disorder within four
weeks of giving birth, but a more relaxed time frame of three
months postpartum has been suggested.2 In fact, labeling
MDD as PPD is common in the medical community if onset
is up to one year after childbirth.3
From the Department of Physiology, Oklahoma State University Center
for Health Sciences and College of Osteopathic Medicine and Sur-
gery, Tulsa, OK.
Reprint requests to Sarah J. Breese McCoy, PhD, Department of Physiology,
OSU Center for Health Sciences, 1111 W. 17th Street, Tulsa, OK 74107.
Email: sjmccoy98@aol.com
This work was not funded by any grant. The author has no financial disclo-
sures to declare and no conflicts of interest to report.
Accepted September 23, 2010.
Copyright © 2011 by The Southern Medical Association
0038-4348/0!2000/10400-0128
128
PPD is a serious medical matter not only because of the
suffering it causes women, but because it can negatively af-
fect infants emotionally, socially, and even cognitively, some-
times far beyond the time of the depression.3 The most severe
adverse outcomes of PPD include increased risk of marital
disruption and divorce, child abuse and neglect, and even
maternal suicide or infanticide. Children of depressed moth-
ers may experience insecurity, low self esteem, and even
decreased intellectual skills or language development.2
Diagnosis
PPD is diagnosed according to the criteria laid out in the
Diagnostic and Statistical Manual IV for MDD. At least five
of the nine possible symptoms must be present for a mini-
mum of two weeks. In addition, one of the symptoms present
must be either sadness or loss of pleasure. The other pos-
sible manifestations include irrational guilt or feelings of
worthlessness, low energy, difficulty concentrating, sui-
cidal thoughts, psychomotor retardation or agitation, changes
in sleep patterns, and changes in appetite.4 However, sleep
disturbances and changes in appetite are a normal part of the
postpartum period, even for women who are not depressed.1
Further, Bernstein et al5 found that women with PPD had less
sad mood and less suicidal tendencies than non-postpartum
women with MDD, as well as more psychomotor agitation or
Key Points
• The etiology of postpartum depression is still uncer-
tain, but various physiological and psychosocial
causes have been investigated.
• Although the mainstays of treatment for postpartum
depression are still psychotherapy and antidepressant
medications, management of sleep disturbances, ex-
ercise, massage, and treatment of other contributing
conditions such as thyroiditis may also be beneficial.
• Postpartum depression is currently underdiagnosed.
Therefore, primary care physicians such as obstetri-
cians, pediatricians, and general practitioners are in a
unique position to positively impact suffering women
and their children by screening for the disorder and
providing referrals for treatment.
© 2011 Southern Medical Association

restlessness and more impaired concentration/trouble making
decisions than depressed non-postpartum women. These dif-
ferences suggest a need for a screening tool that is specifi-
cally geared toward detecting PPD.
The most common PPD screen in use today is the Edin-
burgh Postnatal Depression Scale (EPDS). It is a self-admin-
istered, multiple-choice test with ten questions, each of which
has four possible answers, ranked 0 –3, for a scoring range of
0 –30. The authors recommend that !13 be considered a
positive screen for PPD for a demonstrated sensitivity of 86%
and specificity of 78%.6 Sit and Wisner (2009) reported that
93.4% of patients rated the EPDS “easy or fairly easy” to
complete.7 The EPDS is ideal for busy obstetricians’ prac-
tices where practitioners may not have extensive experience
with psychiatric tests or time to give each postpartum patient
a thorough psychological exam.7
Three of the ten questions of the EPDS deal specifically
with anxiety, which is typically a more prominent feature of
PPD than of non-postpartum MDD. Kabir (2008) posed the
three EPDS anxiety questions (EPDS-3) to 199 mothers, then
adjusted the raw score to compare to the 10-question EPDS.
For that sample, an adjusted score !10 on the EPDS-3 had a
sensitivity of 95% and a specificity of 80% for detecting
PPD. Follow up with a diagnostic psychiatric interview was
necessary. The authors concluded that the EPDS-3 appears to
be a good alternative to the EPDS when the aim is to detect,
rather than to assess the severity of PPD.8
There is now also an Edinburgh Postnatal Depression
Scale-Partner (EPDS-P) screen in which a new mother’s sig-
nificant other rates her depressive symptoms, rather than the
new mother herself. Recent data has shown that the EPDS-P
rating is a better predictor of a new mother’s PPD than even
the EPDS itself.7 Of course, it is only useful if the new
mother’s partner is willing to accompany her to visit her
physician or therapist and participate in her evaluation.
Other useful screening tools include the 9-question Pa-
tient Health Questionnaire (PHQ-9) with both a sensitivity
and specificity of 88%, and the Postpartum Depression
Screening Scale (PDSS). Women who screen positive for
PPD during the initial phase of the 7-item PDSS then
answer 28 additional questions. However, its low specificity
leads to high rates of false-positive screens, which limits its
usefulness.7
Etiology
Women are about twice as likely as men to experience
MDD in general. It is thought that about one-third of this risk
for females is genetic, and the other two-thirds environmen-
tal.9 Men, however, do not experience PPD at all. Therefore,
this particular type of MDD most likely has an underlying
etiology that is at least in large part physiological, rather than
merely psychosocial or circumstantial.10 Although PPD’s or-
igins are not completely understood, various theories have
Southern Medical Journal • Volume 104, Number 2, February 2011
Review Article
been proposed. PPD may, in fact, have several possible un-
derlying causes, which are outlined below.
Placental Steroids
Upon delivery of the placenta at birth, maternal plasma
estrogen and progesterone levels begin to fall rapidly. Since
these hormones have known neural effects at physiological
concentrations, it has long been thought that their changing
levels have psychological effects as well.11
In mice, the brain’s GABAA receptors, whose stimula-
tion promotes relaxation and tranquility, are down-regulated
during pregnancy by neurosteroids derived from progester-
one. These receptors then rapidly rebound in the postpartum
period. Interestingly, mice with defective GABAA receptors
have a significantly higher rate of depressive postpartum
symptoms such as anhedonia. The mice with defective recep-
tors are also more likely to neglect their pups, or even can-
nibalize them.9 The authors suggested that treatment with a
particular GABAA receptor agonist could be very effective.9
Dennis (2008) reviewed two trials in which women were
given either synthetic progestin or transdermal estrogen in a
single dose at 48 hours postpartum, and then screened for
PPD using the EPDS at four or six weeks and again at twelve
weeks postpartum.11 The progestin group was associated with
increased symptoms of negative mood at six weeks postpar-
tum, but not at twelve weeks, as compared to placebo. The
estrogen group had fewer depressive symptoms than women
in the placebo group at both four and twelve weeks postpar-
tum. Taken as a whole, the current body of research on the
relation between placental steroids and PPD seems to support
an etiology for PPD that is at least in part related to changing
estrogen and/or progesterone concentrations after birth.
Autoimmune Disorders
Physiological conditions with known etiologies that tend
to flare up after childbirth are exclusively autoimmune in
nature. One contributor to this flare up is the mother’s expo-
sure to a variety of fetal antigens during delivery. MDD is
characterized by such a postpartum flare and, therefore, at
least some cases of PPD may also be autoimmune in nature.10
For example, postpartum thyroiditis is a condition in
which certain thyroid autoantibodies become detectable in
plasma between six weeks and six months after pregnancy. It
affects 6 –9% of postpartum women who have no history of
thyroid disease. In a quarter of the cases, this disorder pre-
sents with a hyperthyroid phase followed by a hypothyroid
phase, but presentation with only hyperthyroidism or only
hypothyroidism is also common. A few studies have at-
tempted to determine whether any coincident depression is
linked to the thyroid disease itself.12 No firm conclusions
have yet been reached, but given that hypothyroidism’s symp-
toms include depression, some PPD may be thyroid-based.
129
Breese McCoy • Postpartum Depression
Sleep and Circadian Rhythm Disturbances
At least five studies since 1968 have suggested that sleep
disturbance may sometimes be a cause, rather than an effect
of PPD. New moms cannot always sleep when they need to,
because they have to care for their infants. Therefore, any
tendency these women have to depression may be exacer-
bated by fatigue. In contrast, non-postpartum MDD may ac-
tually cause—rather than be caused by—insomnia.5 In short,
MDD sometimes causes insomnia, but insomnia likely con-
tributes to PPD.5
Melatonin is a sleep hormone produced in the brain’s
pineal gland. Its plasma concentrations begin to rise around
bedtime and peak at about 3:00 AM, then fall to nearly un-
detectable levels by the time of rising. Exposure to light,
especially blue light with a wavelength of about 470 nm,
inhibits melatonin release. Bennet et al13 recently reported a
small trial in which subjects with PPD who wore blue-block-
ing glasses when arising at night to take care of their new-
borns recovered significantly faster than controls who had
PPD but did not wear the glasses. The implication is that
disruption of normal melatonin production during the night
may be a contributor to PPD.
Psychosocial Risk Factors
PPD has various psychosocial risk factors, some of which
could be at least partially causative. These risk factors include
MDD during pregnancy, anxiety during pregnancy, history of
MDD, premenstrual dysphoric disorder, undue life stress dur-
ing the prenatal period, lack of social support, marital diffi-
culties, poverty, and young maternal age.1,3
Treatment
Because universal screening is not yet the norm, many
cases of PPD go undetected. Fortunately, PPD usually re-
solves without treatment within a few months, but long-
term suffering is also possible. Given the potential harmful
effects of PPD to both mother and child, treatment is usu-
ally desired.2
Psychological/Psychosocial Intervention
Interpersonal psychotherapy (IPT) has been shown to be
an effective intervention for the treatment of PPD.14 Cuijpers
(2008) conducted a meta-analysis of 17 studies of psycho-
logical treatments for PPD.2 These psychological treatments
ranged from cognitive-behavioral therapy to social support
intervention and IPT. The 17 studies included a total of 1,248
participants—700 who received psychological treatment, 460
controls, and 88 who received treatment other than psycho-
logical. Results showed that, at least over the short term,
women who received psychological intervention had signif-
icantly lower scores on their depression tests than controls.
Not enough data were present to properly compare psycho-
logical treatments with pharmacological ones.2
130
Dennis (2007) did a meta-analysis of nine trials covering
956 women in which either psychosocial or psychological
intervention was made for PPD.15 Both of the treatments
were effective in significantly reducing depressive symptoms.
Although long-term effectiveness was not clear, counseling
appeared to help women suffering from PPD.15
In short, various studies have reported that women re-
ceiving IPT have reduced depressive symptoms over time
compared to their wait-listed or control counterparts.1 Be-
cause there is some risk of side effects to nursing infants of
mothers who are taking antidepressants, IPT is a logical first
line of treatment for depressed, breastfeeding women. An-
other type of therapy which may also be effective for mild
cases of PPD is an abbreviated form of IPT known as Inter-
personal Counseling (IPC).14
Antidepressants
Antidepressant medications have been shown to signifi-
cantly reduce depressive symptoms in women with PPD.15
Although there is a range of antidepressants and anxiolytics
available for the non-breastfeeding new mother with PPD, the
well-known selective serotonin re-uptake inhibitor (SSRI) ser-
traline is the drug of choice for lactating women. Sertraline is
considered relatively safe, because few adverse effects have
been seen in the women’s infants. Other secondary options
include paroxetine and nortriptyline. The greatest risk to nurs-
ing infants appears to be in the first eight weeks after birth. If
breastfeeding can be timed so that it does not occur when
concentrations of the antidepressant medication are at their
peak in milk, risks to the infant are minimized. An excellent
website for monitoring the current knowledge about medica-
tions and breastfeeding is "http://toxnet.nlm.nih.gov#; click
on “LactMed.”1
Managing Sleep Disturbance
Evidence suggests that inhibition of melatonin by expo-
sure to light during the night may contribute to PPD.13 Simple
actions such as using blue-blocking light bulbs or glasses at
night or even learning to care for a newborn during the night
in very low light overall might prove effective as a treatment
for mood dysphoria.13
Exercise
Aerobic exercise may be another efficacious treatment
option for PPD.7 Two studies in Australia found that exercise
for women with PPD was associated with improvement of
depressive symptoms. Uncontrolled and observational studies
have also suggested that PPD may be helped by exercise such
as “pram walking.”16
Exercise may improve PPD symptoms by increasing con-
centrations of endorphins, which are associated with feelings
of well-being. Alternatively, being physically fit may increase
self-esteem or provide a sense of achievement due to weight
© 2011 Southern Medical Association

loss and improved muscle tone. Exercise may even merely be a
beneficial distraction.16 In any case, given its low cost and low
risk, moderate exercise may be attractive to women who might
not opt for expensive counseling or a prescription medication.
Massage
Another non-pharmacologic intervention for PPD that
has reportedly resulted in significant improvement is massage
therapy for either the mother, or for the infant as administered
by the mother. Dimidjian et al17 reported that when a wom-
an’s partner provided 20 minutes of massage to her twice a
week for 16 weeks, depression and anxiety symptoms signif-
icantly decreased over controls, and infant outcomes im-
proved. Although results for infant massage were less clear,
five weekly sessions of infant massage by the mother, as
taught in an infant massage class, were associated with greater
self-reported improvements over controls.17
Treatment of Postpartum Thyroid Conditions
Postpartum thyroid dysfunction may contribute to some
PPD.12 In such cases, PPD might be corrected or at least
improved by treating the thyroid disorder, without the need
for psychotherapy and/or antidepressants.
Recommendations
Fewer than half the cases of PPD are diagnosed. Univer-
sal screening may be the ideal way to detect every woman
who suffers from this unfortunate condition, although a firm
recommendation for such screening has not been made by the
American College of Obstetricians and Gynecologists.7,18
One of the most obvious opportunities for detection of PPD
is the 4 – 6 week postpartum obstetrics visit. Beyond postpar-
tum screening, however, is the relatively new concept of pre-
natal screening for PPD. Kim et al19 recently reported that
giving women the EPDS at 24 –28 weeks gestation resulted in
a risk status that was identical with risk status after delivery
for 90% of patients studied. The author concluded that such
prenatal screening seemed clinically useful.19
Other occasions for detection of PPD include well-child
visits to the pediatrician.20 Understandably, a key issue is the
lack of time during a routine visit to diagnose PPD and pro-
vide adequate education and guidance. Further, particularly in
the pediatrician’s office, a physician may not want to be
placed in the position of giving medical advice to an adult
who is not the actual patient.20 However, two recent studies
have shown that such screenings in pediatricians’ offices can
be practicable and have good results. Chaudron reported detec-
tion of depressive symptoms in postpartum mothers by pedia-
tricians increased with formal screening from a mere 1.6% to
8.5%, while Heneghan noted an improvement of detection in a
high risk inner-city population from 29% to 40%.21,22 Given
these encouraging preliminary findings, the small amount of
time required to administer a self-scoring screening tool and
Southern Medical Journal • Volume 104, Number 2, February 2011
Review Article
provide some referral information might be well worth the po-
tential for improving the lives of mothers and children.
General practitioners (GPs) may also encounter the oc-
casional new mother who presents for treatment of some
other coincidental ailment. This could be particularly impor-
tant for the woman whose PPD onset occurs after her post-
partum obstetric appointment, when she may have no further
contact with her gynecologist for an extended period of time.
Given PPD’s incidence and the number of undiagnosed cases,
the GP who is willing to screen will likely detect new cases.
It is helpful for screening physicians to have strong working
relationships with mental health providers with whom a pa-
tient can follow up.20
Conclusion
The postpartum period is a stressful time of transition,
both physically and psychologically. PPD makes this phase
of life especially burdensome and difficult for some women.
Primary care physicians who are aware of this issue, who
reach out with compassion and help, are in a unique position
to lessen the pain of both mothers and their babies.
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© 2011 Southern Medical Association