Depression - antenatal and postnatal
Exam Tips
- Use the two Whooley questions at first contact/booking and early postnatal review; a positive screen prompts full assessment, not immediate diagnosis.
- EPDS and PHQ-9 support case finding and severity tracking, but diagnosis is clinical using standard depressive criteria plus perinatal context.
- Always assess suicide/self-harm risk and risk to the infant; psychotic symptoms or marked confusion in the first 2 weeks postpartum are psychiatric emergencies.
- Distinguish depression from baby blues: persistence beyond 2 weeks, functional impairment, guilt/hopelessness, and sustained anhedonia favor depressive disorder.
- In prescribing stations, justify risk-benefit discussion: untreated illness carries maternal, obstetric, infant, and family harms; do not stop effective antidepressants abruptly.
- For breastfeeding OSCEs, sertraline is a common first-choice SSRI; document counselling on neonatal adaptation effects and safety-net advice.
Definition
Antenatal and postnatal depression is a depressive disorder occurring during pregnancy or after childbirth, usually considered within the first postnatal year in UK practice. It presents with persistent low mood and/or loss of interest plus cognitive, biological, and behavioural symptoms severe enough to impair maternal functioning, infant care, or bonding, and it is not simply a normal emotional adjustment to pregnancy or new parenthood.
Pathophysiology
Perinatal depression is multifactorial, combining biological vulnerability with psychosocial stress. Core mechanisms include altered monoaminergic signalling (serotonin/noradrenaline/dopamine), dysregulation of the hypothalamic-pituitary-adrenal axis, sleep-wake disruption, and inflammatory/neuroendocrine changes around pregnancy and postpartum (including rapid withdrawal of reproductive steroids and neurosteroids such as allopregnanolone after delivery). These interact with prior depression/anxiety, trauma, relationship adversity, and reduced social support to produce persistent negative affect, cognitive bias, and impaired reward processing; in severe illness this can disrupt maternal-infant attunement and family functioning. See Figure: perinatal stress-neuroendocrine model (standard psychiatry textbook chapter on perinatal mental health).
Risk Factors
- Past depression or anxiety (including previous perinatal episodes)
- Depression during current pregnancy
- Discontinuation of psychotropic medication before or during pregnancy
- Maternal anxiety and high antenatal parental stress
- History of childhood abuse, trauma, or domestic violence
- Lack of social support
- Poor partner relationship or relationship conflict
- Family history of depressive illness
- Unplanned or unintended pregnancy
- Recent adverse life events or unemployment
- Sleep deprivation
- Preterm birth, neonatal illness, or neonatal intensive care admission
- Thyroid dysfunction in pregnancy
- Pre-gestational or gestational diabetes
- Longer time to conception
- Current or previous alcohol/drug misuse
- Depression in the child's father
- Having two or more children
- Baby blues (for later postnatal depression risk)
Clinical Features
Symptoms
- Persistent low mood, sadness, irritability, or emotional numbness
- Loss of interest or pleasure (anhedonia)
- Fatigue and low energy out of proportion to expected postnatal tiredness
- Poor concentration and indecisiveness
- Guilt, worthlessness, or feeling like a 'bad mother'
- Hopelessness or overwhelming responsibility
- Sleep disturbance (including inability to sleep when the baby sleeps)
- Appetite change and weight change
- Anxiety symptoms, including excessive worry about baby health/safety
- Intrusive thoughts, including self-harm thoughts or thoughts of harm coming to the baby
- Social withdrawal and reduced engagement with infant/others
Signs
- Tearful or flat affect, psychomotor retardation or agitation
- Reduced eye contact, slowed speech, or poor self-care
- Impaired mother-infant interaction (reduced verbal/emotional responsiveness)
- Observable functional impairment in daily tasks and infant care
- Risk indicators: self-neglect, suicidality, safeguarding concerns
- Red flags for alternative severe diagnoses: delusions, hallucinations, marked confusion or disorganized behaviour (suggest postpartum psychosis)
Investigations
Management
Lifestyle Modifications
- Provide psychoeducation that perinatal depression is a treatable depressive illness, not a personal failure
- Offer facilitated self-help/low-intensity psychological interventions for milder illness
- Arrange evidence-based talking therapy (CBT or interpersonal therapy), with perinatal mental health input when needed
- Actively strengthen social support (partner/family involvement, health visitor, peer support, practical infant-care support)
- Target sleep protection and routine (shared night-time care where possible, daytime rest planning)
- Address safeguarding, domestic abuse, and substance misuse in parallel with mood treatment
- Use shared decision-making balancing relapse risk against treatment exposure risk in pregnancy/breastfeeding
Pharmacological Treatment
Selective serotonin reuptake inhibitors (first-line when medication is indicated)
- Sertraline 50 mg once daily initially; increase in 50 mg steps at intervals of at least 1 week to usual range 50-200 mg daily
- Fluoxetine 20 mg once daily initially; may increase to 40-60 mg daily if required
- Citalopram 20 mg once daily initially; may increase to maximum 40 mg daily
Sertraline is commonly preferred in breastfeeding because infant serum exposure is usually low. Use the lowest effective dose, avoid abrupt discontinuation, and monitor maternal response, adherence, and infant feeding/behaviour. Counsel on possible neonatal adaptation symptoms with late-pregnancy SSRI exposure and rare risk of persistent pulmonary hypertension of the newborn.
Alternative antidepressants
- Mirtazapine 15 mg at night initially; titrate to 30-45 mg nightly if needed
Consider when SSRIs are ineffective or not tolerated, guided by previous individual response and specialist advice in pregnancy.
Adjunctive treatment for severe/psychotic depression (specialist care)
- Antipsychotic treatment and/or antidepressant combinations under perinatal psychiatry supervision
If psychotic symptoms, severe suicidality, or major functional collapse are present, arrange urgent same-day specialist assessment; consider mother-and-baby unit admission to avoid separation where feasible.
Complications
- Self-harm and suicide (maternal suicide is a leading cause of death in the first postpartum year, though still uncommon)
- Obstetric complications in severe antenatal depression
- Preterm birth and low birthweight
- Possible increased risk of sudden infant death syndrome association
- Impaired mother-infant bonding and attachment difficulties
- Infant neglect risk in severe untreated illness
- Adverse child cognitive, behavioural, and emotional developmental outcomes in a subset of children
- Increased relationship conflict and wider family burden
- Higher risk of recurrent depressive episodes in and outside the perinatal period
Prognosis
Course is variable but broadly similar to depression at other life stages. Untreated antenatal depressive symptoms substantially increase the chance of postnatal depression (around sevenfold in observational data). Many postnatal episodes improve over months, but about one-third remain unwell at 1 year and a smaller proportion at 2 years; relapse risk in future pregnancies and later life depression is significant.
Sources & References
✅NICE Guidelines(1)
- Depression - antenatal and postnatal[overview]
📖Textbook References(11)
- David Randall PhD MRCP (Editor), John Booth PhD MRCP (Editor), K - Kumar and Clark's Clinical Medicine (2025, American Elsevier Publishing Co.) - libgen.li.pdf(pp. 1206)[context]
- David Randall PhD MRCP (Editor), John Booth PhD MRCP (Editor), K - Kumar and Clark's Clinical Medicine (2025, American Elsevier Publishing Co.) - libgen.li.pdf(pp. 1058, 1059)[context]
- David Randall PhD MRCP (Editor), John Booth PhD MRCP (Editor), K - Kumar and Clark's Clinical Medicine (2025, American Elsevier Publishing Co.) - libgen.li.pdf(pp. 1709, 1710)[context]
- David Randall PhD MRCP (Editor), John Booth PhD MRCP (Editor), K - Kumar and Clark's Clinical Medicine (2025, American Elsevier Publishing Co.) - libgen.li.pdf(pp. 1057, 1058)[context]
- David Randall PhD MRCP (Editor), John Booth PhD MRCP (Editor), K - Kumar and Clark's Clinical Medicine (2025, American Elsevier Publishing Co.) - libgen.li.pdf(pp. 1206)[context]
- David Randall PhD MRCP (Editor), John Booth PhD MRCP (Editor), K - Kumar and Clark's Clinical Medicine (2025, American Elsevier Publishing Co.) - libgen.li.pdf(pp. 1058)[context]
- Emergencies in - Obstetrics and Gynaecology, Second Edition (Stergios K. Doumouchtsis, S. Arulkumaran) (Z-Library).pdf(pp. 241, 242)[context]
- Emergencies in - Obstetrics and Gynaecology, Second Edition (Stergios K. Doumouchtsis, S. Arulkumaran) (Z-Library).pdf(pp. 242, 243)[context]
- Emergencies in - Obstetrics and Gynaecology, Second Edition (Stergios K. Doumouchtsis, S. Arulkumaran) (Z-Library).pdf(pp. 264)[context]
- Emergencies in - Obstetrics and Gynaecology, Second Edition (Stergios K. Doumouchtsis, S. Arulkumaran) (Z-Library).pdf(pp. 263, 264)[context]
- Oxford Handbook of Clinical Diagnosis (Huw Llewelyn, Hock Aun Ang, Keir Lewis etc.) (Z-Library).pdf(pp. 419, 420)[context]