Postpartum blues explained

Postpartum blues
Synonyms:Baby blues, maternity blues
Symptoms:Tearfulness, mood swings, irritability, anxiety, fatigue, difficulty sleeping or eating
Onset:Within a few days of childbirth
Duration:Up to 2 weeks
Differential:Postpartum depression, postpartum anxiety, postpartum psychosis
Treatment:Supportive
Medication:No medication indicated
Prognosis:Self-limited
Frequency:Up to 85%

Postpartum blues, also known as baby blues and maternity blues, is a very common but self-limited condition that begins shortly after childbirth and can present with a variety of symptoms such as mood swings, irritability, and tearfulness.[1] [2] Mothers may experience negative mood symptoms mixed with intense periods of joy. Up to 85% of new mothers are affected by postpartum blues, with symptoms starting within a few days after childbirth and lasting up to two weeks in duration. Treatment is supportive, including ensuring adequate sleep and emotional support. If symptoms are severe enough to affect daily functioning or last longer than two weeks, the individual should be evaluated for related postpartum psychiatric conditions, such as postpartum depression and postpartum anxiety. It is unclear whether the condition can be prevented, however education and reassurance are important to help alleviate patient distress.

Signs and symptoms

Symptoms of postpartum blues can vary significantly from one individual to another, and from one pregnancy to the next. Many symptoms of postpartum blues overlap both with normal symptoms experienced by new parents and with postpartum depression. Individuals with postpartum blues have symptoms that are milder and less disruptive to their daily functioning compared to those with postpartum depression. Symptoms of postpartum blues include, but are not limited to:[3]

Onset

Symptoms appear within 4 weeks of delivery and can last for years. (49)

Duration

Postpartum blues may last a few days up to two weeks.[4] [5] If symptoms last more than two weeks, evaluation for postpartum depression is recommended by the American Psychiatric Association.[6]

Causes

The causes of postpartum blues have not been clearly established. Most hypotheses regarding the etiology of postpartum blues and postpartum depression center on the intersection of the significant biological and psychosocial changes that occur with childbirth.

Psychosocial causes

Pregnancy and postpartum are significant life events that increase a woman's vulnerability for postpartum blues. Even with a planned pregnancy, it is normal to have feelings of doubt or regret, and it takes time to adjust to having a newborn. Feelings commonly reported by new parents and lifestyle changes that may contribute to developing early postpartum mood symptoms include:

Risk factors

Most risk factors studied have not clearly and consistently demonstrated an association with postpartum blues. These include sociodemographic factors, such as age and marital status, obstetric factors, such as delivery complications or low birth weight.[7]

Factors most consistently shown to be predictive of postpartum blues are personal and family history of depression. This is of particular interest given of the bidirectional relationship between postpartum blues and postpartum depression: a history of postpartum depression appears to be a risk factor for developing postpartum blues, and postpartum blues confers a higher risk of developing subsequent postpartum depression.

Pathophysiology

Estrogen and progesterone

After delivery of the placenta, mothers experience an abrupt decline of gonadal hormones, namely estrogen and progesterone.[8] Major hormonal changes in the early postpartum period may trigger mood symptoms similarly to how more minor hormonal shifts cause mood swings prior to menstrual periods.[9] Studies have not detected a consistent association between hormone concentrations and development of postpartum mood disorders. Some investigators believe the discrepant results may be due to variations in sensitivity to hormonal shifts across different subgroups of women. Therefore, development of mood symptoms may be related to a woman's sensitivity, based on genetic predisposition and psychosocial stressors, to changes in hormones rather than absolute hormonal levels.[10]

Other

The association between postpartum blues and a variety of other biological factors, including cortisol and the HPA axis,[11] tryptophan, prolactin, thyroid hormone, and others have been assessed over the years with inconclusive results.[12]

Emerging research has suggested a potential association between the gut microbiome and perinatal mood and anxiety disorders.[13] [14]

Diagnosis

Classification

The proper diagnostic classification of postpartum blues has not been clearly established. Postpartum blues has long been considered to be the mildest condition on the spectrum of postpartum psychiatric disorders, which includes postpartum depression and postpartum psychosis. However, there exists some discussion in the literature of the possibility that postpartum blues may be an independent condition.

Criteria

There are no standardized criteria for the diagnosis of postpartum blues. Unlike postpartum depression, postpartum blues is not a diagnosis included in the Diagnostic and Statistical Manual of Mental Disorders.  

Investigators have employed a variety of diagnostic tools in prospective and retrospective studies of postpartum blues, including repurposing screening tools, such as the Edinburgh Postnatal Depression Scale (EPDS) and Beck Depression Index (BDI), as well as developing blues-specific scales. Examples of blues-specific scales include the Maternity Blues Questionnaire[15] and the Stein Scale.[16]

Differential diagnosis

Although symptoms of postpartum blues present in a majority of mothers and the condition is self-limited, it is important to keep related psychiatric conditions in mind as they all have overlap in presentation and similar period of onset.

Postpartum anxiety: Symptoms of anxiety and irritability are often predominant in the presentation of postpartum blues. However, compared to postpartum anxiety, symptoms of postpartum blues are less severe, resolve on their own, and last fewer than two weeks.
  • Postpartum depression: Postpartum depression and postpartum blues may be indistinguishable when symptoms first begin. However, symptoms of postpartum blues are less severe, resolve on their own, and last fewer than two weeks. Mothers who experience severe postpartum blues appear to be at increased risk of developing depression.
  • Postpartum psychosis: Although both conditions can cause periods of high and low moods, the mood swings in postpartum psychosis are significantly more severe and may include mania, hallucinations, and delusions. Postpartum psychosis is a rare condition, affecting 1-2 per 1000 women.[17] Postpartum psychosis is classified as a psychiatric emergency and requires hospital admission.

    • Additionally, a variety of medical co-morbidities can mimic or worsen psychiatric symptoms.  

    Prevention

    Screening

    There are no specific screening recommendations for postpartum blues. Nonetheless, a variety of professional organizations recommend routine screening for depression and/or assessment of emotional well-being during pregnancy and postpartum. Universal screening provides an opportunity to identify women with sub-clinical psychiatric conditions during this period and those at higher risk of developing more severe symptoms.[18] Specific recommendations are listed below:

    Primary prevention

    Given the mixed evidence regarding causes of postpartum blues, it is unclear whether prevention strategies would be effective in decreasing the risk of developing this condition. However, educating women during pregnancy about postpartum blues may help to prepare them for these symptoms that are often unexpected and concerning in the setting of excitement and anticipation of a new baby. Mothers who develop postpartum blues often have significant shame or guilt for feelings of anxiety or depression during a time that is expected to be joyful.[23] It is important to reassure new parents that low mood symptoms after childbirth are common and transient. Obstetric providers may recommend that patients and their families prepare ahead of time to ensure the mother will have adequate support and rest after the delivery. Additionally, they should provide education and resources to family and friends about red flags of more severe perinatal psychiatric conditions that may develop, such as postpartum depression and postpartum psychosis.[24]

    Treatment

    Postpartum blues is a self-limited condition. Signs and symptoms are expected to resolve within two weeks of onset without any treatment. Nevertheless, there are a number of recommendations to help relieve symptoms, including:[25]

    If symptoms do not resolve within two weeks or if they interfere with functioning, individuals are encouraged to contact their healthcare provider. Early diagnosis and treatment of more severe postpartum psychiatric conditions, such as postpartum depression, postpartum anxiety, and postpartum psychosis, are critical for improved outcomes in both the parent and child.

    Prognosis

    Most mothers who develop postpartum blues experience complete resolution of symptoms by two weeks. However, a number of prospective studies have identified more severe postpartum blues as an independent risk factor for developing subsequent postpartum depression.[26] [27] More research is necessary to fully elucidate the association between postpartum blues and postpartum depression.

    Epidemiology

    Postpartum blues is a very common condition, affecting around 50–80% of new mothers based on most sources.[28] However, estimates of prevalence vary greatly in the literature, from 26 to 85%, depending on the criteria used.[29] [30] [31] [32] Precise rates are difficult to obtain given lack of standardized diagnostic criteria, inconsistency of presentation to medical care, and methodological limitations of retrospective reporting of symptoms.

    Evidence demonstrates that postpartum blues exists across a variety of countries and cultures, however there is considerable heterogeneity in reported prevalence rates. For instance, reports of prevalence of postpartum blues in the literature vary from 15% in Japan[33] to 60% in Iran.[34] Underreporting of symptoms due to cultural norms and expectations may be one explanation for this heterogeneity.[35]

    Males

    See also: Paternal depression. Literature is lacking on whether new fathers also experience postpartum blues. However, given similar causes of postpartum blues and postpartum depression in women, it may be relevant to examine rates of postpartum depression in men.

    A 2010 meta-analysis published in JAMA with over 28,000 participants across various countries showed that prenatal and postpartum depression affects about 10% of men.[36] This analysis was updated by an independent research team in 2016, who found the prevalence to be 8.4% in over 40,000 participants.[37] Both were significantly higher than previously reported rates of 3–4% from two large cohort studies in the United Kingdom,[38] [39] which may reflect heterogeneity across countries. Both meta-analyses found higher rates in the United States (12.8–14.1%) compared to studies conducted internationally (7.1–8.2%). Furthermore, there was a moderate positive correlation between paternal and maternal depression (r = 0.308; 95% CI, 0.228–0.384).

    Notes and References

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    2. Web site: Baby blues after pregnancy. 2020-10-29. www.marchofdimes.org. en. 2017-02-19. https://web.archive.org/web/20170219220308/https://www.marchofdimes.org/pregnancy/baby-blues-after-pregnancy.aspx. live.
    3. Web site: Postpartum Depression. American College of Obstetricians and Gynecologists (ACOG). 2019-10-13. 2014-07-14. https://web.archive.org/web/20140714130901/https://www.acog.org/Patients/FAQs/Postpartum-Depression. live.
    4. Web site: Baby blues after pregnancy . live . https://web.archive.org/web/20170219220308/https://www.marchofdimes.org/pregnancy/baby-blues-after-pregnancy.aspx . 2017-02-19 . 2019-10-01 . March of Dimes . en.
    5. Web site: Depression During & After Pregnancy: You Are Not Alone. HealthyChildren.org. American Academy of Pediatrics. 2019-10-13. 2009-12-31. https://web.archive.org/web/20091231002606/http://www.healthychildren.org/English/ages-stages/prenatal/delivery-beyond/Pages/Understanding-Motherhood-and-Mood-Baby-Blues-and-Beyond.aspx. live.
    6. Book: Diagnostic and statistical manual of mental disorders : DSM-5.. ((American Psychiatric Association DSM-5 Task Force)) . 2013. 978-0-89042-559-6. 847226928.
    7. O'Hara MW, Schlechte JA, Lewis DA, Wright EJ . Prospective study of postpartum blues. Biologic and psychosocial factors . Archives of General Psychiatry . 48 . 9 . 801–6 . September 1991 . 1929770 . 10.1001/archpsyc.1991.01810330025004 .
    8. Miller LJ . Postpartum depression . JAMA . 287 . 6 . 762–5 . February 2002 . 11851544 . 10.1001/jama.287.6.762 .
    9. Web site: Postpartum Psychiatric Disorders. Health. MGH Center for Women's Mental. MGH Center for Women's Mental Health. en-US. 2019-10-16. 2008-05-12. https://web.archive.org/web/20080512130834/https://womensmentalhealth.org/specialty-clinics/postpartum-psychiatric-disorders/. live.
    10. Seyfried. L. S.. Marcus. S. M.. 2003. Postpartum mood disorders. International Review of Psychiatry. 15. 3. 231–242. 10.1080/0954026031000136857. 0954-0261. 15276962. 25021211.
    11. O'Keane V, Lightman S, Patrick K, Marsh M, Papadopoulos AS, Pawlby S, Seneviratne G, Taylor A, Moore R . 6 . Changes in the maternal hypothalamic-pituitary-adrenal axis during the early puerperium may be related to the postpartum 'blues' . Journal of Neuroendocrinology . 23 . 11 . 1149–55 . November 2011 . 22004568 . 10.1111/j.1365-2826.2011.02139.x . 8199019 . free .
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    13. Redpath N, Rackers HS, Kimmel MC . The Relationship Between Perinatal Mental Health and Stress: a Review of the Microbiome . Current Psychiatry Reports . 21 . 3 . 18 . March 2019 . 30826885 . 10.1007/s11920-019-0998-z . 73461103 .
    14. Rackers HS, Thomas S, Williamson K, Posey R, Kimmel MC . Emerging literature in the Microbiota-Brain Axis and Perinatal Mood and Anxiety Disorders . Psychoneuroendocrinology . 95 . 86–96 . September 2018 . 29807325 . 6348074 . 10.1016/j.psyneuen.2018.05.020 .
    15. Kennerley H, Gath D . Maternity blues. I. Detection and measurement by questionnaire . The British Journal of Psychiatry . 155 . 356–62 . September 1989 . 2611547 . 10.1192/bjp.155.3.356 . 44208783 .
    16. Stein GS . The pattern of mental change and body weight change in the first post-partum week . Journal of Psychosomatic Research . 24 . 3–4 . 165–71 . 1980 . 7441584 . 10.1016/0022-3999(80)90038-0 .
    17. Web site: Postpartum Psychosis . Postpartum Support International (PSI). 2020-10-29 . 2015-04-06. https://web.archive.org/web/20150406113539/https://www.postpartum.net/learn-more/postpartum-psychosis/. live.
    18. Web site: Postpartum Depression Screening . MedlinePlus Medical Test. 2020-10-29 . 2019-12-07. https://web.archive.org/web/20191207132208/https://medlineplus.gov/lab-tests/postpartum-depression-screening/. live.
    19. Web site: Screening for Perinatal Depression. American College of Obstetricians and Gynecologists (ACOG). 2019-10-17. 2018-12-03. https://web.archive.org/web/20181203200444/https://www.acog.org/Clinical-Guidance-and-Publications/Committee-Opinions/Committee-on-Obstetric-Practice/Screening-for-Perinatal-Depression?IsMobileSet=false. live.
    20. Web site: Screening Recommendations. American Academy of Pediatrics. en-US. 2019-10-17. 2019-10-17. https://web.archive.org/web/20191017150406/http://www.aap.org/en-us/advocacy-and-policy/aap-health-initiatives/Screening/Pages/Screening-Recommendations.aspx. live.
    21. Book: Hagan JF, Shaw JS, Duncan PM . Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents [pocket guide] ]. 4th . Elk Grove Village, IL . American Academy of Pediatrics . 2017 . 2019-10-17 . 2022-05-09 . https://web.archive.org/web/20220509182335/https://brightfutures.aap.org/Bright%20Futures%20Documents/BF4_POCKETGUIDE.pdf . live .
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    31. Seyfried LS, Marcus SM . Postpartum mood disorders . International Review of Psychiatry . 15 . 3 . 231–42 . August 2003 . 15276962 . 10.1080/0954026031000136857 . 25021211 .
    32. Web site: Postpartum Psychiatric Disorders . MGH Center for Women's Mental Health . en-US . 2019-10-16 . 2008-05-12 . https://web.archive.org/web/20080512130834/https://womensmentalhealth.org/specialty-clinics/postpartum-psychiatric-disorders/ . live .
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    37. Cameron EE, Sedov ID, Tomfohr-Madsen LM . Prevalence of paternal depression in pregnancy and the postpartum: An updated meta-analysis . Journal of Affective Disorders . 206 . 189–203 . December 2016 . 27475890 . 10.1016/j.jad.2016.07.044 .
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