Postpartum blues
Other namesBaby blues, maternity blues
SpecialtyPsychiatry, Obstetrics and Gynecology
SymptomsTearfulness, mood swings, irritability, anxiety, fatigue, difficulty sleeping or eating
Usual onsetWithin a few days of childbirth
DurationUp to 2 weeks
Differential diagnosisPostpartum depression, postpartum anxiety, postpartum psychosis
TreatmentSupportive
MedicationNo medication indicated
PrognosisSelf-limited
FrequencyUp 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][4]

  • Tearfulness or crying "for no reason"
  • Mood swings
  • Irritability
  • Anxiety
  • Questioning one's ability to care for the baby
  • Difficulty making choices
  • Loss of appetite
  • Fatigue
  • Difficulty sleeping
  • Difficulty concentrating
  • Negative mood symptoms interspersed with positive symptoms[5]

Onset

Symptoms of postpartum blues generally begin within a few days of childbirth[3][6] and often peak by day four or five.[7]

Duration

Postpartum blues may last a few days up to two weeks.[6][8] If symptoms last more than two weeks, the individual must be evaluated for postpartum depression.[9]

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:[4][10][11]

  • Fatigue after labor and delivery
  • Caring for a newborn that requires 24/7 attention
  • Sleep deprivation
  • Lack of support from family and friends
  • Marital or relationship strain
  • Changes in home and work routines
  • Financial stress
  • Unrealistic expectations of self
  • Societal or cultural pressure to "bounce back" quickly after pregnancy and childbirth
  • Overwhelmed and questioning ability to care for baby
  • Anger, loss, or guilt, especially for parents of premature or sick infants

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.[12][13][3]

Factors most consistently shown to be predictive of postpartum blues are personal and family history of depression.[12] 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.[3][5][14] 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.[15]

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.[16][15]

Other

The association between postpartum blues and a variety of other biological factors, including cortisol and the HPA axis,[17] tryptophan, prolactin, thyroid hormone, and others have been assessed over the years with inconclusive results.[13]

Emerging research has suggested a potential association between the gut microbiome and perinatal mood and anxiety disorders.[18][19]

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.[3]

Criteria

There are no standardized criteria for the diagnosis of postpartum blues.[3] 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[20] and the Stein Scale.[21]

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.[22]
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.[7][23] 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.[24] Specific recommendations are listed below:

  • American College of Obstetrics and Gynecology (ACOG): In 2018, ACOG recommended universal screening for depression and anxiety using a validated tool at least once during pregnancy or postpartum, in addition to a full assessment of mood and well-being at the postpartum visit. This is in addition to existing recommendations for annual depression screening in all women.[25]
  • American Academy of Pediatrics (AAP): In 2017, the AAP recommended universal screening of mothers for postpartum depression at the 1-, 2-, 4-, and 6-month well child visits.[26][27]
  • United States Preventative Services Task Force (USPSTF): In 2016, the USPSTF recommended depression screening in the general adult population, including pregnant and postpartum women.[28] Their recommendations did not include guidelines for frequency of screening.

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.[3] Mothers who develop postpartum blues often have significant shame or guilt for feelings of anxiety or depression during a time is expected to be joyful.[10] 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.[11]

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:[6][8][29]

  • Getting enough sleep
  • Taking time to relax and do activities that you enjoy
  • Asking for help from family and friends
  • Reaching out to other new parents
  • Avoiding alcohol and other drugs that may worsen mood symptoms
  • Reassurance that symptoms are very common and will resolve on their own

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.[30][31]

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.[22][32] 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.[30] However, estimates of prevalence vary greatly in the literature, from 26 to 85%, depending on the criteria used.[31][5][3][7] 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.

Males

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.[35] This analysis was updated by an independent research team in 2016, who found the prevalence to be 8.4% in over 40,000 participants.[36] Both were significantly higher than previously reported rates of 3-4% from two large cohort studies in the United Kingdom,[37][38] 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%).[35][36] Furthermore, there was a moderate positive correlation between paternal and maternal depression (r = 0.308; 95% CI, 0.228-0.384).[35]

References

  1. ↑ "Postpartum Depression". medlineplus.gov. Archived from the original on 2016-07-27. Retrieved 2020-10-29.
  2. ↑ "Baby blues after pregnancy". www.marchofdimes.org. Archived from the original on 2017-02-19. Retrieved 2020-10-29.
  3. 1 2 3 4 5 6 7 8 Seyfried LS, Marcus SM (August 2003). "Postpartum mood disorders". International Review of Psychiatry. 15 (3): 231–42. doi:10.1080/0954026031000136857. PMID 15276962. S2CID 25021211.
  4. 1 2 "Postpartum Depression". American College of Obstetricians and Gynecologists (ACOG). Archived from the original on 2014-07-14. Retrieved 2019-10-13.
  5. 1 2 3 O'Hara MW, Wisner KL (January 2014). "Perinatal mental illness: definition, description and aetiology". Best Practice & Research. Clinical Obstetrics & Gynaecology. 28 (1): 3–12. doi:10.1016/j.bpobgyn.2013.09.002. PMC 7077785. PMID 24140480.
  6. 1 2 3 "Baby blues after pregnancy". March of Dimes. Archived from the original on 2017-02-19. Retrieved 2019-10-01.
  7. 1 2 3 "Postpartum Psychiatric Disorders". MGH Center for Women's Mental Health. Archived from the original on 2008-05-12. Retrieved 2019-10-16.
  8. 1 2 "Depression During & After Pregnancy: You Are Not Alone". HealthyChildren.org. American Academy of Pediatrics. Archived from the original on 2009-12-31. Retrieved 2019-10-13.
  9. ↑ American Psychiatric Association. DSM-5 Task Force. (2013). Diagnostic and statistical manual of mental disorders : DSM-5. ISBN 9780890425596. OCLC 847226928.{{cite book}}: CS1 maint: numeric names: authors list (link)
  10. 1 2 "Postpartum depression". Office on Women's Health. U.S. Department of Health and Human Services. 2018-04-09. Archived from the original on 2019-11-15. Retrieved 2019-10-17.
  11. 1 2 "Postpartum Depression Facts". The National Institute of Mental Health (NIMH). U.S. Department of Health and Human Services. Archived from the original on 2017-06-21. Retrieved 2019-10-17.
  12. 1 2 O'Hara MW, Schlechte JA, Lewis DA, Wright EJ (September 1991). "Prospective study of postpartum blues. Biologic and psychosocial factors". Archives of General Psychiatry. 48 (9): 801–6. doi:10.1001/archpsyc.1991.01810330025004. PMID 1929770.
  13. 1 2 Henshaw C (August 2003). "Mood disturbance in the early puerperium: a review". Archives of Women's Mental Health. 6 (Suppl 2): S33-42. doi:10.1007/s00737-003-0004-x. PMID 14615921. S2CID 11442944.
  14. ↑ Miller LJ (February 2002). "Postpartum depression". JAMA. 287 (6): 762–5. doi:10.1001/jama.287.6.762. PMID 11851544.
  15. 1 2 Health, MGH Center for Women's Mental. "Postpartum Psychiatric Disorders". MGH Center for Women's Mental Health. Archived from the original on 2008-05-12. Retrieved 2019-10-16.
  16. ↑ Seyfried, L. S.; Marcus, S. M. (2003). "Postpartum mood disorders". International Review of Psychiatry. 15 (3): 231–242. doi:10.1080/0954026031000136857. ISSN 0954-0261. PMID 15276962. S2CID 25021211.
  17. ↑ O'Keane V, Lightman S, Patrick K, Marsh M, Papadopoulos AS, Pawlby S, et al. (November 2011). "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. doi:10.1111/j.1365-2826.2011.02139.x. PMID 22004568. S2CID 8199019.
  18. ↑ Redpath N, Rackers HS, Kimmel MC (March 2019). "The Relationship Between Perinatal Mental Health and Stress: a Review of the Microbiome". Current Psychiatry Reports. 21 (3): 18. doi:10.1007/s11920-019-0998-z. PMID 30826885. S2CID 73461103.
  19. ↑ Rackers HS, Thomas S, Williamson K, Posey R, Kimmel MC (September 2018). "Emerging literature in the Microbiota-Brain Axis and Perinatal Mood and Anxiety Disorders". Psychoneuroendocrinology. 95: 86–96. doi:10.1016/j.psyneuen.2018.05.020. PMC 6348074. PMID 29807325.
  20. ↑ Kennerley H, Gath D (September 1989). "Maternity blues. I. Detection and measurement by questionnaire". The British Journal of Psychiatry. 155: 356–62. doi:10.1192/bjp.155.3.356. PMID 2611547. S2CID 44208783.
  21. ↑ Stein GS (1980). "The pattern of mental change and body weight change in the first post-partum week". Journal of Psychosomatic Research. 24 (3–4): 165–71. doi:10.1016/0022-3999(80)90038-0. PMID 7441584.
  22. 1 2 Henshaw C, Foreman D, Cox J (2004). "Postnatal blues: a risk factor for postnatal depression". Journal of Psychosomatic Obstetrics and Gynaecology. 25 (3–4): 267–72. doi:10.1080/01674820400024414. PMID 15715025. S2CID 12141830.
  23. ↑ "Postpartum Psychosis | Postpartum Support International (PSI)". Archived from the original on 2015-04-06. Retrieved 2020-10-29.
  24. ↑ "Postpartum Depression Screening: MedlinePlus Medical Test". medlineplus.gov. Archived from the original on 2019-12-07. Retrieved 2020-10-29.
  25. ↑ "Screening for Perinatal Depression". American College of Obstetricians and Gynecologists (ACOG). Archived from the original on 2018-12-03. Retrieved 2019-10-17.
  26. ↑ "Screening Recommendations". American Academy of Pediatrics. Archived from the original on 2019-10-17. Retrieved 2019-10-17.
  27. ↑ Hagan JF, Shaw JS, Duncan PM, eds. (2017). Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents [pocket guide] (PDF) (4th ed.). Elk Grove Village, IL: American Academy of Pediatrics. Archived (PDF) from the original on 2022-05-09. Retrieved 2019-10-17.
  28. ↑ Siu AL, Bibbins-Domingo K, Grossman DC, Baumann LC, Davidson KW, Ebell M, et al. (January 2016). "Screening for Depression in Adults: US Preventive Services Task Force Recommendation Statement". JAMA. 315 (4): 380–7. doi:10.1001/jama.2015.18392. PMID 26813211.
  29. ↑ "Mom's Mental Health Matters: Moms-to-be and Moms - NCMHEP". www.nichd.nih.gov/. Archived from the original on 2016-10-04. Retrieved 2020-10-29.
  30. 1 2 Bobo WV, Yawn BP (June 2014). "Concise review for physicians and other clinicians: postpartum depression". Mayo Clinic Proceedings. 89 (6): 835–44. doi:10.1016/j.mayocp.2014.01.027. PMC 4113321. PMID 24943697.
  31. 1 2 Howard MM, Mehta ND, Powrie R (May 2017). "Peripartum depression: Early recognition improves outcomes". Cleveland Clinic Journal of Medicine. 84 (5): 388–396. doi:10.3949/ccjm.84a.14060. PMID 28530897.
  32. ↑ Zanardo V, Volpe F, de Luca F, Giliberti L, Giustardi A, Parotto M, et al. (March 2019). "Maternity blues: a risk factor for anhedonia, anxiety, and depression components of Edinburgh Postnatal Depression Scale". The Journal of Maternal-Fetal & Neonatal Medicine. 33 (23): 3962–3968. doi:10.1080/14767058.2019.1593363. PMID 30909766. S2CID 85514575. Archived from the original on 2023-01-15. Retrieved 2020-09-03.
  33. ↑ Watanabe M, Wada K, Sakata Y, Aratake Y, Kato N, Ohta H, Tanaka K (September 2008). "Maternity blues as predictor of postpartum depression: a prospective cohort study among Japanese women". Journal of Psychosomatic Obstetrics and Gynaecology. 29 (3): 206–12. doi:10.1080/01674820801990577. PMID 18608817. S2CID 8152986.
  34. ↑ Akbarzadeh M, Mokhtaryan T, Amooee S, Moshfeghy Z, Zare N (2015). "Investigation of the effect of religious doctrines on religious knowledge and attitude and postpartum blues in primiparous women". Iranian Journal of Nursing and Midwifery Research. 20 (5): 570–6. doi:10.4103/1735-9066.164586. PMC 4598903. PMID 26457094.
  35. 1 2 3 Paulson JF, Bazemore SD (May 2010). "Prenatal and postpartum depression in fathers and its association with maternal depression: a meta-analysis". JAMA. 303 (19): 1961–9. doi:10.1001/jama.2010.605. PMID 20483973.
  36. 1 2 Cameron EE, Sedov ID, Tomfohr-Madsen LM (December 2016). "Prevalence of paternal depression in pregnancy and the postpartum: An updated meta-analysis". Journal of Affective Disorders. 206: 189–203. doi:10.1016/j.jad.2016.07.044. PMID 27475890.
  37. ↑ Ramchandani P, Stein A, Evans J, O'Connor TG (2005). "Paternal depression in the postnatal period and child development: a prospective population study". Lancet. 365 (9478): 2201–5. doi:10.1016/S0140-6736(05)66778-5. PMID 15978928. S2CID 34516133.
  38. ↑ Davé S, Petersen I, Sherr L, Nazareth I (November 2010). "Incidence of maternal and paternal depression in primary care: a cohort study using a primary care database". Archives of Pediatrics & Adolescent Medicine. 164 (11): 1038–44. doi:10.1001/archpediatrics.2010.184. PMID 20819960.
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