Perinatal mental health

• "Perinatal mental health" covers a pregnant person's mental health from pregnancy through the first year after birth. ^[3] It includes the baby blues, perinatal depression, anxiety disorders, obsessive-compulsive disorder, bipolar disorder and postpartum psychosis.
• Mental health problems in the perinatal period are common: treatable mental health problems affect roughly 15 to 20% of women during pregnancy and the postpartum period. ^[6]
• The baby blues are a mild, self-limited emotional reaction that is extremely common after birth (about 45 to 85% of women). It is not a psychiatric disorder and usually settles within two weeks. ^{[7] [9]}
• Perinatal depression affects about one in every five to seven women. It is an illness, not a personal failing, and it can be treated. ^[8]
• Anxiety disorders commonly accompany depression (co-morbidity up to about 70% in some studies) and are an important cause of distress in their own right. ^[8]
• Postpartum psychosis is rare (1 to 2 in 1,000 births) but is a true psychiatric emergency with high rates of suicide and infanticide: it needs same-day specialist assessment and hospital care. ^[8]
• Screening is recommended for everyone receiving pre-pregnancy, pregnancy and postpartum care, using standard tools such as the Edinburgh Postnatal Depression Scale (EPDS) and the Patient Health Questionnaire-9 (PHQ-9). ^[2]
• Most psychiatric medicines are compatible with pregnancy and breastfeeding. The risks of untreated illness are real, so treatment is a risk-choice, not a simple avoidance of tablets. ^[8]

By the end of this page you should be able to:

1. Define the perinatal period and describe what "perinatal mental health" includes.
2. Distinguish the baby blues, perinatal depression, perinatal anxiety disorders, obsessive-compulsive disorder and postpartum psychosis by onset, course and features.
3. State how these conditions are screened for and diagnosed, including the role of the EPDS, PHQ-9, GAD-2 and bipolar screening.
4. Assess immediate safety (suicide and infanticide risk) and act correctly when postpartum psychosis is suspected.
5. Plan management: psychological, pharmacological and emergency care, including psychotropic choice in pregnancy and breastfeeding.
6. Recognise medical mimics and know when to refer.
7. Apply the advice to low-resource settings.

"Perinatal" is an agreed term, but the precise boundaries of "depression" in the perinatal period are debated. The Diagnostic and Statistical Manual of Mental Disorders, 5th edition, defines a "major depressive episode with peripartum onset" as one beginning during pregnancy or within the first four weeks after childbirth. ^{[7] [8]} By contrast, some sources define "perinatal depression" more broadly, including depression starting at any point in pregnancy or up to one year after birth; women can experience perinatal depression up to 12 months after giving birth. ^{[7] [8]} Both definitions are used; estimates of prevalence depend on which one is applied. ^{[8] [3]}

The baby blues are a separate category. They are a very common, transient state of emotional lability after birth: not a psychiatric disorder, not a requirement for treatment and not, in itself, mental illness. ^[8] Postpartum psychosis is at the other extreme: a psychiatric emergency, even though its name suggests a psychotic disorder (in fact it is best regarded as a mood disorder presenting with psychosis). ^[9]

A useful clinical classification:

• Timing. Antenatal (during pregnancy), postpartum (after birth) and perinatal (either or both), as well as a past or pre-existing condition continuing into the perinatal period.
• Severity. Baby blues (mild and self-limiting), mild/moderate depression or anxiety, severe depression or anxiety, and severe mental illness (bipolar disorder or postpartum psychosis).
• Diagnosis. Depressive disorder, anxiety or anxiety-related disorder (including obsessive-compulsive disorder and post-traumatic stress disorder), bipolar disorder, postpartum psychosis, adjustment disorder, or a general medical or substance-related cause.

Perinatal mental health problems are common everywhere. Between 15 and 20% of women experience some form of treatable mental health problem during pregnancy and the postpartum period. ^[6] Perinatal depression overall affects about one in every five to seven women (about 10 to 20%). ^{[8] [9]} More narrowly, major depression affects up to about 20% during pregnancy and the first three months postpartum, but the narrower (and more severe) estimate of major depression is around 7% in the first three months postpartum. ^[5]

• Baby blues. The reported prevalence varies widely with definition and setting, from 26 to 84% in some series and an overall pooled estimate around 39%. ^{[4] [5]} One frequently cited figure is that 45 to 85% of women experience the baby blues. ^[7] Such wide ranges reflect differences between tools, cultures and when women are asked.
• Antenatal depression. Prevalence rises through pregnancy in many studies, from about 7% in the first trimester to about 13% in the second and third trimesters. ^[5]
• Postpartum depression. Reported prevalence ranges from about 5 to 15% in some reviews and from 10 to 20% in others; recent large single-country studies report rates of about 10 to 15%. ^{[6] [9]}
• Postpartum psychosis. 1 to 2 per 1,000 births. ^{[8] [9]} Recurrence in a subsequent pregnancy is greater than 54% in some series. ^[9] Among women with known bipolar disorder, 20 to 30% of parous women develop postpartum psychosis. ^[9]
• Recurrent illness. Women who have had postpartum depression have roughly a 50% chance of it recurring in a subsequent pregnancy. ^[7]
• Mortality. Suicide and substance (drug or alcohol) overdose together account for about 22.7% of pregnancy-related deaths in recent United States data, and mental health conditions overall account for about 23% of pregnancy-related deaths. All such deaths are considered preventable. ^[8] Postpartum depression itself is a risk factor for subsequent postpartum psychosis and for long-term psychiatric illness. ^{[5] [7]}
• Impact on the child. Untreated maternal depression and anxiety are associated with worse obstetric and child outcomes, including pre-eclampsia, gestational diabetes, preterm birth, intrauterine growth restriction, substance use, poorer bonding and later cognitive and emotional problems for the child. ^[8]

An important note on figures: prevalence varies by country, culture, tool and time point, so wide ranges between studies are expected. ^{[4] [5] [6] [7] [8]}

Perinatal mental health problems are usually multifactorial. There is no single cause.

Biological. After delivery, levels of progesterone and oestrogen fall sharply, and other hormonal shifts (including thyroid and stress-hormone changes) follow. Certain subgroups of women appear especially sensitive to these changes: sensitivity to gonadal hormones, sleep disturbance, attachment insecurity and a history of premenstrual mood change all increase risk. ^{[7] [9]} For postpartum psychosis, immune system dysregulation, including autoimmune thyroiditis (found in 19% of studied patients versus 5% of controls), and sleep loss are active areas of research; obstetric and pregnancy factors have largely not been shown to predict it, with the exception of primiparity. ^[9]

Psychosocial. Lack of social support, relationship conflict, stressful life events (including trauma or abuse), domestic violence, financial and housing stress, young maternal age, adolescent pregnancy, substance use, unintended pregnancy, infant illness or loss and poor prior infant relationship are all recognised risk factors. ^{[1] [2] [6] [9]}

Risk factors for postpartum psychosis specifically. ^[9]

• Personal history of bipolar disorder is the single strongest risk factor (20 to 30% of parous women with known bipolar disorder).
• Family history of bipolar disorder or of postpartum psychosis.
• A prior episode of postpartum psychosis.
• Primiparity (first baby).
• Sleep loss.
• Only about one third of women presenting with postpartum psychosis have a prior psychiatric history, and only about one third of those had previously been diagnosed with bipolar disorder; many women present with their first psychiatric episode in the postpartum. ^[9]

Other mental health problem risk factors. ^{[5] [7] [8]}

• Past history of depression, anxiety, bipolar disorder or psychosis, in the woman or in a first-degree relative.
• Current anxiety, depressive symptoms or the baby blues in the early postpartum period: the baby blues cluster is a risk factor for later postpartum depression. ^{[5] [8]}
• A family history of severe perinatal mental illness in a mother, sister or daughter. ^[1]
• Antenatal mental health problems: problems in pregnancy are a strong predictor of postnatal illness. ^[8]
• Concerning treatments: valproate should not be used in women of childbearing potential for mental health conditions unless alternatives are ineffective or not tolerated, and it is contraindicated in pregnancy because of risk of fetal malformations and adverse neurodevelopmental outcomes. ^{[1] [8]}

Perinatal mental illness arises from the interplay of hormonal, biological and psychosocial change. The abrupt fall in progesterone and oestrogen after delivery, the changes in the stress (hypothalamic-pituitary-adrenal) axis, sleep loss and the major life and identity transition of becoming a parent all contribute, with larger effects in women who carry genetic or psychological vulnerability. ^{[5] [7] [9]}

• Baby blues. Thought to reflect the normal readjustment of the first days: hormonal withdrawal, sleep disruption and the first phase of recovery, plus the normal challenges of feeding and care. ^{[4] [5]} It is not clearly predictable from any single biological marker. ^[4]
• Perinatal depression. Combines genetic vulnerability, hormonal sensitivity, prior trauma and current stressors; placental hormones and gonadal steroid withdrawal probably matter most in a subgroup. ^{[7] [8]}
• Anxiety disorders. High co-morbidity with depression (as high as 70% in some settings), with shared risk factors and reinforcing cycles: worry disrupts sleep, and poor sleep worsens both mood and anxiety. ^{[8] [9]}
• Postpartum psychosis. Almost certainly a biological response to childbirth in vulnerable women. The strongest vulnerability is to bipolar disorder; sleep loss is a trigger; immune changes (autoimmune thyroiditis, altered T-cell function) are strongly implicated. ^[9] Hormonal treatment has not proved effective in robust trials. ^[9]

Onset is usually from day 1 to 3 after birth, with symptoms peaking between days 3 and 5 and settling by days 10 to 14. ^{[4] [5] [7]} Features include brief tearful episodes, low or labile mood, anxiety, irritability, poor concentration, loss of appetite, insomnia and a sense of being overwhelmed. ^{[4] [5] [8]}

What distinguishes it from depression: it is mild, normal functioning is preserved, women can usually be comforted and it settles quickly. If symptoms persist beyond 14 days, or are severe, or include self-harm ideas, consider perinatal depression. ^{[5] [7] [8] [9]}

Presentation is as for other depressive episodes (low mood, loss of interest or pleasure, fatigue, sleep and appetite change, guilt, impaired concentration, hopelessness, and sometimes suicidal thoughts). The perinatal context adds features: anxiety, worry about the baby, irritability, intrusive thoughts about harm to the baby, difficulty bonding and guilt about not feeling "happy enough." ^{[8] [9]}

Timing is often in the first three months but can be any time in the first year after birth. Onset during pregnancy is also common and often missed. ^{[5] [8]} Women at the serious end may have suicidal ideas and, more rarely, ideas about harming the baby. ^{[8] [9]}

Either a brief 2-item screen (the two depression identification questions) plus a self-report scale (EPDS or PHQ-9), or referral, is the standard first step. ^{[1] [8]}

Generalised anxiety, panic disorder, phobias, social anxiety, post-traumatic stress disorder and obsessive-compulsive disorder can all begin or worsen in the perinatal period. ^{[1] [8]} Features include persistent excessive worry (often about the baby or birth), feeling on edge, difficulty controlling worry, panic attacks, avoidance, hypervigilance and physical symptoms such as breathlessness and palpitations. Obsessive-compulsive presentation is distinctive: intrusive, unwanted, often frightening thoughts (contamination, harm to the baby, including unwanted sexual or violent images), with checking, reassurance-seeking and mental compulsions such as long internet searches. These thoughts are ego-dystonic: they horrify the woman and she does not want to act on them. ^[8]

Anxiety and depression co-exist in up to about 70% of cases, so checking for both is essential. ^[8]

Typically sudden onset, most often 3 to 10 days after childbirth, sometimes up to 4 weeks. ^{[8] [9]} It presents with a combination of mood, cognitive and psychotic symptoms: confusion and disorientation, insomnia, restlessness, mood fluctuation (mania, depression or mixed states), abnormal or bizarre thoughts, delusions and sometimes hallucinations. ^[9] There is a high risk of suicide and of infanticide, often by accident through neglect as much as by intent. ^{[8] [9]}

Classical clinical red flags: "She is just not herself" (family comment); inability to sleep at all; rapid or pressured speech; confusion or disorientation; paranoid or bizarre beliefs (especially concerning the baby). The onset within the first 2 weeks, plus primiparity or bipolar history, raises suspicion. ^{[1] [9]}

There is no separate physical examination for mental health disorders. However, the perinatal medical context matters. In assessment, and especially when postpartum psychosis is suspected, exclude delirium, infection, anaemia, thyroid disease, metabolic derangement and substance use (see below). ^{[8] [9]}

The most important practical task is to tell baby blues (very common, mild, self-limiting) from perinatal depression (more severe and persistent), and either from postpartum psychosis (rare and an emergency). ^[9]

Where postpartum psychosis is possible, the safest approach is to "treat as if it were postpartum psychosis until proven otherwise," while continuing to exclude medical causes. ^{[1] [8]}

Maternal mental health conditions are clinical diagnoses made by history and assessment, not by a blood test. ^{[2] [8]}

ACOG and the United States Preventive Services Task Force recommend universal screening in the perinatal period; NICE recommends asking identification questions and using tools as part of assessment and monitoring. ^{[1] [2] [8]}

Screening timings recommended (ACOG): at the initial prenatal visit, later in pregnancy (usually around 28 weeks) and at postpartum visits. ^[8] Everyone receiving well-woman, pre-pregnancy, prenatal and postpartum care should be screened for depression and anxiety using a standard, validated tool. ^[2]

• People who have a self-harm or suicide item positive require immediate assessment of likelihood, acuity and severity with risk-tailored management. ^{[2] [8]}
• Suicidal thoughts or psychosis require immediate medical attention. ^{[2] [8] [9]}
• Bipolar disorder should be screened for before starting treatment for anxiety or depression: as many as 1 in 5 women who screen positive for depression may have bipolar disorder, and treating bipolar disorder with an antidepressant alone is harmful. ^{[2] [8]}

• Two depression identification questions (NICE): "During the past month, have you often been bothered by feeling down, depressed or hopeless?" and "During the past month, have you often been bothered by having little interest or pleasure in doing things?" ^[1]
• GAD-2 (NICE): two anxiety questions over the last two weeks, scored 0 to 3 on each, total 0 to 6. A total score of 3 or more suggests considering the GAD-7 or referral. ^[1] If the score is less than 3 but you are still concerned, ask "Do you find yourself avoiding places or activities and does this cause you problems?" ^[1]
• EPDS. A 10-item questionnaire scored 0 to 30, designed for the perinatal period, with anxiety items and a self-harm item. A score of 10 to 13 suggests mild symptoms; 14 or more indicates likely depression. A score of at least 6 on questions 3 to 5 (the EPDS-A) indicates elevated anxiety symptoms. ^[8]
• PHQ-9. A 9-item scale: 5 to 9 mild, 10 to 14 moderate, 15 to 19 moderately severe, 20 or more severe depression. ^[8]
• MDQ. A bipolar screening tool for a lifetime history of mania and hypomania. ^[5]

Screening alone does not diagnose. A positive screen always needs fuller assessment. ^[8]

• Depression: a clinical diagnosis against standard criteria; DS-M-5 major depressive episode requires at least two weeks of five or more symptoms causing impairment. ^{[7] [8]}
• Postpartum psychosis: immediate senior psychiatric assessment; it is an emergency rather than a screening diagnosis. ^{[8] [9]}
• Medical work-up (especially when psychosis is suspected, or clinical picture is unusual): full examination (including neurological assessment), complete blood count, comprehensive metabolic panel, urinalysis, urine toxicology, TSH with free T4 and thyroid peroxidase antibodies, ammonia; brain imaging and assessment for autoimmune encephalitis when there are neurological signs. These are to exclude delirium, infection, thyroid disease, stroke-like causes and autoimmune encephalitis. ^[9]
• Anxiety and OCD: clinical interview focused on worry and on intrusive thoughts and compulsions. Specific perinatal OCD tools exist but are not yet in routine use. ^[8]
• Bipolar screen before any antidepressant: especially in perinatal depression, because a notable proportion of women with depressive symptoms are later found to have bipolar disorder (up to about 7% with antenatal symptoms, about 23% of those with postpartum symptoms). ^[8]

• Depression identification questions at first contact with services and in the early postpartum, and mental health questions at usual contacts through the first year. ^[1]
• At each contact after the first, consider asking the two depression questions and the GAD-2, and using EPDS or PHQ-9 for monitoring. ^[1]
• Assess for any past or present severe mental illness or a family history (mother, sister or daughter) of severe perinatal mental illness, at first contact. ^[1]
• Be alert for postpartum psychosis in the first two weeks after birth when these are present. ^[1]
• If sudden onset of symptoms suggesting postpartum psychosis: refer for immediate specialist assessment within 4 hours. ^[1]

Management depends on the diagnosis, its severity and the immediate risk. Treatment is usually shared between obstetric/midwifery services, primary care and mental health services, with specialist perinatal mental health teams where available. ^{[1] [2] [8]}

Postpartum psychosis is an emergency that requires inpatient (ideally mother-and-baby-unit) care. Any suspected case should have prompt specialist assessment; while awaiting care, do not leave the woman alone and ensure the baby is kept safe. ^{[8] [9]} Where local services allow, the aim is to keep mother and baby together, but separation may be warranted in the acute crisis. ^[9]

The best-studied acute algorithm (Bergink 3-step protocol, widely cited) uses: ^[9]

• Step 1: lorazepam 0.5 to 1.5 mg three times daily for 3 days. (About 4 in 64 women remit at this stage.) ^[9]
• Step 2: add an antipsychotic (high-potency preferred; haloperidol 2 to 6 mg daily, or olanzapine 10 to 15 mg daily). (About 12 in 60 remit at this stage.) ^[9]
• Step 3: add lithium if there is no response after 2 weeks, aiming for a serum level of 0.8 to 1.2 mmol/L. (Remission occurs in the great majority.) ^[9]
• Taper benzodiazepines and antipsychotics once remission is achieved, but continue lithium monotherapy for about 9 months (often at a lower target of 0.6 to 0.8 mmol/L if side effects occur). ^[9]
• For women with a history of postpartum psychosis, prophylactic lithium is recommended in pregnancy or immediately postpartum.

Electroconvulsive therapy (ECT) is an option for patients who do not respond, or where severity demands, and is the most rapidly effective treatment in severe illness. ^[9]

Benzodiazepines and sedative antipsychotics can be used for immediate symptom management. The key point from newer evidence is that lithium should be started as early as possible: most women with postpartum psychosis respond well, and time may be lost by relying on antipsychotics alone. ^[8]

• Psychotherapy is first-line for mild to moderate perinatal depression and many anxiety disorders. Cognitive-behavioural therapy (CBT), interpersonal therapy (IPT) and behavioural activation are all evidence-based; CBT and IPT have the strongest evidence. ^[8]
• Facilitated self-help (CBT-based self-help with brief support over about 6 sessions over 2 to 3 months) is appropriate for persistent sub-threshold symptoms or mild depression. ^[1]
• Non-drug measures matter: sleep protection (including protected nights, help with night feeds and CBT for insomnia), social support, exercise, nutrition and reduction of alcohol use. ^[8]
• ACOG recommends psychotherapy as first-line for mild to moderate perinatal depression. ^[8]

NICE details for moderate or severe depression include high-intensity psychological intervention, a tricyclic/SSRI/(S)NRI if the woman understands the risks, or a combination; and two weeks for assessment after referral and psychological intervention within one month of initial assessment. ^[1]

General principles from NICE and ACOG. ^{[1] [8]}

• Use the drug with the lowest risk profile for that woman, taking into account her previous response; use a single drug where possible; use the lowest effective dose (but not sub-therapeutic doses, which fail to treat and still expose the fetus). ^[1]

• Doses often need adjusting in pregnancy, because metabolic changes, larger volume of distribution and raised kidney filtration reduce serum levels by 40 to 50% by late pregnancy for most drugs. ^[8]

• Discuss benefits and harms honestly, including uncertainty; the woman's central role in the decision; and the risks of stopping a previously effective drug. ^[1]

• When psychotropic medication is needed, check whether blood pressure or diabetes (especially with antipsychotics) changes. ^[1]

• Breastfeeding: discuss benefits, potential risks of medication in milk, and the risks of stopping a medication in order to breastfeed; choose treatments that allow breastfeeding if she wishes. ^[1]

• SSRIs (selective serotonin reuptake inhibitors) are generally first-line for perinatal depression and anxiety. ^[8]

  • Where a drug has worked before, restart the same one; risk profiles are broadly similar across SSRIs, but patients vary. ^[8]
  • Sertraline is often the preferred choice for a patient starting treatment during breastfeeding, because it has the best evidence for low passage into breast milk. ^[8]
  • Paroxetine has an older association with fetal cardiac malformations. Larger and well-controlled studies have not upheld this; it is reasonable to continue or restart it if it has helped before. ^[8]
  • NICE cautions that SSRIs/SNRIs used in the month before delivery carry a small increased risk of postpartum haemorrhage, and that all of these drugs carry risks of discontinuation symptoms in the mother and neonatal adaptation syndrome in the baby (with paroxetine and venlafaxine most notable). All should be used at the lowest effective dose and discussed individually. ^[1]
  • Neonatal adaptation syndrome occurs in up to about 30% of exposed babies: fussing, crying and feeding difficulty lasting less than 2 weeks. Stopping medication in pregnancy to avoid this is not recommended, because there is no clear evidence that stopping lowers the risk. ^[8]

• SNRIs (venlafaxine, duloxetine) and tricyclic antidepressants are acceptable alternatives, with similar considerations. ^[8]

• Anxiety disorders. Wet (benzodiazepines) should be used only short term for severe anxiety or agitation, or as rescue for panic attacks while waiting for an SSRI or SNRI to work. They are linked with a small increased risk of neonatal unit admission and neonatal sedation. ^{[1] [8]}

• Antipsychotics. If a woman with bipolar disorder or severe mental illness is stable on an antipsychotic and at risk of relapse without it, advise her to continue. ^[1] Monitor for excessive weight gain and gestational diabetes (glucose tolerance test recommended). ^[1] If mania or psychosis arises in pregnancy, offer an antipsychotic. ^[1] Depot antipsychotics should not be used for women planning pregnancy, pregnant or considering breastfeeding unless there is a specific non-adherence history. ^[1]

• Valproate. Should not be offered for mental health problems in women planning pregnancy, pregnant or considering breastfeeding. It is contraindicated in pregnancy. ^{[1] [8]}

• Carbamazepine. Should not be offered; it reduces efficacy of oral contraceptives and can reduce fetal harm risk considerations (neural tube defects). ^{[1] [8]}

• Lamotrigine. Can be used with care, including checking levels frequently preconception, during pregnancy and postpartum, because concentrations vary a great deal. ^{[1] [8]}

• Lithium. NICE advises not offering lithium in pregnancy unless an antipsychotic has not worked. ^[1] If used, monitor levels every 4 weeks then weekly from 36 weeks, stop in labour with a 12-hour check after the last dose, keep fluid balance adequate and deliver in hospital. ^[1] Newer evidence supports lithium as highly effective in postpartum psychosis, with serum targets of 0.8 to 1.2 mmol/L acutely. ^{[8] [9]} Fetal risk (cardiac anomaly) is much lower than previously thought; detailed anatomy and fetal echocardiogram are considered if used. ^{[8] [9]} One evidence-based monitoring schedule is every 3 weeks until 34 weeks, weekly until delivery and twice weekly for the first two weeks postpartum; resume the pre-pregnancy dosage immediately after delivery, as most women need a higher dose in late pregnancy. ^{[8] [6]}

• Women who stop mood stabilisers for pregnancy have about an 85% chance of relapsing into a mood episode; this risk must be weighed against medication risks. ^[8]

• Newer agents. Brexanolone (intravenous, 60-hour hospital infusion) and zuranolone (a 2-week oral course) are approved specifically for postpartum depression in some jurisdictions. They act rapidly. Longer-term and breastfeeding data remain limited; these are specialist treatments. ^[8]

• Neonatal monitoring. Any baby exposed to psychotropics in utero should have a full neonatal assessment and further monitoring as needed, because adverse effects can be delayed. ^[1]

• Suspected postpartum psychosis: same day, emergency psychiatric referral; if not already in hospital, emergency department evaluation; never leave unaccompanied. ^{[1] [8] [9]}
• Severe depression or active suicidal ideation: same day senior assessment. ^{[1] [8]}
• Bipolar disorder or past severe illness: specialist perinatal mental health. ^[1]
• Substances or domestic violence: address as part of care and safeguarding concerns. ^[1]
• A baby or mother at risk (child protection): follow local safeguarding protocols. ^[1]

Most perinatal depression and anxiety responds well to treatment within weeks. ^[8] Without treatment, symptoms may last a year or more. ^[8] Postpartum psychosis, with prompt treatment, has a high recovery rate in the acute phase and most women make a full recovery with continuing care; longer-term outcomes depend on relapse prevention, especially lithium maintenance. ^{[8] [9]}

Recurrence. Postpartum psychosis recurs in more than half of women in some series; women with bipolar disorder have a 20 to 30% risk in each pregnancy. ^[9] Postpartum depression recurs in about half of women in a subsequent pregnancy. ^[7]

• Suicide. Perinatal suicide is an important, preventable cause of maternal death. ^[8]
• Infanticide / child harm. Rare but catastrophic, and more likely in untreated severe illness. ^[9]
• Obstetric complications associated with untreated illness: pre-eclampsia, gestational diabetes, preterm birth, intrauterine growth restriction, substance use and less antenatal care. ^[8]
• Neonatal adaptation syndrome with in-utero SSRI/SNRI/tricyclic exposure (up to 30%). ^[8]
• Child development and bonding in untreated or severe illness. ^[8]
• Postpartum psychosis complications including residual mood illness and future bipolar illness. ^[9]

• Screen everyone, as above, in pregnancy and postpartum, using validated tools. ^{[2] [8]}
• Identify risk at the first antenatal visit and again after birth: personal or family severe mental illness, severe perinatal mental illness in a first-degree relative, previous postpartum psychosis, bipolar disorder, substance use, social stress and past depression or anxiety. ^[1]
• Treat or prevent anaemia, sleep loss and isolation; psychoeducation normalising mood changes. ^[8]
• For women at high risk of postpartum psychosis (bipolar disorder, prior postpartum psychosis): pre-conception counselling, a perinatal psychiatry plan, a written care plan agreed before delivery at about 32 weeks and regular early postnatal visits, with prophylactic lithium from late pregnancy or immediately postpartum in highest-risk women. ^[9]
• For women at risk of depression, psychotherapy has been shown to reduce incidence of perinatal depression in trials (for example, by up to about 39% in some programmes): offer psychotherapy to at-risk mothers. ^[7]
• Treat anxiety and depression promptly in pregnancy; avoid untreated illness. ^[8]

• Women with bipolar disorder. High risk of relapse and psychosis postpartum; continue effective medication; valproate avoided; lithium with monitoring; ECT available. ^{[1] [8] [9]}
• Adolescents. Included in screening (e.g., with equivalent tools). ^[2]
• Women in diverse settings. The WHO guide for perinatal mental health integration is written for resource-limited and non-specialist settings and provides stepped care: promotion, prevention, treatment and referral, adjusted to context. ^[3]
• Breastfeeding mothers. Many psychotropics are compatible. Choose medicines with lower transfer (sertraline) and consider dose and timing; use non-drug therapies first where appropriate. ^{[1] [8]}
• Women who decline treatment or have adverse experiences. Build a plan with shared decision-making and access to talking therapies, with clear follow-up. ^{[1] [8]}

• Use a trusted, short tool (EPDS or PHQ-9) and the NICE depression and anxiety questions; ask directly, kindly and in private about self-harm and thoughts of harm to the baby. ^{[1] [2]}
• Brief training of midwives, nurses and community workers, with supervision and clear referral routes, is feasible and is the approach recommended by WHO. ^[3]
• Non-specialist, psychosocial care (CBT-based self-help, interpersonal counselling, group support) is the backbone of care where psychiatrists are unavailable. ^{[1] [3] [8]}
• Watch for danger signs. Suspected postpartum psychosis requires urgent referral, keeping the woman safe; a mother-and-baby unit may not exist, so plan local arrangements in advance. ^{[8] [9]}
• Empower family to recognise early warning signs ("she is not herself", not sleeping), to bring women in and to help with basic care and sleep. ^[9]
• Use generic medicines on the essential medicines list; lithium and antipsychotics can be managed with careful monitoring even where laboratory support is limited, but weigh risks. ^{[3] [8]}
• Avoid valproate and other known teratogens as first-line where possible; use non-teratogenic alternatives first and avoid polypharmacy. ^{[1] [8]}

Related MedGrasp topics (plain text, pending verified links): antenatal care and preconception care; postpartum haemorrhage; hypertensive disorders of pregnancy; thyroid function tests and thyroid disorders; epilepsy in women; bipolar disorder (diagnosis, prophylaxis); treatment of depression in adults; schizophrenia and psychosis; obsessive-compulsive disorder; obsessive-compulsive symptoms in children and postpartum; sleep and insomnia; drugs and teratogens in pregnancy; breastfeeding, lactation and mastitis.

• Perinatal mental health covers pregnancy and the year after birth; it is the commonest complication of childbirth. ^{[3] [6]}
• Treatable mental health problems affect about 15 to 20% of women in the perinatal period, and about one in five to seven birthing individuals overall. ^{[6] [8]}
• The baby blues are common (reported prevalence varies widely, with pooled estimates around 39% and commonly quoted figures of 45 to 85%), usually peak days 3 to 5 and settle by 10 to 14 days. They are not a psychiatric disorder. ^{[4] [5] [7]}
• Perinatal depression affects about one in five to seven women (about 10 to 20%), with more than 25% of women affected by depressive symptoms during the perinatal period and general consensus that major depressive disorder rates range from 10 to 15%. ^{[7] [8]}
• Anxiety disorders frequently co-exist with depression (up to about 70% in some samples) and are an important independent source of distress. ^[8]
• Postpartum psychosis is rare (1 to 2 per 1,000 births), usually starts 3 to 10 days postpartum and is a psychiatric emergency because of suicide and infanticide risk. ^{[8] [9]}
• Suspected postpartum psychosis means same-day specialist assessment (within 4 hours of referral) and inpatient management, ideally in a mother-and-baby unit; never leave her alone. ^{[1] [8] [9]}
• Bipolar disorder is the strongest risk factor for postpartum psychosis (20 to 30% of parous women with bipolar disorder), so screen for bipolar before starting an antidepressant. ^{[2] [9]}
• Everyone should be screened in pregnancy and postpartum using standard tools (EPDS, PHQ-9, GAD-2); a self-harm item positive needs immediate risk assessment. ^{[1] [2] [8]}
• EPDS 14 or more (out of 30) indicates likely depression; PHQ-9 scores of 5 to 9 mild, 10 to 14 moderate, 15 to 19 moderately severe and 20 or more severe. ^[8]
• Psychological (CBT, IPT) is first-line for mild to moderate perinatal depression. ^[8]
• SSRIs are first-line drugs; sertraline is often preferred for breastfeeding; paroxetine can be continued or restarted if it previously helped; avoid valproate as first-line in women of reproductive potential. ^{[1] [8]}
• Benzodiazepines are for short-term severe anxiety or as rescue, not long-term, in pregnancy. ^{[1] [8]}
• Lithium is highly effective for postpartum psychosis (as many as 98% respond) with target serum levels of 0.8 to 1.2 mmol/L acutely, and is monitored closely in pregnancy. ^{[8] [9]}
• Untreated illness carries real risks to mother and baby; most perinatal mental health conditions improve with treatment and support. ^[8]