Mental or behavioural disorders associated with pregnancy, childbirth or the puerperium, without psychotic symptoms

ICD-10F53.0	Mild mental and behavioral disorders associated with the puerperium, not elsewhere classified
DSM-5-TR—	Peripartum onset specifier (no separate DSM-5-TR category)

1. Definition and nosology

Postnatal Depression (ICD-11: 6E20; DSM-5-TR: F32.x / F33.x Major Depressive Disorder with peripartum onset specifier) — a major depressive episode developing after childbirth (onset within 4–6 weeks; clinically up to 1 year). Affects 10–15% of women.

2. History

• Marcé L.V. (1858) — first clinical description of postpartum psychosis and depression.
• EPDS — Cox J.L. et al. (1987) — Edinburgh Postnatal Depression Scale.
• NICE CG192 (2014, 2020 update) — antenatal and postnatal mental health.
• FDA — brexanolone (2019), zuranolone (2023) — first specifically approved drugs for postpartum depression.

3. Epidemiology

• Prevalence: 10–15% (high-income countries), 20–30% (low- and middle-income countries).
• “Baby blues” — milder, short-term (1–2 weeks) — occurs in 50–80% of women; does not require clinical intervention.
• Comorbidity: anxiety, OCD, panic.
• Risk factors: previous depression, family history, depression during pregnancy, lack of partner support, socioeconomic stress.

4. Etiology and pathogenesis

• Hormonal — sharp drop in estrogen and progesterone after childbirth; allopregnanolone dysregulation.
• Sleep disturbance with newborn care.
• Psychosocial stress, relationships, social support.
• Genetic and prior history of affective disorder.

5. Clinical features

• Major depressive episode symptoms (sleep disturbance, appetite loss, anhedonia, worthlessness, suicidal thoughts).
• Specific characteristics: affective distancing towards the infant, difficulties in infant bonding, belief in inability to fulfill the maternal role, intrusive thoughts regarding harming the infant (ego-dystonic — similar to OCD; distinct from postpartum psychosis).
• Suicide risk and, in rare cases, infanticide (higher in postnatal psychosis).

6. Diagnosis

6.1 Unified diagnostic criteria

Major depressive episode criteria (DSM-5-TR five or more symptoms for two weeks; ICD-11) + peripartum onset specifier (DSM-5-TR — during pregnancy or within 4 weeks postpartum; ICD-11 — within about 6 weeks after delivery (puerperium)).

6.2 Differences between sources

• NICE CG192 (2014, 2020 update) — diagnosis and treatment.
• ACOG Committee Opinion 757 (2018) — perinatal depression screening.
• USPSTF — screening in pregnant and postpartum women.

6.3 Diagnostic algorithm

1. EPDS (Edinburgh Postnatal Depression Scale, 10 items) — gold standard screening; cut-off ≥ 10 — possible depression (sensitive screening threshold), ≥ 13 — probable major depression.
2. Clinical interview (assessment of the need for hospitalization and of suicide risk).
3. Postnatal psychosis differential — urgent hospitalization if psychotic symptoms present.
4. Medical evaluation — thyroid (postpartum thyroiditis), anemia.
5. Comorbid anxiety, OCD screening.

6.4 Differential diagnosis

7. Examination and assessment

• EPDS, PHQ-9.
• C-SSRS — suicide and risk of harm to infant.
• TSH, hemoglobin.

8. Treatment

8.1 General principles (NICE CG192 · ACOG · APA)

1. Mild-moderate: Psychotherapy is first-line — CBT, IPT (particularly adapted to the perinatal context).
2. Moderate-severe: psychotherapy + SSRI. In breastfeeding context:
   • Sertraline (least excreted into milk) and paroxetine — first-line;
   • Fluoxetine — long half-life, use with caution;
   • Citalopram, escitalopram — appropriate.
3. Refractory severe PPD:
   • Brexanolone (Zulresso) — IV 60-hour infusion; FDA 2019 approval; monitored in clinic under REMS program; rapid effect.
   • Zuranolone (Zurzuvae) — oral 14 days; FDA 2023 approval; more convenient.
4. ECT — psychotic depression, severe suicide risk, impaired food intake, also safe during pregnancy.
5. Family support, peer support (e.g., postnatal depression helpline).
6. Social service and mother-infant bonding support.
7. Sleep hygiene and involvement of family members in night care.

8.2 Treatment methods

1. Perinatal Interpersonal Therapy (IPT) — Stuart (Stuart S.), Robertson (Robertson M.) — Major role transitions, partner relationships, social support system.
2. CBT Perinatal Adapted — Cognitive disturbances, behavioral activation.
3. Brexanolone (Zulresso) — IV 60-hour; REMS program; clinic monitoring.
4. Edinburgh Postnatal Depression Scale (EPDS) — 10-item self-assessment.
5. ECT — Safe in pregnancy and lactation; in severe refractory cases.

8.3 Differences between sources

• NICE CG192 — sertraline and paroxetine first-line in breastfeeding.
• Louik C. et al. NEJM 2007 · Huybrechts K.F. et al. NEJM 2014 — SSRI in pregnancy cardiac malformations (paroxetine cautiously).
• Meltzer-Brody S. et al. Lancet 2018 — brexanolone RCT.

9. Prognosis

• 70–80% remission with adequate treatment.
• Risk of recurrence in subsequent pregnancies (~25%).
• Without treatment, chronicity and comorbidity.

10. Myths and misconceptions

Myth 1: “PPD is just ordinary ‘baby blues’, transient”

Evidence: baby blues ≤ 2 weeks, mild; PPD clinical depressive episode, requires intervention; can be prolonged.

Myth 2: “Antidepressants are dangerous during breastfeeding”

Evidence: sertraline and paroxetine are acceptable during breastfeeding; milk transfer minimal; clinical counseling.

Myth 3: “Mother is weak, she should ‘fix herself’”

Evidence: PPD is a clinical condition; risk of suicide and infanticide exists; intervention is required.

Myth 4: “Brexanolone cures PPD”

Evidence: Rapid effect, but the cost and need for clinic monitoring are significant; standard approach SSRI + psychotherapy.

Myth 5: “PPD does not affect the infant”

Evidence: PPD affects mother-infant bonding and impacts the child’s cognitive and emotional development; early intervention is crucial.

Myth 6: “Intrusive thoughts (harming a baby) are always a sign of psychosis”

Evidence: In postpartum OCD, intrusive thoughts are ego-dystonic — the patient suffers from them and avoids them; in postpartum psychosis they are ego-syntonic and can lead to behavior — different intervention.

11. Sources

1. WHO. ICD-11. 6E20 Mental or behavioural disorders associated with pregnancy, childbirth or the puerperium, without psychotic symptoms. 2024.
2. APA. DSM-5-TR. 2022.
3. NICE CG192. Antenatal and postnatal mental health. 2014, 2020 update.
4. ACOG Committee Opinion No. 757: Screening for Perinatal Depression. 2018.
5. Cox J.L., Holden J.M., Sagovsky R. Detection of postnatal depression. Development of the 10-item Edinburgh Postnatal Depression Scale. Br J Psychiatry 1987;150:782–786.
6. Meltzer-Brody S. et al. Brexanolone injection in post-partum depression. Lancet 2018;392(10152):1058–1070.
7. Deligiannidis K.M. et al. Effect of zuranolone vs placebo in postpartum depression. JAMA Psychiatry 2021;78(9):951–959.
8. Louik C., Lin A.E., Werler M.M., Hernández-Díaz S., Mitchell A.A. First-trimester use of selective serotonin-reuptake inhibitors and the risk of birth defects. N Engl J Med 2007;356(26):2675–2683.
9. Huybrechts K.F., Palmsten K., Avorn J. et al. Antidepressant use in pregnancy and the risk of cardiac defects. N Engl J Med 2014;370(25):2397–2407.
10. Stuart S., Robertson M. Interpersonal Psychotherapy: A Clinician’s Guide. 2nd ed. London: Hodder Arnold, 2012.