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Postnatal depression (PND) can cause a range of difficulties including self-neglect and/or neglect of the baby. Ask about all aspects of care and life (feeding, changing, sleep, support network) to ascertain the risk.
Key Knowledge
● Affects approximately 10-15% of women in the first year after birth
● Onset typically within the first 3 months, but can occur at any point in the first postnatal year
● Presents like a depressive episode but often with perinatal-specific features: preoccupation with infant, guilt about not being a good enough mother, intrusive thoughts about harming the baby
● The Edinburgh Postnatal Depression Scale (EPDS) can be used as a screening tool
● Risk factors include previous psychiatric illnesses, lack of social support, a negative birth experience, poor relationship with partner, and preterm deliveries.
What is Postnatal Depression?
ICD-11 does not classify postnatal depression as a separate diagnostic entity. It is coded using a cluster approach: 6E20 (Mental or behavioural disorders associated with pregnancy, childbirth or the puerperium, without psychotic symptoms) is assigned alongside the relevant depressive episode code (6A70–6A71) when symptom criteria are met. ICD-11 defines the puerperium as commencing within approximately 6 weeks after delivery.
Core Features of Postnatal Depression
Core features are those of a depressive episode:
AFFECTIVE:
● Depressed mood most of the day, nearly every day
● Loss of interest or pleasure in activities, sometimes including caring for or interacting with the baby
COGNITIVE-BEHAVIOURAL:
● Feelings of worthlessness, excessive guilt (often focused on being a “bad mother”)
● Difficulty concentrating or making decisions
● Thoughts of death/suicidal ideation
NEUROVEGETATIVE:
● Sleep disturbance (beyond what is expected with a newborn)
● Appetite and weight changes
● Reduced energy and fatigue
● Psychomotor agitation or retardation
The criteria are met if at least five characteristic symptoms, including at least one affective symptom, is present most of the day, nearly every day, for at least two weeks. Moreover there must be evidence of significant impairment in areas of functioning such as personal, family, social, educational and occupational.
Perinatal-specific features to explore:
● Bonding difficulties — feeling emotionally detached from the baby, not feeling love for the infant, going through the motions of care without emotional connection
● Intrusive thoughts — unwanted, distressing thoughts about harming the baby (e.g., dropping, suffocating, shaking). These are ego-dystonic and cause intense distress—they are not commands and do not indicate intent to harm, but they must be carefully assessed.
● Anxiety — very common in PND; excessive worry about the baby’s health, constant checking, fear of something terrible happening
● Guilt and shame — powerful feelings of failure
● Breast-feeding difficulties – these are common and can be an important precipitating or perpetuating factor in PND.
Differential Diagnosis for Postnatal Depression
1. “Baby blues”
Key distinctions: “Baby blues” occur within days of delivery, are brief (days, not weeks), and resolve spontaneously. Symptoms are milder. PND persists, worsens, and requires treatment.
2. Postpartum psychosis
Key distinctions: Onset is typically within the first 2 weeks postpartum, often days 3-5. Features include rapidly shifting mood (elation, depression, confusion), psychotic symptoms (delusions, hallucinations), severe disorganisation, and confusion. Any psychotic features in the postnatal period should prompt urgent review.
3. Adjustment disorder
Key distinctions: Adjustment disorder involves an emotional response to the stress of parenthood that does not meet full criteria for a depressive episode. Symptoms are less severe, fewer in number, and more clearly reactive to identifiable stressors.
4. Anxiety disorders (postnatal anxiety, OCD)
Key distinctions: Postnatal anxiety and OCD are common and frequently coexist with PND. Postnatal OCD specifically involves intrusive thoughts, for example, about harming the baby, and prominent rituals (checking, avoiding). The distinction matters for treatment, though the two often co-occur.
5. Bipolar disorder
Key distinctions: The postnatal period is a high-risk time for bipolar relapse. If the presentation includes elevated mood, reduced need for sleep, rapid mood shifts, or psychotic symptoms, consider bipolar affective disorder. Antidepressants alone can precipitate mania.
6. PTSD following traumatic delivery
Key distinctions: Traumatic birth experiences (emergency caesarean, prolonged labour, perceived loss of control) can lead to PTSD. Features include re-experiencing (flashbacks of the delivery), avoidance, and hypervigilance. May coexist with PND.
7. Substance use
Key distinctions: Alcohol or substance misuse may develop or worsen postnatally as a coping mechanism. May present with or mimic depressive symptoms.
8. Physical health issues
Key distinctions: Physical health issues in the postpartum period, such as anaemia, thyroid dysfunction or hormonal changes, may cause or co-exist with PND. Remember necessary investigations.
Risk Assessment in Postnatal Depression
As with every risk assessment, you must consider risk to self, to others and from others. Postnatal risk assessment has specific and critical components.
To self:
● Suicide and self-harm — Suicide is a leading cause of maternal death in the first postnatal year. Assess suicidal ideation, plans, and intent directly. Ask about methods. Be aware that women may minimise or deny ideation due to fear of consequences (baby being removed).
● Self-neglect — Neglect of own nutrition, hygiene, physical health due to low mood or preoccupation with infant
To others (the baby and other children):
● Intrusive thoughts about harming the baby — These must be explored carefully. Distinguish ego-dystonic intrusive thoughts (which cause distress and are not acted upon) from thoughts with intent. Ask: “What stops you from acting on these thoughts?”
● Neglect of the infant — Bonding difficulties, low motivation, and exhaustion can impair basic infant care. Assess whether the baby’s needs (physical and emotional) are being met.
● Older children — Assess whether other children in the household are being adequately supervised and cared for
● Infanticide — Extremely rare but must be considered in severe PND with psychotic features, hopelessness about the future, or delusional thinking involving the infant
From others:
● Domestic violence — The postnatal period is a high-risk time for onset or escalation of domestic abuse. Ask sensitively and directly.
● Social isolation and lack of support — Increases vulnerability to deterioration
● Partner’s mental health — Postnatal depression in partners is common and affects the family system
Communication Tips
Postnatal depression stations frequently involve a new mother presenting with low mood, or a station where you must explain a diagnosis and its implications. Key skills are building rapport quickly, covering both maternal and infant wellbeing, and managing the shame and stigma that many women feel. It is important to be especially sensitive when enquiring about risk to the baby or other children; explaining why you are asking and normalising this part of the assessment can reduce alarm.
Opening:
● “How have you been feeling since the birth?”
● “A lot of women find the postnatal period much harder than they expected—how has it been for you?”
Exploring mood and depressive symptoms:
● “How would you describe your mood over the past few weeks?”
● “Are you able to enjoy things?”
● “How’s your energy?”
● “How are you sleeping when you get the chance?”
● “How’s your appetite been?”
● “How are you feeling about yourself—as a person, as a mother?”
Exploring bonding (sensitively):
● “How are you finding being with your baby?”
● “Do you feel connected to them, or has that been harder than you expected?”
● “Some mothers tell me they love their baby but don’t always feel that emotional closeness—have you experienced anything like that?”
Exploring intrusive thoughts (essential, handle with care):
● “Some mothers with low mood have unwanted, distressing thoughts about something bad happening to their baby—thoughts they really don’t want to have. Has anything like that come into your mind?”
● If yes: “Can you tell me a bit more about those thoughts?”
● “How do you feel when you have those thoughts?” (Distress = more likely ego-dystonic, consistent with OCD/PND)
● “Have you ever felt like you might act on them?” (risk question)
Differentiating from postpartum psychosis:
● “Have you noticed your mood changing very quickly?”
● “Have you had any unusual experiences – hearing or seeing things that others can’t hear or see, or thoughts that felt strange?”
● “Have you had any thoughts about yourself or the baby that others might find unusual?”
Birth experience:
● “How was the birth? Were there any complications?”
● “Are there parts of the birth that stay with you or that you find yourself going over?”
Social support and risk factors:
● “Who do you have around you for support?”
● “How are things with your partner/the baby’s father?”
● “Have you ever felt unsafe at home?” (Screen for domestic violence—ask alone if possible)
Previous mental health:
● “Have you ever felt like this before—before the pregnancy?”
● “Any previous episodes of depression or anxiety? Any previous treatment?”
● “Any family history of mental health problems, particularly around childbirth?”
Impact on infant care:
● “How are you managing the day-to-day care of the baby?” (ask specifically around feeding, sleeping, changing etc)
● “Is there anyone else helping look after the baby at the moment?”
Screening for risk directly:
● “Have you had thoughts that life isn’t worth living, or thoughts of harming yourself?”
● If yes: “Have you made any plans? Have you thought about how you might do it?”
● “Is there anything that would stop you?”
● “Have you ever had any thoughts of wanting to harm the baby?”
CASC Practice Scenarios
Scenario 1: Postpartum Depression
Candidate Instructions
You are the psychiatry core trainee reviewing Ms. Emily Jones, a 34-year-old woman referred by her GP. She is six weeks post-caesarean delivery of her daughter Ava.
Take a history to clarify diagnosis and assess risk.
Actor Instructions
You are quiet but cooperative, answering questions thoughtfully but without volunteering too much unless prompted. Your pregnancy was planned and initially happy. The birth was traumatic, ending in an emergency caesarean section after a long labour, which left you feeling frightened and powerless. The early postnatal period was physically painful and emotionally overwhelming, and you found hospital stays and brief separations from Ava distressing despite reassurance that she was well.
Around two weeks after returning home, your mood deteriorated. Since then, you have felt persistently low, tearful, and hopeless most days, with poor motivation and a sense of emotional numbness. You feel exhausted but sleep is poor, with frequent night-time anxiety focused on Ava’s safety. Your appetite is reduced and you have lost some weight.
You feel intense guilt about motherhood, particularly difficulties with breastfeeding, and are distressed by feeling emotionally distant from Ava. You care for her but it feels mechanical rather than natural, which makes you feel ashamed and fearful that you are a bad mother. You worry excessively about Ava’s health but also sometimes avoid interacting with her because it highlights how disconnected you feel.
Your partner Tom, whom you have been married to for 6 years, is supportive but works long hours, and you feel guilty asking for help. You do not have any other family nearby – they live in Devon where you grew up and you try and see them every 2 months.
Over the past week, you have had fleeting thoughts that your family might be better off without you, but you deny any plans or intent to harm yourself. You clearly and firmly deny any thoughts of harming Ava.
Before this pregnancy you drank alcohol only occasionally. Over recent weeks, you have been drinking several glasses of wine most evenings once the baby is asleep, describing this as a way to “numb things,” and you are increasingly worried about it. You deny illicit drug use and take no regular medication.
After the birth of your son, Max, four years ago, you experienced severe postnatal depression and made a planned suicide attempt by paracetamol overdose (30 tablets), requiring hospital admission and mental health follow-up. You were treated with antidepressants and psychological support and made a full recovery, remaining well until this pregnancy. You took one previous overdose, of 6 paracetamol tablets, when you were 18, during another period of depression, triggered by leaving home to go to university. This depressive episode lasted around three months before self-resolving – you did not see a doctor about this. Otherwise you have not had any other history of mental illness. You would not consider yourself an impulsive person. There is no family history of mental illness.
You are currently on maternity leave from your job as a pharmacist and are financially stable, but you are frightened by how similar this feels to your previous postnatal depression.
Feedback for Scenario 1
Knowledge & Structure & Risk
● Knowledge & Structure:
Key symptoms to ask about include: low mood, anhedonia, fatigue, appetite and sleep disturbance, guilt, impaired bonding, and excessive anxiety around the baby. Clarify onset and duration (distinguishing this from the “baby blues”), and thoroughly establish the functional and emotional impact on parenting and self-worth. Also exclude psychotic symptoms, and make sure you ask about alcohol and drug use. Collateral and social support is useful to explore, including her partner and home circumstances.
● Risk:
Ask about active and passive suicidal ideation and exclude thoughts or intent of harm to the baby – as well as past risk history.
Communication
It is good to have a validating, non-judgemental approach, with reassurance where appropriate. (“Many parents struggle after a tough birth—this can feel incredibly lonely, but you’re not alone”). It is also good to give Emily space to talk, and acknowledge her courage in seeking help.
Authors / Reviewers
Dr Damir Rafi is a psychiatry speciality registrar in forensics, currently working in London.
Dr Sarah Barber is a Psychiatry Registrar, currently taking time out of clinical work to complete a PhD in psychiatric epidemiology.
Dr Grace Crowley is a Psychiatry Registrar, currently taking time out of clinical work to complete a PhD in global mental health.
References and Resources
https://icd.who.int/browse/2026-01/mms/en#1124422593 – ICD11
https://www.rcpsych.ac.uk/mental-health/mental-illnesses-and-mental-health-problems/postnatal-depression – RCPsych – Postnatal Depression
Disclaimer:
This article is intended for use as a learning resource for doctors training in Psychiatry in the UK. It is not intended for patients. If you are looking for information about mental health conditions, please visit www.rcpsych.ac.uk/mental-health to find readable, user-friendly and evidence-based information on mental health problems, treatments and other topics written by qualified psychiatrists, with help from patients and carers. If you are looking for help for a mental health condition, please visit https://www.mind.org.uk/ for information about where help is available.
The article was written by UK doctors and cross-checked against various published sources (see Reference list). We endeavour to keep information up to date, but it should not be relied on for clinical decision making. Consult local guidelines and senior colleagues whenever you are not sure.