Postpartum Depression: An Overview

In the first of a two-part feature, Catherine Birndorf MD and Alexandra Sacks MD, co-authors of the new book, Mother Mind: The Emotional Guide to Pregnancy and Postpartum, discuss the tell-tale signs of postpartum depression.


Motherhood is supposed to be the most natural thing in the world: easy, instinctive, even blissful. But the process can be as depleting as it is gratifying. Even if this baby is your dream come true, you still may find yourself experiencing serious shifts in your mood postpartum.

After giving birth, no one feels joy about the weight she’s gained, the sleep she’s missing, the challenges of breastfeeding, and the responsibility of maintaining a totally dependent creature. While caring for an infant, many mothers neglect to care for themselves, and this is often another trigger for feeling unwell. But how can you tell the difference between the normal stresses of new motherhood and Postpartum Depression (PPD)?

How do I know if I have PPD?

  • The Baby Blues

As many as 80% of new moms experience what are called “the baby blues” in the first couple of weeks after delivery. Because these feelings are so common, we think of this as a normal reaction to the hormonal shifts that follow childbirth, rather than a psychiatric illness. If you have the blues, you don’t feel sad as much as up and down. You may be tearful and extra sensitive.

While unpleasant, these symptoms should not interfere with your ability to function. The baby blues run their course within 2-3 weeks and do not require professional treatment.

  • Postpartum Depression (PPD)

If your baby blues last longer than two weeks, you may be developing PPD. Because up to 50% of PPD cases actually begin during pregnancy, your symptoms may be a continuation of a depression that has been brewing for some time. Or your symptoms might not show up at first: you may feel fine after giving birth and then start to experience symptoms of depression two or three months later, or even up to a year.

In PPD you may not feel blue. Instead you feel like your world has gone from in-color to flat grey tones. You lose interest in the things you used to enjoy, even your favorite TV show. Nothing “pops.” A common complaint we hear from women with PPD is that they love their babies, but they aren’t enjoying life. If you feel this way most days for at least two weeks, you may have PPD.

In addition, you may have trouble sleeping or want to sleep all the time, experience poor appetite or overeating; fatigue or restlessness; trouble concentrating; and tearfulness. You may yearn to avoid the world, think negative thoughts about yourself, and even feel hopeless. With more severe depression, you may want to disappear, escape, or not be alive.

The symptoms of PPD are primarily the same as those of a depression that might occur at any other time in your life. However, your physiology is so different in the postpartum period—because sleep, energy, and appetite are all dysregulated by the baby’s schedule—that it can be hard to distinguish depression from exhaustion. You can take a special Postpartum Depression questionnaire to help you determine if you may have PPD or if you are experiencing the general physical depletion that can occur postpartum.

I’m anxious but not sad. Do I have PPD?

You may be reading this and thinking, “I don’t feel good, but I’m not sad, so I must not have PPD.” However, many women with PPD don’t feel down in the dumps. They’re suffering instead from agitation, anxiety, and self-doubt. If you fall into this category, you may still have PPD: it’s the same disease. In fact, we think that the name “Postpartum Depression” is a bit misleading. The condition could more accurately be described as a variety of Postpartum Mood and Anxiety Disorders.

Excessive worry can be the most debilitating component for most women with PPD. Those women feel guilty and self-critical about almost everything, even aspects of their or their child’s lives that are obviously out of their control. Our patients often make statements like, “I feel guilty whenever the baby cries. I’m worried I’m just not cut out for this. She deserves better.” They feel trapped, lonely, and overwhelmed. They can’t turn off the self-critical voices in their heads insinuating, or even declaring, that they are bad mothers.

Some women with PPD have paralyzing fears about the baby’s breathing, obsessive worries about germs, and disturbing thoughts of harm befalling the baby. They may even think about harming their own children. Women report having difficulty being in the kitchen around knives or near open windows with their babies because they are disturbed by horrible images. The evidence suggests, though, that mothers gripped by these fears are rarely at risk of acting on them. These aversions are, indeed, a strong sign that you’re unlikely to act out in a dangerous way. The women who do become violent are usually suffering from a different, very rare and serious condition called postpartum psychosis.

  • Postpartum Psychosis

This, the most severe form of postpartum psychiatric illness, is seen in only 1-2 out of 1,000 women after childbirth. Symptoms usually come on within the first few days to weeks after delivery and are quite scary to experience and to observe. Most women who experience postpartum psychosis have an underlying Bipolar Disorder. They are typically confused and disorganized. They may have delusions about themselves or their babies, and they may hear voices telling them to inflict harm. Unlike women with PPD, these violent thoughts do not seem wrong to them. In fact, hurting their children may make sense to them as a part of their delusions.

If there is any question that you or someone you know may be experiencing postpartum psychosis, you should immediately alert their doctor and family.

Am I At Risk For Developing PPD?

Becoming a mother doesn’t protect a woman from mood disorders if she has suffered from depression or anxiety in the past. In some women, hormonal shifts can trigger brain changes that leave them feeling worse than usual.

Women with the highest risk for PPD are those with a history of depression in their family or who have had depression or other psychiatric issues themselves. Other risk factors include having had PPD in the past and/or untreated depression or anxiety during pregnancy. Certain stressful life events that occur during your pregnancy or in the early postpartum period – such as a traumatic birth, having your child admitted to the NICU, few family supports, poor or no relationship with the father of the baby, or significant trouble breastfeeding – may also make women more vulnerable.

What Causes Postpartum Depression?

While scientists don’t know the exact cause of PPD, there are some theories. After a woman delivers a baby, her hormone levels crash, leaving her with far less estrogen and progesterone. Some doctors believe that this drastic hormonal shift can trigger PPD. While hormonal flux may contribute to PPD, we believe that the story is not that simple. Some women are more hormonally sensitive than others, and if you have had PMS or emotional responses to taking birth control in the past, you may be in this group. But other women develop PPD because they are prone to depression or anxiety in general, and the postpartum period is a set up for another episode. And still other women only get PPD as a reaction to the psychological and behavioral stresses of the postpartum period, including sleep deprivation, identity shifts, and relationship changes.

In part two of this feature, Drs Birndorf and Sacks, discuss ways to treat and manage PPD. 


Dr. Catherine Birndorf specializes in Reproductive Psychiatry, an important area in mental health which helps women with emotional and psychiatric conditions before, during and after pregnancy and throughout the life cycle. Dr. Birndorf helps patients understand their specific psychiatric problems during times of hormonal changes from menses to menopause. She works with her patients and their families to focus on these psychiatric issues and provides a range of treatment options during this time of transition in a woman’s life. Visit Dr. Birndorf’s website.

Dr. Alexandra Sacks is an Adult Psychiatrist who is interested in the biological, philosophical and emotional links between the mind, body, and brain.  As a therapist, she believes that the best treatment comes from feeling understood.  She uses medications as one tool in this collaboration to integrate with exercise, nutrition, sleep and behavioral wellness.  In addition to her work in Adult Psychiatry as it relates to general anxiety and depression for men and women, she specializes in Reproductive Psychiatry/Women’s Mental Health. Visit Dr. Sacks’ website.

Learn more about their new book: Mother Mind: The Emotional Guide to Pregnancy and Postpartum.