Many women are depressed after childbirth; at least 80% suffer in some way! However, there are differences in how individual women respond. This article describes the range of depressive symptoms a woman might feel after childbirth, starting with a description of what are normal, non-depressive feelings. After reading this chapter, a postpartum mother will see where she falls in the spectrum and can recognize that what she may be feeling is common, and that there is help!

Normal responses to childbirth:

Every woman knows that following a delivery, even the easiest one, she will feel some level of discomfort. This level is influenced by a variety of factors: physical, psychological, environmental.

It usually takes six weeks to three months to recover For at least the first two hours after delivery, the woman experiences physical discomfort. The pain often increases in the days following childbirth, as the woman may experience strong uterine contractions, discomfort from stitches, and engorgement and abrasions due to breastfeeding. It usually takes a new mother six weeks to three months to recover. The pregnancy and birth have depleted her vitamins and minerals, and weeks of postpartum bleeding deplete her iron levels, leaving her with little energy. Her body seeks to repair itself from the strain of childbirth, blood loss, fluid loss, low blood pressure, and muscle strain. There can be stitches that need to heal, as well as possible surgical incisions. Her recovery is further slowed by lack of consistent sleep. In addition, she is experiencing huge hormonal upheaval: estrogen and progesterone levels have plummeted, and the lactating hormone levels are rising.

It is totally normal for sleep-deprived new mothers to be exhausted, unable to concentrate, and even to suffer some mild memory loss. In addition, the new mother has difficulty adjusting to losing control of her environment and being at her baby's beck and call. She cannot shower or eat whenever she pleases, let alone clean the house or make other plans. She feels cooped up in the house with a newborn; she may also feel unattractive with extra maternity pounds. She may feel less sexual interest, so her relationship with her husband may be more tense. Hormones, the new baby, and exhaustion are the typical causes of distress. Getting out, sharing with other women, and exercising are simple solutions. Time and good communication can help iron out these problems.

Baby Blues-

An estimated 80% of women experience temporary moodiness, with crying, sadness, irritability and frustration.1 Depression and fits of crying are interspersed with periods of serenity and pleasure. Individual sensitivity to the hormonal changes (rather than measurable differences in the bloodstream) causes some women and not others to get the baby blues. Spirits are uplifted by a good rest or getting out. These feelings usually resolve themselves by the second or third week after birth, at the latest. Sometimes, some forms of intervention, such as talking to friends or taking extra nutritional supplements, are needed. Women with severe blues have a 25% risk of developing PPD in a later birth. 2

Postpartum Stress Syndrome-

Postpartum stress syndrome is an emotional reaction which falls between baby blues and postpartum depression. Also known as Adjustment Disorder; 20% of those women who have baby blues go on to experience postpartum stress syndrome. Postpartum stress syndrome lasts longer than three weeks. Unlike baby blues, in which feelings of sadness are interspersed with periods of happiness, postpartum stress syndrome is characterized by a sadness which seeps into a woman's pores and permeates her life.

Postpartum stress syndrome causes feelings of anxiety and self-doubt. She wants to be the perfect mother and wife, but at the same time she feels exhausted and overwhelmed. Women experiencing postpartum stress syndrom usually function fairly well and get through their day, though they feel awful inside. Although some women go on to develop clinical depression, most women find relief through the loving support of family and friends as they gradually adjust to their new baby routine. In most instances, reducing day-to-day hassles and lightening responsibilities enable the mother to nurture herself and rediscover her old self. 3

Postpartum Depression-

Postpartum depression can come on without warning. A woman does not have to suffer from baby blues or postpartum stress syndrome first. In fact, a woman can go through a normal childbirth and recover completely, when suddenly PPD strikes like a bolt of lightning.

Postpartum depression can come on without warning What does "depression" mean? Being depressed is an overused phrase, describing a passing period of sad or bad feelings. Conversely, clinical depression is defined as prolonged, intense, sad, empty feelings lasting two weeks or more. To be diagnosed with any major depressive disorder (not just PPD), an individual must experience depressed mood or anhedonia (the inability to experience pleasure) for two weeks, in addition to five or more of the following symptoms: excessive weight loss or gain, insomnia or excessive sleep, fatigue, feelings of worthlessness, difficulty concentrating, suicidal thoughts.4

PPD is a specific category of clinical depression. It usually emerges three to six months after childbirth, but can occur at any time up to a year. Sometimes symptoms appear around the time of weaning or the return of menses, both events being associated with major hormonal changes. Late onset of PPD may occur if psychosocial or environmental factors become more difficult to cope with. Classic symptoms of PPD include: crying, sadness, irritability, anger, lack of control, sleepiness, sleep disturbances, early morning wakefulness, reduction of sexual desire, anxiety, carbohydrate binging, weight gain, or weight loss due to lack of appetite. No one woman has all these symptoms. Fifteen percent of women who give birth suffer from PPD!5

PPD is considered a syndrome, not a disease. A disease, such as pneumonia, has a very specific cause; a syndrome, such as PPD, has multiple associated causes. Since the symptoms of PPD vary from woman to woman, the syndrome often goes undetected or misdiagnosed.

The diagnosis of PPD is further complicated by the fact that it may coincide with other psychological disorders. For example, two other disorders, panic disorder and obsessive-compulsive disorder (OCD) may be exacerbated by childbirth. Panic disorder, part of generalized anxiety disorder (GAD), manifests itself as a panic attack, with abrupt onset of difficulty breathing, palpitations, chest pain, dizziness and a panicky feeling of being "about to die." These may be triggered by an actual event or may arise spontaneously. Obsessive-compulsive disorder is defined as the presence of either obsessions (recurrent, persistent thoughts, images, impulses) or compulsions (repetitive, ritualized behaviors such as excessive hand washing, counting, checking) that are time-consuming and distressing, interfering with a person's functioning and relationships.6

To read a personal account of PPD, please click here.

Postpartum Psychosis

PPD is caused by multiple factors Although postpartum psychosis is fairly uncommon, with only one in one thousand women developing PPP within a few days after childbirth, it can dramatically affect everyone involved. Some new mothers suffering psychosis may have to be hospitalized for a short term or, even more rare, an unfortunate few who do not receive the right treatment in time may harm themselves or their child.

Extreme agitation and not connecting with reality are the first noticeable symptoms of PPP, along with weight loss, paranoia, and behavior that is uncharacteristic for that new mother. Often the initial symptoms may be picked up on the maternity floor. If she is already home, she needs immediate medical attention (in an emergency room) and an examination by a psychiatrist. Postpartum psychosis is triggered by the rapid hormonal changes occurring after childbirth; many such women go on to develop severe premenstrual syndrome (PMS). Both syndromes are linked with a woman's extreme sensitivity to hormonal changes.

Thus we see that a woman's moods can range dramatically after childbirth from normal exhaustion and tension all the way to postpartum psychosis.


Baby blues:

Occurrence: 80% of new mothers

Onset: Up until third week postpartum.

Signs: moodiness, weepiness, nervousness, sleeplessness.

Treatment: Resolves on its own, though increased communication with caring people and catching up on lost sleep helps.

Implications for the future: not an indication as to whether or not a woman will develop PPD.

Postpartum Stress Syndrome (Adjustment Disorder):

Occurrence: One in five new mothers

Onset: From birth until about 3 months postpartum.

Signs: anxiety, self-doubt, helplessness, frequent crying, frustration, irritability, negative feelings.

Treatment: Often considered a normal part of adjusting to parenthood; usually resolves on its own. Recovery is hastened when a woman nurtures herself and reduces her standards of performance and demands on herself during this time.

Implications for future: can pass or progress to full-blown depression.

Postpartum Depression:

Occurrence: 15 -20% of new moms

Onset: from 3 weeks postpartum to one year; average 3-6 months.

Signs: depression, frequent crying, difficulty concentrating, difficulty sleeping, lack of energy, reduced interest in marital relations, reduced appetite or binge eating (carbohydrate cravings), irritability, anger, yelling, feelings of lack of control and hopelessness.

Treatment: Treatments such as talk therapy, medication, natural remedies, vitamins

Implications for future: May recur with succeeding childbirths. Women should be aware that preventive therapies are needed.

Postpartum Psychosis:

Incidence: 1 in 1,000 new mothers

Occurrence: within the first 2 weeks postpartum

Signs: hearing voices or sounds no one else hears. Thoughts of hurting oneself or baby, no sleep in 48 hours, cannot care for baby or self, rapid weight loss without trying. Can't control thoughts, as if someone else were controlling her thoughts and actions.

Treatment: Hospitalization, medication.

Implications for future: Should be under joint psychiatric/obstetric care during next pregnancy and postpartum.

This article has been excerpted from the book Delivery from Darkness: A Jewish Guide to the Prevention and Treatment of Postpartum Depression by Rabbi Boruch Finkelstein; Michal Finkelstein RN, CNM; and Doreen Winter, MSW.