Synopsis
Recognise depression across the first postnatal year, distinguish transient emotional change from severe illness and psychosis, assess parent and infant safety, and deliver timely psychological, social and medication support.
- Postnatal depression may begin during pregnancy, soon after birth or later in the first year; asking only at the six-to-eight-week check misses cases.
- Baby blues are common and usually resolve within two weeks; persistence, worsening or substantial impairment warrants assessment for depression.
- Look for low mood, loss of pleasure, guilt, hopelessness, anxiety, irritability, impaired concentration, sleep difficulty despite opportunity and difficulty feeling connected to the baby.
- Ask about suicide, self-harm, thoughts involving the infant, psychosis, mania, substances, domestic abuse, support and the practical capacity to provide care.
- Unwanted, distressing, resisted intrusive harm thoughts can occur without intent; explore them carefully instead of either dismissing them or assuming dangerousness.
- Use facilitated self-help for persistent subthreshold or mild-to-moderate symptoms and consider high-intensity therapy, antidepressant treatment or combination care for moderate or severe depression.
- Treat feeding as a shared decision: discuss maternal benefit, infant exposure, consequences of switching and the effect of night feeding on recovery and sleep.
- Sertraline or paroxetine are preferred SSRIs during breastfeeding for a full-term healthy infant when a new choice is required, but do not switch an effective SSRI solely for breastfeeding in that setting.
- Review the parent-infant relationship through interaction, emotional availability and practical care, offering dyadic help without blaming the parent.
- Create an explicit safety and follow-up plan that includes the partner or chosen supporter with consent and names out-of-hours contacts.
Key red flags
A specific suicide plan, recent attempt, violent command hallucination or expressed intention to harm the infant requires immediate emergency action.
New elation, reduced need for sleep, grandiosity, paranoia, perplexity or rapidly fluctuating behaviour after birth suggests postpartum psychosis or mania, not routine depression.
Inability to feed oneself or the baby, severe dehydration, near-total insomnia or loss of basic care indicates severe illness and urgent need.
Fever, severe headache, seizure, focal neurology, heavy bleeding, chest pain, breathlessness or collapse needs simultaneous physical and obstetric emergency assessment.
Bruising, controlling behaviour, fear of going home, unsafe sleeping conditions or concerns about another caregiver require safeguarding and domestic-abuse pathways.
Investigation priorities
Define depressive symptoms, anxiety, intrusive experiences, psychosis, mania, cognition, sleep opportunity, function and treatment history.
Management branches
Low mood, anxiety, difficulty coping or bonding concern emerges during the first year after birth.
- Characterise symptoms, timing, birth experience, sleep opportunity, physical recovery, support, feeding and functional change.
- Ask directly about suicide, self-harm, thoughts about the infant, mania, psychosis, substances, abuse and who can keep parent and baby safe.
- Use emergency assessment for acute risk or possible postpartum psychosis; otherwise agree diagnosis, treatment setting and rapid access if symptoms escalate.
An antidepressant is preferred, previously effective or clinically needed during breastfeeding.
- Review prior response, current medicine, infant gestation and health, feeding pattern, interactions and the consequences of switching or stopping.
- When initiating an SSRI for a full-term healthy breastfed infant, consider sertraline or paroxetine as SPS-preferred options; retain an effective existing SSRI when appropriate.
- Monitor maternal activation and suicidality plus infant feeding, alertness, gastrointestinal symptoms and weight, escalating concerns rather than abandoning treatment without review.