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Patient handout

Postpartum depression — perinatal MDD (ACOG 757 2018/2024; USPSTF 2019; NICE NG192 2024; APA 2010 PPD; Meltzer-Brody 2018; Deligiannidis 2023)

PRODUCTION

1. Your condition

This handout is for postpartum depression — perinatal mdd (acog 757 2018/2024; uspstf 2019; nice ng192 2024; apa 2010 ppd; meltzer-brody 2018; deligiannidis 2023). Your care team identified this based on: depressed mood, anhedonia, fatigue, guilt, sleep / appetite disturbance, decreased concentration within 12 months postpartum (dsm-5-tr peripartum specifier; acog 757 2018/2024).

Other reasons your team may use this plan: epds ≥ 10 or ≥ 13 or phq-9 ≥ 10 at routine perinatal screening visit (acog 757 2018/2024; uspstf 2019 curry jama pmid 30747971; cox 1987 pmid 3651732; levis 2020 pmid 33208495); suicidal ideation, thoughts of self-harm, or thoughts of harming infant in postpartum patient — emergency c-ssrs + safety triage (posner 2011 pmid 22193671; trost mmwr 2022 pmid 35587456); prior ppd (~ 35–50% recurrence) or prior mdd (~ 25–30% recurrence) in pregnant or postpartum patient (wisner 2013 pmid 23446353; stewart nejm 2016 pmid 27959687).

2. Your medications

Take these medications exactly as prescribed. Do not stop or change a dose without talking to your provider.

MedicationStarting doseHowWhenWhat it does
cognitive behavioural therapy (CBT)12–16 weekly sessionsin_person_or_telehealthweeklyCBT first-line for mild-to-moderate PPD; Cuijpers meta-analyses + USPSTF 2019 B-grade recommendation; no infant exposure issue (USPSTF 2019 PMID 30747971; APA 2010 PPD; NICE NG192 2024)
interpersonal therapy (IPT)12–16 weekly sessionsin_person_or_telehealthweeklyIPT specifically designed for role-transition and interpersonal-conflict context — high resonance with perinatal life events; USPSTF 2019 B-grade (USPSTF 2019 PMID 30747971; APA 2010 PPD)

Plan: First-line PPD pharmacotherapy + psychotherapy for mild-to-moderate PPD (APA 2010 PPD; ACOG 757 2018/2024; USPSTF 2019 Curry JAMA PMID 30747971; NICE NG192 2024)

3. Your action plan

Use these zones to know what to do based on how you feel.

GREEN — Doing well — mood stabilising, EPDS / PHQ-9 trending down, bonding with infant, sleeping when opportunity (APA 2010 PPD; PSI 2024)
If you have:
  • Mood improving + functional capacity restored (APA 2010 PPD)
  • EPDS or PHQ-9 trending down on serial screening (Cox 1987; Kroenke 2001)
  • Bonding + engaging with infant (PSI 2024)
  • Taking SSRI as prescribed (APA 2010 PPD)
  • Attending psychotherapy sessions if referred (USPSTF 2019; APA 2010 PPD)
  • No suicidal thoughts on serial C-SSRS (Posner 2011)
  • Family supports engaged (PSI 2024)
  • Lethal-means restriction in place (VA/DoD 2019)
Do this:
  • Take SSRI every day at same time — do NOT stop without provider (APA 2010 PPD)
  • Continue psychotherapy as scheduled (USPSTF 2019)
  • Attend perinatal psychiatry + OB + pediatric appointments (APA 2010 PPD; ACOG 757 2018/2024; PSI 2024)
  • Prioritise sleep opportunities — partner / family help with overnight infant care (APA 2010 PPD)
  • Avoid alcohol + recreational drugs + new prescription stimulants without provider (SAMHSA TIP 51 2018)
  • Confirm lethal-means restriction stays in place (VA/DoD 2019)
  • Keep crisis lines accessible — 988 + 1-800-944-4773 (PSI) (SAMHSA TIP 50 2015; PSI 2024)
  • Engage partner / family in mother-infant bonding (PSI 2024)
  • Maintain mother-baby support group attendance (PSI 2024)
YELLOW — Warning — early signs of relapse or new symptoms (worsening mood, sleep < 4 h × 2 d, increasing anxiety, intrusive thoughts about infant) (APA 2010 PPD; NICE NG192 2024; PSI 2024)
If you have:
  • Worsening mood / increased crying / hopelessness (APA 2010 PPD)
  • Sleeping < 4 h/night × ≥ 2 d (Bergink 2012; APA 2010 PPD)
  • Increasing irritability or anxiety (APA 2010 PPD)
  • Intrusive thoughts about the infant (even without intent to act) — distinguishing PPD obsessions from psychotic command hallucinations (PSI 2024; Brockington 2004)
  • Missed medication doses (APA 2010 PPD)
  • Difficulty bonding with infant (PSI 2024)
  • Withdrawal from family or social supports (APA 2010 PPD)
  • Increased alcohol or substance use (SAMHSA TIP 51 2018)
Do this:
  • Use your personal early-warning-sign list + crisis plan IMMEDIATELY (NICE NG192 2024; PSI 2024)
  • Tell partner / trusted family AND your perinatal psychiatrist within 24 h (PSI 2024)
  • Prioritise sleep — partner to take infant overnight if needed (APA 2010 PPD)
  • Check medication adherence — resume immediately if missed; do NOT double dose (APA 2010 PPD)
  • Avoid major decisions, new commitments until reviewed (APA 2010 PPD)
  • Confirm someone safe is with you AND with infant (PSI 2024)
  • Reach out to mother-baby support group or PSI HelpLine 1-800-944-4773 (PSI 2024)
Call your provider if:
  • Sleep < 4 h × 2 consecutive nights (APA 2010 PPD)
  • Warning signs persist > 24–48 h despite self-management (NICE NG192 2024)
  • Return of any suicidal thoughts (Posner 2011; APA 2010 PPD)
  • Missed > 2 doses of medication (APA 2010 PPD)
  • Inability to sleep, eat, or care for self / infant (APA 2010 PPD; PSI 2024)
  • Partner / paternal PPD warning signs (Paulson 2010)
RED — Medical alert — active suicidal thoughts with plan or intent, thoughts of harming infant, emerging psychotic features, manic features on SSRI, severe functional collapse (ACOG 757 2018/2024; Trost MMWR 2022; APA 2010 PPD; STEP-BD Sachs 2007)
If you have:
  • Thoughts or urges to harm yourself OR your baby (Trost MMWR 2022 PMID 35587456; ACOG 757 2018/2024)
  • Suicide plan or intent or means (Posner 2011; Trost MMWR 2022)
  • Hearing voices, paranoia, grandiose beliefs not reality-based — possible postpartum psychosis (ACOG 757 2018/2024; DSM-5-TR)
  • Manic features on SSRI — decreased need for sleep + pressured speech + racing thoughts + grandiosity + risk-taking — STOP SSRI + call perinatal psych (STEP-BD Sachs 2007; APA 2024)
  • Severe functional collapse — unable to care for self or infant (APA 2010 PPD)
  • New severe insomnia + confusion + fluctuating cognition (NICE NG192 2024)
Do this:
  • Call 988 (US) / local crisis line / 911 NOW (SAMHSA TIP 50 2015)
  • Postpartum Support International HelpLine 1-800-944-4773 (text / call) (PSI 2024)
  • Go to nearest emergency department immediately; do NOT drive yourself if confused (APA 2010 PPD)
  • Make sure baby is with another safe caretaker BEFORE you go OR call 911 to coordinate (PSI 2024)
  • Hand any firearms, excess medications, car keys to a trusted person (VA/DoD 2019; APA 2010 PPD)
  • Activate your safety plan; bring medication list (Stanley-Brown 2012 PMID 22642958)
  • STOP your SSRI ONLY if you are having manic features AND call provider — do not stop SSRI for any other reason without provider (STEP-BD Sachs 2007)
Call your provider if:
  • Any red zone trigger — emergency department immediately (ACOG 757 2018/2024; Trost MMWR 2022)

4. When to seek emergency care

Call 911 or go to the nearest emergency room right away if you have:

  • Active suicidal ideation with plan / intent / means OR recent suicide attempt OR thoughts of harming infant in postpartum patient with depressive symptoms — life-threatening; suicide is a leading cause of maternal mortality through 1 year postpartum (Trost MMWR 2022 PMID 35587456; Posner 2011 PMID 22193671; ACOG 757 2018/2024)(life-threatening)
  • Hallucinations, delusions, or grossly disorganised thought / behaviour emerging in a postpartum patient with depressive symptoms — re-evaluate for postpartum psychosis; routes to psych.postpartum-psychosis.v1 (ACOG 757 2018/2024; APA 2010 PPD)(life-threatening)
  • EPDS ≥ 20 + functional impact + (adequate SSRI trial failed at 4–6 wk OR rapid relief needed OR severe presentation) — eligible for brexanolone IV 60-h infusion at REMS-accredited site OR zuranolone 50 mg PO daily × 14 days outpatient (Meltzer-Brody Lancet 2018 PMID 30253856; Deligiannidis AJP 2023 PMID 37467049; APA 2010 PPD)
  • Manic / hypomanic features (decreased need for sleep / pressured speech / racing thoughts / grandiosity / risk-taking) emerging on SSRI initiation OR positive MDQ at baseline (≥ 7) — DISCONTINUE SSRI + add mood stabiliser; routes to psych.bipolar-disorder.core.v1 (STEP-BD Sachs NEJM 2007 PMID 17392295; APA 2024; Hirschfeld AJP 2000 PMID 11058486)

5. Follow-up

Perinatal psychiatry Q2 wk × 12 wk then monthly × 12 mo postpartum; OB postpartum follow-up coordinated; pediatric coordination if breastfeeding on psychotropics (infant pediatrician dosed-in); mother-infant dyadic therapy if attachment disturbance; partner / paternal PPD referral if screening positive; SSRI maintenance ≥ 6–12 months after remission per APA 2010 PPD; preconception counselling for next pregnancy — recurrence ~ 35–50%; Caring Contacts cascade if prior SI episode (Motto 2001 PMID 11433109; Stanley/Brown 2018 PMID 30209345; APA 2010 PPD; PSI 2024)

6. Sources

Guideline: ACOG Committee Opinion 757 (2018, reaffirmed 2024) — Screening for Perinatal Depression + USPSTF 2019 (Curry JAMA PMID 30747971) — Interventions to Prevent Perinatal Depression + NICE NG192 (2014, last updated 2024) Antenatal and Postnatal Mental Health + APA Practice Guideline on Postpartum Depression (2010) + Postpartum Support International (PSI) Perinatal Mental Health Certification 2024

  1. pubmed.ncbi.nlm.nih.gov/30253856
  2. pubmed.ncbi.nlm.nih.gov/37467049
  3. pubmed.ncbi.nlm.nih.gov/3651732