Postpartum Depression Screening

Screening tools for postpartum depression and recommendations for responding to a positive screen
Mother with postpartum depression next to infant in crib
During the first year postpartum, up to 85% of new mothers experience some mood disturbance, and 10-15% will have more severe mood or anxiety symptoms. While depression is very common in the postpartum, the condition is likely to go unrecognized and untreated by the mother’s health care provider, who may see her less frequently than the pediatrician. [Silver: 2006] Because pediatricians are in a unique position to identify maternal postpartum mental health disorders, the American Academy of Pediatrics (AAP) recommends that routine screening for maternal postpartum depression be integrated into the 1-, 2-, 4-, and 6-month well-child visits. [Earls: 2019] While the pediatrician may not formally diagnose postpartum depression, it is important to be vigilant for it, screen routinely, and provide appropriate intervention and referral when encountered. [Earls: 2019]

Other Names

Caregiver depression screening
Maternal depression screening

Key Points

  • Provide crisis information:
    • Dial 988 to reach the 988 Suicide & Crisis Lifeline (formerly known as the National Suicide Prevention Lifeline) to call or chat with a crisis counselor. 24/7. The deaf and hard of hearing can contact the Lifeline via TTY using their preferred relay service or dialing 711, then 988. All calls are confidential.
  • The pediatric clinician’s role in recognizing and referring caregivers for psychiatric disorders is crucial. The American Academy of Pediatrics advises postpartum depression surveillance and screening at the 1-, 2-, 4-, and 6-month visits.
  • When there are concerns, facilitate outreach to the parent’s primary care or obstetric provider, mental health specialist, social worker, or support groups. Ensure there is a safety plan for care for the infant, such as with the other parent or a relative, if the caregiver is suicidal or has thoughts of harming the baby.

Practice Guidelines

Earls MF, Yogman MW, Mattson G, Rafferty J.
Incorporating Recognition and Management of Perinatal Depression Into Pediatric Practice.

Pediatrics. 2019;143(1). PubMed abstract [Earls: 2019]

Postpartum Psychiatric Illness

During an infant's early life, the mother is typically the child's primary source of emotional, cognitive, and social stimulation and interaction. Mothers with postpartum depression may provide their babies with less affection, be less responsive to their infant’s cues, and be more withdrawn, hostile, or irritable towards their infants and families. Associated childhood outcomes to babies whose mother’s experienced untreated or poorly treated depression include postnatal changes in reflexes, motor tone, orientation, and excitability on Brazelton scales, cognitive delays including lower global IQ and language delay, behavioral problems such as eating and sleep difficulties, temper tantrums, hyperactivity and ADHD, emotional and social dysregulation, as well as increased psychiatric morbidity in adolescence. [Burt: 2009] [Quevedo: 2012] [Hay: 2001] [Field: 2010] [Sellers: 2014] In addition, children of depressed mothers are at increased risk for physical abuse. [Cadzow: 1999] Note that while most research in this area is on mothers, similar effects may be seen due to any primary caregiver, regardless of gender or age.
Because evidence supports the connection between a healthy parental bond and children’s long-term mental health, the AAP encourages pediatricians to play an active role in screening for symptoms in mothers and identifying community resources for treatment and referral. [Earls: 2019]
This section briefly reviews 3 major types of postpartum psychiatric illnesses to help pediatricians recognize red flags in parents of new babies.

Postpartum Depression

Postpartum depression affects 1 in 8 mothers, and the incidence is greater for those with premature delivery, Cesarean sections, and other complications of birth. [Burt: 2009] According to the DSM-5, symptoms can begin during pregnancy or the first month postpartum; however, most experts in reproductive psychiatry believe symptoms beginning during the first 6-12 months postpartum should be included as well. [Segre: 2013] The Diagnostic and Statistical Manual of Mental Disorders (DSM-5) [American: 2013] criteria for diagnosing postpartum depression are the same as those for major depressive disorder but use a peripartum specifier. The Portal's Depression provides more details about diagnosis and treatment of depression.

Early Signs

Warning signs for postpartum depression may vary and include:
  • Depressed mood or irritability
  • Lack of enjoyment of usual activities
  • Changes in sleep patterns (insomnia or hypersomnia)
  • Worthlessness or guilt
  • Tearfulness
  • Self-doubt, often about her ability as a mother
  • Changes in weight or appetite
  • Avoidance of social interactions or responsibilities
  • Neglect or loss of interest in the newborn infant or other children
  • Fatigue or lack of energy
  • Changes in appetite
  • Poor concentration
  • Recurrent thoughts of suicide, death, or running away
  • Ruminations, or sometimes worries that she may harm the baby
  • Delusions or hallucinations
When postpartum depression is suspected in a caregiver, help explain that this is a common condition for which there is treatment and hope for recovery. Facilitate outreach to the parent’s primary care or obstetric provider, mental health specialist, social worker, support groups, etc. Ensure there is a safety plan for care of the infant, such as with the other parent or a relative, if the caregiver is suicidal or having thoughts of harming the baby.

Postpartum Anxiety

Postpartum anxiety can occur either in conjunction with depression or on its own. Like depression, it can range from mild to severe, often including OCD symptoms such as irrational and intense fears of contamination or harming the baby. While there is growing evidence to support the diagnosis and treatment of perinatal anxiety to avoid its impacts on the newborn and longer-term child development outcomes, there are currently no screening guidelines for pediatric providers. If a caregiver reports anxiety, you can help troubleshoot ideas to help, such as going for walks, mindful breathing exercises, or allowing others to feed or care for the infant so the affected parent can get needed rest. For more significant anxiety impairing the caregiver’s ability to care for self or infant, offer assistance with referrals to a psychiatrist and other mental health providers.

Postpartum Psychosis

New postpartum psychosis occurs in about 0.25-0.6 per 1000 births. The postpartum risk is about 23 times higher than at any other time in a woman’s life. [Perinatal: 2021] It usually begins with maternal symptoms of psychosis within the first 3-10 days postpartum. [Osborne: 2018] Increasingly, postpartum psychosis is thought to be more related to bipolar disorder than major depression. The biggest maternal risk factors include a history of bipolar illness or a previous episode of postpartum psychosis. Yet, a full understanding of its causes remains incomplete. Symptoms may include a rapidly changing mood, disorientation or confusion, and delusions and/or hallucinations. Infanticide and suicide rates increase significantly for this population; therefore, diagnosis and rapid treatment are imperative for safety of the mother and her family. [Perinatal: 2021]
Currently, the DSM-5 does not have a distinct category for this illness; it considers such episodes as a brief psychotic disorder or major mood disorder with psychotic features with a postpartum specifier. [Monzon: 2014] Help the caregiver contact social work, the parent’s primary care provider, and/or refer the parent to the emergency department for a crisis evaluation if you suspect there is new onset of psychosis. Ensure a safety plan is in place for the infant's care (such as being cared for by the other parent or a relative). Postpartum Disorders (MGH) provides further descriptions of the degrees of postpartum depression and related disorders.

Screens for Postpartum Depression

The American College of Obstetricians and Gynecologists recommends screening pregnant women for depression and anxiety at least once during the perinatal period by using a validated screening tool and providing a full assessment for mood and emotional well-being during their comprehensive postpartum visit. However, because not all mothers have close follow-ups with an obstetric provider, the pediatric clinician’s role in recognizing and referring for psychiatric disorders is crucial. As a result, the American Academy of Pediatrics advises postpartum depression surveillance and screening at the 1-, 2-, 4-, and 6-month visits.
A standardized and validated tool is recommended for screening for postpartum depression.

Edinburgh Postnatal Depression Scale - EPDS (English & Spanish)

Edinburgh Postnatal Depression Scale (English) (PDF Document 120 KB) or Edinburgh Postnatal Depression Scale (Spanish) (PDF Document 54 KB)
A validated, quick 10-question screening tool specifically developed for maternal depression to be used by care providers and includes scoring instructions - a score is calculated by adding the individual items. Free, may be printed without permission.

Patient Health Questionnaire Screeners (PHQ-9 & PHQ-2)

Patient Health Questionnaire (PHQ) Screeners
These free, well-known depression screens offer a 9-question and 2-question version, respectively, and can be used as brief caregiver depression screens.

The Survey of Well-Being of Young Children (SWYC)

The Survey of Well-Being of Young Children (SWYC)
This free tool integrates parental depression screening as part of its age-based screening instruments. The caregiver depression screening in SWYC is based on the PHQ-2. Additional topics addressed under “Family Questions” include caregiver substance use, food security, quality of spouse/partner relationship, and protective factors such as reading to the child. See SWYC: Family Questions for a sample used for ages 1 month through 5 years.

Response to a Positive Screen for Postpartum Depression

Upon positive screen:
  • Evaluate the infant for poor feeding, growth, behavioral issues, and developmental concerns.
  • Discuss the positive screen with the mother/primary caregiver to determine the severity of depression. The PHQ-9 can help rate the severity of the depression as well if additional tools are needed.
  • Refer the parent to a psychiatrist or experienced mental health provider for further assessment and evaluation.
  • With the parent’s consent, consider discussing the positive screen with the parent’s primary health provider. Often, the caregiver’s family doctor, obstetrician, midwife, internist, obstetrician, or psychiatrist may work with the parent to devise a medication management plan, if necessary.
  • If the parent or child’s immediate safety is at risk, refer to the nearest Emergency Room for a psychiatric evaluation. Do not leave the parent and baby alone.

Treatment of Postpartum Depression

Women who have moderate to severe postpartum depression or anxiety are often treated with selective serotonin reuptake inhibitors (SSRIs), such as sertraline (Zoloft) or paroxetine (Paxil), which have been shown least likely to result in detectable or elevated levels of active drug in breastmilk. Although significant complications to babies exposed to SSRI antidepressants or TCAs (tricyclic antidepressants) through breastmilk are very rare, adverse effects have been reported. They are more likely to occur in infants born prematurely or those with impaired metabolism. Mothers and pediatricians should be aware that worrisome behaviors, such as irritability and trouble sleeping or eating, may be side effects of medication exposure or withdrawal (in the early postnatal period). [Weissman: 2004] [Müller: 2013]
Other treatment modalities include increasing maternal sleep, improving maternal support, and talk therapy. Supplementing with formula may be recommended if breastfeeding becomes a large source of stress or cause of sleep deprivation for the new mother. See Postpartum Depression & Breastfeeding (healthychildren.org) for more information.

Services & Referral

Refer caregivers with suspected postpartum depression or anxiety to their primary care clinician, obstetrician, or midwife, or encourage them to follow up with existing mental health support systems they have in place:
For assistance with complicated diagnoses or medication management, refer to:

Coding for Postpartum Depression

ICD-10-CM

  • Z00.1*, Well-child check / Encounter for newborn, infant, and child health examinations, including routine developmental screening. Z00.1* health exam is always listed first as the primary reason for the visit.
    • Z00.129 , Well-child visits >28 days, without abnormal findings
    • Z00.121, Well-child visits >28 days, with abnormal findings
  • Z13.32, Encounter for screening for maternal depression (this can be coded in the mother’s chart but not the infant’s).

Current Procedural Terminology (CPT)

The following CPT code can be used to bill the baby's health insurance when screening the mother for maternal depression. Associate the CPT code with an appropriate ICD-10-CM code, often the Z00.12* well-child code.
  • 96161*, Administration of caregiver-focused health risk assessment instrument (e.g., depression inventory) for the benefit of the patient
CPT Code for Caregiver-Focused Assessment (AAP) provides further detail (login is required).

Resources

Information & Support

Related Portal Content
Depression
Assessment and management information for the primary care clinician caring for the child with depression.

Depression (FAQ)
Answers to questions frequently asked by families with a child diagnosed with depression.

Anxiety Disorders
Assessment and management information for the primary care clinician caring for the child with anxiety.

Anxiety Disorders (FAQ)
Answers to questions frequently asked by families with a child diagnosed with anxiety.

For Professionals

MCPAP for Moms Toolkit for Pediatric Providers
A perinatal psychiatrist provides real-time consultation via the telephone to clinicians. The consultation may involve diagnostic support, guidance for medication treatment (when indicated), psychotherapy and community support needs, treatment planning, and medication concerns regarding preconception, pregnancy, and lactation. A resource team works with providers in arranging outpatient mental health and/or substance use support for patients; Massachusetts Child Psychiatry Access Program.

Postpartum Support International’s Perinatal Psychiatric Consultation Line for Clinicians
A service provided at no cost to assist clinicians with questions related to diagnosis and treatment for patients by calling 1-800-944-4773, ext 4.

Maternal Depression Poster (PDF Document 90 KB)
Encourages new mothers to speak with their doctor if they answered "yes" to either of the 2 questions on this poster.

Postpartum Depression (ACOG)
Clinical information about postpartum depression screening, management, and patient education; American College of Obstetricians and Gynecologists.

For Parents and Patients

Support

Postpartum Support International
Support for women and their partners who are dealing with post-partum depression. Includes professional assessment tools and access to a volunteer network of local service providers and resources.

General

YoMingo (App)
An app that provides maternal mental health content for pregnant/postpartum women in the form of modules that teach skills for identifying and reducing the symptoms of depression and anxiety; free with registration from the University of Utah.

Postpartum Disorders (MGH)
General information about the various forms of postpartum depression; Massachusetts General Hospital.

Depression During & After Pregnancy: A Resource for Women, their Family, & Friends (HRSA) (PDF Document 20 KB)
Information for the woman and/or her family about the definition and symptoms of postpartum depression and when to seek treatment. Includes a perinatal depression booklet in English and Spanish; Department of Health & Human Services.

Postpartum Depression & Breastfeeding (healthychildren.org)
Discusses how postpartum depression affects the baby, when to seek help, how to preserve breastfeeding goals, and the effects of antidepressant medications and breastfeeding; from the American Academy of Pediatrics.

Tools

Edinburgh Postnatal Depression Scale (English) (PDF Document 120 KB)
A self-administered, 10-question, 5-minute screen for maternal depression with scoring instructions. Free, may be printed without permission.

Edinburgh Postnatal Depression Scale (Spanish) (PDF Document 54 KB)
A Spanish, self-administered, 10-question, 5-minute screen for maternal depression with scoring instructions. Free, may be printed without permission.

Services for Patients & Families Nationwide (NW)

For services not listed above, browse our Services categories or search our database.

* number of provider listings may vary by how states categorize services, whether providers are listed by organization or individual, how services are organized in the state, and other factors; Nationwide (NW) providers are generally limited to web-based services, provider locator services, and organizations that serve children from across the nation.

Studies

Maternal Depression (clinicaltrials.gov)
Studies looking at better understanding, diagnosing, and treating this condition; from the National Library of Medicine.

Helpful Articles

PubMed search for articles about postpartum depression within the last 5 years

O'Connor E, Rossom RC, Henninger M, Groom HC, Burda BU.
Primary Care Screening for and Treatment of Depression in Pregnant and Postpartum Women: Evidence Report and Systematic Review for the US Preventive Services Task Force.
JAMA. 2016;315(4):388-406. PubMed abstract

Murray L, Cooper P.
Effects of postnatal depression on infant development.
Arch Dis Child. 1997;77(2):99-101. PubMed abstract / Full Text
Discusses early maternal depression and adverse cognitive and emotional infant development.

Lesesne CA, Visser SN, White CP.
Attention-deficit/hyperactivity disorder in school-aged children: association with maternal mental health and use of health care resources.
Pediatrics. 2003;111(5 Pt 2):1232-7. PubMed abstract / Full Text
Investigates the association between the mental health status of mothers and attention-deficit/hyperactivity disorder (ADHD) in their school-aged children and characterizes the health care access and utilization of families affected by ADHD.

Onunaku, Ngozi.
Improving maternal and infant mental health: focus on maternal depression.
Zero to Three. 2005. / https://www.zerotothree.org/resource/improving-maternal-and-infant-men...
Discusses the impact of maternal depression on the social and emotional health of young children. Recommends specific steps that early childhood programs and public health administrators can take to address the unmet mental health needs of mothers. Ultimately promotes social and emotional health, school readiness, and the future functioning of very young children.

Authors & Reviewers

Initial publication: March 2014; last update/revision: November 2022
Current Authors and Reviewers:
Author: Jessica Lu, MD, MPH
Authoring history
2020: update: Jessica Lu, MD, MPHA
2018: update: Jessica Lu, MD, MPHA
2015: update: Jessica Lu, MD, MPHA
2014: first version: Jessica Lu, MD, MPHA
AAuthor; CAContributing Author; SASenior Author; RReviewer

Page Bibliography

American Psychiatric Association.
Diagnostic and Statistical Manual of Mental Disorders, DSM-5.
Fifth ed. Arlington, VA: American Psychiatric Association; 2013. 978-0-89042-554-1

Burt VK, Quezada V.
Mood disorders in women: focus on reproductive psychiatry in the 21st century--Motherisk update 2008.
Can J Clin Pharmacol. 2009;16(1):e6-e14. PubMed abstract
Review of the significant negative impact of maternal depression on maternal and child health and psychological well-being and other possible consequences of chronic depression.

Cadzow SP, Armstrong KL, Fraser JA.
Stressed parents with infants: reassessing physical abuse risk factors.
Child Abuse Negl. 1999;23(9):845-53. PubMed abstract / Full Text
Examines the relationship among potentially adverse psychosocial and demographic characteristics identified in the immediate postpartum period and child physical abuse potential at 7 months.

Earls MF, Yogman MW, Mattson G, Rafferty J.
Incorporating recognition and management of perinatal and postpartum depression into pediatric practice.
Pediatrics. 2019. PubMed abstract / Full Text

Field T, Diego M, Hernandez-Reif M.
Prenatal depression effects and interventions: a review.
Infant Behav Dev. 2010;33(4):409-18. PubMed abstract / Full Text
Research on the negative effects of prenatal depression and cortisol on fetal growth, prematurity, and low birth weight.

Hay DF, Pawlby S, Sharp D, Asten P, Mills A, Kumar R.
Intellectual problems shown by 11-year-old children whose mothers had postnatal depression.
J Child Psychol Psychiatry. 2001;42(7):871-89. PubMed abstract
Examines long-term sequelae in the children of mothers who were depressed at 3 months postpartum.

Monzon C. M.D., Lanza di Scales, T. MD, Pearlstein, T. MD.
Postpartum psychosis: updates and clinical issues.
Psychiatric Times; (2014) http://www.psychiatrictimes.com/special-reports/postpartum-psychosis-u.... Accessed on 4/28/2020.
In preparation for DSM-5, evidence of the onset of symptoms in postpartum disorders was examined. Study findings suggest that 50% of major depressive episodes that present postpartum actually began during pregnancy.

Müller MJ, Preuß C, Paul T, Streit F, Brandhorst G, Seeliger S.
Serotonergic overstimulation in a preterm infant after sertraline intake via breastmilk.
Breastfeed Med. 2013;8(3):327-9. PubMed abstract / Full Text
Case study of a preterm infant who was exposed to sertraline and its main metabolite desmethylsertraline in utero and via breastmilk.

Osborne LM.
Recognizing and Managing Postpartum Psychosis: A Clinical Guide for Obstetric Providers.
Obstet Gynecol Clin North Am. 2018;45(3):455-468. PubMed abstract / Full Text

Perinatal and Reproductive Psychiatry Program.
Essential Reads: Recognizing Postpartum Psychosis.
MGH Center for Women’s Mental Health; (2021) https://womensmentalhealth.org/posts/postpartum-psychosis-ten-things-n.... Accessed on Nov. 8, 2022.

Quevedo LA, Silva RA, Godoy R, Jansen K, Matos MB, Tavares Pinheiro KA, Pinheiro RT.
The impact of maternal post-partum depression on the language development of children at 12 months.
Child Care Health Dev. 2012;38(3):420-4. PubMed abstract / Full Text
Analyses the effect of the duration of the mother's depression on the language development of children at 12 months old.

Segre LS, Davis WN.
Postpartum depression and perinatal mood disorders in the DSM.
Postpartum Support International. 2013; https://www.postpartum.net/wp-content/uploads/2014/11/DSM-5-Summary-PS...

Sellers R, Harold GT, Elam K, Rhoades KA, Potter R, Mars B, Craddock N, Thapar A, Collishaw S.
Maternal depression and co-occurring antisocial behaviour: testing maternal hostility and warmth as mediators of risk for offspring psychopathology.
J Child Psychol Psychiatry. 2014;55(2):112-20. PubMed abstract / Full Text
Using a longitudinal study of offspring of mothers with recurrent depression, the study tests whether maternal warmth/hostility mediated links between maternal depression severity and child outcomes, and how far direct and indirect pathways were robust to controls for co-occurring maternal antisocial behaviour.

Silver EJ, Heneghan AM, Bauman LJ, Stein RE.
The relationship of depressive symptoms to parenting competence and social support in inner-city mothers of young children.
Matern Child Health J. 2006;10(1):105-12. PubMed abstract
Discusses how negative ratings of parenting competence, low perceived social support, and presence of health-related activity restrictions can be useful markers of likely depression among inner-city mothers of young children.

Weissman AM, Levy BT, Hartz AJ, Bentler S, Donohue M, Ellingrod VL, Wisner KL.
Pooled analysis of antidepressant levels in lactating mothers, breast milk, and nursing infants.
Am J Psychiatry. 2004;161(6):1066-78. PubMed abstract
Analysis of available data on antidepressant levels in nursing infants to calculate average infant drug levels and determine what factors influence plasma drug levels in breast-feeding infants of mothers treated with antidepressants.