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This is a clinician-written, evidence-based summary aligned to the 2026 MLA Content Map. It is intended for medical students and junior doctors preparing for the UKMLA. Always cross-reference with NICE guidance, local protocols, and clinical judgement.
Key points
- Depressive episode in the first year postpartum (peak onset: 4–6 weeks). Affects ~10–15% of new mothers
- Distinguish from: baby blues (day 3–5, self-limiting, affects ~80%) and puerperal psychosis (rare, acute onset, psychiatric emergency)
- Screening: Edinburgh Postnatal Depression Scale (EPDS) — validated tool. Score ≥13 suggests significant depression
- Management follows NICE CG192: guided self-help or CBT for mild-moderate; SSRI (sertraline) + CBT for moderate-severe
- Sertraline is preferred SSRI in breastfeeding (minimal transfer to breast milk)
- Always assess: impact on mother-baby bonding, risk to mother and infant, safeguarding considerations
Overview
Postnatal depression (PND) is a major depressive episode occurring in the first year after childbirth, most commonly presenting at 4–6 weeks postpartum. It is distinct from the "baby blues" (a transient mood disturbance affecting up to 80% of women in the first 3–5 days, resolving spontaneously) and from puerperal psychosis (a rare but severe psychiatric emergency). PND presents with the core features of depression (low mood, anhedonia, reduced energy) alongside specific perinatal concerns: anxiety about the baby, guilt about being a "bad mother," difficulty bonding with the infant, intrusive thoughts about harming the baby (which cause distress rather than indicating actual risk), and disrupted mother-infant interaction. PND affects not only the mother but also infant development, attachment, and the partner relationship.
Epidemiology
Postnatal depression affects approximately 10–15% of women in the UK. It is the most common perinatal mental health complication. Risk factors include: previous depression or PND, antenatal depression or anxiety, poor social support, domestic violence, traumatic birth experience, neonatal complications, unplanned pregnancy, and significant life stressors. Partners can also develop postnatal depression (~5–10%). Fathers and non-birthing partners are increasingly recognised as being at risk. PND is frequently under-recognised due to normalisation ("she is just tired"), stigma, and fear of consequences (baby being taken away).
Clinical Features
Symptoms
Core depression: persistent low mood, tearfulness, anhedonia, fatigue (beyond normal postpartum tiredness)
Guilt: feeling like a bad mother, not coping, failing the baby
Anxiety: excessive worry about baby health, safety, or own ability to parent
Difficulty bonding with the baby — feeling detached, disconnected, or indifferent
Intrusive thoughts about harming the baby (ego-dystonic — cause distress, NOT intent)
Sleep disturbance (beyond that caused by infant feeding), appetite change
Social withdrawal, loss of interest in previously enjoyed activities
Suicidal ideation or thoughts of self-harm
Thoughts of harming the baby with intent or plan
Signs
Tearfulness, flat affect, low energy during consultation
Poor engagement with infant during observation
Self-neglect or neglect of infant care (in severe cases)
Investigations
First-line
EPDS (Edinburgh Postnatal Depression Scale)Validated 10-item screening tool. Score ≥13 suggests significant depression. Item 10 specifically asks about self-harm
Clinical assessmentPsychiatric history, current symptoms, impact on functioning and mother-baby relationship, risk assessment (to self and infant)
Whooley questionsQuick screening at routine contacts: "During the past month, have you been feeling down, depressed, or hopeless?" and "Have you lost interest in doing things?"
Second-line
BloodsTFTs (postpartum thyroiditis can mimic PND), FBC (anaemia)
Specialist
Specialist perinatal mental health assessmentIf severe depression, psychotic features, risk to mother or baby, or history of bipolar disorder/puerperal psychosis
1
Mild to moderate PND
- Facilitated self-help (CBT-based workbooks or online programmes)
- Structured psychological therapy: CBT or interpersonal therapy (IPT)
- Peer support, health visitor input, social support enhancement
- Listening visits by health visitors — NICE recommended
2
Moderate to severe PND
- SSRI: sertraline preferred in breastfeeding (minimal transfer to breast milk, good evidence base)
- Alternative SSRIs: paroxetine (also low breast milk transfer). Avoid fluoxetine if breastfeeding (longer half-life, higher transfer)
- Combine SSRI + psychological therapy (CBT or IPT) for best outcomes
- Discuss medication safety in breastfeeding openly — benefits of treatment usually outweigh small risks
3
Mother-baby relationship
- Assess and support mother-infant bonding — this is a core part of treatment
- Mother-baby therapy or video interaction guidance if bonding difficulties
- Avoid unnecessary mother-baby separation (maintain breastfeeding, skin-to-skin contact)
4
Severe or high-risk cases
- Refer to specialist perinatal mental health team
- If admission needed: Mother and Baby Unit (MBU) — keeps mother and baby together
- If psychotic features develop → consider puerperal psychosis (psychiatric emergency)
- Safeguarding assessment if risk to infant identified
Complications
- Maternal suicide: Leading cause of direct maternal death in the UK within the first year postpartum
- Impaired bonding: Disrupted mother-infant attachment with consequences for infant emotional and cognitive development
- Infant developmental delay: Maternal depression associated with delayed language, cognitive, and social development in infants
- Relationship breakdown: Strain on partner relationship, increased risk of partner depression
- Recurrence: ~50% risk of PND in subsequent pregnancies
UKMLA Exam Tips
- 1Baby blues (day 3–5, self-limiting) vs postnatal depression (persistent, >2 weeks, functional impairment) vs puerperal psychosis (acute, dramatic onset, psychiatric emergency)
- 2EPDS ≥13 = significant depression. Item 10 asks about self-harm — always review this
- 3Sertraline is preferred in breastfeeding. Avoid fluoxetine (long half-life, higher breast milk transfer)
- 4Intrusive thoughts about harming the baby are COMMON in PND and OCD — they cause distress and do NOT indicate actual risk
- 5Maternal suicide is the leading cause of direct maternal death in the UK in the first year postpartum
- 6Mother and Baby Units (MBUs): specialist inpatient units keeping mother and baby together — always preferred over general psychiatric ward
- 7Always screen for bipolar history before starting SSRI — risk of precipitating mania/puerperal psychosis
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