Eduovisual
Pregnancy, Childbirth & Puerperium
Postpartum depression and anxiety: screening and treatment
— Postpartum depression (PPD): major depressive episode with onset during pregnancy or within 4 weeks postpartum per DSM-5 "peripartum onset" specifier, but clinically extended to 12 months postpartum
— Postpartum anxiety (PPA): GAD, panic disorder, OCD (often with intrusive thoughts of harming infant), or PTSD (often birth-trauma related); frequently coexists with PPD
— Postpartum blues: transient tearfulness/lability peaking days 3–5, resolving by 2 weeks; affects up to 80% of mothers — does not require treatment
— PPD prevalence ~10–15%; PPA ~10%; rates higher in adolescents, low-income patients, and pregnancy loss
— Leading cause of maternal mortality in the first postpartum year is suicide and overdose (CDC data)
— Symptoms persisting beyond 2 weeks postpartum
— Functional impairment: inability to care for self or infant, poor bonding, excessive guilt about parenting
— Somatic anxiety, intrusive thoughts of infant harm, hypervigilant checking of breathing
— Sleep disturbance disproportionate to infant's sleep pattern (mother cannot sleep even when infant sleeps)
— Prior history of depression/anxiety (strongest predictor) or prior PPD
— Personal or family bipolar disorder → screen carefully before starting SSRI
— Recent psychosocial stressors, intimate partner violence, unintended pregnancy
— NICU admission, preterm birth, stillbirth, traumatic delivery
— Limited social support, financial insecurity, lack of partner
— Thyroid dysfunction, anemia, vitamin D deficiency (modifiable)
Board pearl: A mother at her 6-week postpartum visit still tearful, anhedonic, and worried obsessively about infant feeding is not "baby blues" — this is PPD until proven otherwise. The 2-week duration cutoff is the single highest-yield distinguishing feature on Step 3 stems.
— Depressed mood, anhedonia, guilt (often "I'm a bad mother")
— Sleep: insomnia even when infant sleeps, or hypersomnia
— Appetite changes, low energy beyond expected fatigue
— Poor concentration, psychomotor changes
— Suicidal ideation — ask directly; also ask about thoughts of harming infant
— Generalized: excessive worry about infant illness, SIDS, feeding adequacy
— Panic: discrete episodes of palpitations, dyspnea, derealization — often mistaken for cardiac/PE
— Postpartum OCD: ego-dystonic intrusive thoughts of harming infant (e.g., dropping baby down stairs); mother is horrified, avoids being alone with infant — low risk of acting on thoughts
— PTSD: intrusive reexperiencing of traumatic delivery, avoidance of medical settings, hypervigilance
— Onset typically within first 2 weeks, rapid
— Delusions (often about infant), hallucinations, disorganization, waxing/waning sensorium
— Strongly associated with bipolar I disorder
— Infanticide risk ~4%, suicide risk ~5% — psychiatric emergency
— Onset, duration, prior psychiatric history, prior PPD/PPA
— Bipolar screen (MDQ): prior mania/hypomania, family history
— Substance use, including alcohol and cannabis
— Breastfeeding status (affects medication choice)
— Thyroid symptoms, postpartum hemorrhage (Sheehan), anemia
— Social: partner support, IPV screening, housing, finances
— Direct questions: "Have you had thoughts of harming yourself or the baby?"
Key distinction: Postpartum OCD intrusive harm thoughts = ego-dystonic, distressing, no plan or psychosis → outpatient SSRI + CBT. Postpartum psychosis harm thoughts = ego-syntonic, delusional, command hallucinations → immediate hospitalization, never leave alone with infant. Missing this distinction is a classic exam trap and a real-world tragedy.
— Affect, eye contact, grooming, psychomotor activity
— Mother–infant interaction: responsiveness to cues, bonding behaviors
— Weight trajectory (significant loss or failure to regain)
— Signs of self-neglect or poor hygiene
— Thyroid: goiter, tremor, tachycardia (postpartum thyroiditis hyperthyroid phase) or bradycardia, dry skin, delayed reflexes (hypothyroid phase)
— Anemia: pallor, tachycardia, conjunctival pallor — common after PPH
— Sheehan syndrome: failure of lactation, amenorrhea, hypotension, fatigue after severe PPH
— Cardiac: peripartum cardiomyopathy can mimic anxiety with dyspnea, palpitations — check JVP, S3, edema
— Pulmonary: rule out postpartum PE in any patient with new dyspnea/tachycardia
— Focal deficits suggest cerebral venous sinus thrombosis (postpartum risk)
— Headache + visual changes → postpartum preeclampsia (BP up to 6 weeks)
— Risk assessment grid: ideation, plan, intent, means, prior attempts
— Protective factors: reasons for living, social support, treatment engagement
— Infant safety: who else is in the home, access to safe sleep
— BP (postpartum hypertension up to 6 weeks)
— HR (tachycardia → anemia, thyroid, PE, anxiety)
— Weight trend
Step 3 management: At the routine 4–6 week postpartum visit, every patient gets a depression screen (EPDS or PHQ-9), BP check, and review of postpartum complications. If screen positive and new tachycardia or weight loss, order TSH, CBC, and consider hCG (retained products) before attributing symptoms to a psychiatric diagnosis. ACOG specifically warns against missing thyroiditis, which peaks 1–6 months postpartum and is highly treatable.
— Edinburgh Postnatal Depression Scale (EPDS): 10 items, validated postpartum and during pregnancy, includes anxiety items; score ≥10 = positive screen, ≥13 = probable major depression; item 10 screens self-harm
— PHQ-9: general MDD screen, score ≥10 = moderate depression; less sensitive for anxiety than EPDS
— GAD-7: for anxiety symptoms; ≥10 = moderate anxiety
— USPSTF (Grade B): screen all pregnant and postpartum persons for depression and anxiety; provide or refer to counseling for those at increased risk
— ACOG: screen at least once during pregnancy and at the comprehensive postpartum visit (now recommended within 12 weeks)
— AAP: pediatricians screen mothers at well-child visits at 1, 2, 4, and 6 months
— TSH (postpartum thyroiditis) — essential
— CBC (postpartum anemia, especially after PPH)
— Comprehensive metabolic panel if symptoms atypical
— Vitamin D, B12 if dietary concerns
— Urine toxicology if substance use suspected
— Urine hCG if symptoms suggest retained products or new pregnancy
— Record specific screening tool, score, and item-by-item review of suicidality
— Document a safety plan even for negative screens with risk factors
Board pearl: The EPDS is preferred postpartum because it omits somatic symptoms (sleep, appetite, fatigue) that overlap with normal postpartum physiology. A PHQ-9 may falsely elevate from sleep deprivation alone. If the stem mentions a postpartum screening tool, EPDS is the right answer; if asked about score thresholds, EPDS ≥10 triggers further evaluation, ≥13 is probable major depression, and any positive answer on item 10 mandates immediate suicide risk assessment regardless of total score.
— Full DSM-5 interview for MDD with peripartum onset specifier
— Anxiety disorder assessment: GAD, panic, OCD, PTSD criteria
— Bipolar screen mandatory before initiating SSRI — use MDQ (Mood Disorder Questionnaire)
— Past hypomania/mania, decreased need for sleep with high energy, family history
— Missing bipolarity → SSRI monotherapy can precipitate mania or postpartum psychosis
— Psychosis screen: any delusions, hallucinations, disorganization
— Alcohol use disorders identification test (AUDIT) or T-ACE
— Cannabis, opioid, stimulant assessment
— Coordinate with breastfeeding plan
— Columbia Suicide Severity Rating Scale (C-SSRS) for structured assessment
— Document ideation type, intent, plan, access to means (firearms in home — counsel removal)
— Birth trauma history → PTSD screening (PCL-5)
— Infant loss / NICU stay → complicated grief evaluation
— IPV screening with patient alone, partner not in room
— Generally not indicated for PPD/PPA
— Neuroimaging if new neurologic deficits, atypical psychosis features, or postpartum headache with red flags (rule out CVST, PRES, pituitary apoplexy)
Key distinction: Distinguishing unipolar PPD from bipolar depression is the single most consequential diagnostic step. Postpartum is the highest-risk period for first manifestation of bipolar disorder. Red flags: rapid-onset symptoms within first 2 weeks, prior episodes of decreased sleep with elevated mood, family history of bipolar I, prior antidepressant-induced activation, and psychotic features. Bipolar depression → mood stabilizer (lithium, lamotrigine) + psychiatric co-management, not SSRI monotherapy. Misclassification is a high-yield Step 3 question and a real-world malpractice scenario.
— Mild symptoms (EPDS 10–12, PHQ-9 5–9): psychotherapy alone is first-line; structured follow-up in 2 weeks
— Moderate symptoms (EPDS 13–19, PHQ-9 10–19): psychotherapy + SSRI; consider patient preference
— Severe symptoms (EPDS ≥20, PHQ-9 ≥20), suicidality, psychosis, or functional collapse: urgent psychiatric evaluation, consider hospitalization, pharmacotherapy mandatory
— Offer counseling-based interventions (CBT, interpersonal therapy) to pregnant and postpartum persons at increased risk for perinatal depression
— Risk markers: prior depression, current depressive symptoms, low income, adolescent, single, IPV history
— Cognitive behavioral therapy (CBT)
— Interpersonal therapy (IPT) — particularly studied in perinatal population, addresses role transitions
— Group therapy and peer support
— Telehealth delivery improves access
— Breastfeeding status (does NOT preclude SSRI)
— Prior treatment response (use what worked before)
— Side effect profile alignment with target symptoms
— Drug interactions, especially with medications used postpartum
— Sleep optimization — protected sleep periods, partner shares nighttime feedings
— Social work referral for tangible support
— Treatment of anemia, thyroid dysfunction, vitamin deficiencies
— Exercise, light exposure, contact with social network
Step 3 management: A postpartum mother at 8 weeks with EPDS 15, no suicidality, breastfeeding, no bipolar history → start sertraline 25–50 mg daily and refer for CBT or IPT. Schedule follow-up in 2 weeks to assess tolerability and again at 4–6 weeks for response. Do not "watch and wait" at this severity — undertreatment leads to chronicity, impaired infant attachment, and higher relapse risk in future pregnancies.
— Sertraline (preferred in breastfeeding): start 25–50 mg daily, titrate to 50–200 mg; lowest relative infant dose (~0.5–2%), undetectable in most infant serum
— Escitalopram: also acceptable in lactation, 10–20 mg daily; low infant exposure
— Paroxetine: acceptable in breastfeeding but avoid initiation during pregnancy (cardiac malformation signal); short half-life → discontinuation syndrome
— Fluoxetine: longer half-life and higher milk concentration → more infant exposure; preferred only if prior response
— Citalopram: QT prolongation at higher doses; less preferred
— Start low to minimize early activation/anxiety
— Expect partial response in 2–4 weeks, full response by 6–8 weeks
— Continue for at least 6–12 months after remission; longer if recurrent
— SNRIs (venlafaxine, duloxetine): acceptable in lactation; useful for comorbid pain
— Bupropion: less data in lactation, may reduce milk supply; avoid in anxiety-predominant or seizure risk
— Mirtazapine: helpful for insomnia and appetite; sedation
— Brexanolone (IV): neurosteroid GABA-A modulator; 60-hour infusion in REMS-certified facility; rapid onset; logistically limited
— Zuranolone (oral, FDA-approved 2023): 14-day oral course for PPD, rapid onset within days; CNS depressant cautions; not recommended during breastfeeding due to limited data
— SSRIs are first-line for postpartum anxiety as well
— Short-term benzodiazepines (lorazepam) only if severe; lowest dose, shortest duration; counsel about sedation and infant monitoring
Board pearl: Sertraline is the answer for first-line pharmacotherapy of PPD in a breastfeeding mother on Step 3 — highest evidence base, lowest infant exposure. Zuranolone is the high-yield new drug to recognize: oral, 14-day course, rapid antidepressant effect, FDA-approved specifically for PPD.
— CBT: identifies and restructures cognitive distortions ("I'm a terrible mother"), behavioral activation; 12–16 sessions
— IPT: focuses on role transition to motherhood, interpersonal disputes, grief; particularly strong evidence in perinatal populations
— Mindfulness-based cognitive therapy for relapse prevention
— Trauma-focused CBT or EMDR for birth-related PTSD
— Hospitalization mandatory
— Antipsychotic (olanzapine, quetiapine) + mood stabilizer (lithium)
— ECT highly effective and rapid — strong option, compatible with breastfeeding
— Never leave mother alone with infant until stabilized
— ECT — safe in pregnancy and postpartum, rapid response, life-saving for suicidality/psychosis
— Transcranial magnetic stimulation (TMS) — increasing evidence, non-systemic
— Ketamine/esketamine — emerging, limited postpartum data, lactation concerns
— Almost all psychotropics enter breast milk in small amounts
— Benefits of treatment + breastfeeding usually outweigh risks
— LactMed database is the authoritative reference
— Monitor infant for sedation, poor feeding, irritability
— SSRIs + tramadol/triptans → serotonin syndrome
— SSRIs + NSAIDs → increased bleeding (postpartum hemorrhage risk)
— SSRIs + tamoxifen (paroxetine, fluoxetine inhibit CYP2D6) — if hormone-sensitive cancer history
CCS pearl: For a CCS-style postpartum psychosis case, the orders are: admit to inpatient psychiatry, suicide and infant-safety precautions, CBC/CMP/TSH/urine tox, olanzapine + lithium (check renal function and pregnancy test), consult psychiatry, social work for infant safety planning, and lactation consult to discuss medication choice. Discharge only with confirmed outpatient psychiatry follow-up within 7 days and identified responsible adult to supervise mother-infant interactions.
— SSRIs predominantly hepatically metabolized
— Sertraline: reduce starting dose to 12.5–25 mg in moderate hepatic impairment; titrate slowly
— Escitalopram: max 10 mg in hepatic impairment
— Avoid duloxetine in chronic liver disease (hepatotoxicity)
— Monitor LFTs at baseline and periodically if pre-existing disease
— Most SSRIs require dose adjustment in severe CKD (GFR <30)
— Sertraline: preferred — minimal renal clearance, no dose adjustment needed
— Venlafaxine: dose reduce 25–50% if CrCl <50
— Lithium (for bipolar PPD/psychosis): highly renally cleared, requires careful monitoring, avoid in CKD if possible, watch in dehydrated postpartum patient
— Plasma volume normalizes by ~2 weeks postpartum
— Hepatic enzyme activity (CYP3A4, CYP2D6) returns to pre-pregnancy baseline by 4–8 weeks
— Mothers who took higher doses in pregnancy may need down-titration postpartum to avoid toxicity and supratherapeutic levels
— Pharmacokinetic clearance reductions begin >35–40 in some agents
— Higher rates of comorbidities (hypertension, diabetes) affect drug choice
— Polypharmacy review
— Hypothyroidism — replete levothyroxine, recheck TSH 6–8 weeks; treat thyroid before assuming SSRI failure
— Anemia — iron repletion can dramatically improve fatigue/mood
— Chronic pain → SNRI (duloxetine) addresses both
Board pearl: A patient stably treated with sertraline 150 mg through pregnancy who presents postpartum at 4 weeks with new tremor, GI upset, and insomnia may be supratherapeutic as pregnancy-induced enzyme induction reverses. Step 3 management: reduce dose, do not add another agent, and reassess in 2 weeks. Always check TSH first in any postpartum patient with worsening or atypical symptoms — postpartum thyroiditis is the great mimic.
— 2–3× higher rates of PPD
— Screen at every encounter; integrate with pediatric well-child visits
— Confidentiality protections vary by state — know local rules on minor consent for mental health treatment
— SSRIs require black box warning discussion about suicidality in <25, with structured follow-up at 1–2 weeks
— Markedly elevated PPD, PTSD, and complicated grief risk
— Distinguish grief from MDD: grief tends to come in waves, preserved self-esteem, sadness focused on loss; depression is pervasive with worthlessness
— Screen for at least 12 months post-loss
— Future pregnancy = high relapse window
— Up to 40% develop depressive symptoms
— Integrated NICU psychosocial support, peer mentoring
— Co-treat SUD and PPD; do not defer psychiatric treatment
— Buprenorphine/methadone compatible with breastfeeding
— Connect to home visiting and child welfare resources proactively
— Validated EPDS translations available
— Somatic presentation more common in some cultures
— Use professional interpreters, not family members
— Non-gestational parents also experience postpartum depression
— Screen all parents; affirm family structure
— Paternal PPD ~10%; screen partners
— Strong correlation with maternal PPD; treat both
— Higher rates due to isolation, trauma history, lack of family support
— Screen for prior trauma, IPV; connect to community resources
Step 3 management: At the 2-month well-child visit, screen mother with EPDS even if she is not your patient — AAP guidelines specifically endorse this. If positive, document, share with mother's primary care/OB with consent, ensure warm handoff to treatment, and continue to screen at 4 and 6 months. Pediatricians failing to screen is a common Step 3 quality-of-care vignette.
— Suicide: leading cause of maternal death in the first postpartum year in the US
— Substance use disorders, overdose
— Chronic recurrent MDD — untreated PPD progresses to chronic depression in ~50%
— Impaired self-care, missed postpartum medical follow-up
— Reduced breastfeeding duration
— Impaired mother–infant bonding and attachment
— Higher rates of insecure attachment patterns
— Cognitive and language delays at 18 months and beyond
— Behavioral and emotional problems in childhood
— Increased pediatric ED utilization
— Failure to thrive in severe cases
— Partner depression risk doubles when mother has PPD
— Marital discord, separation
— Effects on older siblings
— Infanticide ~4%
— Maternal suicide ~5%
— Highest risk period: first 4 weeks postpartum
— SSRI early activation → may transiently worsen anxiety, insomnia in first 2 weeks
— Serotonin syndrome with drug interactions
— Discontinuation syndrome (especially paroxetine, venlafaxine)
— Postpartum hemorrhage modestly increased with SSRIs near delivery
— Persistent pulmonary hypertension of newborn — small absolute risk with late-pregnancy SSRI use
— Benzodiazepine + opioid combinations → respiratory depression in mother and infant
— 50% recurrence risk in subsequent pregnancies
— Preconception planning essential
— Continuation of effective medication often safer than discontinuation
Board pearl: Untreated PPD is not a benign self-limited condition. Step 3 frequently tests the infant developmental consequences — children of mothers with untreated PPD have measurable cognitive and behavioral deficits at age 3–5. Treating mother is treating the child. This frames why "watchful waiting" is the wrong answer at moderate severity.
— Active suicidal ideation with plan or intent
— Homicidal ideation toward infant or others
— Postpartum psychosis (delusions, hallucinations, disorganization, command thoughts)
— Severe functional impairment with inability to care for self/infant
— Catatonia or severe psychomotor retardation
— Voluntary inpatient psychiatry preferred; mother–baby psychiatric units where available
— Involuntary commitment if criteria met (danger to self/others, grave disability) — know your state's statute
— Crisis stabilization unit or partial hospitalization for intermediate severity
— Mobile crisis team for in-home assessment
— Documented safety plan (signed)
— Removal of access to lethal means (firearms, stockpiled medications)
— Identified support person who will stay with patient
— Confirmed outpatient psychiatric follow-up within 7 days
— Crisis line numbers (988 Suicide & Crisis Lifeline) provided
— Infant safety plan — who supervises mother–infant interaction
— Psychiatry: all moderate-severe cases, treatment-resistant, bipolar, psychosis
— Social work: resource navigation, housing, IPV, child welfare
— Lactation: medication compatibility, pumping/feeding plan
— Pediatrics: infant monitoring, attachment intervention
— OB/Gyn: if within 6 weeks, evaluate medical postpartum complications
— If infant safety acutely threatened, CPS notification required
— Document concerns objectively; coordinate with social work
CCS pearl: For postpartum psychosis on CCS, the correct sequence is: immediate one-to-one observation, do not leave mother alone with infant, psychiatric admission, urine tox/TSH/CBC/CMP, antipsychotic + mood stabilizer, ECT consideration if life-threatening, social work for infant placement plan with trusted adult, and notification of pediatrician. Discharging home is always wrong in postpartum psychosis on the exam.
— Onset days 2–5, resolves by day 14
— Mild tearfulness, lability, mood reactivity preserved
— No functional impairment, no suicidality
— Treatment: reassurance, support, monitor for progression
— ≥2 weeks of symptoms, functional impairment
— Sad mood, anhedonia, guilt, suicidality possible
— Critical to distinguish — SSRI monotherapy can trigger mania
— History of hypomania, family history bipolar, rapid onset, atypical features
— Treatment: mood stabilizer, often lithium or quetiapine
— Rapid onset, usually <2 weeks postpartum
— Delusions, hallucinations, disorganization, waxing sensorium
— Strongly bipolar-spectrum
— Emergency hospitalization
— Excessive worry about infant health, daily activities
— ≥6 months of symptoms (may begin in pregnancy)
— Recurrent unexpected panic attacks, anticipatory anxiety
— Often misdiagnosed as PE, MI, asthma
— Intrusive harm thoughts about infant — ego-dystonic
— Compulsive checking (breathing, feeding)
— Distinguish from psychosis: insight preserved, distress is high
— Traumatic delivery, perceived life threat
— Intrusion, avoidance, hyperarousal, negative cognitions
— Trauma-focused CBT, EMDR
Key distinction: Postpartum OCD vs. postpartum psychosis harm thoughts. OCD: thought is "I'm horrified I might drop the baby" — patient avoids stairs, seeks reassurance, no plan, insight intact → outpatient SSRI + CBT. Psychosis: thought is "the baby is the devil and must be saved" — delusional, ego-syntonic, command hallucinations → emergency hospitalization. Conflating these is the most dangerous error in postpartum psychiatry and a perennial high-yield Step 3 distinction.
— Affects 5–10% of postpartum women, often within 1–6 months
— Classic course: transient hyperthyroidism (1–3 months) → hypothyroidism (3–8 months) → euthyroidism (often, but ~20% become permanently hypothyroid)
— Hyperthyroid phase: anxiety, palpitations, weight loss, tremor, insomnia
— Hypothyroid phase: fatigue, weight gain, low mood, cold intolerance
— Higher risk: TPO antibody positive, type 1 diabetes
— TSH is the screening test — order in any postpartum mood/anxiety presentation
— Especially after postpartum hemorrhage
— Fatigue, irritability, poor concentration
— CBC + ferritin; iron repletion
— Postpartum pituitary necrosis after severe PPH with hypotension
— Failure of lactation (earliest sign), amenorrhea, fatigue, hypotension
— Panhypopituitarism — check prolactin, TSH/free T4, ACTH/cortisol, LH/FSH
— Hormone replacement
— Pituitary inflammation, often peripartum
— Headache, visual changes, hypopituitarism
— Common in restrictive diets, vegan mothers
— Fatigue, low mood, cognitive complaints
— Dyspnea, fatigue, edema mimicking depression/anxiety
— Echo if any cardiac symptoms
— Postpartum hypercoagulable state
— New dyspnea, chest pain, headache with focal deficits → urgent imaging
— Opioids, alcohol, cannabis can mimic depression
— Hormonal contraceptives can affect mood
— Severe sleep loss mimics depression; address before diagnosing PPD
Step 3 management: Every postpartum mood/anxiety workup includes TSH, CBC, and a thoughtful review of postpartum complications. A mother at 4 months with anxiety, palpitations, weight loss, and tremor — the answer is postpartum thyroiditis hyperthyroid phase, treat with beta-blocker (propranolol, compatible with lactation), not an SSRI.
— First episode: continue effective dose for 6–12 months after remission
— Recurrent depression (≥2 episodes) or severe index episode: consider indefinite continuation
— Taper gradually over weeks; never abrupt stop (discontinuation syndrome)
— Maintenance psychotherapy (booster CBT/IPT sessions)
— Continued screening at well-woman visits
— Sleep hygiene, exercise, social support
— Identify and address modifiable stressors
— 50% recurrence risk in subsequent pregnancies
— Discuss medication continuation vs. switch in pregnancy planning
— Continuing effective antidepressant through pregnancy is often safer than discontinuation
— Sertraline preferred if changing agents
— Avoid paroxetine in first trimester
— Counsel about prophylactic restart at delivery if previous severe PPD
— Effective contraception is part of PPD management — unintended pregnancy increases relapse
— Progestin-only methods, IUDs preferred while breastfeeding
— Note: hormonal contraception can affect mood in some — monitor
— Exercise: 150 min/week moderate activity has antidepressant effect
— Sleep: protected 4–5 hour blocks
— Light exposure, social connection
— Limit alcohol
— Collaborative care models (PCP + psychiatrist + care manager) improve outcomes
— Warm handoffs from OB to primary care at 12-week visit
— Connect to home visiting programs (Healthy Start, Nurse-Family Partnership)
Board pearl: A patient with severe PPD requiring hospitalization in her first pregnancy who is now planning a second pregnancy should be counseled to continue or restart sertraline before or immediately after delivery for prophylaxis. Discontinuing during pregnancy is the wrong answer — relapse rates during pregnancy off medication exceed 60% in patients with recurrent MDD. Pregnancy itself is not protective against depression.
— Week 1–2: assess tolerability, suicidality, side effects (phone or visit)
— Week 4: assess early response, adjust dose
— Week 6–8: assess full response with repeat EPDS/PHQ-9
— Every 1–3 months during maintenance
— More frequent if suicidality, dose changes, or psychotherapy initiation
— Symptom scales: serial EPDS or PHQ-9 to track response objectively (target ≥50% reduction by 6–8 weeks)
— Functional measures: infant care, return to work, social engagement
— Suicidality: every visit
— Side effects: GI, sexual dysfunction, sleep, activation, weight
— Infant: monitor for sedation, poor feeding, growth — pediatric collaboration
— Labs: TSH at 3 and 6 months if thyroiditis suspected; lithium levels if on lithium
— Response: ≥50% symptom reduction
— Remission: PHQ-9 <5 or EPDS <10 with functional recovery
— Partial response: consider dose increase, augmentation
— No response by 6–8 weeks: switch agent or refer to psychiatry
— Optimize dose to maximum tolerated
— Switch SSRI or to SNRI
— Augmentation: bupropion, mirtazapine, atypical antipsychotic (with breastfeeding considerations)
— Refer for psychiatric consultation, consider ECT, TMS, zuranolone, brexanolone
— Share treatment plan with OB, primary care, and pediatrician (with consent)
— Coordinate with psychotherapist
— Group/peer support: Postpartum Support International, online resources
— FMLA, short-term disability when impairment significant
— Gradual return often helpful
Step 3 management: A patient on sertraline 100 mg for 8 weeks with EPDS 13 (started at 18) is a partial responder. Correct next step: increase sertraline to 150 mg (not switch agents), reassess in 4 weeks, ensure psychotherapy is actively engaged. Switching too early is a common wrong answer.
— Risk-benefit discussion: untreated PPD vs. medication risks
— Document discussion about lactation transfer, infant monitoring
— Black box warning on suicidality in <25 — explicit discussion required
— Patient autonomy: respect informed refusal, document, offer alternatives
— Mental health information is sensitive; default to patient consent before sharing with partner
— Exception: imminent danger to self or others
— Child abuse/neglect: if infant safety acutely threatened (e.g., mother with active psychosis and unsupervised access), CPS notification is required in all 50 states
— Intimate partner violence: varies by state; provide resources regardless
— Tarasoff duty to warn: if specific threats toward an identifiable person
— Criteria typically: danger to self, danger to others, or grave disability
— Know your state's statute (e.g., 5150 in CA, 9.39 in NY)
— Postpartum psychosis with infant safety risk often meets criteria
— Severe depression with hopelessness does not automatically equal incapacity
— Psychosis frequently impairs capacity for treatment decisions
— Document capacity assessment when refusing recommended treatment
— The 6-week postpartum visit is the highest-risk discharge point — many patients are lost to follow-up after this visit
— Warm handoff to primary care or psychiatry
— Document follow-up appointment before discharge
— Provide crisis numbers (988)
— Lower screening and treatment rates in Black and Latina mothers despite higher symptom burden
— Proactively address linguistic, cultural, insurance barriers
— Suicide risk assessment, safety plan, means restriction counseling
— Capacity, informed consent, lactation counseling
Board pearl (Step 3-specific): A mother with postpartum psychosis refuses inpatient admission. Correct action: emergency involuntary psychiatric hold under state statute because she poses danger to self and infant; this is not a violation of autonomy because acute psychosis impairs capacity. Simultaneously, infant safety planning with a non-affected family member or CPS referral is required if no safe caregiver is available. Discharging on her promise is never the right answer.
— Postpartum blues: days 3–5, resolves by day 14
— Postpartum psychosis: usually first 2 weeks
— Postpartum thyroiditis hyper phase: 1–3 months; hypo phase: 3–8 months
— DSM-5 peripartum onset specifier: during pregnancy or within 4 weeks postpartum; clinically up to 12 months
— EPDS: preferred postpartum, ≥10 positive, ≥13 probable MDD
— PHQ-9: general, ≥10 moderate
— GAD-7: anxiety, ≥10 moderate
— MDQ: bipolar screen before SSRI
— Sertraline = preferred SSRI in breastfeeding
— Paroxetine: avoid in pregnancy (cardiac defects), short half-life
— Zuranolone: oral 14-day course, FDA-approved specifically for PPD
— Brexanolone: 60-hour IV infusion, REMS
— Lithium: highly effective for bipolar/psychosis, monitor levels, renal function, thyroid
— ECT: safe and rapid in severe/psychotic PPD, compatible with breastfeeding
— Prior depression/PPD
— Family history bipolar
— Recent psychosocial stressors, IPV
— Pregnancy or infant loss
— Lack of partner support
— Suicide and overdose are leading causes of maternal death in the first postpartum year (CDC)
— USPSTF: Grade B screening; Grade B preventive counseling for at-risk
— ACOG: screen during pregnancy and at comprehensive postpartum visit
— AAP: maternal screening at well-child visits months 1, 2, 4, 6
— OCD harm thoughts: ego-dystonic, insight intact → outpatient SSRI
— Psychosis harm thoughts: ego-syntonic, delusional → emergency hospitalization
— Always check TSH and CBC
— Untreated PPD → impaired attachment, cognitive/behavioral delays
— Treating mother improves child outcomes
— ~10% prevalence, correlates with maternal PPD, screen partners
Board pearl: If the stem mentions a postpartum mother with onset of symptoms within 2 weeks plus any psychotic feature or extreme mood lability, the answer is postpartum psychosis and the disposition is immediate inpatient psychiatric hospitalization with infant safety planning — regardless of how reassuring her affect appears in the office. The waxing-waning sensorium is the dangerous part.
— Stem: postpartum mother with depressive symptoms; key data point is duration and functional impairment
— Symptoms <2 weeks, mild, no impairment → postpartum blues, reassurance
— Symptoms ≥2 weeks with functional impairment → PPD, screen and treat
— Stem: positive EPDS, breastfeeding, no bipolar history
— Answer: sertraline
— Distractors: paroxetine (acceptable but second-line), fluoxetine (higher infant exposure), bupropion (anxiety subtype, milk supply concerns)
— Stem: PPD-like presentation but rapid onset, prior episode of decreased sleep with elated mood, family history
— Answer: mood stabilizer/psychiatric referral, not SSRI monotherapy
— Stem: 10 days postpartum, mother says baby has "evil spirits," not sleeping, disorganized
— Answer: immediate psychiatric hospitalization, do not leave alone with infant
— Wrong answers: outpatient sertraline, reassurance, follow-up next week
— Stem: 3 months postpartum with anxiety, palpitations, weight loss, tremor
— Answer: check TSH → postpartum thyroiditis hyperthyroid phase, treat with propranolol
— Stem: mother distressed by intrusive thoughts of harming infant, recognizes them as unwanted, avoids being alone with baby
— Answer: postpartum OCD → SSRI + CBT, outpatient
— Stem: mother at 2-month well-child visit appears tearful
— Answer: administer EPDS, refer mother to her PCP/OB if positive
— Stem: prior severe PPD, planning next pregnancy
— Answer: continue or restart sertraline; do not discontinue prophylactically
— Stem: PPD with active suicidal ideation and plan
— Answer: emergency department / psychiatric hospitalization, not next-week outpatient follow-up
— Stem: 8 weeks of sertraline, partial response
— Answer: increase dose first, then switch or augment
Step 3 management: Recognize that Step 3 stems often hinge on disposition and follow-up cadence, not just the diagnosis. "Outpatient sertraline + CBT + 2-week follow-up" is correct for moderate PPD; "next available appointment in 6 weeks" is wrong; "no treatment, watchful waiting" is wrong; "hospitalization" is reserved for psychosis, severe suicidality, or grave disability.
Postpartum depression and anxiety are common, dangerous, and highly treatable — screen every pregnant and postpartum patient with EPDS, distinguish blues (≤2 weeks) from PPD (≥2 weeks with impairment) from postpartum psychosis (rapid-onset emergency), rule out thyroid and medical mimics, and treat moderate-to-severe disease with sertraline plus CBT/IPT while reserving hospitalization for psychosis or active suicidality.
Board pearl: The single most important Step 3 instinct in postpartum mental health is to never call something baby blues past two weeks, never miss postpartum psychosis in the first two weeks, never start an SSRI without screening for bipolar disorder, and never discharge a suicidal postpartum patient without a documented safety plan and a confirmed follow-up appointment within 7 days — these four habits prevent the highest-yield exam errors and the highest-stakes real-world tragedies.