Can you experience postpartum depression (PPD) during pregnancy?

Understanding Depression During Pregnancy vs. Postpartum Depression

No, you cannot technically have "postpartum depression" while pregnant—the term itself refers to depression after delivery—but you can absolutely experience depression during pregnancy that is now recognized under the broader diagnostic term "peripartum depression." 1

Terminology and Diagnostic Evolution

The DSM-5 fundamentally changed how we classify depression around childbirth by introducing the "peripartum specifier," which recognizes that depression can begin at any time during pregnancy or within the first four weeks postpartum. 1 This represents a critical shift from the older DSM-IV-TR definition that only applied the postpartum specifier to depression starting within four weeks after delivery. 1

Key Diagnostic Points:

• Depression during pregnancy is called "antenatal depression" or "prenatal depression"—not postpartum depression 2, 3
• The same diagnostic criteria for major depressive disorder apply whether symptoms occur during pregnancy or after delivery 1
• The peripartum specifier now encompasses the entire continuum from conception through four weeks postpartum 1

The Critical Reality: Most "Postpartum" Depression Actually Starts During Pregnancy

Among women who develop incident depressive symptoms in the perinatal period, 80% of cases actually begin during pregnancy, with one-third occurring in the first trimester. 4 This finding is crucial because it means:

• Nearly 10% of women enter pregnancy already experiencing depressive symptoms 4
• Prevalence increases to 16% by the third trimester 4
• About 20% of pregnant women experience antenatal depression 2
• Half of postpartum depression cases actually begin during pregnancy but are not diagnosed until after delivery 5

Why This Distinction Matters for Morbidity and Mortality

The failure to recognize and treat depression during pregnancy has severe consequences:

• Untreated antenatal depression significantly increases the risk of developing postpartum depression 2, 3
• Depression during pregnancy adversely affects birth outcomes and neonatal health 3
• Untreated depression can impair mother-infant attachment and cause cognitive, emotional, and behavioral consequences for children 3
• Effects on infant development can potentially last into adolescence 1

Clinical Screening Recommendations

The American College of Obstetricians and Gynecologists now recommends screening for perinatal depression and anxiety at the initial prenatal visit, later in pregnancy, and postpartum. 6, 5 This represents a shift toward universal screening rather than risk-factor-based screening alone. 2

Screening Implementation:

• Use the Edinburgh Postnatal Depression Scale (EPDS) during pregnancy—despite its name, it's validated for prenatal use with 95% sensitivity and 93% specificity 1, 3
• Screen at the first prenatal visit to identify women entering pregnancy with existing symptoms 4, 5
• Repeat screening throughout gestation, particularly in the third trimester when prevalence peaks 4
• Continue screening postpartum at routine visits 6, 5

Common Pitfall: Misattribution of Symptoms

Antenatal depression frequently goes undiagnosed because depressive symptoms are mistakenly attributed to normal physical and hormonal changes of pregnancy. 2 Healthcare providers may focus exclusively on maternal and fetal physical well-being while missing psychiatric symptoms. 2

Red Flags That Should Not Be Dismissed as "Normal Pregnancy":

• Persistent depressed mood or loss of interest/pleasure lasting at least two weeks 1
• Significant functional impairment 1
• History of mood or anxiety disorder (the strongest risk factor) 7
• Lack of partner support, marital difficulties, or family violence 2
• Unplanned pregnancy or ambivalence toward the pregnancy 2

Treatment Considerations During Pregnancy

Women diagnosed with major depression during pregnancy require close monitoring for up to one year after delivery. 3 Treatment approach depends on severity:

• Mild-to-moderate illness: Refer for psychotherapy as first-line treatment 3
• Severe illness: Consider antidepressants in addition to psychotherapy 3
• For breastfeeding mothers postpartum: Sertraline and paroxetine transfer to breast milk in lower concentrations than other antidepressants 6
• Risk of treatment with antidepressants must be weighed against risk of untreated depression for each patient 3

The evidence is clear: what we traditionally call "postpartum depression" is often a continuation of depression that began during pregnancy, making early prenatal screening and intervention essential for preventing adverse maternal and infant outcomes.