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Woman with depression sitting on a bench outside

When postpartum depression shows up late

Woman with depression sitting on a bench outside3

September 8, 2020

By Nicole Arzt, LMFT

Many people, including healthcare professionals, mistakenly believe that postpartum depression only emerges in the immediate weeks after birth. However, this isn't true. Symptoms of postpartum depression can begin several months after having your baby.

It’s important to understand the symptoms of postpartum depression. Treatment is available, and it’s crucial to learn about how to access appropriate care.

What’s the difference between postpartum depression and depression?

Depression can happen at any time in someone’s life. To meet the criteria for a major depressive episode, you must have most of the following symptoms nearly every day for at least two weeks:

  • Persistent sadness or feelings of emptiness
  • Feelings of hopelessness or helplessness
  • Lack of energy
  • Concentration problems
  • Lack of interest in usual activities or relationships
  • Feeling restless
  • Problems with sleep
  • Poor appetite (overeating or not eating much at all)
  • Bodily aches and pains that don’t have a medical explanation
  • Recurrent thoughts of suicide

The Diagnostic and Statistical Manual of Mental Disorders (DSM V) now recognizes major depressive disorder with peripartum onset, which is commonly referred to as postpartum or perinatal depression. To meet the criteria for this diagnosis, mothers must have major depression symptoms that occur within four weeks of delivery. The ICD-10 criteria, which is another diagnostic tool for mental health providers, extended this window of time to six weeks.

However, some mental health experts argue that these short timelines may be inappropriate. That’s because many women don’t experience (or identify) having symptoms for several months after giving birth. According to Postpartum Support International, symptoms of postpartum depression and other perinatal mood and anxiety disorders can develop up to a year after childbirth.

Related: 7 Postpartum Depression Myths Debunked

When do symptoms of postpartum depression usually start?

Timelines for onset can vary dramatically among women. Prenatal depression can first start during pregnancy. One study found that 11.5% of mothers experienced symptoms before delivery. The majority (66.5%) first experienced symptoms within 6 weeks postpartum, and the remaining 22% first experienced symptoms after the typical 6-week postpartum check-up. Of the “late onset” group, the average onset was around 3 months postpartum.

Unfortunately, it’s challenging to obtain accurate data on postpartum depression statistics. Women face many barriers to receiving adequate care. These barriers include:

  • The stigma of acknowledging difficult feelings
  • Concerns about being judged or misunderstood
  • Fear of losing their child
  • Lack of childcare
  • Lack of time
  • Financial constraints

As a result, health experts postulate that many cases are undetected and undertreated.

Who should you talk to if you think you have postpartum depression?

If you think you have postpartum depression, most people will tell you to talk to someone. But who should that someone be?

Ob-gyn or Primary Care Physician for PPD?

Outside of pregnancy and postpartum, your first call regarding mental health should be your primary care physician. They can help you with diagnosis and ruling out medical causes.

During pregnancy, your ob-gyn basically takes over your PCP’s role and becomes your go-to contact. Generally, your care is transitioned back to your PCP after the 6-week check-up, and your ob-gyn goes back to caring for your gynecological needs.

The lines can be blurry at any point, but it can be particularly confusing who to go to during the weeks and months after your postpartum check-up. This is especially true when you suspect your concerns might be related to pregnancy or childbirth, like late-onset postpartum depression.

There is no wrong answer in this case—either your ob-gyn or PCP should be able to diagnose postpartum depression and help you get treatment. Your PCP may be more likely to diagnose it as depression and your ob-gyn might classify it as late-onset postpartum depression. Your ob-gyn may be more likely than your PCP to refer you to a specialist. But ultimately, you can choose whomever you’re more comfortable talking about it with.

Related: How to get help for perinatal mental health

What does it mean to get referred to a psychologist or psychiatrist?

If your doctor suspects you have depression or anxiety, they will often give you appropriate mental health referrals. You can request in-network referrals, or you can opt to see a professional privately.

Psychologists can provide postpartum therapy and help you cope with your depression. Some psychiatrists also offer therapy, but most of them focus on prescribing medication. Some women meet with both a psychologist and psychiatrist as part of their overall care.

Research shows that psychotherapy and antidepressant medication are both effective options in treating postpartum depression. Therapy offers a safe place to explore your feelings and learn healthy coping skills for managing your symptoms. Medication can help with emotional stabilization. While some ob-gyns and primary care physicians feel comfortable prescribing medication for postpartum depression, many prefer to let a specialist manage this aspect of your care.

Related: What you should know about therapy for perinatal mental health

What if they tell you it’s not postpartum depression?

If you reach out to a health professional several months after giving birth, they might diagnose you with depression, not postpartum depression. This is usually because the practitioner is abiding by the standard 4-6 week post-birth timeline.

It’s crucial to be thorough in sharing your mental health history. This information can assist your provider with proper diagnosing. It can also help with developing the best treatment plan for your care.

It’s also essential to advocate for your needs. If you feel dismissed by a health provider, you are not obligated to continue working with them. Find someone who you feel safe and comfortable with. If you are looking for someone who is trained and certified in perinatal mental health, look for PMH-C. However, if a specialist isn’t available, or you have connected with a therapist without this specialty, you can take comfort in knowing that the recommendations for treating postpartum depression are the same as for depression.

Related: How to advocate for yourself after pregnancy and birth

Final thoughts

Postpartum depression can feel frightening and confusing for mothers. You may not recognize or develop symptoms until several months after your baby is born. That doesn’t make your experience any less valid. If you’re struggling, make sure to reach out for help. You deserve to be healthy and supported during this time.


Nicole Arzt is a Licensed Marriage & Family Therapist with nearly a decade of experience treating women's issues related to parenting and family dynamics, complex trauma, and substance use disorders. She is the proud mama of her newborn son.

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