Why Postpartum Mental Illness Doesn’t Always Look Like Depression

Katie Crenshaw thought she knew all the warning signs of postpartum mental illness. After the births of her first two children, she recognized the crying spells, thoughts of self-harm, and the slow decline of her mental health, and was able to manage those symptoms. By her third child, the 40-year-old had spent years working in labor and delivery, trained as a doula, and built a career advocating for perinatal mental health.

Still, the crisis after her third child did not look, or arrive, how she expected. It didn’t arrive in the weeks following her son’s birth. It slowly crept up a year later, when he weaned from breastfeeding.

Instead of extreme sadness, Crenshaw felt indifferent, coupled with intrusive thoughts of suicide—a picture far from what most people assume when they think of postpartum depression: someone who can’t get out of bed, who can’t function, and who is barely holding on.

But that image misses the wide spectrum of postpartum mental illness that can emerge or worsen after birth, says Tiffany A. Moore Simas, the chair of obstetrics and gynecology at UMass Memorial Health.

“One of the biggest misconceptions is that all postpartum mental health conditions are synonymous with depression,” she says. “Depression has likely gotten the most attention per se, historically, but perinatal mental health includes all mental health conditions and not just depression.”

That mismatch can have serious consequences: When postpartum mental illness is expected to look like depression, symptoms that appear as anxiety, hypervigilance, mania, or detachment can go unrecognized or be dismissed as part of new motherhood. The broader term better captures the full range of what can happen: depression, anxiety, bipolar disorder, obsessive-compulsive disorder (OCD), panic, psychosis, and post-traumatic stress disorder (PTSD).

These illnesses can be particularly difficult to recognize when someone continues to function outwardly. “Like many other diseases in medicine, such as breast cancer, if you cannot see it, [that] doesn’t mean it isn’t there,” says Veerle Bergink, a reproductive psychiatrist at the Icahn School of Medicine at Mount Sinai. “You don’t want to bring your misery into every conversation.”

About one in eight women suffer from postpartum depression in the United States, according to the Centers for Disease Control and Prevention. But depression has become a catch-all term for psychological struggles after childbirth.

One condition easily obscured by the narrow focus on depression is childbirth-related PTSD. It can develop after a frightening or traumatic birth, causing a person to relive the experience, avoid reminders of it, or remain on high alert long after the delivery is over.  A 2017 review of the research, published in the Journal of Affective Disorders, found that about 4 percent of new mothers develop PTSD after birth. Among women in high-risk groups, the rate jumped to 18.5 percent.

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“Trauma history is common in women during pregnancy and postpartum,” says Samantha Meltzer-Brody, the executive dean at UNC School of Medicine. “Women with a history of trauma have a greater risk of postpartum PTSD. For that reason, it is important to have screening for trauma history during the perinatal period.”

But standard screening tools may not capture it. The Edinburgh Postnatal Depression Scale, for example, asks about symptoms including anhedonia, self-blame, sadness, fear, and hopelessness. It screens for depression, not trauma-specific symptoms such as flashbacks, avoidance, or hypervigilance.

A 2026 international survey of more than 11,000 women across 31 countries found that hyperarousal was the most common childbirth-related PTSD symptom cluster, while avoidance was the least common. Yet avoidance better distinguished participants who met the scale’s PTSD criteria: Nearly half of those above the study’s avoidance threshold met the criteria, compared with 3.5 percent of those at or below it.

Identifying the condition matters because PTSD and depression require individualized care. Some SSRIs can treat both depression and PTSD. But if a patient’s symptoms are understood only as depression, the trauma—and the need for trauma-focused treatment—may go unaddressed, according to Meltzer-Brody.

PTSD is not the only condition that can be missed. Bergink says clinicians must also be alert to bipolar disorder and postpartum psychosis, a rare but acute psychiatric emergency.

Postpartum psychosis and manic episodes show a more distinct spike after childbirth, Bergink says. Depression, anxiety, and PTSD, by contrast, are common at other points in a woman’s life too, she says, which makes a single postpartum peak harder to isolate.

Amanda Koenigsberg’s daughter was born 10 years ago by a scheduled C-section performed earlier than planned after her water broke. One moment stuck with her: nurses moving her between gurneys, a doctor calling down the hall not to let her walk. The exchange was over quickly, but it left her feeling like no one knew what was happening, as though she couldn’t trust the people caring for her.

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That night, when staff took her newborn for evaluation, something shifted. “My body and my brain were just on hypervigilance,” says Koenigsberg. For the next year, she was consumed by fears that something would happen to her daughter, and she compulsively logged every feeding, pumping session, and diaper change.

She never called it postpartum depression. To her, that meant the extreme cases she’d heard about in the news. She assumed what she felt was just new motherhood. It wasn’t until her daughter was 10 or 11 months old that a therapist diagnosed her with postpartum anxiety and perinatal OCD.

Even depression itself is broader than its name suggests. Meltzer-Brody, who was the academic principal investigator on the clinical trials that developed two drugs specifically for postpartum depression, says part of the confusion starts with the diagnostic criteria itself.

To meet the clinical definition of a major depressive episode, a person must experience at least five symptoms over two weeks. One of them must be either persistent sadness or anhedonia, the loss of joy or interest in things that once brought pleasure. Not necessarily both.

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“The term depression has been used to encompass what can be a wide range of symptoms,” she says. Those symptoms can include anxiety, anger, and irritability – experiences many people do not associate with the word “depression.”

The two drugs Meltzer-Brody studied offered a different approach. Unlike common antidepressants such as Zoloft and Prozac, which act on the serotonin system and can take weeks to work, brexanolone and zuranolone are neuroactive steroids that act on GABA-A receptors, part of the brain’s primary calming system.

The drugs have drawn attention to the role that reproductive hormones and related brain signaling may play in postpartum depression. Allopregnanolone rises during pregnancy and falls rapidly after delivery, and researchers believe some people may be especially sensitive to those fluctuations. But postpartum depression has many potential causes, and the drugs do not prove that a single hormonal shift triggers the condition.

Crenshaw’s crisis, however, emerged nearly a year after she gave birth. Bergink says her sudden suicidal thoughts and detachment did not resemble childbirth-related PTSD, which is tied to a traumatic birth or its aftermath. Instead, the timing led her to consider another hormonal transition: weaning.

The drop in prolactin and oxytocin, and the body’s return to its pre-pregnancy hormonal state, can trigger serious psychiatric symptoms in a subset of women who are especially sensitive to those shifts, a phenomenon she called almost entirely unstudied, Bergink says.

For now, experiences like Crenshaw’s remain difficult to explain and easy to overlook, especially when they emerge long after birth and bear little resemblance to what most people think of as postpartum depression.