Postpartum depression: Doctors explain why a mother can look fine and still be struggling

Dr. Pretty Duggar Gupta, Consultant - Psychiatrist, Aster Whitefield Hospital

Postpartum depression does not always look like sadness. Experts explain the signs, risk factors, postpartum psychosis and how families can help new mothers.

Amother can be feeding her baby, finishing household chores, greeting relatives and even smiling for photographs, while privately struggling to get through the day. That is one of the most difficult things about postpartum mental health problems: distress does not always look like distress.

The issue has come into sharp focus after a Bengaluru incident in which a mother allegedly killed her four-month-old twin daughters and later attempted suicide. Police are investigating the circumstances surrounding the deaths and the woman's mental state. It would be premature to attribute the incident to postpartum depression or any other psychiatric condition without a medical assessment.

But the tragedy does raise an important question- what can postpartum depression actually look like, and can a mother appear completely fine while struggling severely? According to psychiatrists and obstetricians, the answer is yes.

Can a mother have postpartum depression and still look fine?

Yes. And that is precisely what can make the condition difficult for families to recognise. “Depression after childbirth does not always mean having a visibly unhappy woman,” said Dr Pretty Duggar Gupta, Consultant Psychiatrist at Aster Whitefield Hospital.

A new mother may continue performing her usual responsibilities, caring for her baby, managing domestic chores and interacting normally with people around her, while internally feeling emotionally numb, detached or as though she is simply moving through a routine.

“This is one of the reasons why family members do not notice what the mother is going through,” Dr Gupta said. The absence of obvious sadness, therefore, should not be taken as evidence that everything is fine.

Postpartum depression is not the same as the baby blues

Feeling exhausted, irritable, overwhelmed or emotional after having a baby is not automatically postpartum depression. Sleep deprivation and the enormous physical and emotional adjustment that comes with caring for a newborn can cause temporary mood changes. These are commonly referred to as the “baby blues” and generally settle within about two weeks. When symptoms are more severe, persist beyond that period or begin interfering with everyday functioning, postpartum depression may be involved.

“Fatigue, irritability, mood changes, and being overwhelmed may be normal, especially in the case of sleep deprivation associated with childcare,” Dr Gupta said.

The concern is when these feelings persist, intensify and become increasingly difficult to cope with.

What are the signs of postpartum depression?

Postpartum depression does not have one particular appearance.

A mother may experience persistent sadness or emotional numbness, lose interest in activities she previously enjoyed, feel excessive guilt or worthlessness, become unusually anxious or irritable, or experience significant changes in sleep and appetite.

She may also feel constantly overwhelmed, question her ability to care for her baby or struggle to form an emotional connection with the child. Difficulty bonding with a baby can be a symptom of postpartum depression and does not mean a mother lacks maternal instinct.

Dr Gupta said families should therefore look beyond whether a woman “looks depressed”. Instead of asking, “Why are you stressed?” or telling her to “enjoy this period”, she suggested asking questions such as “How are you really coping?” and “What is the most difficult thing for you at the moment?”

What increases the risk of postpartum depression?

There is no single reason why one woman develops postpartum depression while another does not.

According to Dr Gaana Sreenivas, Consultant Obstetrician & Gynaecologist at Rainbow Children's Hospital, Bannerghatta, a previous history of depression, anxiety or postpartum depression can increase the risk.

Other factors can include a difficult childbirth, premature birth, complications involving the baby, breastfeeding difficulties, conflict between partners, financial stress, inadequate support at home and major changes within the family.

The WHO also notes that low social support, severe stress and other difficult circumstances can increase the risk of maternal mental health problems. Importantly, any woman can develop a mental health disorder during pregnancy or after childbirth. It is not restricted to women with a previous psychiatric history.

Why family support matters
“Postpartum depression is a medical condition, not a failure of a woman or the absence of motherly instinct,” said Dr Deepika Alva, Consultant Obstetrician and Gynaecologist at Motherhood Hospitals, HRBR Layout, Bengaluru.

Dr Alva pointed to practical assistance such as helping with night feeds, sharing household responsibilities and ensuring that the mother gets uninterrupted time to sleep and recover.

Dr Gupta similarly recommended sharing domestic tasks, giving the mother time to rest and accompanying her to a doctor when necessary.

When does postpartum depression become an emergency?

This is where families need to be particularly alert. If a new mother talks about death, suicide, self-harm or harming her baby, that should never be dismissed as an expression of frustration or simply exhaustion.

The National Institute of Mental Health lists thoughts of death, suicide or harming oneself or the baby among symptoms requiring medical attention. There is also another, much rarer condition that families need to know about- postpartum psychosis.

What is postpartum psychosis?
Postpartum psychosis is different from postpartum depression and is a psychiatric emergency. A woman experiencing it may become confused, paranoid or disconnected from reality. She may experience hallucinations, delusions, severe mood changes or unusual beliefs. Symptoms can emerge suddenly, often within the first two weeks after childbirth.

Unlike ordinary worries or intrusive thoughts, psychosis can affect a person's ability to understand what is real. It is rare, but potentially life-threatening. The WHO notes that severe maternal mental illness can carry a risk of self-harm or suicide, while psychotic illnesses can, in some cases, also result in harm to a newborn.

The American Psychiatric Association advises seeking emergency medical attention if a new parent talks about suicide or harming a baby, or appears confused, paranoid, disconnected from reality or is experiencing hallucinations.

Does having frightening thoughts mean a mother will act on them?

Not necessarily. Unwanted, intrusive thoughts about something bad happening to a baby can occur in the postpartum period. Having such a thought is not the same as intending to act on it.

But these thoughts should still be discussed with a healthcare professional, particularly if they are persistent, distressing or accompanied by other concerning symptoms. The more worrying signs are thoughts accompanied by an intention to act, suicidal thinking, psychotic symptoms, severe confusion, paranoia or a loss of contact with reality.

By Dr. Pretty Duggar Gupta, Consultant - Psychiatrist, Aster Whitefield Hospital