Is This Normal Postpartum… or Is It Anxiety or Depression?
By Savannah Patel, MD | Reproductive Psychiatry
After having a baby, almost everything feels a little different. You may cry more easily. You may feel overwhelmed by things that normally would not bother you. You may worry about whether the baby is eating enough, sleeping enough, breathing normally, gaining enough weight…the list can feel endless.
You are also recovering physically, functioning on less sleep, adjusting to a completely different daily rhythm, and experiencing one of the most dramatic hormonal shifts the body goes through.
So it is completely reasonable to wonder:
Is this just normal postpartum stuff? Or… Is this postpartum depression or anxiety?
Unfortunately, it’s not always clear, which is one reason clinicians use validated screening tools during pregnancy and postpartum. Two of the tools I find helpful to understand are the Edinburgh Postnatal Depression Scale (EPDS) and the Perinatal Anxiety Screening Scale (PASS).
These questionnaires do not diagnose depression or anxiety, but they can help us recognize when it may be time to look a little closer.
First: What Actually Counts as “Normal” Postpartum?
The range of normal emotional experiences after having a baby is HUGE. The baby blues are incredibly common…during the first days after delivery, women may feel tearful, irritable, anxious, emotionally sensitive, exhausted, or overwhelmed. These symptoms are generally mild and improve within about two weeks.
Postpartum depression is different. Symptoms tend to be more persistent or severe and can interfere with daily functioning, relationships, sleep, bonding, or the ability to care for yourself.
But sometimes the distinction is more subtle.
Consider sleep.
Normal postpartum: You cannot sleep because your baby is waking up every two hours.
More concerning: Someone else has the baby, you desperately need sleep, but you are lying awake because your mind will not stop racing.
Or worry.
Normal postpartum:You check that your newborn is breathing before you go to bed.
More concerning: You repeatedly check throughout the night, cannot leave the baby with another trusted adult, or feel consumed by the possibility that something terrible will happen.
Or emotion.
Normal postpartum: You cry after a particularly exhausting day.
More concerning: You feel persistently hopeless, guilty, numb, disconnected, or unable to enjoy anything.
What matters is not whether you have any anxiety, sadness, fatigue, or overwhelm. Those things can be part of new motherhood.
What matters more is how intense the symptoms are, how long they last, how much distress they cause, and whether they interfere with your ability to function.
That is where screening tools can be helpful.
The EPDS: A Screen for Perinatal Depression
The Edinburgh Postnatal Depression Scale, usually called the EPDS, is one of the most widely used screening tools for depression during pregnancy and postpartum.
Despite the word postnatal in its name, clinicians use it during pregnancy too.
It contains 10 questions asking how you have been feeling over the previous seven days.
One thing I like about the EPDS is that it focuses primarily on emotional and cognitive symptoms rather than relying heavily on things such as fatigue, appetite changes, and sleep disruption, which matters during pregnancy and postpartum because those symptoms can occur even when someone is psychologically doing quite well.
The EPDS asks about areas including:
your ability to laugh and enjoy things
whether you are looking forward to things
unnecessary self-blame
anxiety and worry
feeling frightened or panicky
feeling overwhelmed
difficulty sleeping because you are unhappy
sadness or misery
crying
thoughts of harming yourself
Each response is scored from 0 to 3, giving a maximum score of 30. But the most important thing to understand is this: An EPDS score is not a diagnosis.
It is a signal that tells us whether a more detailed conversation may be warranted.
What Does an EPDS Score Actually Mean?
There is no single magical number at which someone suddenly “has postpartum depression.” Different clinical settings use different cutoffs depending on whether the priority is catching as many possible cases as possible or reducing the number of false-positive screens.
A large BMJ meta-analysis pooled individual data from more than 15,000 pregnant and postpartum women and compared EPDS scores with formal diagnostic interviews. The researchers found that an EPDS score of 11 or higher provided the best overall balance between sensitivity and specificity. At that cutoff, sensitivity was about 81%. That means that among 100 women who truly had major depression, the screen would identify approximately 81 of them. Specificity was about 88%. That means that among 100 women who did not have major depression, approximately 88 would correctly screen negative.
The questionnaire tells us: We should ask more questions.
It does not tell us: Here is your diagnosis.
And one particular EPDS question always deserves attention regardless of the total score: the item asking about thoughts of self-harm. Any positive response should prompt further clinical assessment rather than simply being folded into the overall score.
But What About Anxiety?
This is an important part of the conversation because the postpartum mental-health discussion sometimes focuses so heavily on postpartum depression that women do not recognize anxiety as something worth treating.
And postpartum anxiety does not always look like someone saying:
“I feel anxious.”
It might sound more like:
“I can't stop researching whether this is normal.”
“Everyone tells me the baby is fine, but I still feel like something is wrong.”
“I don't trust anyone else to take care of her.”
“I'm exhausted, but my brain will not shut off.”
“I keep getting horrible images of something happening to the baby.”
“I feel like everything has to be done exactly right.”
“I constantly need reassurance that we're okay.”
Some degree of vigilance is expected when you suddenly become responsible for a tiny, completely dependent human being. But when worry becomes consuming, difficult to control, repetitive, or interferes with sleep and daily life, it deserves attention.
The PASS: A Screen Designed Specifically for Perinatal Anxiety
The Perinatal Anxiety Screening Scale, or PASS, was developed specifically for anxiety during pregnancy and postpartum. It contains 31 questions and was intentionally designed to capture a broader range of anxiety symptoms than many traditional anxiety questionnaires.
The PASS looks at symptoms across four general areas:
Acute anxiety and adjustment: Things like panic, feeling overwhelmed, feeling keyed up, and difficulty relaxing.
General worry and specific fears: Persistent worry, racing thoughts, fears about pregnancy or the baby, and difficulty controlling anxious thoughts.
Perfectionism, control, and trauma-related symptoms: Repeated checking, difficulty letting go of control, intrusive thoughts, perfectionistic tendencies, and feeling unusually watchful or on guard.
Social anxiety: Worry about embarrassment, criticism, judgment, or social situations.
That breadth is part of what makes the PASS interesting in reproductive psychiatry. It was designed around the fact that anxiety in pregnancy and postpartum does not always present like textbook generalized anxiety disorder.
What Does a PASS Score Mean?
Each PASS question is rated from 0 to 3, giving a possible total score from 0 to 93. In the original validation study, a cutoff of 26 was identified as the optimal threshold for detecting women with an anxiety disorder. At that cutoff, the PASS identified approximately 68% of women who had a diagnosed anxiety disorder. Its reported sensitivity was around 70% in that initial sample. However, specificity was much lower—around 30%. That means the PASS was reasonably good at picking up women who might need further evaluation, but a positive screen certainly did not mean that everyone above the cutoff actually had an anxiety disorder. And this is one area where I would be especially careful about oversimplifying the evidence.
Later studies in different countries and populations have found better diagnostic performance. For example, an Italian validation study using the same cutoff identified approximately 97% of women with an anxiety disorder.
So unlike the EPDS, where we have a very large meta-analysis providing fairly robust estimates, the PASS literature is smaller and its sensitivity and specificity vary by population.
That does not make it a bad tool.
It simply reinforces what it was designed to be: a screening questionnaire—not a diagnostic interview.
Why Not Just Use the EPDS for Anxiety Too?
The EPDS does contain several anxiety-related questions, but it was primarily developed as a depression screen.
In the original PASS validation study, the PASS identified about 68% of women with diagnosed anxiety disorders, compared with only 36% identified by the anxiety portion of the EPDS.
That is one reason a broader anxiety assessment may be useful when a woman's main complaint is worry, panic, intrusive thoughts, checking, perfectionism, or an inability to mentally “switch off.”
ACOG does not mandate one specific anxiety questionnaire; its own toolkit commonly includes the GAD-7. What matters most is that a validated instrument is used and that a positive result actually leads to further evaluation rather than simply becoming another number in the medical record.
Think of a Screen Like a Smoke Detector
This is probably the easiest way to understand both of these questionnaires.
A smoke detector cannot tell you exactly what is burning. It cannot tell you whether there is toast burning in the kitchen or a major fire in another room. But when the alarm goes off, you do not ignore it. You look closer.
The EPDS and PASS work similarly.
They do not tell us: “You have postpartum depression.” “You have generalized anxiety disorder.” “You have OCD.” “You need medication.” Instead, they tell us: Something here deserves a closer look. Sometimes that closer look leads to reassurance. Sometimes it leads to psychotherapy. Sometimes medication may be appropriate.
And sometimes symptoms that initially look like depression or anxiety lead us to evaluate for something else entirely—such as bipolar disorder, OCD, trauma, thyroid dysfunction, anemia, severe sleep deprivation, or another medical or psychiatric condition.
The screen starts the conversation. The clinical evaluation provides the diagnosis.
“But Of Course I'm Anxious. I Just Had a Baby.”
Yes. You probably should care whether your baby is okay. The goal of reproductive psychiatry is not to pathologize normal motherhood. So instead of asking simply: “Am I anxious?”
I think these questions are often more useful:
Can I turn the worry off?
Can I sleep when I actually have the opportunity to sleep?
Can someone I trust care for the baby without my anxiety becoming overwhelming?
Am I still able to experience joy?
Are my worries proportional to what is actually happening?
Do I repeatedly check, Google, seek reassurance, or avoid things because of fear?
Do I feel like myself—even a tired and overwhelmed version of myself—or do I feel fundamentally different?
And perhaps most importantly:
Is this making motherhood harder than it needs to be?
You do not need to score above a particular number before you are allowed to ask for help.
So… Should You Take One of These Screens?
If you have been wondering whether what you are feeling is simply “normal postpartum” or something more, a validated questionnaire can be a useful starting point. But please do not treat the result like a pregnancy test.
A low score does not mean that symptoms causing significant distress should be ignored. A high score does not automatically mean you have a psychiatric diagnosis. Instead, think of the result as another piece of information.
If your answers concern you—or the people who know you well are noticing that you are struggling—it is worth discussing with your OB/GYN, primary care clinician, therapist, or reproductive psychiatrist. You do not have to wait until you are barely functioning.
This article is intended for educational purposes and is not a substitute for individualized medical or psychiatric evaluation. If you are experiencing thoughts of suicide, believe you may harm yourself or someone else, or are experiencing hallucinations, delusions, severe confusion, paranoia, or loss of contact with reality, seek urgent medical care.
References
Levis B, et al. Accuracy of the Edinburgh Postnatal Depression Scale (EPDS) for screening to detect major depression among pregnant and postpartum women: systematic review and meta-analysis of individual participant data. BMJ. 2020;371:m4022. BMJ
Somerville S, et al. The Perinatal Anxiety Screening Scale: development and preliminary validation. Archives of Women's Mental Health. 2014;17:443-454. PubMed
American College of Obstetricians and Gynecologists. Screening and Diagnosis of Mental Health Conditions During Pregnancy and Postpartum. Clinical Practice Guideline No. 4. ACOG
