Pregnancy After Postpartum Depression: Risk and a Plan

The short answer: Having had postpartum depression before raises the chance of it happening again, but it doesn't make it certain. What helps most is planning during pregnancy: telling your OB or midwife early, starting support before the baby comes, working through medication questions with your prescriber, and writing down who does what after the birth.

Two pink lines, and two feelings at once. Joy, real joy. And underneath it, a cold little voice: what if it happens again?

If you had postpartum depression or anxiety after your last baby, you probably remember it in your body. The 3 a.m. dread. The weeks you can't quite account for. And now you're pregnant again, or thinking about it, and nobody has told you how to hold the hope and the fear in the same hand.

Here's what I tell the moms who sit in my office with exactly this: having been through it once is the single most useful thing you bring to this pregnancy. You know what it looks like. You know what helped and what didn't. This time, we plan.

Will postpartum depression come back?

It might, and it might not. Both are real, and I'd rather give you the honest version than a comforting one.

The National Institute of Mental Health lists a personal or family history of depression among the factors that raise the risk of perinatal depression. One of the largest studies on this comes from Denmark, where Rasmussen and colleagues at Statens Serum Institut in Copenhagen followed more than 450,000 first-time mothers with no psychiatric history before their first baby through national health records (PLOS Medicine, 2017). Women who'd been treated for postpartum depression after their first baby were many times more likely to be treated again after their second than women who hadn't. Most of the women in that study who'd been treated once weren't treated again, but the difference in risk was large enough that a previous episode deserves a plan.

Hold that loosely, too. It comes from one country's health records, it only counts episodes that led to a prescription or hospital contact, and it leaves out women with any mental health history before their first pregnancy. It isn't your personal odds. What it does show clearly is that a previous episode is worth taking seriously, and that having it again is not a given.

Your own picture depends on things no study can see: what happened last time, what support you have now, how you're sleeping, what's going on in your life. That's the conversation worth having with your care team.

Say it early, and say all of it

Tell your OB or midwife at the first visit, even if last time was never formally diagnosed, even if you white-knuckled through it without treatment. Say when it started, how bad it got, what helped, and what made getting help hard. A history of postpartum depression is the strongest predictor of having it again, which is the reason your care team should have a plan in place before the baby comes, and the NIMH recommends exactly that.

If you're on medication now, loop in your prescriber before you change anything. The right answer about medication in pregnancy and breastfeeding is individual, and it's a conversation to have with your prescriber.

Talking to your OB, midwife, and prescriber

The American College of Obstetricians and Gynecologists recommends screening for depression and anxiety at the first prenatal visit, again later in pregnancy, and at postpartum visits. You don't have to wait for the questionnaire, though. Questions worth bringing:

• "Given my history, how often will you check in on my mood during pregnancy and after the birth?"
• "Who do I call between appointments if things start to change?"
• "Can you refer me to a therapist who works with pregnancy and postpartum?"
• "Who will make decisions with me about medication, and when should we talk about it?"
• "If I'm struggling after the birth, how quickly can I be seen?"

If saying this out loud feels hard, here's a script for talking to your OB/GYN about postpartum depression. It's fine to read it straight off your phone.

What prevention actually looks like

The U.S. Preventive Services Task Force recommends counseling for people at increased risk of perinatal depression, which includes you. In practice that means starting therapy during pregnancy, before symptoms, so that when the postpartum weeks arrive you already have a person, a plan, and a standing appointment. I'd much rather meet you at twenty weeks than at six weeks postpartum in crisis.

That 2019 recommendation is about prevention for people who aren't depressed right now. If you're already struggling in this pregnancy, that's not something to wait out until the baby comes. It's worth getting support now, and here's an overview of treatment options for depression during pregnancy.

No plan guarantees you won't get depressed again. A plan helps you catch it faster and keeps it from going as far. Last time, you may have gone months before anyone named it. This time it can be days.

The counseling approaches the Task Force reviewed were mainly cognitive behavioral therapy (CBT) and interpersonal therapy (IPT). For a fuller look at the evidence on prevention, I wrote about how to prevent postpartum depression and the plan I help moms build before baby.

The plan, concretely

Write this down before the third trimester ends, with real names and phone numbers.

• Who I call if my mood, anxiety, or sleep changes, and how fast they'll respond
• Follow-up: when my clinician will check in after the birth, without me having to initiate it
• Practical help: who owns dinner, who owns the older kid's bedtime or school run, who takes the baby so I can sleep a four-hour stretch
• Getting to appointments: childcare, transportation, whether video sessions work for me
• Medication: which prescriber I talk to, and what the plan is for pregnancy and breastfeeding
• The urgent list: what changes mean someone calls for help right away, and where my family takes me

Put it on your phone and share it with your partner and one other adult. The point is that the people around you can act on it when you can't.

A timeline for the plan

When	What to do
Trying to conceive, or as soon as you know	Talk to your prescriber before changing any medication. Decide who your therapist will be.
First prenatal visit	Tell your OB or midwife your full history. Ask how they'll check on your mood.
As early as you want; don't wait for a trimester	Start or restart therapy if you haven't already. If you're struggling now, start now. Have the "what's different this time" talk with your partner.
Third trimester	Finish the written plan. Line up help for the older child, meals, and nights. Share the plan.
First weeks after birth	Keep your standing appointment. Let your partner or support person check in using the plan.
Through the first year	Keep checking in. Symptoms don't always start right away, so the plan doesn't expire at six weeks.

Help with an older child is not optional

Second-time postpartum is harder in one specific way: there's a child who needs you at 6:30 a.m. no matter what kind of night it was. Assign the big kid's routines to someone else now, on paper, so you're not negotiating it while leaking and sleepless. I wrote more about what postpartum depression looks like with a second baby if you want the fuller picture.

Your partner may be scared too

If your partner watched you go through it last time, they may be carrying their own worry about this pregnancy. That's worth saying out loud together, early. Partners do better with specifics: what you looked like when things started slipping, what helped, and exactly what you want them to do if they see it again. Their part of the plan should be written down too.

If you're still deciding about another baby

Some of you are reading this before there are two pink lines, trying to decide whether to try at all. That decision deserves its own time, and fear of last time is a legitimate part of it. Here's how I'd think through whether to have another baby when you're going back and forth.

Let's make the plan together

If you'd like help building this, a free 15-minute consultation is a good place to start; pregnancy is my favorite time to begin this work. If you've never been to therapy, here's what the first session is like. You can also read more about postpartum depression support, in person in North Austin or by virtual therapy in Texas and many other states through PSYPACT.

You don't have to be "bad enough" to benefit from support. Many of the moms I work with aren't clinically depressed at all. They're dealing with the everyday stress of becoming a mom, and therapy helps with that just as much as it helps with depression or anxiety.

If you can't keep yourself or your baby safe, call 911 or go to the nearest emergency room. Call or text 988 for crisis support.

For perinatal-specific support and help finding resources, the Postpartum Support International HelpLine (call or text 1-800-944-4773) and the National Maternal Mental Health Hotline (call or text 1-833-852-6262, 24/7) are both free.