Journal of Affective Disorders 113 (2009) 77 – 87

www.elsevier.com/locate/jad

Research report
Maternity blues as a predictor of DSM-IV depression and anxiety
disorders in the first three months postpartum
Corinna Reck⁎, Eva Stehle, Katja Reinig, Christoph Mundt
Department of General Psychiatry, University of Heidelberg, Germany
Received 9 November 2007; received in revised form 9 May 2008; accepted 11 May 2008
Available online 24 June 2008

Abstract

Background: Maternity blues have been described as a relevant risk factor for postpartum depression. Information regarding the
influence of maternity blues on the onset and course of clinical postpartum anxiety disorders is scarce. The goal of this study was to
determine whether maternity blues significantly predict postpartum depression and anxiety disorders in the first 3 months after
delivery in a German sample. Demographic, psychiatric, and obstetric correlates of maternity blues were also investigated.
Methods: Maternity blues were assessed 2 weeks after delivery in a community sample of 853 women using a telephone interview
and the Patient Health Questionnaire-Depression. Depression and anxiety disorders were diagnosed according to DSM-IV criteria
over the first 3 months following delivery. A two-stage screening procedure was applied. In a first stage, the Patient Health
Questionnaire-Depression, the Edinburgh Depression Scale, and two anxiety-screening instruments were employed. In the case of
clinically relevant scores, the Structured Clinical Interview for DSM-IV was administered in a second stage.
Results: The estimated prevalence rate of maternity blues among German women was 55.2%. We found a significant
association between maternity blues and postpartum depression (odds ratio: 3.8) and between maternity blues and anxiety
disorders (odds ratio = 3.9).
Limitations: Based on our predominantly middle class low-risk sample, maternity blues prevalence may be underestimated.
Retrospective assessment of maternity blues 2 weeks postpartum might lead to biased results.
Conclusions: Women with maternity blues should be carefully observed in the first weeks postpartum with the aim of identifying
those at risk of developing postpartum depression/anxiety disorders and providing treatment at an early stage of the disorder.
© 2008 Elsevier B.V. All rights reserved.

Keywords: Maternity blues; Postpartum depression; Anxiety disorder; Puerpartum

1. Introduction Disturbances in the mother–child relationship as well as

Depression and anxiety disorders are the most
frequently occurring mental illnesses in the postpartum
period (Cooper and Murray, 1998; Matthey et al., 2003).
⁎ Corresponding author. Klinik für Allgemeine Psychiatrie, Zentrum
für Psychosoziale Medizin, Voss-Str. 2, 69115 Heidelberg, Germany.
Tel.: +49 0 6221 564465; fax: +49 0 6221 561741.
E-mail address: corinna_reck@med.uni-heidelberg.de (C. Reck).
0165-0327/$ - see front matter © 2008 Elsevier B.V. All rights reserved.
doi:10.1016/j.jad.2008.05.003
emotional and cognitive deficits in infant development
have repeatedly been shown to be related to postpartum
depression (Diego et al., 2002; Cooper and Murray,
1997; Reck et al, 2004, 2006). The few findings
available in the area of anxiety disorders also indicate
an adverse influence of maternal anxiety disorders on
child development (Whaley et al., 1999; Woodruff-
Borden et al. 2002). The low rates of detection and
treatment of postpartum depression and anxiety
78 C. Reck et al. / Journal of Affective Disorders 113 (2009) 77–87
disorders represent an ongoing problem (Ballestrem
et al., 2005). In the early detection of women who may
potentially go on to develop clinically relevant symp-
toms in the postpartum period, the establishment of risk
factors assumes an important role. Links between
postpartum depression and maternity blues (MB) have
been repeatedly demonstrated. MB is a transitory
psychological disorder, characterized by mild depres-
sive symptoms, tearfulness, sorrow/weeping, unstable
moods, anxiety, and confusion (Newport et al., 2002).
Indeed MB has been shown to constitute a specific risk
factor for the occurrence of postpartum depression
(Fossey et al., 1997; Paykel et al., 1980; Lane et al.,
1997; Teissèdre and Chabrol, 2004; Crotty and Sheehan,
2004). Approximately 20% of women suffering from
MB are diagnosed as having major depression in the
first year following delivery (O’Hara et al., 1991;
Campbell et al., 1992). Anxiety has also been frequently
described as a common disorder in the puerperium
(Brockington et al., 2006; Matthey et al., 2003; Ross and
McLean, 2006) and as a feature of MB (e.g. Brock-
ington, 1996; Kennerly and Gath, 1989; Pitt, 1973;
Lanczik et al., 1992). To date, however, the relationship
between MB and postpartum anxiety disorders accord-
ing to DSM-IV has been subject to surprisingly little
investigation. With regard to the relationship between
MB and trait-anxiety, there is evidence to suggest that
symptoms of postpartum blues are related to high levels
of both trait (Ehlert et al., 1990) and state-anxiety
(Gonidakis et al., 2007). Ehlert et al. (1990) studied the
relationship between MB, several other psychological
variables, and salivary cortisol levels. Data analyses
revealed that symptoms of postpartum blues occurred
more frequently in women who reported passive coping
strategies, marital dissatisfaction, or acceptance of their
role as a mother. Affected women showed elevated
morning levels of cortisol on those days on which the
symptoms appeared as compared with both symptom-
free days and mothers without postpartum blues.
A standardized definition of MB has thus far not been
established. Diagnostic differentiation between postpar-
tum depression, maternity blues (MB), and postpartum
psychosis is, however, highly necessary. The exclusion of
symptoms such as sleep disturbances and exhaustion,
which are characteristic of the situation of the mother in
the period following delivery rather than psychopatholo-
gical symptoms, would appear crucial in diagnosing MB.
Despite the fact that MB is not an exclusively depressive
syndrome, a relevant subclinical level of depression
should be given. Accordingly, scales developed by Pitt
(1973) and Kennerly and Gath (1989) contain items
assessing depression. In this context it should, however,
be pointed out that in light of current research, diagnosing
MB exclusively on the basis of depression scales is to be
viewed critically. Using cluster analysis, Kennerly and
Gath (1989) were able to demonstrate that MB and
depression represent two distinct syndromes.
Reported frequencies range from 20 to 80% according
to the measurement instruments and diagnostic criteria
employed (Riecher-Roessler, 1997). In most studies, the
prevalence rate of MB varies between 40 and 60%
(Gonidakis et al., 2007; Hau and Levi, 2003; Nagata et al.,
2000) and usually manifests within the first week to
10 days after delivery (Pitt, 1973; O’Hara, 1987). The
duration varies from a few hours to a few days
(Brockington, 1996). In a sample of Hong Kong Chinese
women, Hau and Levy (2003) found a prevalence rate of
44.3% with a typical peak on the fifth postnatal day.
Cultural differences in prevalence rates have also been
reported. The lowest rate of 15.3% (e.g., Murata et al.,
1998) has been reported in Japan. Data in Germany is
scarcely available. A study carried out by Strobl (2002) in
Munich, Bavaria, revealed a prevalence rate of 42%,
while Lanczik et al. (1992) reported a lower rate of 28.5%.
As far as the present authors are aware, this is the very first
study to be published which assesses the relationship
between MB and depression/anxiety according to DSM-
IV criteria in Germany.
Most studies have failed to find any association between
MB and sociodemographic factors (O’Hara et al., 1991;
Nagata et al., 2000, Henshaw et al., 2004). In a study
carried out by Hau and Levy (2003), the only significant
variable was age, with women between 35 and 39 years of
age showing a significantly lower incidence of MB. With
respect to the duration of MB, they found that in the first
7 days postpartum, 62% experienced blues for 1 or 2 days,
25% for 3 to 4 days and 13% for 5 to 6 days. Contradictory
results have been reported concerning the relationship
between mode of delivery and MB symptoms (Gonidakis
et al., 2007; Henshaw et al., 2004). In a recent study,
Gonidakis et al., (2007) found that delivery by caesarean
section was significantly related to MB within the first
3 days after delivery. According to the results of Hannah et
al. (1992), caesarean section appears to have a longer
lasting influence on mood; this mode of delivery was found
to be associated with Edinburgh Postnatal Depression
Scale (EPDS) scores 6 weeks postpartum. In line with
these findings, Bergant et al. (1998a) showed a significant
relationship between dysphoric mood in the first 5 days
after delivery and delivery by caesarean section.
The present study was conducted using a prospec-
tive, longitudinal design to obtain representative data
from a German community sample with the aim of
examining the following primary hypotheses: (1) there
 C. Reck et al. / Journal of Affective Disorders 113 (2009) 77–87
is a positive relationship between occurrence of MB and
postpartum depression according to DSM-IV criteria,
(2) there is a positive relationship between the
occurrence of MB and a postpartum anxiety disorder
according to DSM-IV criteria. Furthermore the inci-
dence of MB was calculated in a representative German
community sample. In secondary analyses, the relation-
ship between the occurrence of MB and depression and
anxiety-screening scores (Edinburgh Postnatal Depres-
sion Scale and Anxiety Screening Questionnaire) was
assessed 2 and 6 weeks after delivery.
2. Method
2.1. Participants and study design
The study was carried out in south Germany in two
middle-sized towns and their surroundings. In the present
study, the total sample consisted of female in-patients
from six clinics in Heidelberg and Darmstadt who gave
birth between December 2003 and February 2005. The
sample was mainly middle class. Exclusion criteria for
participation in the study included poor command of the
spoken and written German language. On the first day
after delivery, women who had given birth were asked
whether they would be willing to participate in a
telephone interview screening procedure for depressive
and anxiety symptoms 2 weeks postpartum and were
subsequently examined. All women were asked to
complete the Edinburgh Postnatal Depression Scale
(EPDS) (Cox et al. 1987, German translation by Bergant
et al., 1998b) and the Anxiety Screening Questionnaire
(ASQ-15) (Wittchen and Boyer, 1998) 2 weeks post-
partum. Participants were requested to return completed
questionnaires to the study-team.
For the analysis of the prevalences of postpartum
depression and anxiety disorders in the first 3 months
postpartum, a telephone screening consisting of the Patient
Health Questionnaire-Depression (PHQ-D) (Loewe et al.,
2002, Graefe et al., 2004; Spitzer et al., 1999) and the
Anxiety-SCID-Screening (taken from the Structured
Clinical Interview for DSM-IV, Axis I Disorders (SCID-
I), Wittchen et al., 1997) was carried out. This telephone
screening was undertaken at six points in time; 2, 4, 6, 8,
10 and 12 weeks following delivery (results of the
prevalence study are to be published elsewhere, Reck
et al., 2008). Given clinically relevant scores, the
Structured Clinical Interview for DSM-IV (SCID)
(Wittchen et al., 1997) was administered.
The study protocol was approved by the independent
ethics committee of the University Medical Faculty,
Heidelberg. Patient confidentiality was in no way
79
breached. Written informed consent was obtained
following full explanation of the procedures involved.
2.2. Measures
a) The maternity blues (MB) questions formed part of the
telephone interview which took place 2 weeks after
delivery. Since MB symptoms are not included in
official diagnosis systems on account of their mild-
ness, the symptoms documented in numerous studies
and reviews (e.g., Brockington, 1996; Gonidakis et al.,
2007; Kennerley and Gath, 1989; Pitt, 1973) were
drawn upon as a basis for the description of MB. In a
first step, the interviewer described the symptoms and
typical course of MB. Participants were presented with
the following symptoms: tearfulness, sadness, exhaus-
tion, changeable mood, anxiousness, and irritableness.
The interviewer explained that these feelings are
commonly referred to as maternity blues and asked
participants whether they had experienced these
symptoms in the first 10 days after delivery. Women
were informed that they should only answer in the
affirmative given that they had experienced all of the
described symptoms on the same day for at least 1 day.
Following affirmative answers, a second question
followed in which women were asked to state whether
MB were still present at the time of the telephone
interview. At the onset of the study, the second
question was not included on account of the fact that
we did not consider MB to be typical 2 weeks
postpartum. Upon recognizing that some women were
still suffering from MB at the first time of assessment
without meeting criteria for a clinical depressive
disorder, this question was subsequently included.
The third question concerned how long MB had
persisted after delivery. The women were asked to be
as accurate as possible (hours–days) in retrospectively
recalling how long symptoms had lasted.
b) The internationally well-established EPDS is a self-
rating scale for the screening of postpartum depres-
sion. It was developed and validated specifically for
the postpartum period and assesses the mental state
over the past 7 days. According to the German EPDS
validation study conducted by Bergant et al. (1998b),
the cut-off value is set at 10 or more for a minor and
13 or more for a major depressive disorder. In the
current study, we adopted a cut-off score of 13 or
more. In order to avoid confusion, EPDS cut-off
scores were described according to the wording
recommended by Matthey et al. (2006).
c) The Anxiety Screening Questionnaire (ASQ-15) is a
self-report instrument which serves as a syndromal
80 C. Reck et al. / Journal of Affective Disorders 113 (2009) 77–87
screening tool for current anxiety disorders as well as
a diagnostic instrument for generalized anxiety
disorders. The ASQ was administered 2 and
6 weeks after delivery. The ASQ was positively
evaluated given that the presence of at least one of
the following symptoms was affirmed: (1) In the last
2 weeks, anxiety attacks with a sudden feeling of
intense anxiety, apprehension, or agitation; (2) In the
last few weeks, unfounded intense anxiety in social
situations; (3) In the last few weeks, unfounded
intense fear of using public transport, going into
stores, or being in public places; (4) In the last few
weeks, frequent after-effects or memories of an
unusually terrible or threatening event or situation;
(5) In the last few weeks, frequent strain caused by
worries, fears and feelings of tension.
d) The Structured Clinical Interview for DSM-IV, Axis I
Disorders (SCID-I) (Wittchen et al., 1997) is a semi-
structured, economical, efficient, and reliable instru-
ment for the measurement and diagnosis of selected
Axis I mental syndromes and disorders according to the
criteria of the Diagnostic and Statistical Manual of
Mental Disorders (DSM-IV) (American Psychiatric
Association, 1994). Since the diagnosis of generalized
anxiety disorder requires a minimum symptom dura-
tion of 6 months, it is not possible for a de novo onset of
generalized anxiety disorder to occur in the postpartum
period. For this reason, women meeting the criteria of
generalized anxiety disorder in the 3-month postpartum
period with a minimum symptom duration of 2 weeks
within the last four (analogous to the criteria for a
depressive episode) were diagnosed as having acute
adjustment disorder with anxiety (AADA) (Matthey
et al., 2003). In SCID-I, time of onset was also
determined for the depressive and anxiety disorders
under investigation. Participants were asked whether
respective disorders were already present at the time of
pregnancy and also before pregnancy, or whether these
first arose following delivery. Additional ‘postpartum
onset’ was diagnosed given that the disorder emerged
in the first 12 weeks following delivery.
e) Each participant completed a demographic informa-
tion form, comprising sociodemographic and obste-
tric data such as age, number of children, and
educational level, as well as delivery mode and
pregnancy experience.
The research assistants who posed the questions
pertaining to maternity blues, administered the screen-
ing instruments, and conducted the SCID had received
training in order to ensure reliability. For the purpose of
ensuring that reliability was maintained, continuous
checks were made throughout the study.
2.3. Statistical analyses
For the comparison of two groups, we employed the
Mann–Whitney U test (two-sided), and Fisher’s exact
test and the chi-squared test for categorical data.
Prevalence rates are provided in the form of percentages
with a two-sided confidence interval, obtained using a
procedure first presented by Clopper and Pearson
(1934). Relationships between MB and postpartum
depression or anxiety were examined using Fisher’s
exact test and additional odds ratios with corresponding
confidence intervals. Standardized Pearson residuals
were additionally calculated as a measure of the
deviation between observed and expected contingency
table values (absolute values N 2 are meaningful; the sign
(+/−) denotes the direction of deviation from expected
values, Agresti, 2002). A logistic regression with
subsequent likelihood ratio test was performed in
order to assess the influence of the length of MB on
the probability of developing postpartum depression.
Primary parameters were the prevalence rate of MB
and the relationship between MB and postpartum de-
pression as well as between MB and a postpartum
anxiety disorder. Multiple testing was accounted for by
applying a global alpha level of α = 0.05 for the three
parameters, i.e., α = 0.01 for each of the five tests
conducted. These parameters are thus presented with
99% confidence intervals in the case of prevalence rates
and odds ratios, and corresponding p-values are multi-
plied by five. All further analyses were of a purely
explorative nature and were carried out at the 5% level.
All computations were conducted using the statistics
programme R Version 2.4.1 (R: A Language and
Environment for Statistical Computing, R Development
Core Team, R Foundation for Statistical Computing,
Vienna, Austria, 2007).
3. Results
3.1. Response rate and sample characteristics
A total of 1464 German-speaking mothers were
asked to participate in the study, 1024 (70%) of which
consented. The participation rate of 70% is acceptable
and comparable with rates found in other studies
(Ballestrem et al., 2005; Matthey et al., 2003). Reasons
for refusing to partake in the study included a lack of
time (180 i.e., 40.9%), lack of interest (143 i.e., 32.5%)
and the fact that the questions were considered to be too
intimate (25 i.e., 5.7%). 47 women (i.e., 10.7%) stated
other reasons and 45 (i.e., 10.2%) gave no reason for not
taking part in the study.
 C. Reck et al. / Journal of Affective Disorders 113 (2009) 77–87
Of the 1024 participating women, a total of 871 were
reached by telephone 2 weeks after delivery and
provided data regarding MB. In order to differentiate
between women with MB symptoms and those suffering
from depression, we excluded 10 women who were
positively screened for major or minor depression in the
first 2 weeks after delivery using the PHQ-D and who
were additionally diagnosed as being clinically
depressed according to the SCID (n = 4: major depres-
sion; n = 6 minor depression). We also excluded those
women with a depression which had started prior to
delivery from analysis (altogether n = 9, with n = 4 major
depression and n = 5 minor depression). A total of 18
women (one woman met both exclusion criteria; n = 7
major depression, n = 11 minor depression) were thus
excluded from the maternal blues analysis. The final
sample comprised n = 853 postpartum women.
These women had a mean age of 32.8 years (SD = 4.7).
57.3% were primiparous and 42.7% gave birth to their
second to fifth child. The women who were unobtainable
had a mean age of 33.4 years (SD = 4.6). 57.4% of this
group was primiparous and 42.6% gave birth to their
second to fourth child. The two groups did not differ with
respect to age (Mann–Whitney U test, p N 0.05) or pri-
miparity vs. multiparity (Chi² = 0.003, df = 1, p-value =
0.96). Differences were found, however, with respect to
education: 41.5% of the maternal blues sample and 56.6%
of the group with missing MB data had completed tertiary
education (Chi² =10.51, df = 4, p = 0.0012).
3.2. Incidence and timing of maternal blues
471 of the 853 women (55.2%, 99% CI: 50.8–59.6%)
were found to have MB. Data on the second question
concerning whether MB symptoms were present at the
time of the interview were only available for 424 of the 471
women with MB (second question was not initially
included in the interview, see Section 2.2a). 60 of these
424 women reported having MB at the time of the
interview. For the majority of women who provided
information regarding the length of their MB, symptoms
lasted 1 day (31.2%, n = 109). Symptoms lasted an average
of 3.4 days (SD = 3.4, n = 349). 15 women reported having
MB for 11 days or more (4.3%).
3.3. Links between MB and postpartum depressive
disorders
Of the 471 mothers who suffered from MB, 27
(5.7%, 95% CI: 3.8–8.2%) developed postpartum de-
pression (Fig. 1, Table 3a). From a different perspective,
these 27 women constitute 81.8% of the 33 mothers who
81
developed postpartum depression (95% CI: 64.5–93.0%)
(Fig. 2, Table 3b).
A significant relationship was found between the
occurrence of MB and the development of postpartum
depression with onset after delivery (Fisher’s exact test,
target parameter postpartum depression: (p = 0.0098,
odds ratio = 3.8, 99% CI: 1.2–16.5) (Table 1). There
were more women with MB and postpartum depression
than would be expected if there were no association
between the two variables (standardized Pearson
residual = 3.1). While a higher percentage of women
with MB did not develop postpartum depression (Table 3a),
this combination was far less represented in our study than
would be expected in the case of independence (standar-
dized Pearson residual =−3.1) (Table 1).
It was further examined whether the duration of MB
increases the probability of developing postpartum
depression. In a logistic regression, MB duration proved
to be a significant predictor of postpartum depression
(p = 0.032, odds ratio = 1.1, 95% CI: 1.01–1.25), although
the respective model showed poor goodness of fit (log-
likelihood-ratio test, LR = −2.2, p N 0.05). This could
potentially be explained by the fact that less data were
available for longer than for shorter durations of MB.
A significant relationship was found between the
occurrence of MB and EPDS scores of 13 or more 2 and
6 weeks after delivery (2 weeks: Fisher’s exact test,
p b 0.0001, odds ratio = 4.5, 95% CI: 2.3–9.8; 6 weeks:
Fisher’s exact test, p = 0.0008, odds ratio = 4.6, 95% CI:
1.7–15.4) (Table 1). The first administration of the
EPDS 2 weeks after delivery revealed that 14.0% of the
women who suffered from MB obtained an EPDS score
of 13 or more (55 of 394, 95% CI: 10.7–17.8%) (Fig. 1).
This was higher than would be expected if the two
variables were independent (standardized Pearson
residual = 4.6, Table 1). 83.3% of women who had a
score of 13 or more at this time of measurement had
Fig. 1. Percentage of women with maternity blues who suffered in the
postpartum period from depression (MB + PPD), an anxiety disorder
(MB + AD), depression and/or anxiety disorder (MB + AD/PPD), had
an EPDS score of 13 or more 2 or 6 weeks after delivery (MB + EPDS2,
MB + EPDS6), or had a positive ASQ (MB + ASQ2, MB + ASQ6).
82 C. Reck et al. / Journal of Affective Disorders 113 (2009) 77–87

clinical relevance. Furthermore, due to the small number

Fig. 2. Percentage of women with postpartum depression (PPD),
anxiety disorder (AD), depression and/or anxiety disorder (AD/PPD),
an EPDS Score of 13 or more 2 or 6 weeks (EPDS2, EPDS6) after
delivery, or a positive ASQ 2 or 6 weeks after delivery (ASQ2, ASQ6)
and who suffered from maternity blues (MB).
previously suffered from MB (55 of 66, 95% CI: 72.1–
91.4) (Fig. 2).
Six weeks after delivery, 9.9% of the women who had
suffered from MB obtained an EPDS of 13 or more (28 of
282, 95% CI: 6.7–14.0%) (Fig. 1). Observed frequencies
were once again higher than would be expected in the case
of independence (standardized Pearson residual = 3.2,
Table 1). 84.8% of those women who had a score of 13 or
more 6 weeks after delivery had previously suffered from
MB (28 of 33, 95% CI: 68.1–94.9%) (Fig. 2).
3.4. Links between MB and postpartum anxiety
disorders
Given the small number of cases corresponding to
the individual anxiety disorders panic disorder, phobias,
and generalised anxiety, we decided to examine anxiety
as a global variable. Specific phobias were excluded
from analysis on account of their predominantly low
of cases (n = 8), it was not possible to carry out analyses
separately for those women suffering from an anxiety
disorder with onset after delivery. Therefore ‘anxiety
disorder’ includes ‘panic disorder’ and/or ‘agoraphobia’
and/or ‘acute adjustment disorder with anxiety’
(AADA) with onset prior to or after delivery.
An anxiety disorder was found in the postpartum
period for 4.9% of those mothers who suffered from MB
(23 of 471, 95% CI: 3.1–7.2%) (Fig. 1, Table 3). 82.1%
of mothers with a postpartum anxiety disorder had
previously suffered from MB (23 of 28, 95% CI: 63.1–
93.9%) (Fig. 2, Table 3).
There was a significant relationship between the
occurrence of MB and DSM-IV postpartum anxiety
disorders (Fisher’s exact test: p = 0.0168, odds ratio = 3.9,
99% CI: 1.1–20.0) (Table 2). There were more women
with MB and postpartum anxiety disorders than would be
expected if these variables were independent (standar-
dized Pearson residual = 2.9). While a higher percentage
of women with MB did not suffer from an anxiety
disorder (Table 3), this combination was considerably less
represented than would be expected in the case of
independence (standardized Pearson residual = −2.9).
29.9% of those women who had suffered from MB
had a positive ASQ 2 weeks after delivery (118 of 394,
95% CI: 25.5–34.7%) and 27.7% 6 weeks after delivery
(77 of 278, 95% CI: 22.5–33.4%) (Fig. 1). Of those
women with a positive ASQ 2 weeks after delivery,
69.0% had previously suffered from MB (118 of 171,
95% CI: 61.5–75.8%) and 66.4% 6 weeks after delivery
(77 of 116, 95% CI: 57.0–74.9%) (Fig. 2).
At both times of measurement, a significant relation-
ship was found between MB and a positive ASQ (Fisher’s

Table 1
Contingency tables for maternity blues symptoms and depression
Maternity Factors influenced by maternity blues Fisher’s exact test
blues Odds ratio (CI)⁎
N (percent) Standardized Pearson residuals
Postpartum depression (DSM-IV)
No Yes No Yes P = 0.0098
No 376 (44.1) 6 (0.7) 3.1 − 3.1 OR = 3.8
Yes 444 (52.1) 27 (3.2) −3.1 3.1 (1.2–16.5)
EPDS score of 13 or more 2 Weeks postpartum
No Yes No Yes p b 0.0001
No 308 (43.2) 11 (1.5) 4.8 − 4.8 OR = 4.5
Yes 339 (47.5) 55 (7.7) − 4.8 4.6 (2.3–9.8)
EPDS score of 13 or more 6 Weeks postpartum
No Yes No Yes p = 0.0008
No 207 (41.9) 5 (1.0) 3.3 − 3.3 OR = 4.6
Yes 254 (51.4) 28 (5.7) − 3.3 3.2 (1.7–15.4)
⁎99% confidence interval for target parameter depression with postpartum onset, otherwise 95% confidence interval.
Statistics: standardized Pearson residuals, Fisher’s exact test, odds ratio with confidence interval.
 C. Reck et al. / Journal of Affective Disorders 113 (2009) 77–87 83

Table 2
Contingency tables for maternity blues symptoms and anxiety
Maternity Factors influenced by maternity blues Fisher’s exact test
blues Odds ratio (CI)⁎
N (percent) Standardized Pearson Residuals
Postpartum anxiety disorders (DSM-IV)
No Yes No Yes p = 0.0168
No 377 (44.2) 5 (0.6) 2.9 − 2.9 OR = 3.9
Yes 448 (52.5) 23 (2.7) − 2.9 2.9 (1.1–20.0)
ASQ 2 weeks postpartum (Screening)
No Yes No Yes p = 0.00002
No 270 (37.7) 53 (7.4) 4.2 − 4.2 OR = 2.2
Yes 276 (38.5) 118 (16.5) − 4.2 3.7 (1.5–3.2)
ASQ 6 weeks postpartum (Screening)
No Yes No Yes p = 0.0104
No 180 (36.2) 39 (7.8) 2.6 − 2.6 OR = 1.8
Yes 201 (40.4) 77 (15.5) − 2.6 2.3 (1.2–2.8)
⁎99% confidence interval for target parameter postpartum anxiety disorders, otherwise 95% confidence interval.
Statistics: standardized Pearson residuals, Fisher’s exact test, odds ratio with confidence interval.

exact test: Two weeks: p = 0.00002, odds ratio = 2.2, 95%
CI: 1.5–3.2; 6 weeks: p = 0.0104, odds ratio = 1.8, 95% CI:
1.1–2.8) (Table 2). In both cases, there were more women
with MB and a positive ASQ than would be expected if the
two variables were independent (standardized Pearson
residual = 3.7 (2 weeks) and 2.3 (6 weeks)) (Table 2).
In contrast, mother’s age, education, delivery and
pregnancy experience, whether the pregnancy was planned,
sex of the child, or whether the mother was living in a stable
relationship had no influence on the development of MB.
4. Discussion

3.5. Links between MB and postpartum depression or The current study aimed to examine the prevalence of
anxiety disorders MB symptoms and their link to postpartum depression
and anxiety disorders. Sociodemographic and obstetric
The relationship between the occurrence of MB and
the development of depression and/or an anxiety disorder
proved significant (Fisher’s exact test: p = 0.0001, odds Table 3
ratio = 3.5, 95% CI: 1.7–7.6). A current anxiety disorder Percentages of women with and without a postpartum disorder among
and/or postpartum depression was found for 9.3% of women with and without MB (Section A) and percentages of women
women with MB symptoms (44 of 471, 95% CI: 6.9– with and without MB among women with and without a postpartum
12.3%) (Fig. 1). An examination of the group of women disorder (Section B)
with a current anxiety disorder and/or postpartum A Postpartum depression
depression reveals that 80.0% had previously suffered (DSM-IV)
from MB (44 of 55, 95% CI: 67.0–89.6%) (Fig. 2). Maternity blues No Yes
No 98.4 1.6
Yes 94.3 5.7
3.6. Sociodemographic and obstetric correlates
Postpartum anxiety
disorders (DSM-IV)
The investigation of sociodemographic factors and Maternity blues No Yes
pregnancy/delivery-related factors revealed significant No 98.7 1.3
relationships between MB and number of children, a Yes 95.1 4.9
planned return to work, and the occurrence of a phase of
B Maternity blues
depressed mood in earlier pregnancies (see Table 4).
Postpartum depression (DSM-IV) No Yes
In the case of number of children, it is interesting to
No 45.9 54.1
note that women with only one child more frequently Yes 18.2 81.8
suffered from MB. A planned return to work doubled Maternity blues
the risk of developing MB and the occurrence of a phase Postpartum anxiety disorders (DSM-IV) No Yes
of depressed mood in earlier pregnancies increased the No 45.7 54.3
Yes 17.9 82.1
MB-risk three-fold.
84 C. Reck et al. / Journal of Affective Disorders 113 (2009) 77–87

Table 4
Comparison of sociodemographic variables for mothers with (n = 471) and without MB (n = 382)
Sociodemographic influence No maternity n Maternity n Statistics
blues (n = 382) blues (n = 471)
Age [years, mean ± SD] 33.0 ± 4.7 338 32.6 ± 4.8 423 p = 0.1517⁎
Educational level [%]
Lower level secondary school leaving certificate 7.0 23 8.2 34 p = 0.5501+
Higher level secondary school leaving certificate 29.5 97 31.1 129
Vocational A Levels 3.6 12 5.8 24
A Levels 16.1 53 15.2 63
University degree 43.8 144 39.8 165
Number of children [mean ± SD] 1.7 ± 0.8 345 1.4 ± 0.6 434 p b 0.0001⁎
1 48.4 167 64.3 279
2 35.4 122 28.6 124
3 12.5 43 6.7 29
4 3.5 12 0.2 1
5 0.3 1 0.2 1
Planned return to work
No 42 25 p = 0.0017# OR = 2.3 95%
Yes 262 360 CI: 1.3–4.1
Delivery experience
Normal 184 221 p = 0.846+
Forceps 2 2
Vacuum extraction 17 27
Caesarean section 116 139
Pregnancy was pleasant
1 completely agree 90 132 p = 0.211+
2 125 119
3 53 75
4 34 42
5 9 15
6 do not agree at all 4 7
Pregnancy was strenuous
1 completely agree 24 38 p = 0.752+
2 56 78
3 70 87
4 44 50
5 67 83
6 do not agree at all 50 50
Phase of depressed mood after previous pregnancies
No 124 70 p b 0.0001# OR = 3.1 95%
Yes 48 85 CI: 1.9–5.1
Planned pregnancy
No 52 73 p = 0.430# OR = 0.8 95%
Yes 270 322 CI: 0.6–1.3
Sex of child
Male 168 229 p = 0.187# OR = 0.8 95%
Female 170 189 CI: 0.6–1.1
Currently in a relationship
No 7 12 p = 0.641# OR = 0.7 95%
Yes 313 381 CI: 0.2–2.0
⁎u-test, +chi-squared test. #Fisher’s exact test.

correlates of MB development were further evaluated.
The study represents the very first investigation on MB as
a risk factor in the development of depression and anxiety
disorders in a German representative community sample
of women. The central aim was to investigate the degree
to which MB represents a risk factor for the occurrence of
postpartum depression and anxiety disorders.
Concerning the relationship between MB and
depressive symptoms with a postpartum onset, MB
were found to also represent a risk factor for postpartum
 C. Reck et al. / Journal of Affective Disorders 113 (2009) 77–87
depression in Germany. The data indicate that the risk of
developing postpartum depression is significantly
higher given the preceding occurrence of MB. It should,
however, also be noted that approximately 94% of the
group of mothers at risk did not develop depression. In
the search for risk factors it is therefore important to take
into account that despite a heightened risk for
postpartum depression, the probability of not develop-
ing depression is considerably higher for women with
MB in the postpartum period than the probability of
becoming depressive.
A significant relationship was accordingly found
between MB and EPDS scores of 13 or more 2 and
6 weeks post-delivery. These results correspond with those
reported by other authors (Milgrom et al., 2003; Lane et
al., 1997; Paykel et al., 1980; Teissèdre and Chabrol, 2004;
Crotty and Sheehan, 2004). While the relatively high
observed concordance rate of 14% between an EPDS
score of 13 or more and MB 2 weeks postpartum may in
part be seen as a validation of the MB Interview, it also
shows that approximately 41% of the women who
suffered from MB did not have an EPDS score of 13 or
more. The data seem to be particularly interesting in light
of the fact that women who were positively screened for
major or minor depression in the first 2 weeks after
delivery using the PHQ-D were excluded. An EPDS-score
of 13 or more could thus represent an early sign of a
clinically significant postpartum major depression.
In the first 3 months postpartum, a significant relation-
ship was found between the occurrence of MB and anxiety
disorders (panic disorder/agoraphobia, AADA, social
phobia) according to DSM-IV criteria. To the knowledge
of the authors, these are the very first data to be published
concerning the link between MB and anxiety disorders
according to DSM criteria. Our findings are in line with the
clinical observation of other research groups, according to
which anxiety is a common feature of MB (e.g., Kennerly
and Gath, 1989; Lanczik et al., 1992; Pitt, 1973). With
respect to the interpretation of the links between MB and
postpartum anxiety disorders, it must however be pointed
out that a differentiation between disorders with a
postpartum onset and those which had begun prior to
delivery was not possible on account of the small number
of cases. Conclusions can therefore not be drawn
concerning the predictive value of MB for the occurrence
of an anxiety disorder in the postpartum period.
Regarding the rate of MB in Germany, we found a
prevalence rate of 55.2% (95% CI: 52.5–59.12). MB
prevalence rates reported in other studies predominantly
range from 40 to 60% (Gonidakis et al., 2007; Hau and
Levi, 2003; Nagata et al., 2000). MB lasted on average for
3.4 days, although 4.3% of the women even reported a
85
duration of more than 10 days. The present findings thus
primarily confirm previous results indicating that women
with MB symptoms which last for a longer time span are
more at risk of developing postpartum depression in the
following 3 months (Henshaw et al., 2004).
With regard to sociodemographic variables, we
found no relationship between MB and age, education,
planned pregnancy, being a single mother, or sex of the
infant. Concerning obstetric variables, no links were
found between delivery mode and the occurrence of
MB. This finding is in contrast with the results of studies
conducted by Gonidakis et al. (2007) and Hannah et al.
(1992), which found delivery by caesarean section to be
significantly related to MB in the first 3 days after
delivery. We also failed to find a relationship between
the more psychological variable ‘subjective experience
of pregnancy’ as a ‘pleasant’ or a ‘strenuous’ time. Three
variables were found to be related to MB: a reported
history of MB, giving birth to a first child, and planning
to return to work after delivery. It is conceivable that
women giving birth to their first child are more anxious
and worried about adjusting to the new circumstances
and are therefore more uncertain as to whether they will
be successful in meeting the demands with which they
will be faced. The finding that women who intend to
return to work are also more likely to suffer from MB
may result from the anticipation of being doubly
burdened and the feeling of not being able to take the
time to get used to and acquainted with the child.
Several limitations of the study should be considered.
First, the prevalence of MB may be underestimated
given our predominantly middle class low-risk sample.
The influence of education level on rates of refusal
underscore the bias in the sample selection and the
associated risk of prevalence-underestimation; partici-
pants were more highly educated than non-participants
(56% vs. 36%). It was also not possible in the present
study to assess the impact of other significant psychoso-
cial variables. The additional application of measures of
life events, social support, and quality of marital relation-
ship was, for reasons of time economy, not justifiable.
A further limitation might be the retrospective
assessment of MB 2 weeks postpartum. The participants
were asked to recall their experiences in the first days after
delivery 14 days after giving birth. The problem of
retrospective data collection also applied to the question
concerning whether depression had started prior to
delivery. All assessments in the present study were
conducted in the postpartum period and are thus subject to
retrospective reporting bias. Nonetheless, the retrospec-
tive assessment of MB over a period of 2 weeks would
seem reasonable enough to justify our assumption that no
86 C. Reck et al. / Journal of Affective Disorders 113 (2009) 77–87
relevant bias arose in the data. In connection with this
retrospective assessment, a telephone interview appeared
most suitable given that this method allowed the
interviewer to aid the recall of the participating women
by providing an exact description of maternity blues
within the telephone conversation. This method further
allowed an assessment of current psychopathological
status including whether maternity blues were still
present. In a recent study, Osório et al. (2007) demon-
strated high concordance between clinical diagnoses
made on the basis of telephone interviews and those
made in the context of face-to-face contact. Despite the
mentioned limitations of the assessment method used in
diagnosing MB, it should be noted that the MB incidence
rate of 55.2% found in our study as well as the relatively
high rate of concordance (14%) between MB and an
EPDS score of 13 or more 2 weeks postpartum generally
provide support for the validity of the selected method.
It should also be mentioned that it was not possible to
screen all women who gave birth in the respective clinics
and that those women who did not give birth in a clinic
were automatically excluded.
In conclusion, the present findings provide new
insights concerning the relationship between MB,
depression, and anxiety disorders according to DSM-
IV. This study indicates that MB is a risk factor for the
development of depression in the first 3 months after
delivery. Furthermore, there is a significant link between
the occurrence of MB and postpartum anxiety disorders.
Prospective studies which begin during pregnancy and
include the assessment of psychosocial variables are
urgently required in the investigation of the relationship
between MB and postpartum depression/anxiety dis-
orders. Clinicians should be aware that MB could lead to
postpartum depression and might be an indicator for an
already existent anxiety disorder. In the first 2 weeks
postpartum, screenings for MB, depression, and anxiety
symptoms should be applied in order to identify those
women who are at risk of developing clinically
significant psychiatric disorders in the puerpartum and
with the aim of providing an opportunity for prevention
and therapeutic intervention. Appropriate preventive
programmes which commence during pregnancy and
accompany the women throughout the first 3 months
after delivery are required in Germany.
Role of funding source
Study funding was provided by a grant from the Program of
Research Support at the University Medical Faculty, Heidelberg
(funding period: 2003–2004); the University Medical Faculty had no
further role in study design; the collection, analysis, and interpretation
of data; the writing of the report; or the decision to submit the paper for
publication.
Conflict of interest
We state that there are no conflicts of interest, including specific
financial interests or relationships and affiliations relevant to the
subject of our manuscript.
Acknowledgments
First and foremost, we would like to express out
thanks to the women who were prepared to take part in
the study. Our thanks also go to the maternity clinics and
their staff in Heidelberg (St. Josef’s Hospital, Saint
Elisabeth’s Hospital, Salem Hospital and the Gynaeco-
logical Clinic at the University of Heidelberg) as well as
participating clinics in Darmstadt (Alice-Hospital and
Darmstadt Hospital) for their willingness to cooperate
and support in recruiting patients. Further thanks to
Dawn Girlich for her help in manuscript preparation.
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