MATERNITY BLUES: PHENOMENA

AND RELATIONSHIP TO LATER

POST PARTUM DEPRESSION
Catherine C. Hapgood, Gail S. Elkind, and James J. Wright
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As part of a prospective investigation of postnatal psychiatric disorder, 66

women, randomly selected antenatally, completed visual analogue scales
postpartum and rated their mood state daily for two weeks following childbirth.
They were then interviewed using the Goldberg Standardised Psychiatric In-
terview on four occasions up to 14 months postpartum. Dysphoric mood was
temporally related to childbirth. Emotional lability was the important affective
component of the puerperium. A significant correlation was found between the
blues and subsequent postnatal depression. Lability of mood in the puer-
For personal use only.

perium was related to psychiatric symptoms up to 14 months postpartum and

was the strongest predictor of later psychopathology. Maternity blues ratings
were not accounted for by labour variables.

Australian and New Zealand Journal of Psychiatry 1988; 22: 299-306

The affective disturbance which commonly occurs
in the first two weeks following childbirth (“the
blues”) is thought to be a normal transient part of the
early puerperium [ 1,2]. There is now increased recog-
nition of, and interest in, the association between this
mood disturbance and childbirth [3-61. Whether the
blues is truly a minor transitory occurrence, or whether
it is associated with more severe and clinically sig-
nificant postpartum disorder remains unclear and is the
subject of this paper.
Although mood change after childbirth is accepted
as common, no clear definition of the blues exists and
hence there are no widely accepted rating scales. That
negative affective symptoms are experienced postpar-
Department of Psychiatry and Rehavioural Science, University
of Auckland, Private Bag, Auckland, New Zealand
Catherine C Hapgood FRANZCP, Research Fellow
Gail S Elkind PhD, Associate Lecturer
James J Wright MD, FRACP. MRCPsych, FRANZCP, Associate
Professor and Head of Department.
tum significantly more severely than in the non-puer-
peral state has been shown by Knight and Thirkettle
(71. They also demonstrated that the method of
measuring postnatal mood change is vitally important
and suggested that this is because the experience is one
of overall affective dysphoria rather than a depressive
syndrome.
The reported incidence of postnatal blues varies
from 34-79% [8,9].This is at least partly explained by
the general lack of agreement about the definition of
the blues. Descriptive studies have yielded prevalence
rates for individual symptoms occurring postpartum;
tearfulness, depression, anxiety, insomnia, headaches,
confusion and fatigue have all been commonly
reported [2,10]. However, no clear inclusion criteria
exist at this stage. Emotional lability was thought to be
an important component of the blues [ 11-13], but is
not part of Pitt [ 2 ] or Stein’s [ 101 rating scales. The
blues are thought to be transient, but temporal limits
remain arbitrarily defined. The expected level of emo-
tional intensity in a minimal case ranges from that of
Yalom who will accept an isolated episode of weep-
 300 MATERNITY BLUES AND POST PARTUM DEPRESSION
ing in the postnatal period, to pre-determined scores
on clinical rating scales [2,10].
Literature which has addressed the question of
whether the blues is related to maternal mental state in
either pregnancy or postpartum is confounded by the
use of different instruments and time scales, making
direct comparisons difficult. Yalom et al’s [ I ] study
was essentially a descriptive account of mood change
postpartum - 22 of their initial sample of 39 women
were telephoned at eight months postpartum, and only
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one reported prolonged mood change since the puer-
perium. Davidson [ 141 and subsequent workers
[ 15,16,10,17] all found an association between
lowered mood in late pregnancy and greater distress in
the early puerperium. In addition, Handley [ 161 and
Stein [ 101 both found an association between depres-
sion in the first 6 months and 3 months respectively
after childbirth, and antenatal distress with more
severe symptoms in the puerperium. In both these
studies later depression requiring a visit to the general
practitioner, and in Stein’s [ 101 study the Self Rating
For personal use only.
Questionnaire used to assess the blues was also used
to measure depression at 3 months postpartum.
Paykel [ 181 found an association between postnatal
depression at 6 months postpartum and a history of the
blues, in cases in which there was an absence of un-
desirable life events. The clinical account of the blues
was gained retrospectively in this study at the time of
the single assessment interview.
Kendell et al [ 191 used daily visual analogue scales
(VAS) to assess mood change in the first 3 weeks
postpartum, and then used a standardised psychiatric
interview (Goldberg et al. 1970) between 3 and 5
months postpartum to diagnose depression. Higher
depression and lability ratings together with a more
pronounced 5 day peak on the daily ratings, were
found in those women who were depressed postpar-
tum.
However, Kumar and Robson [21] used the same
psychiatric interview [20] at 3 months postpartum in a
prospective design, but failed to show an association
between depression post-natally and either General
Health Questionnaire (GHQ) scores at I week postpar-
tum or a retrospective account of the blues. Their
sample consisted of middle class primiparous women
of higher social class than those of Kendell et al‘s [ 191
randomly selected sample, and they did not use daily
rating scales in the immediate postpartum period.
The present study aimed to clarify the association
between “the blues” and post-partum depression by
using instruments similar to, or identical with, those in
earlier studies, in a prospective design. A factor
analysis of the “blues” VAS was also carried out, to
permit more precise definition of the mental
phenomena involved in the concept of “blues”.
Method
The sample consisted of women randomly selected
from six ante-natal clinics at the National Women’s
Hospital, Auckland, and a nearby private obstetric
practice. This was done to ensure a sample repre-
sentative of women delivering at the hospital. Ex-
clusion criteria initially applied were an inability to
speak English and a planned house move out of the
area in the next twelve months.
The women were approached at 34 weeks of preg-
nancy and asked whether they would take part in the
study. They were given verbal and written information
about the purpose of the study, and assured of con-
fidentiality. Two weeks later the initial research inter-
view was conducted. Demographic data were
obtained, followed by a clinical interview. History of
psychiatric illness, family psychiatric history, past his-
tory of postnatal depression, whether the pregnancy
was planned, past history of abortions (both spon-
taneous and induced) and whether breast feeding was
planned, were recorded.
The woman’s attitudes to her mother were assessed
using visual analogue scales for dependency, close-
ness, identification with, feelings of fondness for and
mixed feelings about mother. These five scales were
chosen on the basis of their face validity, in the absence
of established standard instruments.
Whether or not the woman’s own parents were alive,
living close by, and any separations from them in
childhood were also recorded.
This was followed by a standardised psychiatric in-
terview [20]. The rater (CCH) was a psychiatrically
trained interviewer who had received formal training
in the use of the instrument (as requested by the desig-
ners). (Control studies for inter-rater reliability have
been performed on an independent sample of subjects
together with a proportion of the main sample and will
be reported elsewhere. Ratings obtained by two
qualified psychiatrist raters were similar.) The
Goldberg interview was then re-administered at 6
weeks 3 months 6 months and 14 months postpartum.
Following delivery, details about the spontaneity of
onset of labour and the length of Stage I and Stage I1
 CATHERINE C. HAPGOOD, GAIL S. ELKIND & JAMES J. WRIGHT
were extracted from the obstetric record. Type of
anaesthetic, type of delivery, and any complications
were noted. Two days after delivery the women were
asked about their labour, including whether it had been
as they had expected, and how they felt about it over-
all. The women recorded their mood for the first 2
weeks following childbirth using VAS which were
filled in daily for 14 days, starting on the first postpar-
tum day.
The VAS used six mood scales (happiness, depres-
sion, tears, anxiety, irritability, and lability) which
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were the same VAS as used by Kendell et al [19].
Knight & Thirkettle [7] found VAS ratings to be the
most sensitive method of measuring puerperal mood
state. The VAS were provided in a booklet for the sub-
jects. No titles for the scales were given. The women
were given instructions to fill in their booklet at the
same time each day (early evening) and asked to be as
honest as they could in rating how they had felt in
general on each scale over the past 24 hours. If they
missed a day they were asked to leave the page blank
For personal use only.
and fill in the next days page. They were asked not to
compare their previous ratings. At the same times as
the VAS ratings they were also asked to rate the quan-
tity and quality of their sleep the previous night and
whether the baby had been predominantly restless or
settled in the past 24 hours. All women were seen on
the 2nd-3rd day postpartum to check that they had
remembered to take the booklet to hospital with them
and to check again that they fully understood the in-
structions. Ninety five women returned completed
questionnaires at the 6 weeks postpartum interview.
On each occasion when the Goldberg Standardised
Psychiatric Interview was administered, a DSM-111
Axis I diagnosis was made (again by CCH), and
Research Diagnostic Criteria (Spitzer et a1 [ 2 2 ] were
applied. The verbatim transcripts of a proportion of in-
terviews where a diagnosis had been made were dis-
cussed with two other psychiatrists (JMK & JJW) and
agreement on diagnosis was reached with that of CCH
in all instances examined.A total Goldberg score was
also calculated for each interview using Goldberg’s
method, i.e. the sum of all the symptom scores, plus
twice the mental state rating. A further overall rating
was also made which gave an indication of severity of
disorder on a 5 point scale (0 = No symptoms, 1 =
symptoms of minor significance for which no treat-
ment is necessary 2 = symptoms requiring intervention
by a general practitioner, 3 = psychiatric intervention
required. 4 = inpatient psychiatric treatment needed).
30 I
Results
The mean age of women in this sample was 28 years
(SD 5.6 years; range 17 to 43). At the time of initial
interview 74% of the sample were legally married and
26% were in de facto relationships with the father of
the baby. Racial origins were Caucasian (7 1 %),
Polynesian (non-Maori) (16%), Maori (1 1%) and
other, Chinese and Indian (2%).
The social class of the sample did not differ from
that of the New Zealand general population [23].
Using the woman’s occupation, the social class dis-
tribution was 2 1 % in Classes 1 and 2,41% in 3 and 4,
19% in 5 and 6; 19% had never held jobs in the paid
work force. Using the partner’s occupation, the social
class distribution was: 31% in 1 and 2, 49% in 3 and
4, and 16% in 5 and 6. Four percent of the partners
were not working. (The Revised SE index distribution
for New Zealand male work force is 1 & 2=2 1 c/o, 3 &
4=5 1%, 5 & 6=20%). At the time of the initial research
interview 52% of the sample were employed and 48%
described their normal occupation as household
duties.
The DSM-111 axis I diagnoses made in the postpar-
tum period were major depressive disorder, adjust-
ment disorder with depressed mood, and adjustment
disorder with mixed emotional features (depression
and anxiety). There were 2 cases of adjustment disor-
der with anxious mood at 6 weeks postpartum.
Eighteen women were diagnosed as having major
depressive disorder at some stage, 10 of whom had no
diagnosis in the antenatal period and were therefore
new cases. The total score on the Goldberg, i.e. the
symptom score plus twice the mental state rating,
therefore essentially represented the severity of affec-
tive disorder postpartum.
Strategy for Overall Data Analysis
66 subjects completed all of the VAS on all 14 days
postpartum. Some summarising of the daily data items
was necessary to make a factor analysis feasible. This
was done by adding together the scores over several
days (1-5) (6-9) (10-14) for each mood scale. This
resulted in minimal distortion of the raw data, in the
sense that this data smoothing accounted for more of
the total variance after factor analysis than other
methods of collapsing the data across time. It also
produced the most clinically meaningful factors. The
resulting 18 items were subjected to a principal com-
 302 MATERNITY BLUES AND POST PARTUM DEPRESSION

Table I . Maternity blues factors and item loadings

Items Factors
Early Mlddie Late Happiness Lability
Unhapplness Unhappiness Unhapplness
Days 1-5:
-Depression .83
-Tearfulness .a0
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-Anxiety .88
-Irritability .68

Days 6-9:
-Depression .76
-Tearfulness .79
-Anxiety .62
-Irritability .87

Days 10-14:
-Depression .83
-Tearfulness .82
-Anxiety .58
-Irritability .75
For personal use only.

Happiness:
-Days 1-5 .71
-Days 6-9 .91
-Days 10-14 .90

Lability:
-Days 1-5 .82
-Days 6-9 .82
-Days 10-14 .87

ponents analysis with varimax rotation. Five factors
were identified. These factors were tentatively
labelled early unhappiness, middle unhappiness, late
unhappiness, happiness and lability. Items were as-
signed only to the factor on which they had the highest
loading; the lowest of these loadings was .58 (see
Table 1). Five “blues factor scores” subsequently
created for each subject each consisted of the sum of
the unweighted item scores divided by the numbers of
items on that factor [24].
A two-stage general linear modelling procedure was
then used to establish predictive relations between
these “blues” factor scores and outcome measures of
depression. First, the outcome measures were
predicted from the Goldberg scores at the 36th week
of pregnancy (heading 1, table 2). Then the remain-
ing variance in each of the later Goldberg scores was
predicted from the five “blues” factor scores (heading
2, table 2). Thus, the predictive usefulness of the col-
lective factor scores was measured after controlling for
the effects of immediate pre-natal state.
Heading 3, table 2, shows the unique predictive value
of each factor after the other four factors have been
partialled out first.
A critical assessment was then applied to the results
to exclude alternate logical associations, namely:
(a) Mann-Whitney U tests were used to compare
primigravidae with multigravidae on each blues fac-
tor. They did not differ significantly on any of the 5
factor scores by Mann-Whitney U tests. Prediction of
T scores from blues factors was repeated using two
separate groups i.e., primiparae vs multiparae and very
little difference was found. Parity did not therefore
seem to be important.
(b) A history of family and personal psychiatric his-
tory was added to the linear model to see if the predic-
 CATHERINE C. HAPGOOD, GAIL S. ELKIND & JAMES J. WRIGHT 303

Table 2. Prediction of Goldberg scores at 6,13,26 and 60 weeks postpartum from antenatal Goldberg score
and blues factor scores, as measured by F-ratios

Postpartum Goldberg scores

6 weeks 13 weeks 26 weeks 60 weeks

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(n=62) (n=60) (n=58) (n=56)

1. Antenatal Goldberg score
(36th week of pregnancy) 2.5V 1.71 8.90** 0.64

2. Combined perinatal blues factors

(After removing effect of antenatal Goldberg score) 2.94‘ 6.30’*’ 2.40’ 3.32*

3. Unique predictive value of each blues factor score

(After removing effects of antenatal Goldberg score
and the other four blues factor scores)
-early unhappiness 0.29 0.20 1.01 0.20
-middle unhappiness 0.21’ 0.23 2.58 1.26
-late unhappiness 2.08 0.04 1.13 7.17’*
For personal use only.

-happiness 0.34 0.62 0.25 0.49

-lability 2.36 9.15” 5.97” 7.56“

* = p<0.05 ** = p<O.Ol *‘* = p<O.OOl

tion of later depression was improved. However, these
two new variables accounted for very little of the
variance. The one exception was history of psychiatric
disorder which by itself was a unique predictor for
depression at fourteen months post partum (F = 4.28,
p<O.OS) even when the S blues factors and family
psychiatric history were all co-varied out first.
However, when two-way interactions were added to
the above model then there was some improvement in
prediction. There were significant interactive effects
between family psychiatric history, middle unhappiness,
and Goldberg scores at weeks 6, 13 and 60; between
family psychiatric history, late unhappiness and
subsequent Goldberg scores; and between family
psychiatric history, liability and Goldberg scores at
weeks 13 and 60. None of these two-way interactions
was significant at more than two of the four time periods
tested, however.
(c) Further tests were undertaken to test for inde-
pendence of “blues” factor scores from demographic
variables. The relationship of maternity blues factor
scores to other variables which might logically or
theoretically be related to later depression was as-
sessed, to check the independence of the factors per
se. General linear models attempting to predict the fac-
tor scores from the following groups of independent
variables were used in this exercise: (1) Labour vari-
ables, length of stages I and 11, type of anaesthetic, and
type of delivery did not predict “blues” factors. (2)
Planned pregnancy, previous abortion, pre-menstrual
tension (PMT) whether or not breastfeeding at 6 weeks
postnatally, number of feeds in 24 hours at 6 weeks
postnatally and degree of difficulty breastfeeding at 6
weeks postnatally. None of these variables alone or in
combination predicted “blues” factors with the single
exception of middle unhappiness which was predicted
by PMT alone (F = 4.08, p<O.OS).
 304 MATERNITY BLUES AND POST PARTUM DEPRESSION
(3) Subject’s relationship with her own mother, with
respect to mother alive, mother in Auckland,
childhood separation from mother, history of
childhood physical abuse, closeness to mother, being
like mother, dependence on mother, fondness of
mother and ambivalent feelings about mother. None
of the “blues” factors was predicted by the overall
model. However, ambivalent feelings about mothers,
for the set of mothers of first babies only, predicted
late unhappiness [F(I , 15)=4.84,p<O.O5] and early un-
happiness [F(I , 15)=5.74, p<O.O5] uniquely, after all
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other variables in the model had been co-varied out
first.
(4) Help from subject’s mother after delivery. A
number of variables on availability of help from this
source were considered, but are not given here. None
of these variables predicted any maternity blues fac-
tors, singly or in combination.
Finally, the results were also analysed using diag-
nostic categories for comparison, rather than Goldberg
scores. The average scores for each blues rating (not
For personal use only.
factors) were compared across 14 days for two
categories
(a) women who developed major depressive disor-
der in the first six months following childbirth (n=10);
(b) women who had no psychiatric diagnosis at any
stage during the study and were seen at all research in-
terviews (n=47) using Mann Whitney U tests.
The detailed results of this analysis have been
reported elsewhere (251.Of significance to the present
study was the fact that an association was
demonstrated between “blues” with post-partum
depression of sufficient severity to be diagnosed as
DSM-I11 major depressive disorder. This association
was also most marked using the lability scales as the
index of “blues”.
Discussion
These results confirm an association between early
postpartum affective disturbance (blues) and late
postpartum disorder severe enough to be diagnosed as
major depression using DSM-I11 criteria. Specifically,
the findings of Kendell et a1 [ 191 are confirmed in all
respects except the presence of a “day 5” peak of sig-
nificant affective “blues” symptoms. The present
results are compatible with the findings of other
authors, although close comparison can only be made
to that of Kendell.
The factor analysis of the “blues” VAS data sug-
gested that the phenomena so loosely described as
“blues” are quite complex. The method used here,
(rotation to orthogonality of principle component fac-
tors, then naming the factors by their high weighted
VAS components) enables us only approximately to
describe the independent subjective components, but
this appears a useful approximation.
Firstly, while dysphoria is a necessary aspect of the
“blues” almost by definition, and has been widely
reported in the puerperium [2,7,10,19] the presence of
nearly independent temporal components has not been
widely recognised.
Happiness might have been expected to be inverse-
ly related to dysphoria but was in fact uncorrelated
with it, suggesting that some women experience them-
selves to be both happy and miserable at this time. The
assumption is that women are happy at having a baby
at this time, but are also experiencing more negative
and fluctuating affects which may or may not be due
to identifiableexternal stressors. It may also be that the
social expectation of being happy at this time influen-
ces ratings. The emergence of lability as a separate fac-
tor was of interest and importance and seems to
indicate that women distinguish the phenomena of
“spirits going up and down” as an independent
phenomenon from intensity of mood.
It has been suggested by Robin [ 1 11 and Ballinger
[ 121that lability is an essential component of the blues,
and these results appear to support that belief. Kenner-
ley el a1 [ 131 described lability of mood as an essen-
tial component of primary blues and these results
provide further confirmation.
The phenomenon of lability is not measured by con-
ventional mental state scales such as the General
Health Questionnaire used by Kumar and Robson,
which may be why no linkage between the blues and
later depression was found in their study. Knight and
Thirkettle suggest that mood change in the puerperium
is not accompanied by symptoms typical of a depres-
sive or anxiety disorder, but more one of strong nega-
tive affective feelings. Our results indicate that lability
of affect may also be an essential feature of the blues
without any very close parallel to affects experienced
in psychopathological states. Separate pheno-
menological conceptions to those applied in rating
psychopathology may therefore be needed when the
“blues”are described. This has implications for the ap-
plication of conventional mood rating scales to the
“blues”, which might be wholly misleading.
 CATHERINE C. HAPGOOD, GAIL S. ELKIND & JAMES J. WRIGHT
Total scores on the Coldberg semi-structured psychiatric
interview were predicted by maternity blues factor scores
at each time interval postpartum, including 14 months.
Emotional lability was the most important predictor of
later psychiatric symptoms. Middle unhappiness was
related to depression at 6 weeks post partum. An
unexpected finding was a strong relationship between
late unhappiness and depression at 14 months post
partum.
The results of the analyses using extrinsic variables
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reasonably exclude a number of more trivial inter-
pretations of the predictive relations found. Ante natal
mood alone did not predict the “blues”. The interac-
tive effect of both past psychiatric history and positive
family history of psychiatric illness improved the
power of the blues factors to predict later mental state
marginally, but was not a major explanatory com-
ponent. The blues factors themselves could not be
predicted by any demographic data. The only positive
findings were that a history of psychiatric disorder
either alone or in combination with family psychiatric
For personal use only.
history was predictive of dysphoria early in the puer-
perium (early unhappiness). A past history of
premenstrual tension was related to middle unhappi-
ness. A weak association was demonstrated between
ambivalent feelings towards the woman’s own
mother, and early and late dysphoria. Lability was not
predicted by past psychiatric history, family history of
psychiatric disorder or a history of premenstrual ten-
sion. Individual blues factors were not predicted by
whether or not the pregnancy was planned, labour vari-
ables, a past history of abortion (spontaneous or
therapeutic) or whether or not the mother was
breastfeeding. Marital status, parity, total number of
pregnancies, social class and race did not appear to be
related to puerperal affective experience.
These data indicate that those women who ex-
perience marked lability of mood during the first two
weeks postpartum may be at risk of later depression,
and yet will report themselves as being no less happy
than other women at this time. In clinical practice it
can appear a reasonable course of action to discharge
women from hospital if they display severe dysphoria
and lability postpartum in order that they might be in
their own environment, where follow up is then under-
taken by other health care workers. However, this
mood change may well herald the onset of later depres-
sion - particularly in the presence of past psychiatric
history and family psychiatric history. There would
seem therefore to be a strong case for careful assess-
305
ment of “the blues” in the puerperium in the same way
as physical state is assessed, since this may be one of
the few predictors of the most common complication
of the postnatal period, postnatal deptession.
The results of this study together with those of Ken-
nerley confirm that the experience of “spirits going up
and down” is a critical phenomenon of “the blues”.
Severe lability in the puerperium may be predictive of
depression in later months. It is therefore essential to
use a scale (or clinical evaluation) in which this chang-
ing mood is directly assessed, or the predominant fea-
ture of the blues may be unintentionally missed.
Acknowledgements
The authors are grateful to the Auckland Medical
Research Foundation and the Ruth Spencer Trust
which supported this work.
We wish to thank the obstetricians and nursing staff
at National Women’s Hospital for their cooperation
and help with this study, and Mrs Josie McCallion for
secretarial assistance.
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For personal use only.
24. Wainer H. Estimating coefficients in linear models: It don’t make
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25. Hapgood CC. Paper presented to the Annual College Congress of
the RANZCP, Auckland, May, 1987.

REBECCA L. COOPER MEDICAL RESEARCH FOUNDATION

Applications are invited for grants available in 1989 in the fields of DIABETES, ARTHRITIS a
SCHIZOPHRENIA.
The Rebecca L. Cooper Medical Research Foundation was founded in 1984 with the purposg
of funding medical research throughout Australia.
In 1989 grants will be given for research in the above fields, and it is expected that the value
each grant will be between $5,000 and $10,000, and is preferably for specific equipment. Co
mitments for continued support cannot be given.
Application forms will be sent on request, either by phone or letter; the completed application
be received no later than Friday 11th November 1988. Results will be sent out by the seconc
week of December.
All enquiries should be addressed to :
The Rebecca L. Cooper Medical
Research Foundation
P.O. Box 257
Bondi Road
BOND1 N.S.W. 2026.
Telephone number (02) 30 3378.