Over the previous couple of months, there have been several review articles the connection between sleep disturbance and perinatal depression. Clinically, sleep disturbance is common amongst women with depression while pregnant and/or within the postpartum. Much of information on this association comes from cross-sectional studies; thus, it’s difficult to find out if sleep disturbance causes or contributes to depression and/or anxiety, or if sleep disturbance is merely a symptom of depression or anxiety.

Sleep Disturbance and Risk of Perinatal Depression

In the primary meta-analysis, Fu and colleagues analyzed data from a complete of ten studies including 39,574 participants. Overall, women who experienced poor sleep quality while pregnant had a better risk of developing depression. In comparison with women who reported no significant sleep problems while pregnant, women with disrupted sleep had a 3.72-fold higher risk of depression while pregnant and a 2.7-fold higher risk of postpartum depression.

The meta-analysis from Li and colleagues checked out the association between sleep disturbance while pregnant and risk of postpartum depression, analyzing data from 16 studies with a complete of 12,614 participants. Just like the primary meta-analysis described above, this meta-analysis also observed that sleep disturbance while pregnant resulted in a statistically significant increased risk of PPD (OR: 2.36, 95% CI: 1.72, 2.32). Nevertheless, they noted that risk of PPD was only increased with sleep disturbance occurring through the third trimester, not when it occurred only in the primary or second trimesters. 

What Comes First? Sleep Disturbance or Depression?

While many studies show an association between sleep disturbance and perinatal depression, the studies are cross-sectional, not longitudinal, so it’s difficult to know whether sleep disturbance precedes and causes or contributes to depression, or if sleep disturbance occurs as a symptom of depression.  

To raised understand the connection between sleep and perinatal depression, several studies have followed women longitudinally and have assessed sleep and depressive symptoms while pregnant and the postpartum period. For instance, Bao and colleagues followed 412 women from the primary trimester of pregnancy until 6 weeks postpartum. The Pittsburgh Sleep Quality Index (PSQI) was used to evaluate the sleep quality, and the Edinburgh Postnatal Depression Scale (EPDS) was used to evaluate the symptoms of depression. 

The researchers identified 4 distinct sleep quality trajectories: stable-good (46.1%), worsening (16.4%), improving (17.5%), and stable-poor (16.0%). The bottom risk of postpartum depression was observed within the stable-good group. In comparison with this group, women with stable-poor sleep had a 3.57-fold increased risk of PPD and ladies within the worsening group had a 2.56-fold increased risk of PPD.  

While this longitudinal study hints that sleep disturbance may contribute to the onset of depression, the authors note that the connection is more complicated. Women within the stable-poor sleep group had higher levels of depression at baseline, an element that increases risk for PPD. As well as, women within the stable-good sleep group tended to have more social support, an element that’s related to decreased risk for PPD.  

Should We Screen for Sleep Problems During Pregnancy?

Given the strong association between sleep disturbance while pregnant and perinatal depression, should clinicians specifically be asking about sleep? Commonly used depression screening tools, resembling the EPDS and the Patient Health Questionnaire-9 items (PHQ-9), do include questions on sleep. (The shortened PHQ-2 doesn’t ask about sleep.) Nevertheless, within the absence of other depressive symptoms, sleep problems on their very own wouldn’t typically be flagged as concerning or needing additional follow-up.

Future studies are needed to find out the utility of assessing sleep as a method of identifying women liable to perinatal depression. Sleep disturbance is common amongst pregnant and postpartum women; thus, labeling women with sleep problems as being at increased risk for perinatal depression may yield a high variety of false positives. Nevertheless, this symptom when combined with other risk aspects could also be more useful in clinical settings. Further research may additionally help to discover specific sleep parameters – for instance, duration or severity of sleep disturbance — which may be more precise in determining risk of perinatal depression.  

Ruta Nonacs, MD PhD

References

Bao C, Jin D, Sun S, Xu L, Wang C, Tang W, Zhang W, Bao Y, Xu D, Zhou S, Yu X, Zhao K. Trajectories and Depressive Symptoms Throughout the Perinatal Period: A Longitudinal Population-Based Study in China.  Front Psychiatry. 2022 Mar 31;13:762719.

Fu T, Wang C, Yan J, Zeng Q, Ma C.  Relationship between antenatal sleep quality and depression in perinatal women: A comprehensive meta-analysis of observational studies.  J Affect Disord. 2023 Feb 3;327:38-45.

Li H, Li H, Zhong J, Wu Q, Shen L, Tao Z, Zhang H, Song S.  Association between sleep disorders while pregnant and risk of postpartum depression: a scientific review and meta-analysis.  Arch Womens Ment Health. 2023 Feb 4.