There may be a well-established association between sleep disturbance and suicide, with studies consistently showing that individuals who experience poor sleep are at increased risk of suicidal thoughts and behaviors. Moreover, other studies have documented that sleep disturbance is more prevalent in individuals who’ve attempted or died by suicide in comparison with the overall population. While sleep disturbance is amazingly common in women throughout the perinatal period, the association between suicidal thoughts and behaviors and sleep disturbance in pregnant and postpartum women has not been well studied.

In a recent article, Arditi-Arbel and colleagues reviewed published research studies including data on sleep disturbance and suicidal thoughts and behaviors. They identified a complete of 51 studies with a complete of 45,942 participants exploring risk aspects for perinatal suicidal thoughts and behaviors. Eleven studies, most of them cross-sectional, specifically examined the connection between sleep and suicidal thought and behaviors. Given the differing methodologies across the studies, the researchers weren’t in a position to conduct a meta-analysis; nevertheless, their review of the literature indicates that sleep disturbance while pregnant and the postpartum period is related to increased rates of suicidal thoughts and behaviors. For instance, a cross-sectional study examined the connection between depression, suicidal ideation (SI) and sleep disturbance in 267 pregnant women within the late second and early third trimester who were recruited from obstetric clinics. This study observed that pregnant women with high rumination and insomnia suffered from higher rates of depression (35.6%) and SI (17.3%) in comparison with pregnant women who slept well (1.2% depressed, 4.9% suicidal) (Kalmbach et al, 2020). On this cohort, they observed that amongst women with perinatal depression, SI was more commonly reported in women who experienced insomnia and nocturnal hyperarousal (Kalmbach et al, 2021).

The authors also examined psychosocial aspects which will moderate or mediate the connection between sleep disturbance and suicidal ideation. In a scientific review, they noted, lack of  belongingness or social isolation may explain the connection between sleep disturbance and suicidal ideation (Littlewood et al, 2017). In addition they hypothesize that lack of quality sleep could also be more outstanding or impactful in women with inadequate social supports; thus, sleep deprivation may partially mediate the results of inadequate social supports on risk for perinatal depression. 

Clinical Implications

This review indicates that sleep disturbance is a very important, and potentially preventable risk factor for suicidal thoughts and behaviors in pregnant and postpartum women. This finding is consistent with other studies indicating that sleep disturbance may contribute to or exacerbate depressive symptoms in perinatal populations. Nevertheless, it is a complex, and infrequently bi-directional, relationship. While insomnia is usually a symptom of depression, insomnia often exacerbates or increases the severity of depression. 

Interventions targeting insomnia may help to scale back risk of depressive symptoms and suicidal ideation. A small randomized controlled trial found that treatment of insomnia (with either trazodone or diphenhydramine) initiated throughout the third trimester of pregnancy reduced subsequent risk for postpartum depression (PPD). Larger studies are needed to higher understand the impact of those interventions on risk for depression and suicidal ideation.

Many researchers on this field have argued for more careful screening for sleep disturbance in pregnant and postpartum women; nevertheless, sleep disturbance is one of the common symptoms reported by pregnant and postpartum women. While insomnia could also be a risk factor for depression and/or suicidal ideation in some women, the vast majority of women with pregnancy and postpartum-related sleep problems don’t go on to experience depression or suicidal ideation. 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 and/or suicidal ideation.

Ruta Nonacs, MD, PhD

References

Arditi-Arbel B, Hamdan S, Winterman M, Gvion Y. Suicidal ideation and behavior amongst perinatal women and their association with sleep disturbances, medical conditions, and known risk aspects. Front Psychiatry. 2023 Jan 19;13:987673.

Khazaie H, Ghadami M, Knight D, Emamian F, Tahmasian M. Insomnia treatment within the third trimester of pregnancy reduces postpartum depression symptoms: a randomized clinical trial. Psychiatry Res. (2013) 210:901–5.