Abstract
This study evaluated the relationship between sleep quality and symptoms of depression and anxiety in women studied in pregnancy and postpartum. Scores on standardized measures of sleep (PSQI) at 6 months postpartum, and symptoms of anxiety and depression (OASIS, the PHQ9, and EPDS) were assessed by structured interviews in 116 women in pregnancy and/or postpartum. Poor sleep quality was significantly associated with greater symptoms of depression and anxiety. Women who had significantly higher OASIS (anxiety) scores (β = .530, p < .001), PHQ9 (depression) scores (β = .496, p < .001), and EPDS (postpartum depression and anxiety) scores (β = .585, p < .001) also had elevated total PSQI scores after adjustment for covariates, including prenatal depression and anxiety scores. Though inferences about causality are not feasible, these results support emerging research showing sleep quality is a risk factor for negative maternal affect in the postpartum period. Assessment of maternal sleep hygiene is worth consideration as a component of identifying women at risk for postpartum depression and anxiety.
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Abbreviations
- PSQI:
-
Pittsburgh Sleep Quality Index
- PHQ9:
-
Patient Health Questionnaire -9-item
- EPDS:
-
Edinburgh Postnatal Depression Scale
- OASIS:
-
Overall Anxiety Severity and Impairment Scale
- SCID:
-
Structured Clinical Interview for DSM-5
References
Abeysena, C., & Jayawardana, P. (2011). Sleep deprivation, physical activity and low income are risk factors for inadequate weight gain during pregnancy: A cohort study. Journal of Obstetrics and Gynaecology Research, 37, 734–740.
Alvaro, P. K., Roberts, R. M., & Harris, J. K. (2013). A systematic review assessing bidirectionality between sleep disturbances, anxiety, and depression. Sleep, 36, 1059–1068.
American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (DSM-V). (Fifth Edition, Text Revision ed.) Washington, DC: American Psychiatric Association.
Bei, B., Milgrom, J., Ericksen, J., Trinder, J. (2010). Subjective perception of sleep, but not its objective quality, is associated with immediate postpartum mood disturbances in healthy women. Sleep, 33(4), 531–538.
Blair, L. M., Porter, K., Leblebicioglu, B., & Christian, L. M. (2015). Poor sleep quality and associated inflammation predict preterm birth: Heightened risk among african americans. Sleep, 38, 1259–1267.
Breslau, N., Roth, T., Rosenthal, L., & Andreski, P. (1996). Sleep disturbance and psychiatric disorders: A longitudinal epidemiological study of young adults. Biological Psychiatry, 39, 411–418.
Buysse, D. J., Reynolds, C. F., Monk, T. H., Berman, S. R., & Kupfer, D. J. (1989). The Pittsburgh Sleep Quality Index: A new instrument for psychiatric practice and research. Psychiatry Research, 28, 193–213.
Cox, J. L., Holden, J. M., & Sagovsky, R. (1987). Detection of postnatal depression. Development of the 10-item Edinburgh Postnatal Depression Scale. British Journal of Psychiatry, 150, 782–786.
Creti, L., Libman, E., Rizzo, D., Fichten, C. S., Bailes, S., Tran, D. L., et al. (2017). Sleep in the Postpartum: Characteristics of First-Time, Healthy Mothers. Sleep Disorders, 2017, 8520358.
Dautovich, N. D., McCrae, C. S., & Rowe, M. (2008). Subjective and objective napping and sleep in older adults: Are evening naps “bad” for nighttime sleep? Journal of the American Geriatrics Society., 56, 1681–1686.
Davidson, J. R. (2009). Insomnia treatment options for women. Obstetrics and Gynecology Clinics of North America, 36, 831–851.
Ebert, R. M., Wood, A., & Okun, M. L. (2015). Minimal effect of daytime napping behavior on nocturnal sleep in pregnant women. Journal of Clinical Sleep Medicine, 11, 635–643.
First, M. B., Gibbon, M., Spitzer, R. L., & Williams, J. B. W. (1996). User’s Guide for the Structured Interview for DSM-IV Axis I Disorders—Research Version (SCID-1, version 2.0, February 1996 final version). New York: Biometrics Research.
Ford, D. E., & Cooper-Patrick, L. (2001). Sleep disturbances and mood disorders: An epidemiologic perspective. Depression and Anxiety, 14, 3–6.
Gavin, N. I., Gaynes, B. N., Lohr, K. N., Meltzer-Brody, S., Gartlehner, G., & Swinson, T. (2005). Perinatal depression: A systematic review of prevalence and incidence. Obstetrics and Gynecology, 106, 1071–1083.
Goyal, D., Gay, C. L., & Lee, K. A. (2007). Patterns of sleep disruption and depressive symptoms in new mothers. Journal of Perinatal and Neonatal Nursing, 21, 123–129.
Hays, J. C., Blazer, D. G., & Foley, D. J. (1996). Risk of napping: excessive daytime sleepiness and mortality in an older community population. Journal of the American Geriatrics Society, 44, 693–698.
Jomeen, J., & Martin, C. R. (2007). Replicability and stability of the multidimensional model of the Edinburgh Postnatal Depression Scale in late pregnancy. Journal of Psychiatric and Mental Health Nursing, 14, 319–324.
Kendler, K. S., Neale, M. C., Kessler, R. C., Heath, A. C., & Eaves, L. J. (1993). A longitudinal twin study of 1-year prevalence of major depression in women. Archives of General Psychiatry, 50, 843–852.
Krawczak, E. M., Minuzzi, L., Hidalgo, M. P., & Frey, B. N. (2016). Do changes in subjective sleep and biological rhythms predict worsening in postpartum depressive symptoms?. Archives of Womens Mental Health: A prospective study across the perinatal period.
Kroenke, K., Spitzer, R. L., & Williams, J. B. (2001). The PHQ-9: Validity of a brief depression severity measure. Journal of General Internal Medicine, 16, 606–613.
Lewis, B. A., Gjerdingen, D., Schuver, K., Avery, M., & Marcus, B. H. (2018). The effect of sleep pattern changes on postpartum depressive symptoms. BioMed Central Womens Health, 18, 12.
Logsdon, M. C., Wisner, K. L., & Pinto-Foltz, M. D. (2006). The impact of postpartum depression on mothering. Journal of Obstetric, Gynecologic, and Neonatal Nursing, 35, 652–658.
Luke, B. (2005). The evidence linking maternal nutrition and prematurity. Journal of Perinatal Medicine, 33, 500–505.
Manea, L., Gilbody, S., & McMillan, D. (2012). Optimal cut-off score for diagnosing depression with the Patient Health Questionnaire (PHQ-9): a meta-analysis. Canadian Medical Association Journal, 184, E191–E196.
Mcbean, A. L., & Montgomery-Downs, H. E. (2015). Diurnal fatigue patterns, sleep timing, and mental health outcomes among healthy postpartum women. Biological Research for Nursing, 17, 29–39.
Misri, S., Kendrick, K., Oberlander, T. F., Norris, S., Tomfohr, L., Zhang, H., et al. (2010). Antenatal depression and anxiety affect postpartum parenting stress: A longitudinal, prospective study. Canadian Journal of Psychiatry, 55, 222–228.
Misri, S., & Swift, E. (2015). Generalized anxiety disorder and major depressive disorder in pregnant and postpartum women: maternal quality of life and treatment outcomes. Journal of Obstetrics and Gynaecology Canada, 37, 798–803.
Moehler, E., Brunner, R., Wiebel, A., Reck, C., & Resch, F. (2006). Maternal depressive symptoms in the postnatal period are associated with long-term impairment of mother–child bonding. Archives of Womens Mental Health, 9, 273–278.
Murray, L., & Carothers, A. D. (1990). The validation of the Edinburgh Post-natal Depression Scale on a community sample. British Journal of Psychiatry, 157, 288–290.
Norman, S. B., Cissell, S. H., Means-Christensen, A. J., & Stein, M. B. (2006). Development and validation of an Overall Anxiety Severity And Impairment Scale (OASIS). Depression and Anxiety, 23, 245–249.
Okun, M. L., & Coussons-Read, M. E. (2007). Sleep disruption during pregnancy: How does it influence serum cytokines? Journal of Reproductive Immunology, 73, 158–165.
Okun, M. L., Hall, M., & Coussons-Read, M. E. (2007). Sleep disturbances increase interleukin-6 production during pregnancy: Implications for pregnancy complications. Reproductive Science, 14, 560–567.
Okun, M. L., Hanusa, B. H., Hall, M., & Wisner, K. L. (2009). Sleep complaints in late pregnancy and the recurrence of postpartum depression. Behavioral Sleep Medicine, 7, 106–117.
Okun, M. L., Luther, J., Prather, A. A., Perel, J. M., Wisniewski, S., & Wisner, K. L. (2011). Changes in sleep quality, but not hormones predict time to postpartum depression recurrence. Journal of Affective Disorders, 130, 378–384.
Okun, M. L., Luther, J. F., Wisniewski, S. R., & Wisner, K. L. (2013). Disturbed sleep and inflammatory cytokines in depressed and nondepressed pregnant women: An exploratory analysis of pregnancy outcomes. Psychosomatic Medicine, 75, 670–681.
Perlis, M. L., Giles, D. E., Buysse, D. J., Tu, X., & Kupfer, D. J. (1997). Self-reported sleep disturbance as a prodromal symptom in recurrent depression. Journal of Affective Disorders, 42, 209–212.
Qiu, C., Gelaye, B., Zhong, Q. Y., Enquobahrie, D. A., Frederick, I. O., & Williams, M. A. (2016). Construct validity and factor structure of the Pittsburgh Sleep Quality Index among pregnant women in a Pacific-Northwest cohort. Sleep and Breathing, 20, 293–301.
Saxbe, D. E., Schetter, C. D., Guardino, C. M., Ramey, S. L., Shalowitz, M. U., Thorp, J., et al. (2016). Sleep quality predicts persistence of parental postpartum depressive symptoms and transmission of depressive symptoms from mothers to fathers. Annals of Behavioral Medicine, 50, 862–875.
Sharkey, K. M., Pearlstein, T. B., & Carskadon, M. A. (2013). Circadian phase shifts and mood across the perinatal period in women with a history of major depressive disorder: A preliminary communication. Journal of Affective Disorders, 150, 1103–1108.
Spielberger, C. D., Gorsuch, R. L., & Lushene, R. E. (1970). Manual for the State-Trait Anxiety Inventory (Form Y). Palo Alto, CA: Consulting Psychologists Press.
Suzuki, S., Dennerstein, L., Greenwood, K. M., Armstrong, S. M., Sano, T., & Satohisa, E. (1993). Melatonin and hormonal changes in disturbed sleep during late pregnancy. Journal of Pineal Research, 15, 191–198.
Taylor, D. J., Lichstein, K. L., Weinstock, J., Sanford, S., & Temple, J. R. (2007). A pilot study of cognitive-behavioral therapy of insomnia in people with mild depression. Behavioral Therapy, 38, 49–57.
Teran-Perez, G., Arana-Lechuga, Y., Esqueda-Leon, E., Santana-Miranda, R., Rojas-Zamorano, J. A., & Velazquez, M. J. (2012). Steroid hormones and sleep regulation. Mini Reviews in Medicinal Chemistry, 12, 1040–1048.
Tham, E., Liu, J., Innis, S., Thompson, D., Gaylinn, B. D., Bogarin, R., et al. (2009). Acylated ghrelin concentrations are markedly decreased during pregnancy in mothers with and without gestational diabetes: relationship with cholinesterase. American Journal of Physiology, Endocrinology and Metabolism, 296, E1093–E1100.
Tham, E. K., Tan, J., Chong, Y. S., Kwek, K., Saw, S. M., Teoh, O. H., et al. (2016). Associations between poor subjective prenatal sleep quality and postnatal depression and anxiety symptoms. Journal of Affective Disorders, 202, 91–94.
Tomfohr, L. M., Buliga, E., Letourneau, N. L., Campbell, T. S., & Giesbrecht, G. F. (2015). Trajectories of sleep quality and associations with mood during the perinatal period. Sleep, 38, 1237–1245.
Tomfohr-Madsen, L. M., Clayborne, Z. M., Rouleau, C. R., & Campbell, T. S. (2017). Sleeping for two: An open-pilot study of cognitive behavioral therapy for insomnia in pregnancy. Behavioral Sleep Medicine, 15, 377–393.
Tsuno, N., Besset, A., & Ritchie, K. (2005). Sleep and depression. Journal of Clinical Psychiatry, 66, 1254–1269.
Wirz-Justice, A. (2006). Biological rhythm disturbances in mood disorders. International Clinical Psychopharmacology, 21, S11–S15.
Wisner, K. L., Chambers, C., & Sit, D. K. (2006). Postpartum depression: A major public health problem. Journal of the American Medical Association, 296, 2616–2618.
Wolfson, A. R., Crowley, S. J., Anwer, U., & Bassett, J. L. (2003). Changes in sleep patterns and depressive symptoms in first-time mothers: Last trimester to 1-year postpartum. Behavioral Sleep Medicine, 1, 54–67.
Zhong, Q. Y., Gelaye, B., Sanchez, S. E., & Williams, M. A. (2015). Psychometric Properties of the Pittsburgh Sleep Quality Index (PSQI) in a Cohort of Peruvian Pregnant Women. Journal of Clinical Sleep Medicine, 11, 869–877.
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NIH (R01 HD073491: MPI Coussons-Read & Dunkel Schetter).
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Michele L. Okun, Roberta A. Mancuso, Calvin J. Hobel, Chris Dunkel Schetter and Mary Coussons-Read declare that they have no conflicts of interest.
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All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. Informed consent was obtained from all patients for being included in the study.
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Okun, M.L., Mancuso, R.A., Hobel, C.J. et al. Poor sleep quality increases symptoms of depression and anxiety in postpartum women. J Behav Med 41, 703–710 (2018). https://doi.org/10.1007/s10865-018-9950-7
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DOI: https://doi.org/10.1007/s10865-018-9950-7