Insomnia treatment in the third trimester of pregnancy reduces postpartum depression symptoms: a randomized clinical trial

Managing Sleep Disorders during Pregnancy

Sleep disturbances and disorders are common during pregnancy, and they can be risk factors for a number of serious pregnancy-related sleep disorders. These include postpartum depression, pregnancy-induced hypertension, gestational diabetes, and intrauterine growth retardation. In addition, certain chronic sleep disorders, such as narcolepsy, are quite challenging to manage in the context of pregnancy and during lactation, particularly with medications that can be teratogenic. This review discusses 4 common sleep disorders and their impacts on pregnancy, and suggests ways to deal with these disorders that improves maternal and fetal outcomes safely. The review discusses diagnosis and treatment of obstructive sleep apnea, restless legs syndrome, insomnia, and narcolepsy in pregnancy.

Selective serotonin reuptake inhibitors for depression in pregnancy

Perinatal depression is associated with a high risk of morbidity and mortality and may have long-term consequences on child development. The US Preventive Services Task Force has recently recognized the importance of identifying and treating women with depression in the perinatal period. However, screening and accessing appropriate treatment come with logistical challenges. In many areas, there may not be sufficient access to psychiatric care, and, until these resources develop, the burden may inadvertently fall on obstetricians. As a result, understanding the risks of perinatal depression in comparison with the risks of treatment is important. Many studies of selective serotonin reuptake inhibitors in pregnancy fail to control for underlying depressive illness, which can lead to misinterpretation of selective serotonin reuptake inhibitor risk by clinicians. This review discusses the risks and benefits of selective serotonin reuptake inhibitor treatment in pregnancy within the context of perinatal depression. Whereas selective serotonin reuptake inhibitors may be associated with certain risks, the absolute risks are low and may be outweighed by the risks of untreated depression for many women and their offspring.

Associations between poor subjective prenatal sleep quality and postnatal depression and anxiety symptoms

BACKGROUND

Symptoms of depression and anxiety are common during pregnancy and the postnatal period. A risk factor for mood disorders is poor sleep quality. In this study we investigate the effects of poor subjective prenatal sleep quality on postnatal depressive and anxiety symptoms, independent of prenatal depression or anxiety, amongst pregnant women in the general population.

METHODS

We analysed data from a subset of women taking part in a prospective cohort study, Growing Up in Singapore towards Healthy Outcomes. The participants completed the Edinburgh Postnatal Depression Scale and State-Trait Anxiety Inventory between 26 and 28 weeks of pregnancy (Time 1) and at 3 months postpartum (Time 2), and the Pittsburgh Sleep Quality Index at Time 1. Logistic regression analyses were used to investigate the associations between subjective prenatal sleep quality and postnatal depressive and anxiety symptoms, while adjusting for prenatal depressive/anxiety symptoms and education.

RESULTS

Although borderline-high depressive/anxiety symptoms were the strongest predictors of postnatal depressive/anxiety, independent of this, poor subjective sleep quality during pregnancy was also associated with borderline-high postnatal depressive symptoms, but not with postnatal anxiety.

LIMITATIONS

Sleep quality and prenatal/postnatal mood were derived from self-reported questionnaires, which may be more susceptible to bias.

CONCLUSION

Although treatment of symptoms of prenatal depression and anxiety will be the most important for reducing postnatal depression and anxiety, in addition to that, future studies may explore treatments improving prenatal sleep quality, particularly for women with antenatal depressive symptoms.

Prazosin for Trauma Nightmares and Sleep Disturbances in Combat Veterans with Post-Traumatic Stress Disorder

Background

Prazosin is significantly effective to reduce sleep disturbance and trauma nightmare in patients with post-traumatic stress disorder (PTSD); however, results of different studies were evaluated.

Objectives

The current randomized clinical trial aimed to assess the effects of prazosin on sleep parameters and nightmares among veterans with chronic PTSD.

Materials and Methods

Thirty-two veterans with chronic war-induced PTSD and distressing nightmares were randomized into prazosin and placebo groups for eight weeks. The main symptoms were qualified using the recurrent distressing dreams item of the clinician administered PTSD scale (CAPS) and the daytime symptom severity was measured by PTSD checklist (PCL) and the objective sleep quality assessment by actigraphy.

Results

Compared with placebo, prazosin had no significant effects on reduction of daytime symptoms (P = 0.69) and frequency and intensity of trauma-related nightmares. Also, there were no significant differences between pre- and post-treatment actigraphy measurements (P > 0.05).

Conclusions

The study findings showed that prazosin had no significant effect on reduction of PTSD symptoms as well as nightmares among veterans with chronic PTSD. Further clinical trials are needed to define the effect of prazosin on sleep physiology and whether such effects regarding the therapeutic response.

Insomnia and sleep deficiency in pregnancy

Insomnia and sleep deficiency in pregnancy are very common with most women reporting sleep disturbances during pregnancy. Insomnia and sleep deficiency are also more prevalent as pregnancy progresses, possibly related to pregnancy-related physical symptoms or discomfort. There is increasing evidence indicating that these sleep problems may be associated with adverse maternal and fetal outcomes such as depressive symptoms, increased pain during labor, more Caesarean sections, preterm birth, and low birth weight. Treatment of insomnia remains challenging as some of the more commonly used sleep inducing medications such as benzodiazepines and hypnotic benzodiazepine receptor agonists may be associated with adverse neonatal outcomes. Nonpharmacological treatments such as cognitive behavioral therapy are available but the data in pregnancy is often lacking.

The relationship between sleep and postpartum mental disorders: A systematic review

BACKGROUND

Postpartum mental disorders (e.g., anxiety, depression, psychosis) are serious conditions that affect approximately 10-15% of women after childbirth, and up to 40% of women at risk for these disorders. Research reveals an association between poor sleep quality/quantity and symptoms of anxiety, depression and psychosis. The aim of this systematic review was to evaluate the available evidence for the relationship between sleep and postpartum mental disorders.

METHODS

Searches included MEDLINE, EMBASE, and EBM Reviews - Cochrane Central Register of Controlled Trials, PsycINFO and EBSCOHost CINAHL through June 30, 2014. Manual searching was performed on reference lists of included articles. Published primary research in any language was included.

RESULTS

There were 3187 unique titles/abstracts and 44 full-text articles reviewed. Thirty-one studies were included. Evidence was found for the impact of self-reported poor sleep during pregnancy and the postpartum on the development of postpartum depression, with not enough evidence for either postpartum anxiety or psychosis. The evidence for objectively assessed sleep and the development of postpartum disorders was mixed. Among the 31 studies included, 1 was strong, 13 were moderate and 17 were weak.

LIMITATIONS

Research design, method of assessment, timing of assessment, recruitment strategies, representative adequacy of the samples and inclusion/exclusion criteria all varied widely. Many studies did not use tools validated for the perinatal population and had small sample sizes without power analysis.

CONCLUSIONS

Sleep interventions represent a potential low-cost, non-pharmacological prevention and treatment strategy for postpartum mental illness. Further high-quality research is needed on this topic area.

A review of sleep-promoting medications used in pregnancy

Approximately 4% of adults who have symptoms of insomnia resort to various hypnotic or sedating medications for acute symptom relief. Although typically a common practice for nonpregnant adults, this is not the case for the thousands of pregnant women who also report substantial sleep issues. Unfortunately, a paucity of randomized controlled trials in this population, scant empiric evidence regarding the appropriateness of prescribing options, and the concern of subsequent teratogenicity restricts the ability of clinicians to make informed decisions. We synthesized the current research regarding hypnotics and sedating medications used (both on- and off-label) during pregnancy and their association with adverse outcomes. Medications that we investigated included benzodiazepines, hypnotic benzodiazepine receptor agonists, antidepressants, and antihistamines. Overall, the examined studies showed no correlation of increased risk of congenital malformations. However, benzodiazepines and hypnotic benzodiazepine receptor agonists may increase rates of preterm birth, low birthweight, and/or small-for-gestational-age infants. The small number of studies and the small number of subjects prohibit any definitive interpretation regarding the consequences of the use of hypnotic or sedating medications in pregnancy. Additional case reports, randomized clinical trials, and epidemiologic studies are needed urgently.

Sleep patterns and sleep disturbances across pregnancy

OBJECTIVE

This study sought to characterize sleep patterns and sleep problems in a large sample of women across all months of pregnancy.

METHODS

A total of 2427 women completed an Internet-based survey that included the Pittsburgh Sleep Quality Index (PSQI), Epworth Sleepiness Scale, vitality scale of the Short Form 36 Health Survey (SF-36), Insomnia Severity Index (ISI), Berlin questionnaire, International Restless Legs Syndrome (IRLS) question set, and a short version of the Pregnancy Symptoms Inventory (PSI).

RESULTS

Across all months of pregnancy, women experienced poor sleep quality (76%), insufficient nighttime sleep (38%), and significant daytime sleepiness (49%). All women reported frequent nighttime awakenings (100%), and most women took daytime naps (78%). Symptoms of insomnia (57%), sleep-disordered breathing (19%), and restless legs syndrome (24%) were commonly endorsed, with no difference across the month of pregnancy for insomnia, sleep-disorder breathing, daytime sleepiness, or fatigue. In addition, high rates of pregnancy-related symptoms were found to disturb sleep, especially frequent urination (83%) and difficulty finding a comfortable sleep position (79%).

CONCLUSIONS

Women experience significant sleep disruption, inadequate sleep, and high rates of symptoms of sleep disorder throughout pregnancy. These results suggest that all women should be screened and treated for sleep disturbances throughout pregnancy, especially given the impact of inadequate sleep and sleep disorders on fetal, pregnancy, and postpartum outcomes.

Poor sleep quality of third-trimester pregnancy is a risk factor for postpartum depression

Background

The aim of this study was to investigate whether poor sleep quality of third-trimester pregnancy is a risk factor for postpartum depression.

Material/Methods

Third-trimester pregnant women (T0, n=293) were tested using the first socio-demographic, Pittsburgh Sleep Quality Index, and Edinburgh Postnatal Depression Scale assessments, and received a diagnosis of depression. Three months (T1, n=223) after delivery, scale filling was finished and the structured interview was performed again.

Results

We found that 73 persons (32.7%) were low income, 84 persons (37.7%) were middle-income, and 66 persons (29.6%) were higher income. The overall prevalence of postpartum depression was 9.4% (21 persons). After controlling for other factors, age, household income, marital satisfaction, and sleep quality were significantly related to postpartum depression, in which age and sleep quality scores (a higher score was associated with poorer sleep quality) were positively related to postpartum depression, and household income and marital satisfaction were negatively related to postpartum depression. Moreover, third-trimester sleep quality score was positively related to postpartum depressive symptoms.

Conclusions

Poor third-trimester subjective sleep quality is a risk factor for postpartum depression.

Consensus clinical practice guidelines for the diagnosis and treatment of restless legs syndrome/Willis-Ekbom disease during pregnancy and lactation

Restless legs syndrome (RLS)/Willis-Ekbom disease (WED) is common during pregnancy, affecting approximately one in five pregnant women in Western countries. Many report moderate or severe symptoms and negative impact on sleep. There is very little information in the medical literature for practitioners on the management of this condition during pregnancy. Accordingly, a task force was chosen by the International RLS Study Group (IRLSSG) to develop guidelines for the diagnosis and treatment of RLS/WED during pregnancy and lactation. A committee of nine experts in RLS/WED and/or obstetrics developed a set of 12 consensus questions, conducted a literature search, and extensively discussed potential guidelines. Recommendations were approved by the IRLSSG executive committee, reviewed by IRLSSG membership, and approved by the WED Foundation Medical Advisory Board. These guidelines address diagnosis, differential diagnosis, clinical course, and severity assessment of RLS/WED during pregnancy and lactation. Nonpharmacologic approaches, including reassurance, exercise and avoidance of exacerbating factors, are outlined. A rationale for iron supplementation is presented. Medications for RLS/WED are risk/benefit rated for use during pregnancy and lactation. A few are rated "may be considered" when RLS/WED is refractory to more conservative approaches. An algorithm summarizes the recommendations. These guidelines are intended to improve clinical practice and promote further research.

PTSD-related paradoxical insomnia: an actigraphic study among veterans with chronic PTSD

Background:

Sleep disturbance is a common self-reported complaint by PTSD patients. However, there are controversies in documenting objective indices of disrupted sleep in these patients. The aim of the present study was to assess sleep disturbances in veterans with chronic PTSD, using both subjective and objective assessments.

Methods:

Thirty two PTSD patients with complaints of insomnia were evaluated using the Clinician Administrated PTSD Scale version 1 (CAPS) and completed the Pittsburg Sleep Quality Index (PSQI) for subjective evaluation of their sleep. For objective evaluation, participants underwent two consecutive overnight actigraphic assessments. Total Sleep Time (TST), Sleep Latency (SL), Sleep Efficiency (SE) and Number of Awakening (NWAK) were measured in all participants.

Results:

Participants underestimated TST (p less than 0.0001), SE (p less than 0.0001) as well as NASO (0.03) in the questionnaire compared to the actigraphic assessment and overestimated SL (p less than 0.0001).

Conclusions:

Objective sleep parameters do not adversely affect veterans with chronic PTSD. Self-reported sleep disturbance in these patients is not reliable and objective sleep assessments are necessary.

Sleep disorders in pregnancy

Sleep disturbances are common in pregnancy and may be influenced by a multitude of factors. Pregnancy physiology may predispose to sleep disruption but may also result in worsening of some underlying sleep disorders, and the de novo development of others. Apart from sleep disordered breathing, the impact of sleep disorders on pregnancy, fetal, and neonatal outcomes is poorly understood. In this article, we review the literature and discuss available data pertaining to the most common sleep disorders in perinatal women. These include restless legs syndrome, insomnia, circadian pattern disturbances, narcolepsy, and sleep-disordered breathing.