Assessment and relationship of sleep quality to depression in early pregnancy

Low socioeconomic status negatively affects sleep in pregnant women

OBJECTIVE

To evaluate the effect of socioeconomic status on measures of sleep quality, continuity, and quantity in a large cohort of pregnant women.

DESIGN

Prospective, longitudinal study.

PARTICIPANTS

One hundred seventy (170) pregnant women at 10-20 weeks gestation.

METHODS

Sleep quality was assessed with the Pittsburgh Sleep Quality Index. Sleep duration and continuity (sleep fragmentation index [SFI]) were assessed with actigraphy at 10-12, 14-16, and 18-20 weeks gestation. Because sleep did not significantly differ across time, averages across all three time points were used in analyses. Socioeconomic status (SES) was defined by self-reported annual household income. Linear regression analyses were used to model the independent associations of SES on sleep after adjusting for age, race, parity, marital status, body mass index (BMI), perceived stress, depressive symptoms, and financial strain.

RESULTS

On average, women reported modestly poor sleep quality (M = 5.4, SD = 2.7), short sleep duration (391 [55.6] min) and fragmented sleep (SFI M = 33.9, SD = 10.4. A household income < $50,000/year was associated with poorer sleep quality (β = -.18, p < 0.05) and greater sleep fragmentation (β = -.18, p < 0.05) following covariate adjustment.

CONCLUSIONS

Low SES was associated with poorer sleep quality and fragmented sleep, even after statistical adjustments. Perceived stress and financial strain attenuated SES-sleep associations indicating that psychosocial situations preceding pregnancy are also important to consider.

Habitual snoring and depressive symptoms during pregnancy

Background

Depression is frequently observed in patients with untreated sleep-disordered breathing (SDB) in the general population. Pregnant women are particularly vulnerable since pregnancy increases the risk of both SDB and depressive symptoms. However, no study has investigated whether SDB symptoms prior to or in early pregnancy are associated with such mood problems.

Methods

A retrospective chart review of pregnant women. Women were included if they attended prenatal clinics between June 2007 and July 2010, were ≥18 years old, pregnant with a single fetus, and had been screened for habitual snoring as well as depressive symptoms using the Edinburgh Postnatal Depression Scales (EPDS).

Results

In total, 362 women were included and 32.3% reported habitual snoring. Twenty-nine percent of women had an EPDS score ≥10. Significantly more snoring women, compared to non-snorers, had an EPDS score ≥10 (42.7% vs. 22.9%, p < 0.001) despite the mean EPDS values not reaching statistical significance (6.1 ± 4.9 vs. 5.4 ± 5.0, p = 0.2). In a logistic regression model controlling for parity, the presence of pre-pregnancy obesity, presence of a partner, sleep quality, African American race, maternal educational level, pre-eclampsia, and diabetes, snoring was independently associated with a prenatal EPDS score ≥10 (O.R. 2.0, 95%CI 1.13-3.46; p = 0.023).

Conclusion

Maternal snoring may be a risk factor for prenatal depressive symptoms. Further investigation of the temporal relationship between maternal snoring and depressive symptoms is warranted.

Psychosocial Characteristics and Gestational Weight Change among Overweight, African American Pregnant Women

Objectives. To describe psychosocial factors identified as contributors of weight gain in the general population and to examine the relationship between these factors and gestational weight gain among low socioeconomic status, African American, overweight pregnant women. Methods. African American women (n = 120) with a pregravid body mass index ≥25 kg/m² completed measures of eating, sleep, and depressed mood between 14 and 24 weeks of gestation. Weight was tracked. Descriptive statistics, correlations, and linear regression modeling were used to characterize the sample and examine predictors of gestational weight gain. Results. Four percent screened positive for night eating syndrome, with 32% consuming at least 25% of their daily caloric intake after dinner (evening hyperphagia). None met criteria for binge eating disorder; 4% reported occasional binge episodes. Cognitive restraint over eating was low. Participants slept 7.1 (SD = 1.9) h per night and reported 4.3 (SD = 3.6) awakenings per week; 18% reported some level of depressed mood. Night and binge eating were related to each other, sleep quality, and depressed mood. Eating due to cravings was the only psychosocial variable to predict gestational weight gain. Conclusions. Depressed mood, night eating, and nighttime awakenings were common in this cohort, while cognitive restraint over eating was low. Most psychosocial variables were not predictive of excess gestational weight gain.

The relationship between sleep and mood in first-time and experienced mothers

Sleep disruption has been suggested to contribute to postpartum mood, but few studies have explored differences in this relationship between nulliparous and multiparous mothers. This study compared the interaction of sleep and mood as a function of parity. Thirty-five nulliparous and 34 multiparous mothers completed questionnaires on mood and sleep, and wore actigraphs for 7 days during the third trimester of pregnancy and within 2 weeks postpartum. Mood and objective sleep were better in multiparas than in nulliparas after delivery. However, other than a stronger association between subjective sleep and stress in nulliparous mothers, the relationship between sleep and mood did not differ significantly between the two groups. This suggests that parity might play only a limited role in the interaction between sleep and mood during the immediate postpartum period.

Short sleep duration, complaints of vital exhaustion and perceived stress are prevalent among pregnant women with mood and anxiety disorders

Background

Psychiatric disorders have been associated with sleep disorders in men and non-pregnant women, but little is known about sleep complaints and disorders among pregnant women with psychiatric disorders.

Methods

A cohort of 1,332 women was interviewed during early pregnancy. We ascertained psychiatric diagnosis status and collect information about sleep duration, daytime sleepiness, vital exhaustion and perceived stress. Logistic regression procedures were used to estimate odds ratios (ORs) and 95% confidence intervals (CIs).

Results

Approximately 5.1% of the cohort (n=68) reported having a physician-diagnosis of mood or anxiety disorder before interview. Compared with women without a psychiatric diagnosis, the multivariable-adjusted OR (95% CI) for short sleep duration in early pregnancy (≤6 hours) were 1.95 (1.03-3.69). The corresponding OR (95%CI) for long sleep duration (≥9 hours) during early pregnancy was 1.13 (0.63-2.03). Women with psychiatric disorders had an increased risk of vital exhaustion (OR=2.41; 95%CI 1.46-4.00) and elevated perceived stress (OR=3.33; 95%CI 1.89-5.88). Observed associations were more pronounced among overweight/obese women.

Conclusions

Women with a psychiatric disorder were more likely to report short sleep durations, vital exhaustion and elevated perceived stress. Prospective studies are needed to more thoroughly explore factors that mediate the apparent mood/anxiety-sleep comorbidity among pregnant women.

Poor sleep quality is associated with preterm birth

STUDY OBJECTIVES

Preterm birth (PTB) is a major public health priority and the most common adverse pregnancy outcome. Several risk factors have been identified, but a gap in the understanding of the underlying etiology of PTB persists. Poor sleep quality is a correlate of adverse health outcomes. Therefore, we evaluated whether sleep quality during pregnancy was a clinically relevant risk factor for PTB.

DESIGN

Observational.

MEASUREMENTS AND RESULTS

Participants included 166 pregnant women (mean age = 28.6 ± 5.5 years). Self-report questionnaires, including the Pittsburgh Sleep Quality Index (PSQI), were administered at 14-16, 24-26, and 30-32 weeks gestation. Logistic regression models were used to evaluate whether sleep quality was associated with preterm delivery. Poor sleep quality was a predictor of preterm birth, with the largest effects in early pregnancy (14-16 weeks) (OR: 1.25 95% CI [1.04-1.50], P = 0.02) and more modest effects in later pregnancy (30-32 weeks) (OR: 1.18 95% CI [0.98-1.42], P = 0.07). With every one-point increase on the PSQI, the odds of preterm birth increase 25% in early pregnancy and 18% in later pregnancy.

CONCLUSIONS

Poor sleep quality, in both early and late pregnancy, is associated with an increased risk of delivering preterm. Currently the specific pathway(s) through which disturbed sleep contributes to PTB are unknown. We suggest that poor sleep may contribute to increased risk for PTB both independently, as well as in conjunction with other established risk factors, such as stress.

Sleep disturbances in depressed and nondepressed pregnant women

BACKGROUND

Sleep disturbances and symptoms of depression are common during pregnancy. Both are independent and interrelated risk factors for adverse outcomes. It is unclear the degree to which sleep differs between depressed and nondepressed pregnant women. We sought to (1) describe and compare sleep disturbances in depressed pregnant and nondepressed pregnant women, (2) determine the impact of selective serotonin reuptake inhibitors (SSRI) treatment on sleep, and (3) evaluate whether sleep at 20 weeks is associated with increased depressive symptoms and major depressive disorder (MDD) in later pregnancy.

METHODS

Pregnant women (N = 240) were recruited in the second trimester (20 weeks gestation) and assigned to depressed (N = 59) and nondepressed (N = 181) groups based on a Structured Clinical Interview for DSM-IV diagnosis of major depressive disorder. The Structured Interview Guide for the Hamilton Rating Scale with Atypical Depression Supplement was administered at 20, 30, and 36 weeks gestation from which the sleep variables were obtained.

RESULTS

Depressed women had more fragmented sleep at each assessment (P values≤.05). However, the frequency of insomnia symptoms was greater for depressed women only at 20 weeks gestation. SSRI use, regardless of MDD status, did significantly affect several sleep variables. Among the nondepressed women, those with short or longer sleep duration, symptoms of insomnia and long periods of nocturnal waketime had higher Structured Interview Guide for the Hamilton Rating Scale with Atypical Depression Supplement scores later in pregnancy (P values≤.05).

CONCLUSIONS

At 20 and 30 weeks gestation sleep was more disturbed in depressed pregnant women compared to nondepressed pregnant women. At 36 weeks, sleep was disturbed regardless of depression status or SSRI use. Among the nondepressed women, disturbed sleep in conjunction with SSRI use was associated with higher depressive symptoms.

Partner relationship satisfaction and maternal emotional distress in early pregnancy

Background

Recognition of maternal emotional distress during pregnancy and the identification of risk factors for this distress are of considerable clinical- and public health importance. The mental health of the mother is important both for herself, and for the physical and psychological health of her children and the welfare of the family. The first aim of the present study was to identify risk factors for maternal emotional distress during pregnancy with special focus on partner relationship satisfaction. The second aim was to assess interaction effects between relationship satisfaction and the main predictors.

Methods

Pregnant women enrolled in the Norwegian Mother and Child Cohort Study (n = 51,558) completed a questionnaire with questions about maternal emotional distress, relationship satisfaction, and other risk factors. Associations between 37 predictor variables and emotional distress were estimated by multiple linear regression analysis.

Results

Relationship dissatisfaction was the strongest predictor of maternal emotional distress (β = 0.25). Other predictors were dissatisfaction at work (β = 0.11), somatic disease (β = 0.11), work related stress (β = 0.10) and maternal alcohol problems in the preceding year (β = 0.09). Relationship satisfaction appeared to buffer the effects of frequent moving, somatic disease, maternal smoking, family income, irregular working hours, dissatisfaction at work, work stress, and mother's sick leave (P < 0.05).

Conclusions

Dissatisfaction with the partner relationship is a significant predictor of maternal emotional distress in pregnancy. A good partner relationship can have a protective effect against some stressors.

A prospective investigation of the relationships among sleep quality, physical symptoms, and depressive symptoms during pregnancy

The aim of this study was to examine the prospective relationship between pregnancy physical discomforts experienced during the second trimester and late pregnancy depressive symptoms, as well as the mediating effect of sleep quality on antenatal depressive symptomatology. Healthy pregnant women (N=257) completed the Physical Symptoms Questionnaire, the Beck Depression Inventory, and the Pittsburgh Sleep Inventory at early-mid second trimester, and then again at late third trimester. Physical symptoms and sleep quality at the first time point were both correlated moderately with depressive symptoms at late pregnancy. Discomfort associated with physical symptoms was a better predictor of depressive symptoms than Frequency of symptoms, although a score combining Frequency, Discomfort and Effect of symptoms on life was the strongest predictor of depressive symptoms. Results of the hierarchical regression analyses of the mediation model indicated that physical symptoms at early-mid second trimester predicted depressive symptoms in the last trimester both directly, and via poor sleep quality (prospectively), which mediated the relationship. The clinical implications of these findings for antenatal care are discussed.

Influencing Factors on Antenatal Depression

PURPOSE

This study examined the influencing factors on antenatal depression among pregnant women.

METHODS

This was a cross sectional descriptive study with 255 pregnant women who visited a general hospital in a metropolitan city for their regularly scheduled check-up. Measurement tools employed were the Korean version of Beck Depression Inventory (BDI), the food habits, and the Pittsburg Sleep Quality Index (PSQI). Socio-demographic variables and the status of high risk pregnancy were identified. Influencing factors on antenatal depression were identified using a stepwise multiple regression analysis.

RESULTS

The mean score of antenatal depression was 7.2 +/- 5.0; 18.4% with mild depression, 5.9% had moderate depression, with 0.8% identified with severe depression on BDI scale. Influencing factors on antenatal depression accounted for 47.8% of the total variance which consisted of quality of sleep, marital satisfaction, food habits, gestation periods, sexual satisfaction, high risk pregnancy, and age.

CONCLUSION

Findings show that antenatal depression should be monitored on a regular basis during early pregnancy and in high risk pregnancy if possible, and quality of sleep and food habits should be incorporated in the management of antenatal depression.

Obstructive sleep apnea is more common than central sleep apnea in methadone maintenance patients with subjective sleep complaints

OBJECTIVES

Opioid-dependent patients treated with methadone have subjective sleep complaints and disrupted sleep on polysomnography (PSG). Previous studies of sleep-disordered breathing (SDB) in this population have focused on central sleep apnea (CSA). Our objectives were to: (1) characterize obstructive sleep apnea (OSA) and CSA in patients in methadone maintenance treatment (MMT) for opioid dependence; (2) examine factors associated with SDB in this population; and (3) investigate whether SDB was related to severity of subjective sleep complaints in MMT patients with subjective sleep disturbances.

METHODS

We analyzed OSA and CSA from one night of home PSG in 71 patients who were in MMT for at least 3 months and had a Pittsburgh Sleep Quality Inventory (PSQI) score >5.

RESULTS

OSA (defined as obstructive apnea-hypopnea index (OAHI) > or = 5) was observed in 35.2% of our sample. OSA was associated with higher body mass index, longer duration in MMT, and non-Caucasian race. CSA (defined as central apnea index (CAI) > or = 5) was observed in 14.1% of the sample. CSA was not associated with methadone dose or concomitant drug use. Subjective sleep disturbance measured with the PSQI was not related to OSA or CSA.

CONCLUSIONS

SDB was common in this sample of MMT patients and OSA was more common than CSA. Given the lack of association between presence of SDB and severity of subjective sleep difficulties, factors other than sleep apnea must account for complaints of disturbed sleep in this population.

The utility of the Illness Perception Questionnaire in the evaluation of mental health practitioners' perspectives on patients with schizophrenia

RATIONALE, AIMS, OBJECTIVES: The Illness Perception Questionnaire (IPQ) was designed as a measure of illness perception and has been used extensively for measuring the perceptions of people with physical illness. Latterly modified versions of the IPQ have been used to measure the illness perceptions of people with mental health problems and their carers. This study examined the utility of a modified version of the IPQ to measure changes in mental health practitioners' illness perceptions about schizophrenia after undertaking psychosocial intervention training.

METHOD

A total of 245 mental health practitioners who undertook psychosocial intervention training completed a modified version of the IPQ before and after training. The structure of the questionnaire was tested using confirmatory factor analysis. The internal consistency of sub-scales embedded in the instrument was also examined.

RESULTS

The hypothesized structure failed to account for the data. Model fit indices revealed a poor fit to the data across all models evaluated. Cronbach's alpha revealed a number of sub-scales in the instrument to have mediocre internal consistency characteristics.

CONCLUSIONS

The modified version of the IPQ is not suitable for evaluating the impact of psychosocial intervention training on changes in illness perceptions of schizophrenia in mental health practitioners. However, the study has highlighted the need to develop a valid and reliable measure to assess the illness perceptions health professionals have of patients in their care.

Validation of a perceptions of care adjective checklist

BACKGROUND

This study describes the psychometric characteristics, validity and reliability of the revised version of the perceptions of care adjective checklist (PCACL-R) with women who had recently given birth. Data were collected from a national survey of women's experiences of maternity care (n = 2960).

METHODS

Internal consistency, predictive validity, convergent validity, discriminant validity and confirmatory factor analyses were applied to the data.

RESULTS

Confirmatory factor analysis revealed an excellent fit to a bi-dimensional structure entirely consistent with the negative and positive valencing of adjectives in the measure, supporting the use of the instrument as a two subscale tool comprising positive and negative subscales. The PCACL-R revealed good convergent validity against measures of satisfaction with care and excellent divergent validity characteristics assessed against duration of labour. Discriminant validity was assessed against measures of area-based maternal deprivation, partner status and type of delivery. These analyses revealed commendable discriminant validity of the PCACL-R. Internal consistency characteristics of the positive and negative subscales of the PCACL-R were acceptable. The predictive validity of the PCACL-R was also found to be excellent.

CONCLUSION

The PCACL-R is consequently recommended as a valid, reliable, respondent acceptable and easy to administer instrument to assess women's experiences of their care during labour and childbirth. The measurement characteristics of the PCACL-R suggest that the tool could be incorporated into both clinical and research contexts with confidence. The checklist terms used are applicable to other phases of maternity care and indeed to a wide range of health care contexts. Exploratory use in with other user groups is recommended.

Depression and anxiety through pregnancy and the early postpartum: an examination of prospective relationships

BACKGROUND

The aim of this study was to explore the prospective relationship between depressive symptoms and anxiety across pregnancy and the early postpartum.

METHODS

Participants (N=207) completed the State-Trait Anxiety Inventory Trait subscale, Beck Depression Inventory, and social support and sleep quality measures at two time points during pregnancy and once in the early postpartum period.

RESULTS

After accounting for the relative stability of anxiety and depression over time, depressive symptoms earlier in pregnancy predicted higher levels of anxiety in late pregnancy and anxiety in late pregnancy predicted higher depressive symptomatology in the early postpartum. A bi-directional model of depression and anxiety in pregnancy was supported.

LIMITATIONS

Data were based on self-reports and participating women were predominantly tertiary educated with high family incomes.

CONCLUSION

Our findings suggest that depressive symptoms precede the development of higher levels of anxiety and that anxiety, even at non-clinical levels, can predict higher depressive symptoms. Clinicians are advised to screen for anxiety and depression concurrently during pregnancy.

Sleep complaints in late pregnancy and the recurrence of postpartum depression

This study evaluated the relationship between sleep quality in late pregnancy and recurrence of postpartum major depression (PPMD) through 28 weeks postpartum. The Pittsburgh Sleep Quality Index (PSQI) at 36 weeks gestation was assessed in 51 non-depressed women with a history of PPMD; recurrence was determined by the 21-item Hamilton Rating Scale for Depression and the Schedule for Affective Disorders and Schizophrenia. Sleep quality in late pregnancy was not related to recurrence per se, but it was related to timing of recurrence (Kruskal-Wallace = 9.78, p = .008). Rapid recurrence (within 4 weeks post delivery) was preceded by fewer sleep complaints (mean PSQI for early recurrers = 4.8 vs. 7.3 for non-recurrers, p = .09). Recurrence after 4 weeks postpartum was preceded by more sleep complaints in late pregnancy (mean PSQI for late recurrers = 9.9 vs. 7.3 for non-recurrers, p = .02). Sleep quality in late pregnancy may help in identifying women at risk for a PPMD recurrence.