Depression and suicidal ideation in pregnancy: exploring relationships with insomnia, short sleep, and nocturnal rumination

Emotion regulation strategies and perceived stress during pregnancy in expectant mothers and fathers

BACKGROUND

Stress during pregnancy can increase physical and mental health risks in parents and offspring. Emotion regulation (ER) may protect against prenatal stress; however, ER is understudied in expectant parents, particularly expectant fathers. This study aimed to evaluate associations between ER strategies (reappraisal, suppression, ratio of suppression-to-reappraisal) and perceived stress among expectant parents, and also test whether expectant mothers and fathers differed in ER strategy use and perceived stress levels.

METHODS

N = 83 expectant parents (62.7% mothers) in the third trimester completed measures assessing perceived stress,reappraisal, and suppression. ANCOVA, hierarchical regression, and multilevel models were used to evaluate associations between ER strategies and perceived stress, and test for sex differences.

RESULTS

Controlling for age and education, lower reappraisal and higher suppression were associated with higher perceived stress; in addition, higher suppression-to-reappraisal ratios were associated with greater perceived stress. Mothers and fathers did not differ in perceived stress, reappraisal, or suppression; however, suppression-to-reappraisal ratios significantly differed.

CONCLUSION

Increasing ER skills such as reappraisal while reducing suppression may be beneficial for decreasing stress in expectant parents. Expectant fathers report similar levels of perceived stress to mothers and would benefit from prenatal mental health screening and intervention.

"Finding my voice again" - women's experiences of psychological therapy in perinatal secondary care settings: a qualitative study

Introduction

Although women often experience mental health comorbidities in the perinatal period, the evidence-base for psychological therapy across diagnostic boundaries in the perinatal period remains limited. As there is a need to understand experiences of therapy, irrespective of diagnosis, to inform intervention provision, the aims of this study were to explore women's experiences of psychological therapy for perinatal mental health difficulties and to identify the mechanisms that women attributed to the most significant therapeutic change for themselves and/or the mother-infant relationship.

Method

Semi-structured interviews were conducted with 16 women who received therapy within specialist perinatal community mental health settings in the Northwest of England, the UK. Interview data were analysed using reflexive thematic analysis.

Results

One overarching theme entitled participant life stories were at the heart of therapy was identified alongside three other main themes: 1.) We're in this together - therapeutic bond and establishing a coherent sense of self, 2.) Surfing the urge to 'fix' feelings - Sitting with emotions improved regulation and 3.) Seeing myself in a new light - Shifting self-blame to self-compassion enhanced self-efficacy. Theme 1 consisted of three subthemes. Participants described the quality of the therapeutic relationship as the fundamental foundation to (re)connecting with their needs, values and boundaries, which improved their sense of agency, self-esteem, therapeutic engagement and self-understanding. Shifting emotional avoidance to emotional engagement improved their self-regulation. Considering alternative factors that could have contributed to their experiences helped them to defuse self-blame and enhance self-compassion. Finally, changes in their mental health led to positive relational changes in their relationship with their infant and improved communication with partners.

Discussion

Sensitivity, engagement and responsivity experienced in the therapist-woman relationship was reported to be mirrored in the mother-infant relationship. Developing a coherent sense of self and self-regulation skills both appeared to heighten women's self-compassion and empathy for their infants, which also seemed to improve their ability to tolerate uncertainty and mixed emotions within themselves and their infants. The mechanisms of change in the perinatal period are important to consider at a stakeholder, therapist and service management level to parsimoniously and best meet the needs of women and the mother-infant relationship.

Sleep and depression in couples during the transition to parenthood

OBJECTIVES

The objectives were to: (1) investigate the prevalence, differences and changes in sleep quality over time among Chinese couples during pregnancy and at 6 weeks and 6 months postpartum and (2) examine the association between sleep quality and depressive symptoms.

METHOD

This study was part of an intervention study for postnatal depression. Childbearing couples were recruited from antenatal clinics. Data on sleep and depression during pregnancy and at 6 weeks and 6 months postpartum were collected using the Pittsburgh Sleep Quality Index (PSQI) and Edinburgh Postnatal Depression Scale, respectively.

RESULTS

The prevalence of sleep disturbance (PSQI score > 5) during pregnancy and at 6 weeks and 6 months postpartum was 45.0%, 62.8% and 36.8%, respectively, among women and 26.4%, 36.4% and 27.3%, respectively, among men. Sleep quality declined significantly in both partners from pregnancy to 6 weeks postpartum, followed by a significant improvement by 6 months postpartum. The results revealed significant correlations between partners' scores on sleep quality across the perinatal period, with women experiencing poorer sleep quality than men. Poor sleep was associated with depressive symptoms across the perinatal period for both partners.

CONCLUSIONS

This study highlights the importance of screening couples for sleep disturbances throughout pregnancy and the postnatal period and assisting them to develop strategies to improve sleep quality during the transition to parenthood.

Dynamic Associations Among Sleep, Emotion Dysregulation, and Desire to Live in a Perinatal Sample

OBJECTIVE

The present study prospectively examined dynamic associations among sleep, emotion dysregulation, and desire to live during the perinatal transition, as it was theorized that these factors may contribute to the emergence of postpartum suicide risk.

METHOD

Ninety-four women ( Mage = 29.2 years; 23.4% Latina) wore wrist actigraphs and completed twice daily surveys for 7 days during the third trimester of pregnancy, 6 weeks postpartum, and 4 months postpartum. Multilevel, change-as-outcome models were built to examine changes in attractor dynamics among sleep, emotion dysregulation, and desire to live, as well as if sleep-emotion dysregulation dynamics differed based on participants' desires to live.

RESULTS

From pregnancy to 6 weeks postpartum, emotion dysregulation ( B = -0.09, p = .032) and desire to live ( B = -0.16, p < .001) exhibited more stable temporal patterns around higher emotion dysregulation and lower desire to live. Compared to women who reported consistently high desires to live, those who experienced fluctuations in their desires to live exhibited lower, more stable sleep efficiency during pregnancy ( B = -0.90, p < .001). At 4 months postpartum, those with fluctuating desires to live exhibited a coupling dynamic whereby low sleep efficiency predicted increases in emotion dysregulation ( B = -0.16, p = .020).

CONCLUSIONS

This study was the first to examine nonlinear dynamics among risk factors for postpartum suicide, which may be evident as early as pregnancy and 6 weeks postpartum. Sleep health, in particular, warrants further exploration as a key susceptibility factor in the emergence of postpartum suicide risk.

PREREGISTRATION

Open Science Framework ( https://osf.io/qxb75/?view_only=799ffe5c048842dfb89d3ddfebaa420d ).

Insomnia, poor sleep quality and perinatal suicidal risk: A systematic review and meta-analysis

Suicidal risk in mothers is a public health priority. Risk factors include biological, psychological and psychosocial factors. Among the biological factors, the role of sleep disturbances as potential contributors to increased suicidal risk during the peripartum period is becoming apparent. To explore this further, we conducted a systematic review following the PRISMA criteria. Currently, 10 studies have examined the role of insomnia and poor sleep quality in suicidal risk during the peripartum period and have involved 807,760 women. The data showed that disturbed sleep and poor sleep quality increase the risk of suicidal ideation in both pregnant women with and without perinatal depression. The results of the meta-analysis indicated that insomnia and poor sleep quality increase the odds of suicidal risk in pregnant women by more than threefold (OR = 3.47; 95% CI: 2.63-4.57). Specifically, the odds ratio (OR) for poor sleep quality was 3.72 (95% CI: 2.58-5.34; p < 0.001), and for insomnia symptoms, after taking into account perinatal depression, was 4.76 (95% CI: 1.83-12.34; p < 0.001). These findings emphasise the importance of assessing and addressing sleep disturbances during the peripartum period to mitigate their adverse effects on peripartum psychopathology and suicidal risk.

Efficacy of cognitive behavioral therapy for insomnia in the perinatal period: a meta-analysis of randomized controlled trials

The meta-analysis aims to explore the effect of cognitive behavioral therapy for insomnia (CBT-I) in the perinatal period. Randomized controlled trials (RCTs) assessed the effects of CBT-I in perinatal women with insomnia, published in English, were eligible. Electronic searches were performed using PubMed, Embase (Elsevier), PsycINFO (Ebsco), and Web of Science (Clarivate Analytics). Insomnia Severity Index (ISI) as the primary outcome was used to estimate the pooled effects and durable efficacy of CBT-I. The secondary outcome measures were Edinburgh Postnatal Depression Scale (EPDS) and Pittsburgh Sleep Quality Index (PSQI). Of 46 studies reviewed, seven studies met the inclusion criteria. The meta-analysis indicated significant improvement in insomnia as measured with the ISI (standardized mean difference (SMD) =  - 0.62, 95% confidence intervals (CI) - 0.77, - 0.47, I2 = 28%). At the follow-up time point, the meta-analysis indicated the durable efficacy of CBT-I (SMD = - 0.47, 95% CI - 0.90, - 0.03, I2 = 73%). Definite improvement of CBT-I on EPDS (SMD = -0.31, 95% CI - 0.55, - 0.06, I2 = 33%) and PSQI (SMD = - 0.82, 95% CI - 1.27, - 0.38, I2 = 68%) score change post-intervention were found. In sub-analyses, CBT-I had similar effect sizes, independent of possible modifiers (study population, comparison group, delivery format, etc.). This meta-analysis demonstrates that CBT-I is effective in alleviating insomnia, depression, and sleep quality among perinatal women. It is equally important to find that CBT-I has a durable efficacy on insomnia in the perinatal period. However, it is necessary to include larger samples and conduct rigorous RCTs to further explore this issue.

Supplementary Information

The online version contains supplementary material available at 10.1007/s41105-023-00502-z.

The role of effective factors on suicidal tendency of women in Turkey

Background/Aim

This study aims to identify the variables that influence the suicidal tendency of women who are married, have had a relationship or are currently in a relationship in Turkey.

Methods

This study uses cross-sectional data from the 2014 Hacettepe University Institute of Population Studies National Research on Domestic Violence Against Women in Turkey. Data from 6,458 women between the ages of 15 and 49 were analyzed in this dataset. Binary logistic regression was used to determine the factors influencing women's suicidal tendencies.

Results

Based on the analysis's findings, age, education level, health status, number of children, the sector in which the spouse/partner works, the drinking status of the spouse/partner, the situation where the spouse/partner fights with another man in a way that involves physical violence, the cheating status of the spouse/partner, the controlling behaviour of the spouse/partner, exposure to various types of violence by both the spouse/partner and someone other than the partner, and the household income level variables were found to be associated with the suicidal tendency of women.

Conclusion

Prioritizing women who are, in particular, between the ages of 15 and 24, live in the south of Turkey, have a high school education, are in poor health, are childless, have low household incomes, live with an unemployed spouse or partner, and are exposed to various forms of violence from their partner or other sources can be achieved more effective results in reducing and preventing women's suicidal behaviors.

Insomnia During the Perinatal Period and its Association with Maternal and Infant Psychopathology: A Systematic Review and Meta-Analysis

PURPOSE OF REVIEW

While sleep serves important regulatory functions for mental health, sleep disturbances, in particular insomnia, may contribute to mental disorders. Since insomnia symptoms are frequent during the perinatal period, the aim of this work is to systematically review the potential association between perinatal insomnia and maternal and infant psychopathology.

RECENT FINDINGS

A systematic search was conducted according with PRISMA guidelines, and meta-analytic calculations were conducted. Totally, 34 studies were included and involved 835,021 perinatal women. Four meta-analysis yielded four statistically significant random-effect models. All models show that women with perinatal symptoms of insomnia possess increased odds of developing clinically relevant symptoms of depression OR = 3.69, p = 0.001 and anxiety OR = 2.81; p < 0.001, as well as increased suicidal risk OR = 3.28; p < 0.001, and distress in the newborn OR = 2.80 (P = 0.007). These findings emphasize the role of assessing and addressing insomnia during the perinatal period to mitigate its negative effect on maternal and infant mental health via sleep regulation.

A systematic review of clinical psychological guidance for perinatal mental health

BACKGROUND

Guidelines on psychological and/or psychosocial assessment and intervention in the perinatal period can provide beneficial practice guidance for healthcare professions to reduce maternal distress and potential mortality. As little is known about the similarities in recommendations across guidelines, which could impact the quality of therapeutic intervention women receive, this systematic review was conducted to draw out the consistent guidance for perinatal psychological and/or psychosocial therapeutic input.

METHOD

Eight literature and two guideline databases were searched alongside guideline development institutions, and organisations of maternity or perinatal mental health care. All relevant guidance was searched for and extracted before guideline quality was assessed using the AGREE-II instrument. Included guidelines had a primary or secondary focus on psychological assessment and therapeutic intervention for perinatal mental health difficulties. Using a narrative synthesis approach, recommendation consistencies and inconsistencies were outlined.

RESULTS

From the 92 records screened, seven guidelines met the inclusion criteria. Only two guidelines were rated high (> 80%) across all assessed domains, with the other guidelines scoring between poor and excellent across domains. Highest rated domains across all seven guidelines were clarity of presentation (75%) and scope and purpose (70%). Recommendations for structured psychological assessment and intervention were most commonly reported in the guidelines; however, the level of detail and depth of information varied across guidelines. Whilst assessment and intervention recommendations for mother-infant dyad and partners were considered, research into working therapeutically with these client groups in perinatal mental health services is only just emerging. Hence, guideline recommendations for working with the mother-infant dyad and partners were based on consensus of expert opinion.

CONCLUSION

Perinatal mental health guidelines were consistent in scope but showed considerable variability in quality and depth of recommendations, which could have implications for standards of clinical practice. However, there is still a need to improve the evidence underpinning recommendations in perinatal mental health guidelines to advance the implementation of psychological and/or psychosocial interventions. High quality interventions in the perinatal period could improve outcomes for women and their families.

Effects of fatigue, rumination thinking, and sleep quality on hopelessness in family caregivers of cancer patients

BACKGROUND

The heavy care burden, long-term dependence of caring for cancer patients, and changing social roles put family caregivers at high risk of mental disorders and hopelessness. This explored the relationship between fatigue, sleep quality, rumination, and hopelessness, and provides suggestions to maintain caregivers' mental health.

METHODS

We investigated 536 family caregivers of cancer patients in three grade A hospitals in Liaoning Province who met the inclusion criteria on the Beck Hopelessness Scale (BHS), Fatigue Scale-14 (FS-14), Nolen-Hoeksema Ruminative Responses Scale (RRS), and Pittsburgh Sleep Quality Index (PSQI). Data were analyzed with SPSS 26.0, and Amos 22.0 was used to fit the structural equation model.

RESULTS

The family caregivers had a higher degree of hopelessness and fatigue, while sleep quality and rumination were positively correlated with hopelessness (r = 0.483-0.906; P < 0.05). Fatigue and sleep quality can indirectly affect hopelessness through rumination thinking, while hopelessness has a direct effect on sleep.

CONCLUSIONS

There are multiple action paths between fatigue and sleep quality, rumination thinking, and hopelessness. Family caregivers' physical and mental health can be maintained and hopelessness avoided by improving sleep quality, alleviating fatigue, and psychological counseling.

Common sleep disorders in pregnancy: a review

In this review, we provide a comprehensive overview of common sleep disorders during pregnancy, including their characterization, prevalence, risk factors, and possible contribution to maternal and fetal outcomes. We conducted a quasi-systematic literature search of the MEDLINE database and identified 744 studies from 1991 through 2021, inclusive, that met our inclusion criteria. We synthesized the existing literature on sleep disorders during pregnancy and highlighted controversies, research gaps, and needed clinical developments. Our review covers a range of sleep disorders, including insomnia, obstructive sleep apnea, restless legs syndrome, and circadian rhythm disorders. We discuss the prevalence of these disorders in pregnancy and their potential impact on maternal and fetal health outcomes. We also explore the relationship between sleep disorders, pre-pregnancy comorbidities such as obesity, and pregnancy-related conditions such as gestational diabetes mellitus and preeclampsia. In addition to summarizing the existing literature on sleep disorders during pregnancy, we also highlight opportunities for further research in this area. We suggest that future studies should strive to employ validated and objective measurement tools for sleep disorders and prioritize utilization of longitudinal methods with participant follow-up through postpartum, mid-life, menopause, and beyond. We also put forward investigation into the impact of circadian rhythm disruption on reproductive physiology and early pregnancy outcomes as an area of important work. Overall, our review provides valuable insights on sleep and reproduction and into common sleep disorders during pregnancy and their potential impact on maternal and fetal health outcomes.

Reducing cognitive arousal and sleep effort alleviates insomnia and depression in pregnant women with DSM-5 insomnia disorder treated with a mindfulness sleep program

Objectives

Combining mindfulness with behavioral sleep strategies has been found to alleviate symptoms of insomnia and depression during pregnancy, but mechanisms for this treatment approach remain unclear. The present study examined nocturnal cognitive arousal and sleep effort as potential treatment mechanisms for alleviating insomnia and depression via a mindfulness sleep program for pregnant women.

Methods

Secondary analysis from a proof-of-concept trial of 12 pregnant women with DSM-5 insomnia disorder who were treated with Perinatal Understanding of Mindful Awareness for Sleep (PUMAS), which places behavioral sleep strategies within a mindfulness framework. Data were collected across eight weekly assessments: pretreatment, six sessions, and posttreatment. Measures included the insomnia severity index (ISI), Edinburgh postnatal depression scale (EPDS), pre-sleep arousal scale's cognitive factor (PSASC), and the Glasgow sleep effort scale (GSES). We used linear mixed modeling to test cognitive arousal and sleep effort as concurrent and prospective predictors of insomnia and depression.

Results

Most patients reported high cognitive arousal before PUMAS (75.0%), which decreased to 8.3% after treatment. All insomnia remitters reported low cognitive arousal after treatment, whereas half of nonremitters continued reporting high cognitive arousal. Both nocturnal cognitive arousal and sleep effort were associated with same-week changes in insomnia throughout treatment, and sleep effort yielded a prospective effect on insomnia. Lower levels of nocturnal cognitive arousal and sleep effort prospectively predicted reductions in depression.

Conclusions

The present study offers preliminary evidence that reducing sleep effort and nocturnal cognitive arousal may serve as key mechanisms for alleviating insomnia and depression via mindfulness-based insomnia therapy. ClinicalTrials.gov ID: NCT04443959.

Perinatal Understanding of Mindful Awareness for Sleep (PUMAS): A single-arm proof-of-concept clinical trial of a mindfulness-based intervention for DSM-5 insomnia disorder during pregnancy

OBJECTIVES

Cognitive-behavioral therapy is effective for prenatal insomnia, but unresolved cognitive arousal limits patient outcomes. Therapies aimed at reducing cognitive arousal may benefit pregnant women with insomnia. This proof-of-concept trial evaluated Perinatal Understanding of Mindful Awareness for Sleep (PUMAS, which combines mindfulness with behavioral sleep strategies) on insomnia, depression, and cognitive arousal.

METHODS

A single-arm trial of 12 pregnant women with DSM-5 insomnia disorder (n = 5/12 with comorbid depression) who received six sessions of PUMAS delivered individually via telemedicine. Pretreatment and posttreatment outcomes included the insomnia severity index (ISI), Edinburgh postnatal depression scale (EPDS), pre-sleep arousal scale's cognitive factor (PSASC; nocturnal cognitive arousal), perinatal-focused rumination (appended to PSASC), and Glasgow sleep effort scale.

RESULTS

Eleven of 12 patients completed all sessions. Intent-to-treat analyses revealed a 10.83-point reduction in ISI (Cohen's dz = 3.05), resulting in 83.3% insomnia remission. PUMAS produced large reductions in EPDS (Cohen's dz = 2.76 in depressed group), resulting in all five baseline depressed patients remitting from depression. PUMAS produced large reductions in nocturnal cognitive arousal, perinatal-focused rumination, and sleep effort (all Cohen's dzs>2.00). Patients were highly satisfied with PUMAS and identified the telemedicine format and meditation app as positive features of its delivery. Patients rated sleep restriction and guided meditations as the most helpful treatment components.

CONCLUSION

Prenatal insomnia patients were highly engaged in PUMAS, which produced large acute reductions in insomnia, depression, and cognitive arousal. These findings support the concept and feasibility of PUMAS for pregnant women with insomnia who present with or without comorbid depression.

CLINICALTRIALS

GOV ID

NCT04443959.

Relationship between depressive symptoms and sleep quality and cognitive inhibition ability in prenatal pregnant women

BACKGROUND

Sleep problems and cognitive changes are typical in pregnant women with depressive symptoms. However, the relationship between sleep quality and executive dysfunction remains unclear. This study aims to explore the differences in sleep quality and cognitive inhibition between pregnant women with and without depressive symptoms in the third trimester of pregnancy and investigate the correlations between sleep quality, cognitive inhibition and depressive symptoms.

METHODS

In the third trimester, 169 women without depressive symptoms and 88 women with depressive symptoms participated in the study. Edinburgh Postpartum Depression Questionnaire (EPDS) was used to assess depressive symptoms, and Pittsburgh Standard Sleep Quality Index Questionnaire (PSQI) was used to investigate sleep quality. The color-word Stroop task is used to evaluate cognitive inhibition.

RESULTS

Compared with women without depressive symptoms, pregnant women with depressive symptoms showed worse sleep quality and Stroop task performances (response speed and accuracy). In addition, the speed of cognitive inhibition plays a mediating role in the relationship between sleep quality and prenatal depressive symptoms.

CONCLUSION

This research emphasizes the importance of sleep quality screening and cognitive training for depression during pregnancy and childbirth in ensuring women's mental health during pregnancy and childbirth.

Psychometric properties of the difficulties in emotion regulation Scale in a perinatal sample

BACKGROUND

One in five pregnant and postpartum individuals experience an anxiety, depressive, and/or trauma-related disorder. Emotion dysregulation (ED) underlies the development and maintenance of various mental health disorders. The Difficulties in Emotion Regulation Scale (DERS) is the most comprehensive and commonly used measure of emotion dysregulation, yet limited evidence supports its use in the perinatal population. The present study aims to evaluate the validity of the DERS and its six subscales in a perinatal sample and to assess its predictive utility in identifying perinatal individuals with a disorder characterised by emotion dysregulation.

METHODS

Pregnant and postpartum individuals (N = 237) completed a diagnostic clinical interview and self-report measures of anxiety, depression, and perceived social support.

RESULTS

The DERS subscales demonstrated good internal consistency and construct validity, as it strongly correlated with measures of anxiety and depression and failed to correlate with a measure of perceived social support. Results from an exploratory factor analysis supported a 6-factor solution, suggesting structural validity. An ROC analysis revealed good to excellent discriminative ability for the DERS full scale and four of the subscales. Finally, an optimal clinical cut-off score of 87 or greater was established with a sensitivity of 81% for detecting a current anxiety, depressive, and/or trauma-related disorder.

CONCLUSIONS

This study provides evidence for the validity and clinical utility of the DERS in a treatment-seeking and community sample of pregnant and postpartum individuals.

Screening and Diagnosis of Mental Health Conditions During Pregnancy and Postpartum: ACOG Clinical Practice Guideline No. 4

PURPOSE

To review evidence on the current understanding of mental health conditions in pregnancy and postpartum, with a focus on mood and anxiety disorders, and to outline guidelines for screening and diagnosis that are consistent with best available scientific evidence. The conditions or symptoms reviewed include depression, anxiety and anxiety-related disorders, bipolar disorder, suicidality, and postpartum psychosis. For information on psychopharmacologic treatment and management, refer to American College of Obstetricians and Gynecologists (ACOG) Clinical Practice Guideline Number 5, "Treatment and Management of Mental Health Conditions During Pregnancy and Postpartum" (1).

TARGET POPULATION

Pregnant or postpartum individuals with mental health conditions. Onset of these conditions may have predated the perinatal period or may have occurred for the first time in pregnancy or the first year postpartum or may have been exacerbated in that time.

METHODS

This guideline was developed using an a priori protocol in conjunction with a writing team consisting of one specialist in obstetrics and gynecology and one maternal-fetal medicine subspecialist appointed by the ACOG Committee on Clinical Practice Guidelines-Obstetrics and two external subject matter experts. ACOG medical librarians completed a comprehensive literature search for primary literature within Cochrane Library, Cochrane Collaboration Registry of Controlled Trials, EMBASE, PubMed, and MEDLINE. Studies that moved forward to the full-text screening stage were assessed by two authors from the writing team based on standardized inclusion and exclusion criteria. Included studies underwent quality assessment, and a modified GRADE (Grading of Recommendations Assessment, Development and Evaluation) evidence-to-decision framework was applied to interpret and translate the evidence into recommendation statements.

RECOMMENDATIONS

This Clinical Practice Guideline includes recommendations on the screening and diagnosis of perinatal mental health conditions including depression, anxiety, bipolar disorder, acute postpartum psychosis, and the symptom of suicidality. Recommendations are classified by strength and evidence quality. Ungraded Good Practice Points are included to provide guidance when a formal recommendation could not be made because of inadequate or nonexistent evidence.

The stress of losing sleep: Sex-specific neurobiological outcomes

Sleep is a vital and evolutionarily conserved process, critical to daily functioning and homeostatic balance. Losing sleep is inherently stressful and leads to numerous detrimental physiological outcomes. Despite sleep disturbances affecting everyone, women and female rodents are often excluded or underrepresented in clinical and pre-clinical studies. Advancing our understanding of the role of biological sex in the responses to sleep loss stands to greatly improve our ability to understand and treat health consequences of insufficient sleep. As such, this review discusses sex differences in response to sleep deprivation, with a focus on the sympathetic nervous system stress response and activation of the hypothalamic-pituitary-adrenal (HPA) axis. We review sex differences in several stress-related consequences of sleep loss, including inflammation, learning and memory deficits, and mood related changes. Focusing on women's health, we discuss the effects of sleep deprivation during the peripartum period. In closing, we present neurobiological mechanisms, including the contribution of sex hormones, orexins, circadian timing systems, and astrocytic neuromodulation, that may underlie potential sex differences in sleep deprivation responses.

Mindfulness as an Adjunct or Alternative to CBT-I

Mindfulness-based interventions (MBIs) are programs that teach mindfulness concepts through guided meditation and self-regulation practices. MBIs have been found to improve sleep and reduce cognitive arousal, which are central to the development and perpetuation of insomnia. In this article, we review theoretic frameworks and clinical trial effectiveness data supporting MBIs for insomnia. Based on this review, we provide suggestions for using MBIs as an adjunct or alternative treatment option to CBT-I with regard to how, when, and for whom. We conclude with an agenda for future directions that can clarify the use of mindfulness as a treatment option for insomnia.

Factors associated with the mental health status of pregnant women in China: A latent class analysis

Background

Prenatal mental health is a neglected public health issue that places pregnant women at a higher risk for mental disorders. The purpose of this study was to investigate the influencing factors of prenatal mental disorders and provide a scientific basis to guide and promote the mental health of pregnant women.

Methods

The study sample comprised 973 women in their first pregnancy, who were in their second trimester and third trimester, who underwent obstetric outpatient checkups at the Maternal and Child Health Hospital in Huai'an, who were recruited in the survey that was conducted from July to December 2017. The Chinese mental health scale (CMHS) was used to assess the mental health of pregnant women. The present study uses the chi-square test to compare the rates of class with different demographic variables, a latent class analysis to identify psychological symptoms, and multiple logistic regression analysis to examine whether the demographics predicted class membership.

Results

The chi-square test results showed that participants who reported feeling different in the perinatal period (χ² = 6.35, P = 0.04), having marital satisfaction (χ² = 15.8, P < 0.001), with an in-law relationship (χ² = 29.43, P < 0.001), with a friend relationship (χ² = 24.81, P < 0.001), with basic diseases (χ² = 8.04, P = 0.02), and taking birth control pills (χ² = 8.97, P = 0.01) have different probabilities of being classified. Three latent classes were identified: the high symptoms group (6.89%), the moderate symptoms group (20.56%), and the low symptoms group (72.56%). Pregnant women in the third trimester [odds ratio (OR) = 1.83, 95% confidence interval (CI): 1.04-3.25, P = 0.04], with a poor in-law relationship (OR = 2.82, 95% CI:1.45-5.51, P = 0.002), with a bad friend relationship (OR = 3.17, 95% CI: 1.31-7.71, P = 0.01), and who had basic diseases (OR = 1.70, 95% CI: 1.00-2.90, P = 0.04) tended to be classified under the high symptoms group than under the low symptoms group. Pregnant women with a bad friend relationship (OR = 2.15, 95% CI: 1.08-4.28, P = 0.03) and taking birth control pills (OR = 1.51, 95% CI: 1.08-2.11, P = 0.02) were more likely to be placed under the moderate symptoms group than under the low symptoms group.

Conclusions

A pregnant woman's mental health status factors include feeling different in the perinatal period, those with marital satisfaction, those with an in-law relationship, those with a friend relationship, those with basic diseases, and those taking birth control pills. To ensure a smooth progress of pregnancy and promote the physical and mental health of pregnant women, psychological screening and psychological intervention measures should be strengthened.

Self perceived health and stress in the pregnancy during the COVID-19 pandemic

Introduction

The COVID-19 pandemic has had numerous maternal and neonatal consequences, especially at the mental level. Pregnant women experience a rise in anxiety symptoms and prenatal stress.

Aims

The aim was to describe self-perceived health status, general stress and prenatal stress and to analyze relations and associations with sociodemographic factors.

Methods

A quantitative, descriptive and cross-sectional study was conducted using non-probabilistic circumstantial sampling. The sample was recruited during the first trimester of pregnancy during the control obstetrical visit. The Google Forms platform was used. A total of 297 women participated in the study. The Prenatal Distress Questionnaire (PDQ), the Perceived Stress Score (PSS) and the General Health Questionnaire (GHQ-28) were used.

Results

Primiparas presented higher levels of worry about childbirth and the baby (10.93 ± 4.73) than multiparous women (9.88 ± 3.96). Somatic symptoms were present in 6% of the women. Anxiety-insomnia was scored positively by 18% of the women. In the Spearman correlation analysis, statistically significant values were found between almost all study variables. A positive correlation was observed between self-perceived health and prenatal and general stress levels.

Discussion

During the first trimester of gestation, prenatal concerns increase when levels of anxiety, insomnia and depression also increase. There is a clear relationship between prenatal worries, anxiety, insomnia and depression with stress. Health education that focuses on mental health of pregnant women would help reduce worries during pregnancy and would improve the pregnant women perception of her health and well-being.

Cognitive-behavioral therapy for insomnia prevents and alleviates suicidal ideation: insomnia remission is a suicidolytic mechanism

STUDY OBJECTIVES

Insomnia is associated with elevated levels of suicidal thoughts and behaviors. Emerging evidence suggests that cognitive-behavioral therapy for insomnia (CBTI) may reduce suicidal ideation (SI). However, the role of digital therapeutics in both the alleviation and prevention of SI remains unclear, and treatment mechanisms facilitating SI reductions have not been clearly identified.

METHODS

A total of 658 adults with Diagnostic and Statistical Manual of Mental Disorders, 5th Edition insomnia disorder enrolled in a single-site randomized controlled trial evaluating the efficacy of digital CBTI relative to attention control. Outcomes were measured at pretreatment, posttreatment, and 1-year follow-up.

RESULTS

Before treatment, 126 patients endorsed SI (19.1% prevalence). Among those with baseline SI, CBTI patients reported lower SI rates at posttreatment (30.0% vs 54.5%, p = .005) and 1-year follow-up (29.6% vs 46.8%, p = .042) relative to control. PRODCLIN analysis estimated that half of suicidolytic effects of CBTI were mediated through insomnia remission. Among those without baseline SI, CBTI did not directly prevent new onset SI. However, insomnia remitters reported lower rates of new-onset SI at posttreatment relative to non-remitters (1.5% vs 6.5%, p = .009). Mediation analysis supported a significant indirect effect wherein CBTI increased the likelihood of insomnia remission, which was associated with SI prevention (αβ = -3.20, 95% CI = -5.74 to -0.87).

CONCLUSION

Digital CBTI reduces insomnia symptoms, which promotes SI alleviation and prevention. For nonsuicidal patients, digital CBTI may serve as a highly accessible monotherapy for improving sleep, thereby reducing the risk for SI. For suicidal patients, digital CBTI may be appropriately administered as an adjunct treatment to support mainline intervention more directly targeting suicidogenic thoughts.

Discrimination is associated with poor sleep quality in pregnant Black American women

BACKGROUND

Heightened exposure to racial/ethnic discrimination is associated with poorer sleep health among non-pregnant adults. This relationship has received limited research attention among pregnant women, despite the importance of prenatal sleep quality for optimal maternal and child health outcomes.

METHODS

We utilized perinatal data from a sample of Black American women (n = 600) participating in a cohort study who reported their lifetime experiences of racial/ethnic discrimination and gendered racial stress during early pregnancy and reported on their sleep quality and depressive symptoms during early and mid-pregnancy. Hierarchical multiple linear regression models were fit to examine associations between lifetime experiences of racial/ethnic discrimination or gendered racial stress and sleep quality during early and mid-pregnancy. We also adjusted for women's concurrent depressive symptoms and tested whether the discrimination/sleep quality association varied by socioeconomic status.

RESULTS

Greater exposure to racial/ethnic discrimination was associated with poorer sleep quality during early (ΔR2 = 0.04, ΔF = 26.08, p < 0.001) and mid-pregnancy (ΔR2 = 0.02, ΔF = 9.88, p = 0.002). Similarly, greater gendered racial stress was associated with poorer sleep quality during early (ΔR2 = 0.10, ΔF = 65.72, p < 0.001) and mid-pregnancy (ΔR2 = 0.06, ΔF = 40.43, p < 0.001. These findings largely held after adjustment for concurrent prenatal depressive symptoms. Socioeconomic status did not modify the observed relationships.

CONCLUSIONS

Efforts to decrease institutional and interpersonal experiences of racial/ethnic discrimination and gendered racism would benefit the sleep quality of pregnant Black American women, particularly during early pregnancy.

Insomnia during pregnancy and severe maternal morbidity in the united states: nationally representative data from 2006 to 2017

STUDY OBJECTIVES

Using a large, nationally representative database, we aimed to estimate the prevalence and trends of insomnia among pregnant women over a 12-year period. In addition, we aimed to examine the interplay among insomnia, maternal comorbidities, and severe maternal morbidity (SMM).

METHODS

We conducted a serial cross-sectional analysis of pregnancy-related hospitalizations in the United States from the 2006 to 2017 National Inpatient Sample (NIS). ICD-9 and ICD-10 codes were used to capture diagnoses of insomnia and obstetric comorbidities during delivery and non-delivery hospitalizations. The primary outcome was the diagnosis of SMM at delivery. We used logistic regression to assess the association between insomnia and SMM. Joinpoint regression was used to estimate trends in insomnia and SMM.

RESULTS

Of nearly 47 million delivery hospitalizations, 24 625 women had a diagnosis of insomnia, or 5.2 per 10 000 deliveries. The annual incidence increased from 1.8 to 8.6 per 10 000 over the study period. The crude rate of insomnia was 6.3 times higher for non-delivery hospitalizations. Patients with insomnia had more comorbidities, particularly neuromuscular disease, mental health disorders, asthma, and substance use disorder. Prevalence of non-blood transfusion SMM was 3.6 times higher for patients with insomnia (2.4% vs. 0.7%). SMM increased annually by 11% (95% CI = 3.0% to 19.7%) in patients with insomnia. After adjusting for comorbidities, there remained a 24% increased likelihood of SMM for patients with insomnia.

CONCLUSIONS

Coded diagnosis of insomnia during pregnancy has increased over time, and this burden disparately affects women of low socioeconomic status. Diagnosis of insomnia is an independent predictor of SMM.

Women with perinatal suicidal ideation–A scoping review of the biopsychosocial risk factors to inform health service provision and research

Objectives

This review aims to map the existing evidence on perinatal suicidal ideation, identify biopsychosocial risk factors associated with suicidal ideation and make recommendations for service provision and future research.

Methods

Scoping review guided by Arskey’s and O’Malley’s (2005) framework. Five academic databases (PsycINFO, MEDLINE, CINAHL, ASSIA and Academic Search Complete) were searched from 1^st January 2009 to 1^st April 2022. Studies were screened by title, abstract and full text against inclusion and exclusion criteria. Primary qualitative, quantitative and mixed-methods studies, written in English pertaining to perinatal suicidal ideation were included. Forty-one studies met the eligibility criteria, data were extracted and narratively synthesised. Findings are reported in accordance with the PRISMA-SR extension.

Key conclusions

Findings were mapped onto the biopsychosocial framework and include sleep deprivation, maternal age, pregnancy complications, mood disorders, intimate partner violence, childhood maltreatment/abuse, low socioeconomic status, alcohol and tobacco misuse, miscarriage/perinatal loss, birth trauma and sleep deprivation. The findings demonstrate that the biopsychosocial risk factors for perinatal suicidal ideation are varied and complex.

Implications for practice

The minimisation of women’s experiences may lead to detrimental consequences and there is a need for increased knowledge of mental health problems by those working with women in the perinatal period to ensure safety planning conversations occur with every woman meeting ‘at risk’ criteria.

Racial/ethnic disparities in subjective sleep duration, sleep quality, and sleep disturbances during pregnancy: an ECHO study

In the United States, racial/ethnic minoritized groups experience worse sleep than non-Hispanic Whites (nHW), but less is known about pregnant people. This is a key consideration since poor sleep during pregnancy is common and associated with increased risk of adverse perinatal outcomes. This study reports the prevalence of subjective sleep measures in a multi-racial/ethnic pregnant population from the Environmental influences on Child Health Outcomes (ECHO) program. Participants' self-reported race and ethnicity were grouped into: nHW, non-Hispanic Black/African American (nHB/AA), Hispanic, non-Hispanic Asian (nHA). Analyses examined trimester-specific (first (T1), second (T2), third (T3)) nocturnal sleep duration, quality, and disturbances (Pittsburgh Sleep Quality Index and ECHO maternal sleep health questionnaire). Linear or multinomial regressions estimated the associations between race/ethnicity and each sleep domain by trimester, controlling for body mass index and age, with nHW as reference group. We repeated analyses within maternal education strata. nHB/AA participants reported shorter sleep duration (T2: β = -0.55 [-0.80,-0.31]; T3: β = -0.65 [-0.99,-0.31]) and more sleep disturbances (T2: β = 1.92 [1.09,2.75]; T3: β = 1.41 [0.09,2.74]). Hispanic participants reported longer sleep duration (T1: β = 0.22 [0.00004,0.44]; T2: β = 0.61 [0.47,0.76]; T3: β = 0.46 [0.22,0.70]), better sleep quality (Reference group: Very good. Fairly good T1: OR = 0.48 [0.32,0.73], T2: OR = 0.36 [0.26,0.48], T3: OR = 0.31 [0.18,0.52]. Fairly bad T1: OR = 0.27 [0.16,0.44], T2: OR = 0.46 [0.31, 0.67], T3: OR = 0.31 [0.17,0.55]), and fewer sleep disturbances (T2: β = -0.5 [-1.0,-0.12]; T3: β = -1.21 [-2.07,-0.35]). Differences persisted within the high-SES subsample. Given the stark racial/ethnic disparities in perinatal outcomes and their associations with sleep health, further research is warranted to investigate the determinants of these disparities.

Repetitive negative thinking in the perinatal period and its relationship with anxiety and depression

BACKGROUND

Rumination and worry represent two types of repetitive negative thinking (RNT), and their predictive and maintaining roles are well-established in depression and anxiety, respectively. Furthermore, there is an emerging literature on the link between RNT and psychological wellbeing in the perinatal period.

METHODS

We conducted a scoping review of studies that have investigated the relationship between RNT and perinatal depression and anxiety. We identified 87 papers eligible for inclusion in the review; they included cross-sectional and longitudinal studies, as well as treatment evaluations (pilot trials and randomised controlled trials).

RESULTS

Cross-sectional studies provided evidence of an association between RNT (i.e., rumination and worry) and depression and anxiety, in both pregnancy and postpartum. Longitudinal findings were mixed. Whilst antenatal worry consistently predicted subsequent depression and anxiety (both later in pregnancy and postpartum), rumination did not consistently predict depression. However, there was some evidence that rumination interacted with other processes to predict later psychopathology. Three randomised controlled trials evaluated whether psychological treatments reduce RNT in the perinatal period, only one of which included a clinical sample.

LIMITATIONS

No experimental investigations were eligible for inclusion in the review.

CONCLUSIONS

Further studies are needed to further our understanding of the nature and role of RNT in pregnancy and postpartum, and its consequences for maternal mental health. These include (but are not limited to) experimental investigations, studies with large clinical samples, and RCTs evaluating the effectiveness of psychological interventions targeting RNT to prevent and treat perinatal depression and anxiety.

Construct of the Association between Sleep Quality and Perinatal Depression: A Literature Review

Pregnancy is characterized by hormonal and physiological changes; some of these changes cause changes in sleep, presenting excessive sleep in early pregnancy due to the action of progesterone, and difficulty sleeping at the end of pregnancy due to weight gain and frequency of urination. Objective: to identify and systematize the evidence on the association between sleep quality and perinatal depression in pregnant and postpartum women. Methods: an integrative literature review was carried out with a search in the CINAHL, MEDLINE, and SCOPUS databases using the PRISMA flowchart. Results: Of the 92 articles, 10 studies were included according to the eligibility criteria. Results indicate that poor sleep quality during pregnancy is predictive of prenatal and postnatal depression. Sleep quality worsens with increasing gestational and maternal age. Conclusions: Sleep quality during pregnancy is associated with perinatal depression, a global public health problem with high prevalence. Due to its severe consequences for women, children, and families, perinatal depression needs to be identified early, preferably during pregnancy or soon after childbirth, justifying the priority of screening and prevention.

Review of suicidal ideation during pregnancy: risk factors, prevalence, assessment instruments and consequences

Background

Pregnancy is a period when women are particularly vulnerable to suicidal ideation and a great opportunity for suicide risk prevention.

Aims

This study aimed to establish a comprehensive understanding of suicidal ideation prevalence, risk factors, screening tools, consequences and management during pregnancy.

Method

A literature search was performed in MEDLINE and PsycInfo databases from 2016 to 2021. A narrative synthesis of the literature and a critical overview of the current issues/questions to be addressed within the topic of suicidal ideation during pregnancy was performed.

Results

The prevalence of suicidal ideation during pregnancy was between 2.73 and 18% internationally. The risk factors identified were major depressive disorder, anxiety disorder, difficulties with sleep, previous suicide attempts, high rumination, low incomes, being black, being young, low educational level, partner violence, having poor support, food insecurity, history of child abuse, high obstetric risk, multiparity, previous induced abortion and exposure to tobacco or human immunodeficiency virus diagnosis. The screening tools used for suicidal ideation during pregnancy were item 10 of the Edinburgh Postpartum Depression Scale and item 9 of the Patient Health Questionnaire. Results showed that suicidal ideation during pregnancy is associated with poor cognitive development in children and low birth weight. No case management studies on suicidal ideation were found.

Limitations

The main limitation of the available studies was the lack of articles with a high degree of methodological rigour on this subject.

Conclusions

This narrative review is a state-of-the-art paper about suicidal ideation during pregnancy. Further research is needed, and researchers should carry out systematic reviews and meta-analyses, leading to Clinical Practice Guidelines in this area. This effort would improve our evidence-based practice in Perinatal Psychology and prevent associated suicidal behaviour.

The prevalence of suicide ideation and predictive factors among pregnant women in the third trimester

BACKGROUND

Pregnancy is a period for women undergo major physical and psychological changes. Suicide is a cause of maternal death and suicidal ideation is a key factor in suicidal behavior. The purpose of this study was to investigate the prevalence of suicidal ideation in the third trimester and associated predictors including psychological factors such as attachment.

METHODS

A cross-sectional study included 432 pregnant women in the third trimester of pregnancy was conducted in a tertiary hospital. The Edinburgh Postpartum Depression Scale (EPDS) was used to assess prenatal depression and suicidal ideation. The Zung Self-Rating Anxiety Scale (SAS) and Experience of Close Relationship (ECR) scale were used to assess anxiety and attachment respectively.

RESULTS

The results showed that the EPDS scale screened 6.71% of pregnant women with suicidal ideation. Compared with those without suicidal ideation, pregnant women with suicidal ideation had a higher prevalence of insecure attachment, higher scores on the two dimensions of attachment (attachment avoidance and attachment anxiety), and higher prevalence of prenatal depression and anxiety. Binary logistic regression showed that marital satisfaction was a protective factor for suicidal ideation, while prenatal depression, prenatal anxiety and attachment anxiety were risk factors for suicidal ideation.

CONCLUSIONS

The suicidal ideation among pregnant women was high, which should be given more attention. In the process of preventing and intervening suicidal ideation, in addition to the emotional state of pregnant women, their psychological factors such as attachment anxiety should also be considered.

Maternal Suicide Ideation and Behaviour During Pregnancy and the First Postpartum Year: A Systematic Review of Psychological and Psychosocial Risk Factors

Suicide is a leading cause of maternal death during pregnancy and up to a year after birth (perinatal period). Many psychological and psychosocial risk factors for maternal suicidal ideation and behaviour have been investigated. Despite this, there have been no attempts to systematically search the literature on these risk factors. Additionally, few studies have described how the risk factors for suicidal ideation, attempted suicides and suicide deaths differ, which is essential for the development of tools to detect and target suicidal ideation and behaviour. Seven databases were searched up to June 2021 for studies that investigated the association between suicidal ideation and/or suicidal behaviour and psychological/psychosocial risk factors in pregnant and postpartum women. The search identified 17,338 records, of which 59 were included. These 59 studies sampled a total of 49,929 participants and investigated 32 different risk factors. Associations between abuse, experienced recently or during childhood, and maternal suicide ideation, attempted suicide and death were consistently reported. Social support was found to be less associated with suicide ideation but more so with suicide attempts. Identifying women who have experienced domestic violence or childhood abuse and ensuring all women have adequate emotional and practical support during the perinatal period may help to reduce the likelihood of suicidal behaviour.

Examining Patient Feedback and the Role of Cognitive Arousal in Treatment Non-response to Digital Cognitive-behavioral Therapy for Insomnia during Pregnancy

OBJECTIVE

Insomnia affects over half of pregnant and postpartum women. Early evidence indicates that cognitive-behavioral therapy for insomnia (CBTI) improves maternal sleep and mood. However, standard CBTI may be less efficacious in perinatal women than the broader insomnia population. This study sought to identify patient characteristics in a perinatal sample associated with poor response to CBTI, and characterize patient feedback to identify areas of insomnia therapy to tailor for the perinatal experience.

PARTICIPANTS

Secondary analysis of 46 pregnant women with insomnia symptoms who were treated with digital CBTI in a randomized controlled trial.

METHODS

We assessed insomnia, cognitive arousal, and depression before and after prenatal treatment, then 6 weeks postpartum. Patients provided feedback on digital CBTI.

RESULTS

Residual cognitive arousal after treatment was the most robust factor associated with treatment non-response. Critically, CBTI responders and non-responders differed on no other sociodemographic or pretreatment metrics. After childbirth, short sleep (<6 hrs/night) was associated with maternal reports of poor infant sleep quality. Patient feedback indicated that most patients preferred online treatment to in-person treatment. Although women described digital CBTI as convenient and helpful, many patients indicated that insomnia therapy would be improved if it addressed sleep challenges unique to pregnancy and postpartum. Patients requested education on maternal and infant sleep, flexibility in behavioral sleep strategies, and guidance to manage infant sleep.

CONCLUSIONS

Modifying insomnia therapy to better alleviate refractory cognitive arousal and address the changing needs of women as they progress through pregnancy and early parenting may increase efficacy for perinatal insomnia.Name: Insomnia and Rumination in Late Pregnancy and the Risk for Postpartum DepressionURL: clinicaltrials.govRegistration: NCT03596879.

Quality of Life of Pregnant Women with Systemic Lupus Erythematosus

OBJECTIVE

 To assess the quality of life (QoL) of pregnant women with systemic lupus erythematosus (SLE) treated at a high-risk prenatal outpatient clinic during the third trimester of gestation.

METHODS

 An observational descriptive study was performed in a high-risk prenatal outpatient clinic. Women in the third trimester of pregnancy and undergoing antenatal care between July 2017 and July 2019 answered the abbreviated World Health Organization Quality of Life (WHOQOL-BREF) questionnaire, consisting of 26 questions divided into 4 domains (physical, psychological, social and environmental).

RESULTS

 We interviewed 50 pregnant women with a mean gestational age of 30 weeks (standard deviation [SD]: 10 weeks) who were diagnosed with SLE. The average age of the participants was 30 years (SD: 14.85), and the average time since the diagnosis of SLE was of 9.06 years (SD: 6.8 years). Most participants had a partner, did not plan their pregnancy (76%), and did not use contraception prior to pregnancy (80%). The score of each domain ranges from 0 (the worst score) to 100 (the best score). The means ±  SDs of the scores of the participants on each domain were: physical - 52.21 ±  18.44); psychological - 64.17 ±  18.56); social - 66.33 ±  27.09); and environmental - 64.56 (18.53). The means ±  SDs of the general QoL, and health-related QoL items were of 70.50 ±  24.06 and 70.00 ±  30.72 respectively.

CONCLUSION

 The physical domain presented the lowest scores compared with the other three domains. Pregnant women with SLE had high overall QoL scores, and their health-related QoL scores were also relatively high.

Emotion regulation during pregnancy: a call to action for increased research, screening, and intervention

This paper serves as a call to action for increased focus on emotion regulation during pregnancy. We make this case by summarizing the limited research to date on this topic, which has demonstrated that emotion regulation in pregnant people has important mental health, caregiving, and developmental correlates throughout the perinatal period. Given its crosscutting and modifiable nature, bolstering emotion regulation during pregnancy has the potential for considerable intergenerational consequences, and it is critical to further investigate this construct.

Suicide and Maternal Mortality

PURPOSE OF REVIEW

Suicide is a leading cause of death in the perinatal period (pregnancy and 1 year postpartum). We review recent findings on prevalence, risk factors, outcomes, and prevention and intervention for suicide during pregnancy and the first year postpartum.

RECENT FINDINGS

Standardization of definitions and ascertainment of maternal deaths have improved identification of perinatal deaths by suicide and risk factors for perinatal suicide. Reports of a protective effect of pregnancy and postpartum on suicide risk may be inflated. Clinicians must be vigilant for risk of suicide among their perinatal patients, especially those with mental health diagnoses or prior suicide attempts. Pregnancy and the year postpartum are a time of increased access to healthcare for many, offering many opportunities to identify and intervene for suicide risk. Universal screening for suicide as part of assessment of depression and anxiety along with improved access to mental health treatments can reduce risk of perinatal suicide.

Suicidal ideation and behavior among perinatal women and their association with sleep disturbances, medical conditions, and known risk factors

OBJECTIVE

Suicide is considered one of the leading causes of maternal mortality, especially among women with postpartum depression. In the current systematic review, we conducted a qualitative data synthesis of recent studies exploring novel risk factors including sleep disturbances and medical conditions, alongside known and significant risk factors for perinatal suicidality.

EVIDENCE ACQUISITION

We conducted a systematic search of the literature according to PRISMA guidelines on PubMed, PsycNET, and Scopus databases. Search terms were "pregnancy" "OR" "postpartum" "OR" "peripartum" "OR" "perinatal" "OR" "postnatal" combined with the Boolean "AND" operator with "suicide" "OR" "suicidality" "OR" "suicidal ideation" "OR" "suicidal behavior."

EVIDENCE SYNTHESIS

The initial search yielded 1,458 records, of which 51 research reports that met inclusion criteria were analyzed. These 51 studies sampled a total of 45,942 participants. Clinically, sleep disturbance, psychopathology, and social support have been identified as dominant risk factors for suicidal behavior among pregnant and postpartum women, as well as medical conditions and aversive life events.

CONCLUSION

Monitoring sleep disturbance, depression, and perceived social support is critical given that they are significant risk factors for suicide among perinatal women. Early identification of perinatal women who may be at risk of suicide, although not depressed, is crucial.

LIMITATIONS

The use of tools designed to identify depression to identify suicidal risk, fail to identify women who are at risk but who do not suffer from depression. Other methodological limitations are the lack of longitudinal studies and the complexity of examining suicidal behavior in sample studies.

DSM-5 insomnia disorder in pregnancy: associations with depression, suicidal ideation, and cognitive and somatic arousal, and identifying clinical cutoffs for detection

Study Objectives

The study had three primary goals. First, we estimated survey-assessed DSM-5 insomnia disorder rates in pregnancy, and described associated sociodemographics, and sleep-wake and mental health symptoms. Second, we derived cutoffs for detecting DSM-5 insomnia disorder using common self-report measures of sleep symptoms. Third, we identified clinically relevant cut-points on measures of nocturnal cognitive and somatic arousal.

Methods

Ninety-nine women (85.9% in the 2^nd trimester) completed online surveys including DSM-5 insomnia disorder criteria, the Insomnia Severity Index (ISI), Pittsburgh Sleep Quality Index (PSQI), Presleep Arousal Scale's Cognitive (PSASC) and Somatic (PSASS) factors, and Edinburgh Postnatal Depression Scale.

Results

DSM-5 insomnia disorder rate was 19.2%. Insomnia was associated with depression, suicidality, nocturnal cognitive and somatic arousal, and daytime sleepiness. An ISI scoring method that aligns with DSM-5 criteria yielded excellent metrics for detecting insomnia disorder and good sleep. Regarding quantitative cutoffs, ISI ≥ 10 and ISI ≥ 11 (but not ISI ≥ 15) were supported for detecting DSM-5 insomnia, whereas ISI ≤ 7 and ISI ≤ 9 performed well for detecting good sleep. PSQI cutoff of 5 was supported for detecting insomnia and good sleep. The optimal cutoff for nocturnal cognitive arousal was PSASC ≥ 18, whereas the optimal cutoff for somatic arousal was PSASS ≥ 13.

Conclusions

Insomnia disorder affects a large segment of pregnant women. Empirically derived cutoffs for insomnia, good sleep, cognitive arousal, and somatic arousal may inform case identification and future perinatal sleep research methodology.

Mother-to-Infant Bonding is Associated with Maternal Insomnia, Snoring, Cognitive Arousal, and Infant Sleep Problems and Colic

OBJECTIVE

Emerging evidence links maternal and infant sleep problems to impairments in the mother-to-infant bond, but the independence and directionality of these associations remain unclear. The present study characterized concurrent and prospective effects of maternal sleep disturbances and poor infant sleep on the mother-infant relationship. As common sequalae of problematic sleep, nocturnal cognitive hyperarousal and daytime sleepiness were investigated as facilitating mechanisms.

PARTICIPANTS

Sixty-seven pregnant women enrolled in a prospective study on maternal sleep.

METHODS

Sociodemographic information and clinical symptoms were measured prenatally then weekly across the first two postpartum months. Women reported insomnia symptoms, sleep duration, snoring, daytime sleepiness, nocturnal cognitive arousal (broadly focused and perinatal-specific), perseverative thinking, depression, infant colic, infant sleep quality, and mother-infant relationship quality. Mixed effects models were conducted to test hypotheses.

RESULTS

Prenatal snoring and weak maternal-fetal attachment augured poorer postpartum bonding. Poor infant sleep was associated with increased odds for maternal insomnia and short sleep. Impairments in the mother-to-infant bond were linked to maternal insomnia, nocturnal perinatal-focused rumination, daytime sleepiness, depression, and poor infant sleep. Postnatal insomnia predicted future decreases in mother-infant relationship quality, and nocturnal cognitive hyperarousal partially mediated this association.

CONCLUSIONS

Both maternal and infant sleep problems were associated with poorer mother-to-infant bonding, independent of the effects of maternal depression and infant colic. Perseverative thinking at night, particularly on infant-related concerns, was linked to impaired bonding, rejection and anger, and infant-focused anxiety. Improving maternal and infant sleep, and reducing maternal cognitive arousal, may improve the maternal-to-infant bond.

Insomnia evaluation and treatment during peripartum: a joint position paper from the European Insomnia Network task force "Sleep and Women," the Italian Marcè Society and international experts task force for perinatal mental health

Insomnia symptoms are frequent during peripartum and are considered risk factors for peripartum psychopathology. Assessing and treating insomnia and related conditions of sleep loss during peripartum should be a priority in the clinical practice. The aim of this paper was to conduct a systematic review on insomnia evaluation and treatment during peripartum which may be useful for clinicians. The literature review was carried out between January 2000 and May 2021 on the evaluation and treatment of insomnia during the peripartum period. The PubMed, PsycINFO, and Embase electronic databases were searched for literature published according to the PRISMA guidance with several combinations of search terms "insomnia" and "perinatal period" or "pregnancy" or "post partum" or "lactation" or "breastfeeding" and "evaluation" and "treatment." Based on this search, 136 articles about insomnia evaluation and 335 articles on insomnia treatment were found and we conducted at the end a narrative review. According to the inclusion/exclusion criteria, 41 articles were selected for the evaluation part and 22 on the treatment part, including the most recent meta-analyses and systematic reviews. Evaluation of insomnia during peripartum, as for insomnia patients, may be conducted at least throughout a clinical interview, but specific rating scales are available and may be useful for assessment. Cognitive behavioral therapy for insomnia (CBT-I), as for insomnia patients, should be the preferred treatment choice during peripartum, and it may be useful to also improve mood, anxiety symptoms, and fatigue. Pharmacological treatment may be considered when women who present with severe forms of insomnia symptoms do not respond to nonpharmacologic therapy.

Should we target insomnia to treat and prevent postpartum depression?

Postpartum depression (PPD) is a major public health problem that affects approximately 12-18% of women and is associated adverse maternal and infant outcome. Given that untreated maternal depression has negative consequences for both the mother and her child, it is important to deploy effective measures to treat or prevent PPD. Antidepressant treatment after delivery has been proposed for prophylaxis, however, this is not firmly established. Since insomnia is an early sign and a common symptom of PPD in this contribution we argue that management of insomnia may play a key role in the treatment and prevention of PPD. To this aim we by discussed the current evidence about the potential prophylactic role of antidepressants compared to that of insomnia treatment in PPD. We concluded that insomnia symptoms may be a better therapeutic target to prevent or treat PPD which is heterogeneous entity and may be more responsive to interventions addressing a common and early symptom such as insomnia.

Loganin ameliorates depression-like behaviors of mice via modulation of serotoninergic system

RATIONALE

Depression is a serious neuropsychiatric disorder, which is characterized by sustaining mood disorders. Loganin, a major iridoid glycoside from Corni fructus, has a variety of pharmacological activities, including neuroprotective effect and hypnotic effect. However, little is known about the effects of loganin on stress-induced depression.

OBJECTIVE

To investigate the effects of loganin on behavioral despair of mice, and whether serotonin (5-HT) and/or noradrenaline (NE) are involved in this process.

METHODS

We tested the effectiveness of loganin using tail suspension test (TST). The possible mechanism was explored using reserpine-induced ptosis and hypothermia, and 5-HTP-induced head-twitch response in mice. The changes of 5-HT and NE in the prefrontal cortex, hippocampus, and striatum were measured through high-performance liquid chromatography (HPLC) analysis. Then, we identified the effects of depleting 5-HT and NE by PCPA (p-chlorophenylalanine) and DSP-4 (N-(2-chloroethyl)-N-ethyl-2-bromobenzylamine hydrochloride) pretreatment, respectively.

RESULTS

Loganin (12.5/50 mg/kg) induced antidepressant-like effects in mice submitted to TST. Loganin (12.5/50 mg/kg) ameliorated the reserpine-induced hypothermia and ptosis, as well as increased 5-HTP-induced head-twitch responses in mice. Loganin (50 mg/kg) significantly increased the levels of 5-HT in the prefrontal cortex, hippocampus, and striatum. Furthermore, only PCPA treatment could eliminate loganin-induced antidepressant-like effects in TST.

CONCLUSION

Loganin exerts antidepressant-like effect in the TST depending on 5-HT levels in the central nervous system, which provide a potential agent for depression therapy.

A pathogenic cycle between insomnia and cognitive arousal fuels perinatal depression: exploring the roles of nocturnal cognitive arousal and perinatal-focused rumination

STUDY OBJECTIVES

Depression is among the most prevalent perinatal complications, yet modifiable risk factors remain elusive. Over half of perinatal women endorse clinical insomnia symptoms, which are etiologically implicated in depression in nonperinatal samples. Yet, prospective data on perinatal insomnia and depression are mixed. We sought to clarify temporal associations of insomnia and depression during peripartum, and to investigate cognitive arousal as a potential mechanism facilitating this relationship.

METHODS

Seventy pregnant women completed sociodemographic information and baseline sleep and mood symptoms between gestational weeks 25 and 30. Beginning at gestational week 30, participants completed 17 weekly online surveys assessing insomnia, depression, and three cognitive arousal indices (nocturnal cognitive arousal, perseverative thinking, and perinatal-focused rumination). Mixed effects models were conducted to test hypotheses.

RESULTS

Women were at risk for depression when experiencing insomnia (odds ratio [OR] = 2.36, 95% confidence interval [CI] = 1.28 to 4.35), nocturnal cognitive arousal (OR = 3.05, 95% CI = 1.60 to 5.79), perinatal-focused rumination (OR = 2.05, 95% CI = 1.11 to 3.79), and perseverative thinking (OR = 7.48, 95% CI = 3.90 to 14.32). Prospective analyses revealed bidirectional effects between insomnia and cognitive arousal, and both predicted future depression. Nocturnal cognitive arousal mediated 23-43% of the effect of insomnia on depression. Insomnia mediated 12%-18% of the effect of nocturnal cognitive arousal on depression. A similar pattern was observed with perinatal-focused rumination. Depression did not predict insomnia.

CONCLUSION

Nocturnal cognitive arousal, including ruminating on perinatal concerns while trying to fall asleep, fuels insomnia. In turn, lying awake at night provides an opportunity for nocturnal cognitive arousal. This cycle feeds perinatal depression. Daytime cognitive arousal may indirectly disrupt sleep as perseverating during the day persists into the night.

Nocturnal cognitive hyperarousal, perinatal-focused rumination, and insomnia are associated with suicidal ideation in perinatal women with mild to moderate depression

OBJECTIVES

This prospective study explored associations among insomnia, nocturnal cognitive hyperarousal, and nocturnal perinatal-focused rumination with suicidal ideation (SI) in perinatal women with depression.

METHODS

From late pregnancy through early postpartum, 39 depressed women completed 17 weekly surveys assessing SI, insomnia, depression, stress, and cognitive arousal.

RESULTS

Women with nocturnal cognitive hyperarousal at baseline, relative to those with low cognitive arousal, were at greater risk for new onset SI (33% vs 1%). Moreover, nocturnal perinatal-focused rumination was independently associated with SI. SI-risk was highest when women reported clinical insomnia combined with nocturnal cognitive hyperarousal (OR = 5.66, p = 0.037) or perinatal-focused rumination (OR = 11.63, p = 0.018). Daytime perseverative thinking was not uniquely associated with SI.

CONCLUSIONS

Nocturnal cognitive arousal predicts the development of new onset SI, and perinatal-focused rumination is also uniquely associated with SI-risk in late pregnancy and early parenting. Critically, SI-risk is highest when perinatal women endorsed insomnia and high cognitive arousal at the same time. Future research should determine whether alleviating nocturnal cognitive arousal, pregnancy- and fetal/infant-related concerns, and insomnia with psychotherapy reduces SI for women with perinatal depression.

Estimating the cumulative risk of postnatal depressive symptoms: the role of insomnia symptoms across pregnancy

PURPOSE

Insomnia symptoms during late pregnancy are a known risk for postnatal depressive symptoms (PDS). However, the cumulative effect of various risk factors throughout pregnancy has not been explored. Our aim was to test how various insomnia symptoms (sleep latency, duration, quality, frequent night awakenings, early morning awakenings) and other risk factors (e.g., history of depression, symptoms of depression and anxiety, as well as sociodemographic factors) in early, mid-, and late pregnancy predict PDS.

METHODS

Using data from the FinnBrain Birth Cohort Study and logistic regression analyses, we investigated the associations of distinct insomnia symptoms at gw 14, 24, and 34 with depressive symptoms (Edinburgh Postnatal Depression Scale score ≥ 11) 3 months postnatally. We also calculated separate and combined predictive models of PDS for each pregnancy time point and reported the odds ratios for each risk group.

RESULTS

Of the 2224 women included in the study, 7.1% scored EPDS ≥ 11 3 months postnatally. Our predictive models indicated that sleep latency of ≥ 20 min, anxiety in early pregnancy, and insufficient sleep during late pregnancy predicted the risk of PDS. Furthermore, we found highly elevated odds ratios in early, mid-, and late pregnancy for women with multiple PDS risk factors.

CONCLUSION

Screening of long sleep latency and anxiety during early pregnancy, in addition to depression screening, could be advisable. Odds ratios of risk factor combinations demonstrate the magnitude of cumulating risk of PDS when multiple risk factors are present.

Insomnia symptoms during pregnancy: A meta-analysis

Reports of sleep disturbances are common during pregnancy, yet estimates of prevalence of insomnia symptoms during pregnancy vary widely. The goals of the current review were to summarize the existing data on prevalence of insomnia symptoms during pregnancy and to explore potential moderators, including trimester, gestational age, maternal age, symptoms of anxiety and symptoms of depression. A systematic search of PubMed, PsycInfo and Web of Science was conducted for articles published from inception up to June 2020. In total, 24 studies with a total of 15,564 participants were included in the analysis. The overall prevalence of insomnia symptoms during pregnancy was 38.2%. Trimester was a significant moderator, such that prevalence of insomnia symptoms was higher in the third trimester (39.7%) compared to first (25.3%) and second (27.2%) trimesters. No other variables significantly moderated the prevalence of insomnia symptoms. The results of the current meta-analysis suggest that the prevalence of insomnia symptoms is higher during pregnancy, particularly in the third trimester. Future research should examine the efficacy and safety of insomnia treatments with this population.

Perinatal Insomnia and Mental Health: a Review of Recent Literature

PURPOSE OF REVIEW

The perinatal period is a time of high risk for insomnia and mental health conditions. The purpose of this review is to critically examine the most recent literature on perinatal insomnia, focusing on unique features of this period which may confer specific risk, associations with depression and anxiety, and emerging work on perinatal insomnia treatment.

RECENT FINDINGS

A majority of perinatal women experience insomnia, which may persist for years, and is associated with depression and anxiety. Novel risk factors include personality characteristics, nocturnal perinatal-focused rumination, and obesity. Mindfulness and physical activity may be protective. Cognitive-behavioral therapy for insomnia is an effective treatment. Perinatal insomnia is exceedingly common, perhaps due to factors unique to this period. Although closely linked to perinatal mental health, more work is needed to establish causality. Future work is also needed to establish the role of racial disparities, tailor treatments, and determine whether insomnia treatment improves perinatal mental health.

Nocturnal cognitive arousal is associated with objective sleep disturbance and indicators of physiologic hyperarousal in good sleepers and individuals with insomnia disorder

BACKGROUND

Cognitive arousal is central to models of sleep disturbance and insomnia, but findings remain mixed regarding whether cognitive arousal is associated with objective sleep disturbance and physiologic hyperarousal. This study explored associations of objective nocturnal wakefulness and indicators of physiologic hyperarousal with cognitive arousal in healthy sleepers and individuals with insomnia.

METHODS

In sum, 52 adults (51.9% women; 18 with insomnia disorder, 34 healthy sleepers) underwent two overnight polysomnography (PSG) studies (adaptation + baseline nights) and a multiple sleep latency test (MSLT). Baseline depression was assessed and presleep cognitive arousal and somatic arousal were recorded for each night. Multivariate regression was used to evaluate associations of PSG sleep parameters with insomnia, cognitive arousal, and somatic arousal.

RESULTS

Analyses showed that high levels of nocturnal cognitive arousal were associated with prolonged sleep latency, lower sleep efficiency, and shorter total sleep time by PSG on both nights. An association between nocturnal cognitive arousal and wake after sleep onset was observed on night one only. Moreover, greater nocturnal cognitive arousal was associated with greater likelihood of obtaining short sleep and with longer MSLT sleep latencies. Insomnia diagnosis, depression, and somatic arousal were not associated with PSG sleep parameters or MSLT latency.

CONCLUSIONS

Heightened cognitive arousal at night is linked to objective sleep disturbances and indicators of physiologic hyperarousal at night and during the day. For patients with insomnia, cognitive arousal may contribute to the 24-hr physiologic hyperarousal. Cognitive arousal may be a critical therapeutic target for severe or treatment-resistant sleep disturbance.