Sleep and postpartum depression

Risk and protective factors for postpartum depression among Polish women - a prospective study

This prospective study conducted at a single center in 2022 aims to identify risk and protective factors for postpartum depression (PPD) in Polish women and to assess the impact of pregnancy, delivery, the postpartum period, and psychosocial factors on PPD. After delivery and 4 weeks later, 311 women filled out two questionnaires of our design related to risk factors for PPD. Immune Power Personality Questionnaire, Walsh Family Resilience Questionnaire, and Edinburg Postnatal Depression Scale were also applied. The predictors of PPD identified at two time points included: use of antidepressants, previous depressive episodes, family history of depression, risk of preterm delivery, anxiety about child's health, and breastfeeding and sleep problems. Risk factors for PPD found only after delivery were: suicidal ideation before pregnancy, stressful life events, premature rupture of the membranes, and cesarean section. Inhalation analgesia during labor reduced the PPD frequency. At 4 weeks' postpartum, regular physical activity was also predictive of PPD, while breastfeeding, financial satisfaction, and sufficient sleep duration were protective factors. PPD after delivery was negatively correlated with capacity to confide, hardiness, assertiveness, self-complexity, and communication. PPD at 4 weeks postpartum decreased belief systems, organization patterns, and communication. Two proposed self-designed questionnaires can be useful for effectively screening PPD in the Polish population.

A novel tool for risk assessment, screening, diagnosis, assessment, and therapy in postpartum depression

Postpartum depression (PPD), as a common condition occurring in women in the postnatal period, is underdiagnosed, seldom identified, and infrequently treated. Undiagnosed PPD can have negative consequences for overall quality-of-life outcomes in the mother, psychological growth of the infant, and bonding between the infant and its mother. However, early diagnosis and prompt treatment of PPD can lead to an improvement in postpartum maternal health and a healthier relationship between the mother and her infant. Additionally, early identification of risk factors in the prenatal and antenatal period can enable preventive treatment and ensure that the expectant or pregnant woman remains free of disease after giving birth. Therefore, we propose a protocol for the risk assessment, screening, diagnosis, assessment, and therapy of postnatal depression (RASDAT). The RASDAT protocol recommends assessment of risk factors for PPD in the perinatal period as well as early diagnosis and treatment in the early-to-mid postpartum period. It also recognizes, for the first time, insomnia and anxiety as important predictors, comorbidities, and poor prognostic factors in postpartum depression. Further studies are necessary to determine the feasibility and applicability of this novel tool, including costs of availing health facilities, burden on the health system, and knowledge, attitudes, and practices among physicians and clinical pharmacists regarding PPD and its resolution.

Predictors associated with night sleep disturbance among breastfeeding women

OBJECTIVE

The aim of this study was to investigate the incidence of somnological disorders among Kazakhstani women who breastfeed and to assess the association of this phenomenon with some medical and social characteristics.

METHODS

The authors used the standardized questionnaire of A.M. Vein and Y.I. Levin to assess nocturnal sleep among 1101 breastfeeding women in the Republic of Kazakhstan, applied Pearson's chi-square test to study the correlation between sleep disturbances and duration of breastfeeding, and multiple logistic regression to assess the influence of various medical and social factors on somnological disorders. Data collection occurred in February 2023.

RESULTS

On average, 80% of breastfeeding women (ranging from 79% to 85.9%) experienced some form of nocturnal sleep disorders, with no significant association found between these disorders and breastfeeding duration (p = 0.234), while urban residence, history of operative delivery, child's health issues, and low satisfaction levels with various aspects were associated with over twofold increased odds of experiencing sleep disorders (p ≤ 0.05).

CONCLUSIONS

The elevated prevalence of nocturnal sleep disorders among breastfeeding Kazakhstani women serves as a risk indicator for adverse health outcomes, with predictors including place of residence, obstetric complications, child health issues, and satisfaction levels with social conditions and personal expression opportunities.

Women's mental health during late pregnancy: A survey conducted in Shandong Province, China

BACKGROUND

  The study aimed to investigate the general mental health status and its associated factors in women during late pregnancy. The objective was to provide a scientific basis for developing psychological interventions tailored to this specific population.

METHODS

  The research was conducted from May 2021 to July 2022, involving the recruitment of 200 women attending maternal and child health clinics for their late-pregnancy checkups. Data collection was carried out using a comprehensive approach, involving several validated tools. The participants completed a general demographic and sociological questionnaire along with four standardized psychological assessment scales: the 12-item General Health Questionnaire (GHQ-12), the Athens Insomnia Scale (AIS-8), the Generalized Anxiety Disorder 7 (GAD-7), and the 9-question Patient Health Questionnaire (PHQ-9). A total of 200 valid questionnaires were collected for analysis.

RESULTS

  The study revealed that the overall prevalence of positive detection of general mental health problems in women during late pregnancy was 11%. Significant differences were observed in the positive detection rate of general mental health status based on various factors such as the quality of relationships with husbands, pregnancy intentions, insomnia, anxiety, and depression (p<0.01). Furthermore, participants with general mental health problems displayed notably higher scores on the AIS-8, PHQ-9, and GAD-7 scales compared to those without such problems (p<0.01). Regression analysis indicated that pregnancy intention and PHQ-9 scores were influential factors affecting the general mental health of women during late pregnancy (p<0.05).

CONCLUSION

  The study highlights high rates of general mental health problems during late pregnancy, with unplanned pregnancy and elevated depression scores as key risk factors. Regular mental health screening and targeted interventions are essential to support women during this critical period and enhance the well-being of both mothers and babies.

The role of benzodiazepines in common conditions: a narrative review focusing on lormetazepam

This review aimed to examine the place of benzodiazepines, specifically lormetazepam, in the treatment of insomnia, including during pregnancy or in patients with psychodermatoses. PubMed was searched for the term "lormetazepam" in association with MeSH terms encompassing anxiety, insomnia/sleep disorders, pregnancy/gestation, and psychodermatoses/skin disorders. English-language articles up to 31 July 2022 were identified. Ad hoc searches for relevant literature were performed at later stages of review development. Multiple randomized, placebo-controlled studies have demonstrated that lormetazepam dose-dependently increases total sleep time, decreases wakefulness over a dosing range of 0.5-2.0 mg, and improves subjective assessments of sleep quality. Lormetazepam is as effective as other benzodiazepines in improving sleep duration and quality, but is better tolerated than the long-acting agents with minimal next-day effects. Benzodiazepines can be used as short-term monotherapy at the lowest effective dose during the second or third trimesters of pregnancy; lormetazepam is also a reasonable choice due to its limited transplacental passage. Insomnia associated with skin disorders or pregnancy can be managed by effective symptom control (especially itching), sleep hygiene, treatment of anxiety/depression, and a short course of hypnotics.

Consensus Panel Recommendations for the Pharmacological Management of Breastfeeding Women with Postpartum Depression

INTRODUCTION

Our consensus statement aims to clarify the use of antidepressants and anxiolytics during breastfeeding amidst clinical uncertainty. Despite recent studies, potential harm to breastfed newborns from these medications remains a concern, leading to abrupt discontinuation of necessary treatments or exclusive formula feeding, depriving newborns of benefits from mother's milk.

METHODS

A panel of 16 experts, representing eight scientific societies with a keen interest in postpartum depression, was convened. Utilizing the Nominal Group Technique and following a comprehensive literature review, a consensus statement on the pharmacological treatment of breastfeeding women with depressive disorders was achieved.

RESULTS

Four key research areas were delineated: (1) The imperative to address depressive and anxiety disorders during lactation, pinpointing the risks linked to untreated maternal depression during this period. (2) The evaluation of the cumulative risk of unfavorable infant outcomes associated with exposure to antidepressants or anxiolytics. (3) The long-term impact on infants' cognitive development or behavior due to exposure to these medications during breastfeeding. (4) The assessment of pharmacological interventions for opioid abuse in lactating women diagnosed with depressive disorders.

CONCLUSIONS

The ensuing recommendations were as follows: Recommendation 1: Depressive and anxiety disorders, as well as their pharmacological treatment, are not contraindications for breastfeeding. Recommendation 2: The Panel advocates for the continuation of medication that has demonstrated efficacy during pregnancy. If initiating an antidepressant during breastfeeding is necessary, drugs with a superior safety profile and substantial epidemiological data, such as SSRIs, should be favored and prescribed at the lowest effective dose. Recommendation 3: For the short-term alleviation of anxiety symptoms and sleep disturbances, the Panel determined that benzodiazepines can be administered during breastfeeding. Recommendation 4: The Panel advises against discontinuing opioid abuse treatment during breastfeeding. Recommendation 5: The Panel endorses collaboration among specialists (e.g., psychiatrists, pediatricians, toxicologists), promoting multidisciplinary care whenever feasible. Coordination with the general practitioner is also recommended.

Prenatal exposure to poly- and perfluoroalkyl substances and postpartum depression in women with twin pregnancies

BACKGROUND

Women with multiple pregnancies are vulnerable to experience postpartum depression (PPD). Emerging evidence indicates an association between poly- and perfluoroalkyl substances (PFAS) exposure and PPD in women delivering singletons. The health risks of PFAS may also be present in women delivering twins.

OBJECTIVE

To estimate the impacts of prenatal PFAS exposure on the risk of PPD in women with twin pregnancies.

METHODS

Our study included 150 mothers who gave birth to twins and were enrolled in the Wuhan Twin Birth Cohort. The concentrations of maternal plasma PFAS were measured in each trimester and averaged. Eight individual PFAS were included in analyses. We used Edinburgh Postnatal Depression Scale to evaluate maternal depression at early pregnancy and 1 and 6 months after childbirth. The outcome was dichotomized using a cutoff value of ≥10 for main analyses. Associations were examined using multiple informant models and modified Poisson regressions. PFAS mixture effects were estimated using quantile g-computation.

RESULTS

Using quantile g-computation models, a quartile increase in the PFAS mixture during the first, second, third, and average pregnancy was significantly associated with a relative risk (RR) of 1.73 (95% CI: 1.42, 2.12), 1.54 (95% CI: 1.27, 1.84), 1.75 (95% CI: 1.49, 2.08), and 1.63 (95% CI: 1.35, 1.97) for PPD at 6 months after childbirth, respectively. The results of the single-PFAS models also indicated significant positive associations between individual PFAS and PPD at both 1 and 6 months.

CONCLUSIONS

The first study of women with twin pregnancies suggests that prenatal exposure to PFAS increases PPD risk up to 6 months postpartum. Twin pregnant women should receive long-term follow-up after delivery and extensive social support.

PsyNBIOsis: Investigating the Association between Maternal Gestational Diabetes, Mental Health, Diet and Childhood Obesity Risk: Protocol for a Prospective, Longitudinal, Observational Study

BACKGROUND

Gestational diabetes mellitus (GDM) is associated with poorer maternal mental health (depression and anxiety). Maternal mental health and GDM are likely to influence diet, which in turn impacts the course of GDM. Maternal diet may also be directly or indirectly associated with changes in infant anthropometry. The aims of this study are to (1) examine the associations between maternal GDM, mental health and diet, and (2) evaluate the associations between these maternal factors, breastmilk composition and infant anthropometry.

METHODS

This prospective, observational, longitudinal cohort study compares a cohort of women with and without GDM. Maternal mental health and diet are assessed using validated questionnaires. Breastmilk composition is measured with the Human Milk Analyzer, and infant body composition is measured with air displacement plethysmography.

SIGNIFICANCE AND IMPACT

Once data have been collected, PsyNBIOsis will provide evidence for the associations between maternal mental health, GDM status and diet, and their impact on breastmilk composition and early infant growth. The results may inform the Developmental Origins of Health and Disease framework and provide data on which to build cost-effective interventions to prevent both the development of mental health issues in mothers and adverse growth patterns in infants.

Postpartum Insomnia and Poor Sleep Quality Are Longitudinally Predictive of Postpartum Mood Symptoms

OBJECTIVE

Insomnia and poor sleep quality are frequently reported by perinatal women. Both are noted to increase the risk of postpartum depression, with less known about their association with postpartum anxiety. This study sought to assess whether perinatal sleep disturbances predicted depression and anxiety symptoms across each month of the first 6 months postpartum in women with a history of depression.

METHODS

Pregnant women without active depression at enrollment ( N = 159), 18 to 45 years of age, were recruited. In late pregnancy and for up to 6 months postpartum, women completed monthly online questionnaires including the Insomnia Symptom Questionnaire, Pittsburgh Sleep Quality Index, Edinburgh Postnatal Depression Scale, and Generalized Anxiety Disorder-7. Repeated-measures multilevel models were used to predict depression and anxiety across the postpartum.

RESULTS

The prevalence of insomnia was 20.4%, and the prevalence of poor sleep quality was 67.8% across the first 6 months postpartum. Postpartum insomnia and poor sleep quality at the between-subject and within-subject levels tended to uniquely predict greater depressive and anxiety symptoms, even after controlling for demographic characteristics, prenatal insomnia, and prenatal poor sleep quality.

CONCLUSIONS

Most of the women in our sample had sleep disturbances across the perinatal period. Consistent with the extant literature, postpartum insomnia and poor sleep quality, but not prenatal measures of sleep, longitudinally predicted greater postpartum depression and anxiety symptoms. The chronic sleep deprivation of insomnia and the subjective experience of poor sleep quality are uniquely relevant risks of postpartum mood disorders. Evaluation and mitigation of perinatal sleep disturbance are ideal opportunities to reduce postpartum mood disorders and subsequent health outcomes.

The Insomnia Severity Index: Factor Structure and Measurement and Structural Invariance across Perinatal Time Points

Insomnia is associated with adverse outcomes in women in the perinatal period; thus, the assessment of insomnia is important for pregnant women. The Insomnia Severity Index (ISI) is an instrument used globally to assess the severity of insomnia. However, its factor structure and structural invariance for pregnant women have not been studied. Therefore, we aimed to conduct factor analyses to search for the best model to fit its structural invariance. A cross-sectional study with the ISI was conducted at one hospital and five clinics in Japan from January 2017 to May 2019. A set of questionnaires was administered on two occasions with a one-week interval. The study included 382 pregnant women ranging in gestational age from 10 to 13 weeks. One week later, 129 participants answered the retest. After exploratory and confirmatory factor analyses, the measurement and structural invariance between parity and two time points was tested. The two-factor structure model showed an acceptable fit for the ISI in pregnant women (χ² (12) = 28.516, CFI = 0.971, RMSEA = 0.089). The model also showed satisfactory measurement and structure invariance between parity and time points. The findings indicate that the ISI's use would be appropriate for pregnant women as a two-factor subscale of "severity" and "impact", regardless of the parity or time point. The ISI's factor structure may vary by subject; hence, it is necessary to confirm the measurement and structural invariance of the subject for whom the ISI will be used. Furthermore, interventions that focus not only on total scores and cutoff points but also on the phenomenon of subscales should be considered.

Perinatal Depressive Symptoms among Pregnant Employees in Taiwan

This was a longitudinal study of perinatal depressive symptoms among females employed in a large electronics manufacturer in Taiwan, conducted from August 2015 through October 2016. We used questionnaires to collect data on perceived job strain, social support, and the Edinburgh Postnatal Depression Scale (EPDS) scores at three perinatal time-points (pregnancy, delivery, and return to the workplace). Of the 153 employees who agreed to participate, 82 completed the three stages. The prevalence of perinatal depressive symptoms for the three stages was 13.7%, 16.8%, and 15.9%, respectively. The incidence at 3 weeks after childbirth and 1 month after returning to the workplace was 11.0% and 6.8%, respectively. During the third trimester of pregnancy, sleep problems (odds ratio [OR] = 6.2, 95% confidence Interval [95% CI] = 2.1-19.3), perceived job strain (OR = 4.4, 95% CI = 1.5-14.3), and lack of support from family or friends (OR = 7.0, 95% CI = 1.3-40.8) were significant risk factors. Sleep problems (OR = 6.0, 95% CI = 1.7-23.5) and lack of support from family or friends (OR = 27.6, 95% CI = 4.1-322.3) were associated with an increased risk of perinatal depressive symptoms at 3 weeks after childbirth. After returning to the workplace, perceived job strain (OR = 18.2, 95% CI = 2.2-435.7) was a significant risk factor. These findings could provide insight about early symptom detection, and more studies to clarify the association would be worthwhile.

Effect of brexanolone on depressive symptoms, anxiety, and insomnia in women with postpartum depression: Pooled analyses from 3 double-blind, randomized, placebo-controlled clinical trials in the HUMMINGBIRD clinical program

BACKGROUND

Brexanolone is currently the only treatment specifically approved for postpartum depression (PPD) in the United States, based on the results from one Phase 2 and two Phase 3 double-blind, randomized, controlled trials in the HUMMINGBIRD program.

METHODS

Adults with PPD randomized to a 60-h infusion of brexanolone 90 μg/kg/h (BRX90) or placebo from the 3 trials were included in these post hoc analyses. Data on change from baseline (CFB) in the 17-item Hamilton Rating Scale for Depression (HAMD-17) total score, HAMD-17 Anxiety/Somatization and Insomnia subscales, and Clinical Global Impression of Improvement (CGI-I) scale were pooled. Response rates for HAMD-17 (≥50 % reduction from baseline) and CGI-I (score of 1 or 2) scales and time to response were analyzed.

RESULTS

Patients receiving BRX90 (n = 102) versus placebo (n = 107) achieved a more rapid HAMD-17 response (median, 24 vs 36 h; p = 0.0265), with an Hour-60 cumulative response rate of 81.4 % versus 67.3 %; results were similar for time to CGI-I response (median, 24 vs 36 h; p = 0.0058), with an Hour-60 cumulative response rate of 81.4 % versus 61.7 %. CFB in HAMD-17 Anxiety/Somatization and Insomnia subscales also favored BRX90 versus placebo, starting at Hour 24 through Day 30 (all p < 0.05), and response rates for both subscales were higher with BRX90.

LIMITATIONS

The study was not powered to assess exploratory outcomes.

CONCLUSIONS

Brexanolone was associated with rapid improvement in depressive symptoms and symptoms of anxiety and insomnia compared with placebo in women with PPD. These data continue to support the use of brexanolone to treat adults with PPD.

Trajectory of Perinatal Depressive Symptoms from the Second Trimester to Three Months Postpartum and Its Association with Sleep Quality

Purpose

Few studies have explored the association between sleep quality and depressive symptoms in perinatal women from the second trimester to the postpartum period. This study aims to explore this relationship using a longitudinal design.

Patients and Methods

Participants were enrolled at 15 gestational weeks. Demographic information was collected. Perinatal depressive symptoms were measured using the Edinburgh Postnatal Depression Scale (EPDS). Sleep quality was measured employing the Pittsburgh Sleep Quality Index (PSQI) at five timepoints from enrollment to three months postpartum. Overall, 1416 women completed the questionnaires at least thrice. A Latent Growth Curve (LGC) model was performed to identify the relationship between the trajectories of perinatal depressive symptoms and sleep quality.

Results

Of the participants, 23.7% screened positive at least once on the EPDS. The perinatal depressive symptoms trajectory, fitted by the LGC model, decreased at early pregnancy and increased from 15 gestational weeks to three months postpartum. The intercept of sleep trajectory positively affected the intercept of perinatal depressive symptoms' trajectory; the slope of sleep trajectory positively affected both the slope and the quadratic coefficient of perinatal depressive symptoms' trajectory.

Conclusion

The trajectory of perinatal depressive symptoms increased from 15 gestational weeks to three months postpartum following a quadratic trend. Poor sleep quality was associated with depression symptoms beginning at the onset of pregnancy. Moreover, rapidly declining sleep quality could be a significant risk factor for perinatal depression (PND). These findings call for greater attention to perinatal women who report poor and persistently deteriorating sleep quality. Additional sleep-quality evaluations, depression assessments, and referrals to mental health care providers may benefit these women and support PND prevention, screening, and early diagnosis.

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.

Trajectories and Depressive Symptoms During the Perinatal Period: A Longitudinal Population-Based Study in China

Most women in the perinatal period face sleep issues, which can affect their mental health. Only a few studies have focused on sleep trajectories and depressive symptoms of women during the perinatal period in China. This study aims to explore the development trajectory of sleep quality by classifying pregnant women according to the changes in their sleep quality during pregnancy and postpartum and investigate the correlation between different sleep quality trajectory groups and depressive symptoms. The Pittsburgh Sleep Quality Index (PSQI) was used to assess the sleep quality, and the Edinburgh Postnatal Depression Scale (EPDS) was used to assess the symptoms of depression. Participants (n = 412) completed the assessment of sleep quality, depressive symptoms, and some sociodemographic and obstetric data at 36 weeks of gestation, 1 week after delivery, and 6 weeks after delivery. The group-based trajectory model (GBTM) was used to complete the trajectory classification, and logistic regression was used to analyze the predictive factors of postpartum depressive symptoms. Four different sleep quality trajectories were determined: "stable-good," "worsening," "improving," and "stable-poor" groups. The results demonstrate that poor sleep trajectories, social support and parenting experience during the perinatal period are related to postpartum depression. Screening for prenatal sleep problems is crucial for identifying the onset of perinatal depressive symptoms.

Evaluating depression and anxiety throughout pregnancy and after birth: impact of the COVID-19 pandemic

BACKGROUND

The COVID-19 pandemic presents unique social, economic, and psychological challenges for individuals globally. Thus, women who are pregnant face unprecedented mental health challenges.

OBJECTIVE

We sought to determine the impact of the pandemic on perinatal depression and anxiety in a longitudinal pregnancy cohort. We hypothesized increased depression and anxiety scores in women during pregnancy and after birth in the pandemic at all time points.

STUDY DESIGN

Participants were enrolled in the Ontario Birth Study, a pregnancy cohort embedded in clinical care at Mount Sinai Hospital, Toronto, Canada. Perinatal depression and anxiety were assessed using the 2-Item Patient Health Questionnaire and 2-Item Generalized Anxiety Disorder Questionnaire in early pregnancy, whereas the Edinburgh Postnatal Depression Scale and 2-Item Generalized Anxiety Disorder Questionnaire were used in late pregnancy and after birth. Logistic regression models were created to examine the association of the pandemic with clinically elevated mental health scores in the prepandemic group vs pandemic group while adjusting for covariates.

RESULTS

A total of 1159 survey responses from 649 participants between March 1, 2019, and February 28, 2021, were used to conduct this study. Participants were assessed in early pregnancy (n=416), in late pregnancy (n=373), and after birth (n=370). Responses received on or before February 29, 2020, were considered the “prepandemic” responses, whereas responses after the aforementioned date were considered the “pandemic” responses. Mean rank scores of depression and anxiety were significantly higher in the pandemic group (P=.02 and P=.003, respectively) in the postpartum period. There was no significant association between pandemic time and antenatal scores. However, postnatally, mothers were 2.6 times more likely to score ≥13 on the Edinburgh Postnatal Depression Scale during the pandemic than before the pandemic (95% confidence interval, 1.2–5.7; P=.02). Adjustment for ethnicity and income strengthened this association as the odds ratio increased to 3.3 (95% confidence interval, 1.4–8.0; P=.007).

CONCLUSION

Pandemic-associated increases in depression and anxiety scores were confined to the postpartum period, highlighting a need for increased screening and interventions for perinatal mood and anxiety disorders postnatally as this pandemic continues.

The Association between Postpartum Practice and Chinese Postpartum Depression: Identification of a Postpartum Depression-Related Dietary Pattern

Conflicting results of Chinese traditional postpartum practices have aroused concerns over their health effects. The role of postpartum practices in postpartum depression (PPD) is still a matter of discussion, especially from a dietary practice point of view. The current study was designed to (1) explore the association between postpartum practices and PPD, (2) to identify the dietary pattern related to PPD, and (3) to identify the possible pathways among postpartum practices and PPD. This study is part of the YI Study, which was a cross-sectional study conducted in 10 cities in China. Data for 955 postpartum women were used in the current analysis. The Edinburgh Postnatal Depression Scale (EPDS-10) was used to evaluate PPD with a cutoff value of 9. Postpartum practice was based on the participants’ self-reported practices. Individual practices were recorded and categorized as dietary and non-dietary practices. The dietary pattern was identified based on the food intake frequencies of 25 food groups using the method of reduced rank regression. Structural equation modeling was used to explore the potential pathways between postpartum practices and PPD. The current study observed significant associations between postpartum practices and PPD (Adjusted OR = 1.41, 95% CI: 1.04–1.90). A similar trend was also found between dietary postpartum practices and PPD (Adjusted OR = 1.39, 95%CI: 1.03–1.88) but not for non-dietary practices and PPD (Adjusted OR = 1.26, 95%CI: 0.92–1.75). A PPD-related dietary pattern was identified with the characteristics of a high intake of meat and eggs and a lower intake of vegetables, mushrooms, and nuts. This dietary pattern was significantly associated with a higher chance of adhering to postpartum practice (Adjusted OR = 1.26, 95% CI: 1.10–1.44). Based on the pathway analysis, this study also observed the association between postpartum practices and PPD, and the association between dietary practices and PPD were both mediated by sleep quality. In conclusion, this study demonstrated that a substantial proportion of women in modern China experience traditional postpartum Chinese practices and that either overall or dietary-related postpartum practices are associated with a higher risk of PPD. The current dietary practices in postpartum rituals may play an important role in developing PPD. A culturally embedded, science-based dietary guideline is required to help women to achieve both physical and psychological health in the postpartum period.

Effects of family relationship and social support on the mental health of Chinese postpartum women

Background

Numerous studies suggest that interpersonal relationships and social support influence the development of postpartum depression and sleep quality for women. However, the effect of support from the husband or the mother-in-law has not been thoroughly validated. The current study examined the relative contribution of marital satisfaction, perceived caring of the mother-in-law, and social support on postpartum depression and sleep quality simultaneously in a path model.

Methods

A cross-sectional study was conducted from March to June 2017 in Hebei, China, using a self-report questionnaire. A total of 817 women participated at 6 weeks postpartum. Sociodemographics and information about marital satisfaction, perceived caring of the mother-in-law, social support, postpartum depression, and sleep were collected. Path analysis was used to analyze the cross-sectional data.

Results

The final model had a highly satisfactory fit. Marital satisfaction and perceived caring of mother-in-law had both direct and indirect effects on postpartum depression through social support, but these two variables had only an indirect effect on sleep quality through social support and postpartum depression. Sleep quality is a consequence of postpartum depression at 6 weeks after delivery. The prevalence of minor and major postpartum depressive symptoms at 6 weeks postpartum was 41.49 and 23.13%, respectively. A total of 371 (45.41%) women experienced sleep disturbance at 6 weeks postpartum.

Conclusions

These findings suggest that interpersonal relationships with family members play important roles in postpartum depression and sleep quality through social support in Chinese women. Improving the relationship between new mothers and their husbands or mothers-in-law and then enhancing social support might reduce postpartum depression and sleep disturbance.

The Relevance of Insomnia in the Diagnosis of Perinatal Depression: Validation of the Italian Version of the Insomnia Symptom Questionnaire

BACKGROUND

Sleep disorders are common in perinatal women and may underlie or trigger anxiety and depression. We aimed to translate and validate and evaluate the psychometric properties of the Italian version of the Insomnia Symptom Questionnaire (ISQ), in a sample of women during late pregnancy and 6-months postpartum according to the DSM-5 criteria.

METHODS

The ISQ was administered to 292 women prenatally along with other measures of sleep quality, depression, and anxiety, to examine its construct and convergent validity. Women were readministered the ISQ six months postdelivery to assess test-retest reliability. Women were divided into DSM-5 No-Insomnia (N = 253) and Insomnia (N = 39) groups.

RESULTS

The insomnia group had received more psychopharmacotherapy, had more psychiatric family history, increased rates of medically assisted reproduction, of past perinatal psychiatric disorders, and scored higher on almost all TEMPS-A dimensions, on the EPDS, HCL-32, PSQI, and on ISQ prenatally and postnatally. ISQ scores correlated with all scales, indicating adequate convergent and discriminant validity; furthermore, it showed antenatal-postnatal test-retest reliability, 97.5% diagnostic accuracy, 79.5% sensitivity, 94.9% specificity, 70.5% positive predictive power, and 92.8% negative predictive power.

CONCLUSIONS

The ISQ is useful, valid, and reliable for assessing perinatal insomnia in Italian women. The Italian version showed equivalent properties to the original version.

Prevalence and Risk Factors of Postpartum Depression in Women: A Systematic Review and Meta-analysis

AIM

The current systematic review aimed to present the pooled estimated prevalence and risk factors of PPD.

BACKGROUND

Postpartum depression seriously affects the physical and mental health of the mother and child. However, high-quality meta-analysis is limited, which restricts the screening and intervention of postpartum depression.

DESIGN

A systematic review and meta-analysis.

METHODS

Cochrane Library, PubMed, Embase and Web of Science were searched for cohort and case-control studies investigating the prevalence and risk factors of postpartum depression from inception to December 31st, 2020. Meta-analyses were performed to identify postpartum depression prevalence and risk factors using a random-effects model.

RESULTS

Of the 33 citations evaluated, 27 reported the prevalence of postpartum depression in 33 separate study populations containing 133,313.

SUBJECTS

Pooled prevalence in all studies was 14.0% (95%CI, 12.0%-15.0%). The prevalence varied according to country (from 5.0% to 26.32%) and developing countries, especially China, have a high prevalence of postpartum depression. The following risk factors were associated with postpartum depression: gestational diabetes mellitus(OR = 2.71, 95%CI 1.78-4.14, I²  = 0.0%), depression during pregnancy(OR = 2.40, 95%CI 1.96-2.93, I²  = 96.7%), pregnant women give birth to boys(OR = 1.62; 95%CI 1.28-2.05; I²  = 0.0%), history of depression during pregnancy(OR = 4.82, 95%CI 1.32-17.54, I²  = 74.9%), history of depression(OR = 3.09, 95%CI 1.62-5.93, I²  = 86.5%) and epidural anaesthesia during delivery(OR = .81, 95%CI .13-4.87, I²  = 90.1%).

CONCLUSIONS

The prevalence of postpartum depression seems to be high, especially in developing countries. Gestational diabetes mellitus, depression during pregnancy, pregnant women give birth to boys, history of depression during pregnancy, history of depression, epidural anaesthesia during delivery were identified as risk factors for postpartum depression. Understanding the risk factors of PPD can provide the healthcare personnel with the theoretical basis for the patients' management and treatment.

IMPLICATIONS FOR PRACTICE

This systematic review and meta-analysis identified six significant risk factors for PPD, which provides nurses with a theoretical basis for managing and treating women with PPD to effectively improve the screening rate, intervention rate and referral rate of women with PPD.

Investigating the link between sleep and postpartum depression in fathers utilizing subjective and objective sleep measures

Background

While fathers are at risk of developing poorer sleep and depressive symptoms in the postpartum period, they represent an understudied population in the literature. The present study aimed to explore the association between sleep and postpartum depressive symptoms in fathers using subjective and objective sleep measures.

Methods

Fifty-four fathers reporting no history of depression took part in this cross-sectional study. At 6 months postpartum, paternal sleep was assessed for 2 weeks utilizing a self-report daily sleep diary, a self-report perceived sleep quality rating, and actigraphy. In the same period, depressive symptoms in fathers were assessed with the Center for Epidemiologic Studies-Depression Scale (CES-D).

Results

Regression analyses showed that paternal subjective sleep variables captured by the sleep diary (total nocturnal sleep time and number of night awakenings) were not related to postpartum depressive symptoms. However, self-reported perceived sleep quality was significantly associated with postpartum depressive symptom severity in fathers independently of demographic variables related to depression. Alternatively, the objective sleep variables (total nocturnal sleep time, number of night awakenings, sleep efficiency, and wake after sleep onset), measured by actigraphy, did not demonstrate a significant relationship with paternal depression scores.

Conclusions

These findings highlight the importance of perceived sleep quality, along with better understanding its association with postpartum depressive symptoms. Implementing a multi-measure approach enabled us to expand our knowledge about how different facets of sleep relate to postpartum depression, specifically in fathers. The results have important implications for the development of clinical interventions targeting paternal sleep and mood in the postpartum period.

The Impact of Maternal Symptoms of Perinatal Insomnia on Social-emotional Child Development: A Population-based, 2-year Follow-up Study

Background: Poor sleep quality is a common problem in pregnant women, however there is scarce research evidence regarding the association between maternal perinatal insomnia and later social-emotional child development.Participants: This study is part of the Akershus Birth Cohort, a longitudinal population-based study. Birth record and questionnaire data of 1,346 women were used.Methods: Maternal symptoms of insomnia were measured at pregnancy week 32 and at eight weeks postpartum and social-emotional child development was assessed at two years of child age. Correlational and multiple linear regression analyzes were performed.Results: Both, pre- and postnatal symptoms of insomnia were significantly correlated with poorer social-emotional child development two years later (r = 0.09, p < .01 and r = 0.13, p < .001). Adjusting for potential confounding factors, the prospective effect of maternal symptoms of perinatal insomnia on social-emotional child development remained significant in the multiple linear regression analyzes (β = 0.08, p < .01 and β = 0. 10, p < .01).Conclusions: We found a prospective effect of maternal symptoms of perinatal insomnia on social-emotional child development, highlighting the potential relevance of both pre- and postnatal maternal sleep for later social-emotional child development. Future studies ought to examine the bio-psycho-social mechanisms and implications of poor maternal sleep in the perinatal time in more detail.

A prospective study on the course of sleep disturbances in first-time fathers during the transition to parenthood

INTRODUCTION

This study examined sleep disturbances in first-time fathers from the third trimester of their partner's pregnancy to 2 months postpartum to determine prevalence, incidence, and persistence of sleep disturbances and identify associated determinants.

METHODS

Men expecting their first child were recruited from local prenatal classes and university-affiliated obstetric clinics. During their partner's third trimester of pregnancy and 2 months postpartum, 459 men completed standardized online self-report questionnaires measuring sociodemographics, lifestyle, and psychosocial variables and sleep quality.

RESULTS

Disturbed sleep (Pittsburgh Sleep Quality Index [PSQI] global score >5) increased from 29.6% during the third trimester to 44.7% at 2 months postpartum. The incidence of poor sleep at 2 months postpartum was 33.7%. Among men with disturbed sleep at the antenatal assessment, 70.6% continued to have sleep disturbances at 2 months postpartum. An increase in depressive symptoms and higher parenting stress was independently associated with onset and persistence of disturbed sleep at 2 months postpartum.

CONCLUSIONS

Sleep is compromised in expectant and new fathers. Strategies aimed at improving sleep, depressed mood, and managing the challenges of parenting may be important components to include in prenatal interventions aimed at enhancing the transition to parenthood and infant development.

The influence of sleep quality on weight retention in the postpartum period

Poor sleep in the postpartum is often treated as an unavoidable consequence of childbirth. This study aims to compare objective and subjective measures of sleep, explore the relationship between sleep and postpartum weight retention (PPWR), and investigate factors that may contribute to sleep quality in the postpartum period. In this cross-sectional cohort, PPWR, sleep quality (Pittsburgh Sleep Quality Index (PSQI)), and objective sleep and physical activity (accelerometry) were assessed in 109 women 0–52 weeks postpartum. Anthropometric and demographic data were collected. Gestational weight gain (GWG) was classified as inadequate, appropriate, or excessive according to Institute of Medicine guidelines. Average GWG (33.7 lbs) and PPWR (5.39 lbs) were not different between “good” (PSQI < 6) and “bad” (PSQI ≥ 6) sleepers. Following adjustment, mothers with excessive GWG who were “bad” sleepers had 5.26 higher odds of PPWR ≥ 10 lbs compared with all other combinations of GWG and PSQI. PSQI was not correlated with total sleep time (accelerometer-derived). Light activity and moderate-to-vigorous physical activity (MVPA) were associated with reduced odds of being a “bad” sleeper. The influence of GWG on PPWR was modified by postpartum sleep quality. Both light activity and meeting the MVPA guidelines in the postpartum were associated with higher sleep quality.

Novelty Subjectively rated poor sleep may represent the number of awakenings and wake after sleep onset in postpartum women. Poor postpartum sleep quality increases excessive postpartum weight retention in women with excessive GWG. Women doing light-to-vigorous physical activity in the postpartum are less likely to experience poor sleep quality.

Effects of sleep restriction during pregnancy on postpartum maternal behavior in female rats

Preclinical studies evaluating the effects of gestational sleep restriction on maternal behavior are needed in order to provide information on the background mechanisms underlying this relationship. In this study, 32 female 90 days-old Wistar-Hannover rats were distributed in two groups: Control group (CTRL - n = 13), not subjected to any manipulation during pregnancy; and sleep restriction group (SR - n = 19) - subjected to sleep restriction during the whole pregnancy (21 days). Maternal behavioral analysis was conducted from postpartum day 1 (PPD1) to PPD7, based on observational ethograms. On PPD11 the animals were subjected to the grooming analysis algorithm, followed by the elevated plus maze. Results from an ethogram-based analysis indicated a decrease in self-grooming among sleep-deprived rats (denoting reduced anxiety-like behavior), but no significant differences were found in maternal behavior (except for a slight increase in high arched-back nursing). Controlled analysis detected an impairment in high-arched back nursing in sleep-deprived animals. The grooming microstructure analysis showed an increased frequency of incorrect transitions among sleep restricted animals, indicating increased anxiety-like behavior. No significant differences were observed in the elevated-plus maze. In conclusion, sleep-restricted pregnant rats display an equivalent or slightly increased maternal behavior during the postpartum period, when compared to control animals.

Effects of sleep modulation during pregnancy in the mother and offspring: Evidences from preclinical research

Disturbed sleep during gestation may lead to adverse outcomes for both mother and child. Animal research plays an important role in providing insights into this research field by enabling ethical and methodological requirements that are not possible in humans. Here, we present an overview and discuss the main research findings related to the effects of prenatal sleep deprivation in animal models. Using systematic review approaches, we retrieved 42 articles dealing with some type of sleep alteration. The most frequent research topics in this context were maternal sleep deprivation, maternal behaviour, offspring behaviour, development of sleep-wake cycles in the offspring, hippocampal neurodevelopment, pregnancy viability, renal physiology, hypertension and metabolism. This overview indicates that the number of basic studies in this field is growing, and provides biological plausibility to suggest that sleep disturbances might be detrimental to both mother and offspring by promoting increased risk at the behavioural, hormonal, electrophysiological, metabolic and epigenetic levels. More studies on the effects of maternal sleep deprivation are needed, in light of their major translational perspective.

Symptoms of Daytime Sleepiness and Sleep Apnea among Pregnant Women

Objectives

Despite the fact that sleep disturbances have been associated with poor maternal and neonatal health outcomes in pregnancy, no studies have assessed excessive daytime sleepiness or the risk for sleep apnea among pregnant Saudi Arabian women. We sought to estimate the prevalence of excessive daytime sleepiness (EDS) and the high risk for sleep apnea (OSA) in a sample of pregnant Saudi women.

Methods

An anonymous self-report questionnaire was completed by 517 pregnant women who attended obstetric outpatient clinics at King Abdulaziz Medical City, Riyadh, Saudi Arabia, for a routine pregnancy check. We collected demographic and clinical data for all patients and used the Berlin Questionnaire and the Epworth Sleepiness Scale to determine the primary outcomes.

Results

A high risk of OSA was found in 37.1% of women (95% confidence interval (CI): 33.00%-41.50%), and EDS was found in 32.1% (95% CI: 28.10%-36.30%). The presence of both (EDS and a high risk of OSA) was found in 14.9% of women (95% CI: 11.90%-18.30%). We found increased odds of EDS in women who reported pain three times or more per week (adjusted odds ratio (aOR) = 2.59) and insomnia (aOR = 1.65). Older women (≥ 37 years) (aOR = 3.00), those who reported pain once a week (aOR = 1.99), pain twice a week (aOR = 2.75), three times or more a week (aOR = 2.57), and insomnia (aOR = 1.95) increased the odds of high risk for OSA.

Conclusions

EDS and a high risk for OSA affected a large portion of the pregnant women included in the study, primarily those who reported pain and insomnia. Our study provides important information for gynecologists to help promote healthy sleep and manage the issues arising from sleep disturbances among pregnant women as part of their daily practice.

Research Recommendations on the Effects of Postpartum Depression and Pain on Infant Care and Development

Postpartum depression is one of the most common complications of childbirth, and another is pain. A growing body of research shows that the severity and duration of postpartum pain can increase a woman's risk for postpartum depression. Postpartum depression and pain negatively affect maternal well-being, and postpartum depression has been associated with adverse outcomes in children. However, there is a dearth of information about the effects of postpartum depression and pain on infant care and development. The objectives of this commentary were to highlight the need to address this gap in the literature, offer a preliminary conceptual model to advance the field, and ignite new lines of inquiry to inform infant care and development.

A randomized controlled pilot study of the effectiveness of magnolia tea on alleviating depression in postnatal women

The magnolia tea has been used in traditional oriental medicine for multiple purposes including sleep aid. Postpartum depression is a mental illness that adversely affects the health and well-being of many families with newborns. Given the known effectiveness and relative safety, herein we aimed to investigate whether magnolia tea has a palliative effect on postpartum depression. The qualified participants were randomly assigned to the intervention group or the control group. The participants in the intervention group drunk magnolia tea, while the control group received regular postpartum care only. The outcome variables including Postpartum Sleep Quality Scale (PSQS), Edinburgh Postnatal Depression Scale (EPDS), and Postpartum Fatigue Scale (PFS) were assessed and compared. In comparison with the control group, the intervention group demonstrated significant difference for physical-symptom-related sleep inefficiency (PSQS Factor 2) at 3 weeks post-test (t = -2.10, p = .03). The comparison results also revealed significant differences for PFS at both 3 weeks post-test (t = -2.02, p = .04) and 6 weeks post-test (t = -1.99, p = .04). Further, magnolia tea intervention significantly alleviated the symptoms of depression, reflected by the EPDS scores at 3 weeks post-test (t = -2.38, p = .02) and 6 weeks post-test (t = -2.13, p = .02). Our trial results suggested that drinking single-ingredient magnolia tea for a 3-week duration has positive effects on postpartum women. Magnolia tea is recommended as a supplementary approach to ameliorate sleep quality of postpartum women, while alleviating their symptoms of depression.

Neuroendocrine Effects of Lactation and Hormone-Gene-Environment Interactions

While correlational studies suggest that lactation may confer a certain level of protection from mental illness, this benefit is not uniformly expressed in all women who choose to breastfeed. We propose here that the neuroendocrine "resetting" induced by lactation may predispose toward positive affect states in a subset of hormone-sensitive mothers, with hormone-gene and hormone-environment interactions determining the ultimate psychological outcome. We find evidence to suggest that higher secretion of prolactin/oxytocin as well as lower secretion of vasopression/androgens in lactating mothers may protect against postpartum depression and anxiety, decrease levels of irritability, and optimize stress responses. On the other hand, while the abrupt withdrawal of estradiol/progesterone in the immediate postpartum period tends to be associated with adverse psychological outcomes, the chronic suppression of estrogens/progestogens induced by lactation may have antidepressant and anxiolytic effects over time. Finally, the hypo-cortisolemic state seen in lactating mothers appears to be associated with improved stress reactivity and circadian rhythms. We also discuss hormone-gene and hormone-environment interactions likely to modulate any potential psychological benefits related to lactation and focus on those factors that are either easy to screen for or known to be modifiable. In sum, neuroendocrine alterations induced by lactation may play a key role in determining reproductive psychiatric risk in a subset of hormone-sensitive women. Using these neuroendocrine factors as an individualized index of risk can help in devising targeted programs to support these women in pursuing lactation or, for those not able or willing, accessing psychological interventions in a timely manner.

Sleep quality is associated with vasopressin methylation in pregnant and postpartum women with a history of psychosocial stress

BACKGROUND

The relationship between disturbed sleep and stress is well-documented. Sleep disorders and stress are highly prevalent during the perinatal period, and both are known to contribute to a number of adverse maternal and foetal outcomes. Arginine vasopressin (AVP) is a hormone and a neuropeptide that is involved in stress response, social bonding and circadian regulation of the sleep-wake cycle. Whether the AVP system is involved in regulation of stress response and sleep quality in the context of the perinatal mental health is currently unknown. The objective of the present study was to assess the relationship between levels of cumulative and ongoing psychosocial risk, levels of disordered sleep and AVP methylation in a community sample of pregnant and postpartum women.

METHODS

A sample of 316 participants completed a battery of questionnaires during the second trimester of pregnancy (PN2, 12-14 weeks gestation), third trimester (PN3, 32-34 weeks gestation), and at 7-9 weeks postpartum (PP). Disordered sleep was measured using the Sleep Symptom Checklist at PN2, PN3 and PP; cumulative psychosocial risk was assessed with the Antenatal Risk Questionnaire (ANRQ) at PN2; salivary DNA was collected at the follow-up (FU, 2.9 years postpartum); and % methylation were calculated for AVP and for two of the three AVP receptor genes (AVPR1a and AVPR1b). Women were separated into high (HighPR) and low (LowPR) psychosocial risk groups, based on their scores on the ANRQ.

RESULTS

Women in the HighPR group had significantly worse sleep disturbances during PN2 (p < .001) and PN3 (p < .001), but not at PP (p = .146) than women in the LowPR group. In HighPR participants only, methylation of AVP at intron 1 negatively correlated with sleep disturbances at PN2 (r_s=-.390, p = .001), PN3 (r_s=-.384, p = .002) and at PP (r_s= -.269, p = .032). There was no association between sleep disturbances and AVPR1a or AVPR1b methylation, or between sleep disturbances and any of the AVP methylation for the LowPR group. Lastly, cumulative psychosocial stress was a moderator for the relationship between AVP intron 1 methylation and disordered sleep at PN2 (p < .001, adjusted R² = .105), PN2 (p < .001, adjusted R² = .088) and PP (p = .003, adjusted R² = .064).

CONCLUSIONS

Our results suggest that cumulative psychosocial stress exacerbates sleep disorders in pregnant women, and that salivary DNA methylation patterns of the AVP gene may be seen as a marker of biological predisposition to stress and sleep reactivity during the perinatal period. Further research is needed to establish causal links between AVP methylation, sleep and stress.

The effect of perceived social support during early pregnancy on depressive symptoms at 6 weeks postpartum: a prospective study

BACKGROUND

Postpartum depression was associated with maternal suffering and diminished functioning, increased risk of marital conflict as well as adverse child outcomes. Perceived social support during pregnancy was associated with postpartum depression among women. However, its causal relationship remains unclear. Therefore, we prospectively evaluate the association between perceived social support during early pregnancy and postpartum depressive symptoms.

METHODS

We prospectively examined whether perceived social support during early pregnancy affected depressive symptoms at 6 weeks postpartum in a cohort of 3310 women. Perceived social support and postpartum depression were assessed by ENRICHD Social Support Instrument (ESSI) and the postpartum Edinburgh Postpartum Depression Scale (EPDS), respectively. Prevalence of postpartum depressive symptoms was 11.4% (EPDS cutoff≥10). As a test of heterogeneity of association in subpopulations, logistic regression models were performed to analyze the association between social support and postpartum depressive symptoms in strata which were defined by the potential confounder candidates. After multiple imputation, multivariable logistic regression was performed to assess the effect of social support on postpartum symptoms in individual items and total score. Two models were built. Model I adjusted for the variables associated with social support or postpartum depression and changed the association estimates by ≥10%. Model II adjusted for all variables that may be related to social support or postpartum depression.

RESULTS

Significant associations between low perceived social support and postpartum depressive symptoms was found(Model I odds ratio: 1.63, 95% confidence interval: 1.15, 2.30; Model II odds ratio: 1.77, 95% confidence interval: 1.24-2.52). Stratified analyses showed that there was little evidence of heterogeneity of association in subpopulations by basic characteristics of participants.

CONCLUSIONS

These findings suggest that early intervention may be able to help protect against depression symptoms at 6 weeks postpartum.

Link between insomnia and perinatal depressive symptoms: A meta-analysis

Evidence shows the possible link between insomnia and perinatal depressive symptoms. In order to find a convergent quantitative answer, we collected data via the search of Medline, EMBASE and reference tracking, which included nine studies (a total sample of 1,922 women). An aggregate effect size estimate (correlation coefficient) was generated using the comprehensive meta-analysis software. For the meta-analytic procedure, a random effects model was set a priori. Moderating factors, including study design, method of assessment of depression, geographical origin of data, publication year, mean age, % married, breastfeeding rate, quality and type of data, % primiparous and history of depression, were examined via categorical or univariate mixed-effects (method of moments) meta-regression methods. Heterogeneity and publication bias were examined using standard meta-analytic approaches. We found a significant, medium-size relationship between insomnia and perinatal depressive symptoms (point estimate, 0.366; 95% confidence interval [CI], 0.205-0.508; p < 0.001; n = 9) and this was significantly heterogeneous (Q, 118.77; df, 8; p < 0.001; I² , 93.26%). The effect size estimate was significant for studies reporting no history of depression (point estimate, 0.364; 95% CI, 0.035-0.622; p < 0.05; n = 5) and for study design. With meta-regression, no moderating factor (age, marriage rate, breastfeeding rate, pregnancy history or publication year) significantly mediated the effect size estimate. The depression assessment scale used, but not other categorical variables, explained the magnitude of heterogeneity. We found that insomnia during the perinatal period is associated with depressive symptoms, which warrants screening pregnant mothers for insomnia and depression.

Stress-related sleep reactivity is associated with insomnia, psychopathology and suicidality in pregnant women: preliminary results

INTRODUCTION

Depression and anxiety symptoms are commonly experienced by women during pregnancy and may have negative consequences on mothers and newborns. Deterioration of sleep quality throughout pregnancy increases insomnia, which may lead to adverse outcomes including increased psychopathology in the perinatal period. Thus, identifying women at high risk of developing insomnia may have important clinical implications on maternal-fetal outcomes. Stress-related sleep reactivity is a well-established risk factor for future insomnia, depression, and anxiety in general adult samples. However, little is known of sleep reactivity and its relations to sleep and mood pathology in pregnancy. Therefore, we explored sleep reactivity in pregnant women and its relations to prenatal symptoms of insomnia, depression, anxiety, and suicidality.

METHOD

Sixty-two pregnant women (mean age 33.6 ± 3 years, 20.6 ± 0.6 weeks of pregnancy) were evaluated during their routine visit at the Gynecological Unit of the University of Pisa, Italy, using the Insomnia Severity Index (ISI) for insomnia symptoms, the Ford Insomnia Response to Stress Test for sleep reactivity (FIRST), Edinburgh Postnatal Depression Scale (EPDS) for depressive symptoms, and the Zung Self Rating Anxiety Scale (SAS) for anxiety symptoms. Item #10 of the EPDS was used to assess for suicidality. Differences in means between women with high vs low stress-related sleep reactivity were calculated using t-test or Mann-Whitney U/Wilcoxon test. Linear/multiple regression analyses have been performed to study associations between variables.

RESULTS

Pregnant women with high stress-related sleep reactivity, relative to those with low reactivity, reported greater symptoms of insomnia (t = 6.5, 0.004) as well as higher rates of depression (62.0% vs 6.1%, p < 0.001), anxiety (55.1% vs 15.1%, p = 0.030), and suicidality (17.2% vs 3.0%, p = 0.025). Multivariate models revealed sleep reactivity to correlate independently with symptoms of insomnia, depression, and anxiety, when controlling for comorbid symptoms.

CONCLUSIONS

In mid-pregnancy, women with high sleep reactivity report elevated symptoms of insomnia, depression, and anxiety, and are more likely to endorse suicidal ideation. As a prognostic marker of future insomnia and psychiatric illness, early detection of high prenatal sleep reactivity holds potential to prevent the development of sleep and mood pathology during pregnancy, thereby potentially improving maternal and child outcomes.

The Role of Circadian Rhythms in Postpartum Sleep and Mood

Women often experience sleep disturbances and worsening sleep quality throughout pregnancy and postpartum. Circadian rhythms are closely linked to sleep problems and mood disorders. This systematic review provides a summary of studies of circadian rhythms and associated sleep problems and maternal distress, among postpartum women. Articles were idenitfied through a systematic literature search. Circadian rhythm disturbances were strongly correlated with depression, social factors and mothers`s exposure to light postpartum. Future research should include larger, prospective studies as well as randomized controlled trials for measuring effect of circadian rhythm interventions on postpartum mental health outcomes.

"To Cope with Everyday Life, I Need to Sleep" - A Phenomenographic Study Exploring Sleep Loss in Parents of Children with Atopic Dermatitis

PURPOSE

The whole family is affected when a child has atopic dermatitis (AD), and parents experience sleep disruption related to the child's condition leading to physical and mental exhaustion, mood swings, loss of concentration and lower job performance. This study aimed to explore and describe perceptions of sleep in parents of children <2 years old with AD, consequences of parental sleep loss, and what strategies the parents used to manage sleep loss and to improve sleep.

DESIGN AND METHODS

This qualitative interview study had an inductive and descriptive design. Twelve parents (eleven mothers and one father) participated in the study. Data analysis was performed using a phenomenographic approach.

RESULTS

Three categories of description were found: Acceptance and normalization of parental sleep loss; Changed routines and behavior to compensate for sleep loss; and Support is needed to gain sleep and manage daily life.

CONCLUSIONS

Sleep loss due to the child's AD affected the parents' emotional state, mood, well-being, cognitive function, ability to concentrate and take initiative, and sensitivity to stress and sound negatively. The parents managed their sleep loss mainly by changing their behavior and creating new routines, by taking me-time and through support from partners.

PRACTICE IMPLICATIONS

Pediatric nurses should acknowledge sleep loss in parents of small children with AD in time to prevent negative consequences, which affect the well-being of the entire family. Advice on how to improve sleep should be given early to increase the parents' understanding, make them feel safer and strengthen them in their parenthood.

Non-pharmacological interventions for improving postpartum maternal sleep: A systematic review and meta-analysis

Evidence suggests that poor postpartum sleep quality is a risk factor for the development of postpartum depression. As such, non-pharmacological interventions have been developed to help improve sleep in the postpartum period. The primary aims of this systematic review and meta-analysis were to determine if non-pharmacological interventions improved maternal sleep and to compare the effectiveness of different intervention types. Secondary aims included examining effects on maternal mood and infant sleep. We searched MEDLINE, EMBASE, CINAHL, PsycINFO, and Web of Science from their inceptions to September 2017 and found 15 eligible studies. Non-pharmacological sleep interventions were found to improve subjective reports of maternal sleep (Cohen's d = -0.54, 95%CI = -0.88 to -0.19). Massage (Cohen's d = -1.07 95%CI = -1.34 to -0.79) and exercise (Cohen's d = -0.82 95%CI = -1.28 to -0.37) interventions had the largest impact on maternal sleep quality. Positive effects on nocturnal infant sleep were found for interventions overall (Cohen's d = -0.27 95%CI = -0.52 to -0.02) but not for maternal depression (Cohen's d = -0.08 95%CI = -0.28 to 0.12). Despite evidence suggesting improvements in subjective maternal sleep, more research must be conducted on the durability of effects of non-pharmacological interventions using objective measures of sleep quality.

Rationale, design, and baseline data for the Healthy Mom II Trial: A randomized trial examining the efficacy of exercise and wellness interventions for the prevention of postpartum depression

Approximately 13-19% of women experience postpartum depression and approximately one-third of women who have a history of depression develop depression during the postpartum phase. Exercise is an efficacious intervention for depression among adults; however, few studies have examined the effect of exercise on postpartum depression. The purpose of this study was to conduct a randomized controlled trial examining the effect of exercise and wellness interventions on preventing postpartum depression among women at risk. Specifically, women (n = 450) who were on average 4.35 weeks postpartum and had a history of depression were randomly assigned to one of the following three conditions: (1) Telephone-based exercise intervention; (2) telephone-based wellness/support intervention (covered topics such as sleep, stress, and healthy eating); or (3) usual care. Both interventions lasted six months. The exercise intervention was based on social cognitive theory and the Transtheoretical model and was specifically designed to motivate postpartum women to exercise. The primary dependent variable was depression based on the Structured Clinical Diagnostic Interview (SCID). Secondary dependent variables included the Edinburgh Postnatal Depression Scale, PHQ-9, and Perceived Stress Scale. Potential mediator variables included quality of sleep, postpartum social support, fatigue, and exercise attitudes. Questionnaires were administered at baseline, six, and nine months. The purpose of this paper is to summarize the methodology, study design, and baseline data for this study. This trial will provide important information regarding the efficacy of exercise and wellness interventions for preventing postpartum depression.

Associations of postpartum sleep, stress, and depressive symptoms with LPS-stimulated cytokine production among African American and White women

BACKGROUND

Postpartum is a period of unique psychosocial stress characterized by sleep disturbance, risk for depressed mood, and heightened parenting stress. However, data on effects of these exposures on inflammatory immune function are limited.

METHODS

This study examined associations among sleep, psychosocial stress (i.e., parenting stress, general perceived stress), mood (i.e., depressive symptoms), serum cytokine levels, and LPS-stimulated proinflammatory cytokine production among 69 women (32 African American, 37 White) assessed at 7-10weeks postpartum.

RESULTS

No associations between behavioral measures and serum cytokine levels were observed among women of either race. In African American women, but not Whites, poorer sleep quality, greater parenting stress, and greater depressive symptoms were associated with greater LPS-stimulated IL-6 and IL-8 production (ps≤0.05). Also in African Americans, greater general perceived stress was associated with greater IL-8 production, and greater depressive symptoms with greater stimulated TNF-α production (ps≤0.05). Simple mediation models highlighted the bidirectional relationship between stress and sleep in relation to inflammation among African American women.

CONCLUSIONS

Significant effects of both stress/distress and poor sleep quality on proinflammatory cytokine production during postpartum were observed uniquely among African American women. These data are consistent with an allostatic load model which predicts that conditions of chronic stress impart vulnerability to dysregulated responses to novel stressor exposures. The bidirectional nature of the stress-sleep relationship has clinical relevance. Studies examining whether interventions focused on one or both of these psychological factors during postpartum is beneficial for inflammatory profiles would be informative. In addition, examination of these models in relation to maternal health at postpartum, including delivery related wounds and other infections, is warranted.

Sleep Quality Predicts Persistence of Parental Postpartum Depressive Symptoms and Transmission of Depressive Symptoms from Mothers to Fathers

BACKGROUND

Early parenthood is a time of chronic sleep disturbance and also of heightened depression risk. Poor sleep quality has been identified both as a predictor of postpartum depressive symptoms and as a consequence.

PURPOSE

This study sought to clarify causal pathways linking sleep and postpartum depression via longitudinal path modeling. Sleep quality at 6 months postpartum was hypothesized to exacerbate depressive symptoms from 1 month through 1 year postpartum in both mothers and fathers. Within-couple associations between sleep and depression were also tested.

METHODS

Data were drawn from a low-income, racially and ethnically diverse sample of 711 couples recruited after the birth of a child. Depressive symptoms were assessed at 1, 6, and 12 months postpartum, and sleep was assessed at 6 months postpartum.

RESULTS

For both partnered mothers and fathers and for single mothers, depressive symptoms at 1 month postpartum predicted sleep quality at 6 months, which in turn predicted depressive symptoms at both 6 and 12 months. Results held when infant birth weight, breastfeeding status, and parents' race/ethnicity, poverty, education, and immigration status were controlled. Mothers' and fathers' sleep quality and depressive symptoms were correlated, and maternal sleep quality predicted paternal depressive symptoms both at 6 and at 12 months.

CONCLUSIONS

Postpartum sleep difficulties may contribute to a vicious cycle between sleep and the persistence of depression after the birth of a child. Sleep problems may also contribute to the transmission of depression within a couple. Psychoeducation and behavioral treatments to improve sleep may benefit new parents.

Association between temperature and maternal stress during pregnancy

BACKGROUND

Maternal psychological stress during pregnancy has essentially been conceptualized as a teratogen. However, little is known about the effect of temperature on maternal stress during pregnancy. The aim of this study is to investigate the relationship between temperature and maternal stress during pregnancy.

METHODS

In 2010, a total of 1931 eligible pregnant women were enrolled across Shanghai from four prenatal-care clinics during their mid-to-late pregnancy. Maternal life-event stress and emotional stress levels during pregnancy were assessed by the "Life Event Scale for Pregnant Women" (LESPW) and "Symptom Checklist-90-Revised Scale" (SCL-90-R), respectively. Exposure to ambient temperature was evaluated based on daily regional average in different moving average and lag days. The generalized estimating equations were used to evaluate the relationship between daily average temperature/temperature difference and maternal stress.

RESULTS

After adjusting for relevant confounders, an U-shaped relationship was observed between daily average temperature and maternal Global-Severity-Index (GSI) of the SCL-90-R. Cumulative exposures to extremely low temperatures (< P5, 1.4-10.5℃, lag 0-1 days, 0-2 days and 0-5 days) and extremely high temperatures (≥ P95, 31.2-34.1℃, lag 0-1 days and 0-2 days), and acute exposures to extremely low (lag day 0, 1, 2 and 3) and high (lag day 0, 1) temperatures, all induced higher risks of high GSI (the highest tertile), compared to the risk induced by exposed to an optimal temperature range (20-25℃) (P< 0.05). Increased temperature difference was associated with high maternal GSI (P< 0.05). However, non-significant associations were observed between daily average temperatures/temperature differences and maternal log-transferred LESPW scores.

CONCLUSIONS

Cumulative and acute exposures to extremely low/high temperatures may both induce emotional stress during pregnancy.

Psychological Distress in Healthy Low-Risk First-Time Mothers during the Postpartum Period: An Exploratory Study

Psychological distress, defined as depression, anxiety, and insomnia in this study, can occur following the birth of a baby as new mothers, in addition to marked physiological changes, are faced with adapting to new roles and responsibilities. We investigated the cooccurrence of stress, depression, anxiety, and insomnia in mothers during the postpartum period; tested the feasibility of study methods and procedures for use in this population; and identified new mothers interest in using cranial electrotherapy stimulation (CES) as an intervention for reducing psychological distress. We recruited healthy, low-risk, English speaking first-time mothers, ages 18-32 years, with healthy babies (N = 33), within 12 months of an uncomplicated birth. Participants completed the PSS, HAM-D₁₄, HAM-A₁₇, and PSQI₁₉. No problems were encountered with study procedures. Mothers reported a high interest (4.9) in the potential use of CES to treat or prevent the occurrence of psychological distress. All participants (N = 33) reported moderate levels of depression and anxiety, while 75.8% (n = 25) reported insomnia. PSS scores were within the norms for healthy women. Further research is recommended to investigate if our findings can be replicated or if different patterns of associations emerge. Implications for clinical practice are addressed.

Polyunsaturated Fatty Acid (PUFA) Status in Pregnant Women: Associations with Sleep Quality, Inflammation, and Length of Gestation

Mechanistic pathways linking maternal polyunsaturated fatty acid (PUFA) status with gestational length are poorly delineated. This study examined whether inflammation and sleep quality serve as mediators, focusing on the antiinflammatory ω-3 docosahexaenoic acid (DHA; 22:6n3) and proinflammatory ω-6 arachidonic acid (AA; 20:4n6). Pregnant women (n = 135) provided a blood sample and completed the Pittsburgh Sleep Quality Index (PSQI) at 20–27 weeks gestation. Red blood cell (RBC) fatty acid levels were determined by gas chromatography and serum inflammatory markers [interleukin (IL)-6, IL-8, tumor necrosis factor-α, IL-1β, and C-reactive protein] by electrochemiluminescence using high sensitivity kits. Both higher serum IL-8 (95% CI = 0.10,3.84) and poor sleep (95% CI = 0.03,0.28) served as significant mediators linking lower DHA:AA ratios with shorter gestation. Further, a serial mediation model moving from the DHA:AA ratio → sleep → IL-8 → length of gestation was statistically significant (95% CI = 0.02, 0.79). These relationships remained after adjusting for depressive symptoms, age, BMI, income, race, and smoking. No interactions with race were observed in relation to length of gestation as a continuous variable. However, a significant interaction between race and the DHA:AA ratio in predicting preterm birth was observed (p = 0.049); among African Americans only, odds of preterm birth decreased as DHA:AA increased (p = 0.048). These data support a role for both inflammatory pathways and sleep quality in linking less optimal RBC PUFA status with shorter gestation in African American and European American women and suggest that African-Americans have greater risk for preterm birth in the context of a low DHA:AA ratio.