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Ojelere BO, Adeoye IA. Sleep pattern and disorders among pregnant women in Ibadan, Southwest Nigeria. BMC Womens Health 2024; 24:250. [PMID: 38643114 PMCID: PMC11031875 DOI: 10.1186/s12905-024-03086-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2024] [Accepted: 04/10/2024] [Indexed: 04/22/2024] Open
Abstract
BACKGROUND Sleep is essential for pregnant women's and the offspring's health and wellbeing. Poor sleep and disorders have been linked with adverse fetal outcomes and delivery conditions. However, pregnant women often experience several forms of sleep disruption, which has been scarcely reported in low and middle-income countries (LMIC), including Nigeria where the influence of lifestyle factors has also been lacking. We investigated sleep patterns and disorders and the associated factors among pregnant women in Southwest, Nigeria. METHOD A cross-sectional study was conducted among five hundred (500) pregnant women attending Adeoyo Maternity Teaching Hospital. A semi-structured questionnaire was used to examine different domains of sleep and associated disorders, namely sleep quality (Pittsburgh Sleep Quality Index (> 5 and ≤ 5)), insomnia (Insomnia Severity Index (> 8 and ≤ 8)), restless leg syndrome (Restless Leg Syndrome Rating Scale (> 10 and ≤ 10). Significant covariates such as physical activity, minimum dietary diversity, smoking and alcohol intake were also assessed. We conducted bivariate and multivariate analysis at p < 0.05 significance level. RESULTS The mean age of participants was 30.4 ± 4.8 years. The pattern of sleep disorder in pregnant were poor sleep quality (50%), restless leg syndrome (58.2%) and insomnia (33.4%). Being currently married (AOR = 6.13; 95% CI: (1.65-22.23)), increasing gestational age: second trimester (AOR = 8.25;95% CI: (1.78-38.17)) to third trimester (AOR = 10.98; 95% CI: (2.44-49.48)) increased the odds of poor sleep quality. Factors associated with restless leg syndrome were marital status [AOR = 3.60; 95% CI; (1.25-10.35)], religion, rigorous physical activities [AOR = 1.52; 95% CI: (1.05-2.21)] and alcohol consumption [AOR = 3.51; 95% CI: (1.00-12.27)]. Factors associated with insomnia were maternal age [AOR = 1.83; 95% CI: (1.11-3.01)], income [AOR = 2.99 (1.26-7.16)] and rigorous physical activity [AOR = 2.55 (1.61-4.02)]. CONCLUSION Poor sleep quality, restless leg syndrome and insomnia were typical among pregnant women in Ibadan, Southwest Nigeria. Thus, awareness and education on the importance of sleep and its risk and protective factors, such as alcohol consumption, smoking, rigorous activity and spousal and family support, should be increased to reduce poor sleep quality and sleep disorders (restless leg syndrome and insomnia) during the pregnancy period.
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Affiliation(s)
- Blessing O Ojelere
- Department of Epidemiology and Medical Statistics, Faculty of Public Health, College of Medicine, University of Ibadan, Ibadan, Nigeria
| | - Ikeola A Adeoye
- Department of Epidemiology and Medical Statistics, Faculty of Public Health, College of Medicine, University of Ibadan, Ibadan, Nigeria.
- Consortium of Advanced Research for Africa (CARTA), Nairobi, Kenya.
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Perry A, Gordon-Smith K, Lewis KJS, Di Florio A, Craddock N, Jones L, Jones I. Perinatal sleep disruption and postpartum psychosis in bipolar disorder: Findings from the UK BDRN Pregnancy Study. J Affect Disord 2024; 346:21-27. [PMID: 37940050 DOI: 10.1016/j.jad.2023.11.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Revised: 10/31/2023] [Accepted: 11/01/2023] [Indexed: 11/10/2023]
Abstract
BACKGROUND Women with bipolar disorder (BD) are at high risk of postpartum psychosis (PP). The factors that increase risk of PP among women with BD are not fully understood. Here, we examine whether sleep disruption in the perinatal period (poor sleep quality in late pregnancy and sleep deprivation related to childbirth) is associated with PP in a longitudinal study of pregnant women with BD. METHODS Participants were 76 pregnant women with lifetime DSM-5 bipolar I disorder or schizoaffective-BD, followed from week 12 of pregnancy to 12 weeks postpartum. Demographics and lifetime psychopathology were assessed at baseline via semi-structured interview (Schedules for Clinical Assessment in Neuropsychiatry). Psychopathology and sleep disruption within the current perinatal period were assessed in the third trimester and at 12 weeks postpartum. Data were supplemented by clinician questionnaires and case-note review. RESULTS After controlling for prophylactic use of mood stabilising medication, the loss of at least one complete night of sleep across labour/delivery was associated with five times the odds of experiencing PP compared to no or less than one night of sleep loss across labour/delivery (OR 5.19, 95 % CI 1.45-18.54; p = 0.011). Sleep quality in late pregnancy was not associated with PP, and perinatal sleep disruption was not associated with postpartum depression. LIMITATIONS Lack of objective measures of sleep factors. CONCLUSIONS In the context of other aetiological factors, severe sleep loss associated with childbirth/the immediate postpartum may act as a final trigger of PP. These findings could have important clinical implications for risk prediction and prevention of PP.
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Affiliation(s)
- A Perry
- Psychological Medicine, University of Worcester, UK
| | | | - K J S Lewis
- Division of Psychological Medicine and Clinical Neurosciences, School of Medicine, Cardiff University, UK; Department of Psychiatry, Brigham & Women's Hospital, Harvard Medical School, Boston, MA 02115, United States of America
| | - A Di Florio
- Division of Psychological Medicine and Clinical Neurosciences, School of Medicine, Cardiff University, UK
| | - N Craddock
- Division of Psychological Medicine and Clinical Neurosciences, School of Medicine, Cardiff University, UK
| | - L Jones
- Psychological Medicine, University of Worcester, UK
| | - I Jones
- Division of Psychological Medicine and Clinical Neurosciences, School of Medicine, Cardiff University, UK
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Al-Abri K, Edge D, Armitage CJ. Prospective analysis of factors associated with perinatal depression. Midwifery 2024; 128:103871. [PMID: 37967499 DOI: 10.1016/j.midw.2023.103871] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2023] [Revised: 09/13/2023] [Accepted: 11/01/2023] [Indexed: 11/17/2023]
Abstract
BACKGROUND Perinatal depression is a significant public health problem that has adverse effects on both mothers and infants. Little research has been conducted on how depressive symptoms change throughout the perinatal period, especially in the Middle East. This study examines changes in depressive symptoms from pregnancy to the postnatal period, and what explains these changes. METHODS This prospective study recruited 306 Omani women in the third trimester of pregnancy and followed them up two to eight weeks after delivery. The Edinburgh Postnatal Depression Scale (EPDS), with a cut-off of ≥12, was used to assess depressive symptoms in both the antenatal and postnatal periods. Independent t-tests, one-way ANOVA, Tukey's honestly significant difference test and Chi-square tests were used to analyse the data. RESULTS The prevalence of depressive symptoms was 27.12 % (n = 83) during late pregnancy and 29.30 % (n = 81) during the postnatal period. Four groups of women were identified based on the EPDS scores: 1) antenatal depression group (8.82 %; n = 27); 2) ante- and postnatal depression group (14.38 %; n = 44); 3) postnatal depression group (12.09 %; n = 37); and 4) non-depression group (54.90 %; n = 168). Depressive symptoms were associated with low birth weight babies (d = 0.50), which confirms the negative effects of depression on perinatal health outcomes. When compared to the non-depression group, the three depressed groups had higher antenatal Perceived Stress Scale (PSS) scores (ds > 0.52), while the non-depression group had higher antenatal and postnatal Maternity Social Support Scale (MSSS) scores (ds > 0.63), and better relationships with the mother-in-law antenatally (d= 0.57). CONCLUSION The present study of this Middle Eastern cohort shows that there were distinct groups of women experiencing perinatal depressive symptoms, influenced by various psychosocial and obstetric factors, which were comparable to those identified in more regularly studied populations. However, this study also identified other novel factors, such as the quality of family relationships. There is a need for additional research into the factors associated with these groups in order to develop appropriate interventions.
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Affiliation(s)
- Khalood Al-Abri
- Division of Psychology and Mental Health, University of Manchester, G35 Coupland 1 Building, Manchester, UK; Department of Community and Mental Health, College of Nursing, Sultan Qaboos University, Oman.
| | - Dawn Edge
- Division of Psychology and Mental Health, University of Manchester, G35 Coupland 1 Building, Manchester, UK; Equality, Diversity & Inclusion Research Unit, Greater Manchester Mental Health NHS Trust, UK
| | - Christopher J Armitage
- Division of Psychology and Mental Health, University of Manchester, G35 Coupland 1 Building, Manchester, UK; Manchester Academic Health Science Centre, Manchester University NHS Foundation Trust, UK; NIHR Greater Manchester Patient Safety Translational Research Centre, University of Manchester, UK
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Delgado A, Louis JM. Sleep Deficiency in Pregnancy. Sleep Med Clin 2023; 18:559-571. [PMID: 38501527 DOI: 10.1016/j.jsmc.2023.06.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/20/2024]
Abstract
Sleep is a critical aspect of one's daily life for overall health, with a recommended 7 to 9 hours in adulthood (ages 26-64). Up to a third of women do not sleep sufficiently, and pregnant women are at an increased risk for sleep deficiency. Throughout pregnancy, sleep is affected in differing ways. For example, in the first trimester, hormones affect sleep cycles, but by the third trimester, physical complaints such as increasing frequent urination and fetal movement create frequent awakenings. Associations between sleep deficiency and gestational diabetes, hypertensive disorders, depression, and some evidence regarding preterm birth exist. A woman's labor course and perception of delivery are also negatively affected by short sleep duration.
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Affiliation(s)
- Arlin Delgado
- Department of Obstetrics and Gynecology, Morsani College of Medicine, University of South Florida Morsani College of Medicine, 2 Tampa General Circle, Tampa, FL 33606, USA
| | - Judette M Louis
- Department of Obstetrics and Gynecology, Morsani College of Medicine, University of South Florida Morsani College of Medicine, 2 Tampa General Circle, Tampa, FL 33606, USA.
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Chen X, Liu Y, Liu M, Min F, Tong J, Wei W, Sun L, Zhang T, Meng Q. Prevalence and associated factors of insomnia symptoms among pregnant women in the third trimester in a moderately developing region of China. BMC Public Health 2023; 23:2319. [PMID: 37996812 PMCID: PMC10668519 DOI: 10.1186/s12889-023-17269-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Accepted: 11/20/2023] [Indexed: 11/25/2023] Open
Abstract
BACKGROUND Insomnia is the most common sleep disorder in the general population, especially among pregnant women, and it is considered a major public health issue. Not only can it cause mental and physical problems in pregnant women, but it may also affect the growth of the fetus. However, there are few reports on the prevalence and influencing factors of insomnia symptoms in third-trimester women in China. The objective of this study was to assess the prevalence of insomnia symptoms among pregnant women in the third trimester in a moderately developing region of China and to further explore the associated factors of insomnia symptoms from various aspects. METHODS A cross-sectional survey was conducted among eligible pregnant women in the third trimester from December 2022 to February 2023. Data on socio-demographic characteristics, clinical characteristics, and behavioral and psychological characteristics of pregnant women were collected through a structured questionnaire. The Chi-square test and multivariate logistics regression were applied to explore the associated factors of insomnia symptoms. RESULTS A total of 535 pregnant women in the third trimester were included in this study, and the prevalence of insomnia symptoms was 59.8%. Multivariate logistic regression analysis revealed that pregnant women who lived together with elders (OR: 0.58, 95% CI: 0.40-0.86), had low perceived stress (OR: 0.58, 95% CI: 0.35-0.97), had no threatened abortion (OR: 0.55, 95% CI: 0.32-0.93) and had good doctor-patient communication (OR: 0.66, 95% CI: 0.45-0.98) were more likely to stay away from insomnia symptoms. However, pregnant women with anxiety symptoms (OR: 2.27, 95% CI: 1.28-4.03), fear of childbirth (OR: 1.63, 95% CI: 1.11-2.40) and a high experience of COVID-19 fear (OR: 1.61, 95% CI: 1.03-2.54) tended to have insomnia symptoms. CONCLUSIONS The prevalence of insomnia symptoms in pregnant women is high in Lianyungang city in eastern China in the third trimester. Insomnia symptoms is influenced by multiple factors. There is an urgent need to develop interventions to reduce the prevalence of insomnia symptoms in the third trimester and to focus on pregnant women with risk factors for insomnia symptoms.
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Affiliation(s)
- Xu Chen
- Lianyungang Maternal and Child Health Hospital, 669 Qindongmen Street, Haizhou District, Lianyungang, Jiangsu, China
| | - Yuan Liu
- Lianyungang Maternal and Child Health Hospital, 669 Qindongmen Street, Haizhou District, Lianyungang, Jiangsu, China
| | - Meilin Liu
- Lianyungang Maternal and Child Health Hospital, 669 Qindongmen Street, Haizhou District, Lianyungang, Jiangsu, China
| | - Fanli Min
- Lianyungang Maternal and Child Health Hospital, 669 Qindongmen Street, Haizhou District, Lianyungang, Jiangsu, China
| | - Jiao Tong
- Lianyungang Maternal and Child Health Hospital, 669 Qindongmen Street, Haizhou District, Lianyungang, Jiangsu, China
| | - Wei Wei
- Lianyungang Maternal and Child Health Hospital, 669 Qindongmen Street, Haizhou District, Lianyungang, Jiangsu, China
| | - Lizhou Sun
- First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu, China
| | - Teng Zhang
- Lianyungang Maternal and Child Health Hospital, 669 Qindongmen Street, Haizhou District, Lianyungang, Jiangsu, China.
| | - Qian Meng
- Lianyungang Maternal and Child Health Hospital, 669 Qindongmen Street, Haizhou District, Lianyungang, Jiangsu, China.
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Palagini L, Cipriani E, Caruso V, Sharma V, Gemignani A, Bramante A, Miniati M, Riemann D. Insomnia During the Perinatal Period and its Association with Maternal and Infant Psychopathology: A Systematic Review and Meta-Analysis. Curr Psychiatry Rep 2023; 25:617-641. [PMID: 37819491 DOI: 10.1007/s11920-023-01463-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/06/2023] [Indexed: 10/13/2023]
Abstract
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.
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Affiliation(s)
- Laura Palagini
- Department of Experimental and Clinic Medicine, Section of Psychiatry, University of Pisa, Via Roma 67, 56100 Pisa, Italy.
| | - Enrico Cipriani
- Department of Surgical, Medical, Molecular, and Critical Area Pathology, University of Pisa, Via Savi, 10-56126 Pisa, Italy
| | - Valerio Caruso
- Department of Experimental and Clinic Medicine, Section of Psychiatry, University of Pisa, Via Roma 67, 56100 Pisa, Italy
| | - Verinder Sharma
- Department of Psychiatry, Western University, London, ON, Canada
- Department of Obstetrics & Gynaecology, Western University, London, ON, Canada
- Parkwood Institute Mental Health, St. Joseph's Health Care, London, ON, Canada
| | - Angelo Gemignani
- Department of Surgical, Medical, Molecular, and Critical Area Pathology, University of Pisa, Via Savi, 10-56126 Pisa, Italy
| | - Alessandra Bramante
- President of the Italian Section Marcè Society for Perinatal Psychopathology, Milan, Italy
| | - Mario Miniati
- Department of Experimental and Clinic Medicine, Section of Psychiatry, University of Pisa, Via Roma 67, 56100 Pisa, Italy
| | - Dieter Riemann
- Department of Psychiatry and Psychotherapy, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
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Okun ML, Lac A. Postpartum Insomnia and Poor Sleep Quality Are Longitudinally Predictive of Postpartum Mood Symptoms. Psychosom Med 2023; 85:736-743. [PMID: 37506301 DOI: 10.1097/psy.0000000000001234] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/30/2023]
Abstract
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.
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Affiliation(s)
- Michele L Okun
- From the Biofrontiers Center (Okun) and Department of Psychology (Lac), University of Colorado Colorado Springs, Colorado Springs, Colorado
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Kember AJ, Elangainesan P, Ferraro ZM, Jones C, Hobson SR. Common sleep disorders in pregnancy: a review. Front Med (Lausanne) 2023; 10:1235252. [PMID: 37671402 PMCID: PMC10475609 DOI: 10.3389/fmed.2023.1235252] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2023] [Accepted: 08/02/2023] [Indexed: 09/07/2023] Open
Abstract
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.
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Affiliation(s)
- Allan J. Kember
- Department of Obstetrics and Gynaecology, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
- Dalla Lana School of Public Health, Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, ON, Canada
- Shiphrah Biomedical Inc., Toronto, ON, Canada
| | - Praniya Elangainesan
- Temerty Faculty of Medicine, Medical Education, University of Toronto, Toronto, ON, Canada
| | - Zachary M. Ferraro
- Department of Obstetrics and Gynaecology, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Claire Jones
- Department of Obstetrics and Gynaecology, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
- Division of Reproductive Endocrinology and Infertility, Mount Sinai Hospital, Toronto, ON, Canada
| | - Sebastian R. Hobson
- Department of Obstetrics and Gynaecology, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
- Dalla Lana School of Public Health, Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, ON, Canada
- Temerty Faculty of Medicine, Medical Education, University of Toronto, Toronto, ON, Canada
- Temerty Faculty of Medicine, Institute of Medical Science, University of Toronto, Toronto, ON, Canada
- Maternal-Fetal Medicine Division, Mount Sinai Hospital, Toronto, ON, Canada
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Loret de Mola C, Carpena MX, Dias IM, Meucci R, Goicochea-Romero A, Cesar J. Sleep and its association with depressive and anxiety symptoms during the last weeks of pregnancy: A population-based study. Sleep Health 2023; 9:482-488. [PMID: 37391279 DOI: 10.1016/j.sleh.2023.05.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2022] [Revised: 04/21/2023] [Accepted: 05/03/2023] [Indexed: 07/02/2023]
Abstract
OBJECTIVE To evaluate the association between sleep characteristics and depressive and anxiety symptoms during the immediate postpartum period. METHODS People who had hospital births during 2019 in the municipality of Rio Grande (southern Brazil) were assessed with a standardized questionnaire concerning sociodemographic (eg, age and self-reported skin color) and health-related variables (eg, parity and stillbirth) (n = 2314) 24-48 hours after birth. We used the Munich Chronotype Questionnaire to assess sleep latency, inertia, duration, and chronotype; the Edinburgh Postpartum Depression Scale for depressive symptoms; and the General Anxiety Disorder 7-Item Scale to evaluate anxiety symptoms. We used logistic regression models to calculate odds ratios. RESULTS The prevalence of depressive symptoms was 13.7%, and of anxiety symptoms was 10.7%. Depressive symptoms were more likely in those with vespertine chronotype (odds ratios = 1.63; 95% CI: 1.14-2.35) and those with a sleep latency of more than 30 minutes (OR = 2.36; 95% CI: 1.68-3.32). The probability of depressive symptoms decreased by 16% for each additional hour of sleep (OR = 0.84; 95% CI: 0.77-0.92). Sleep inertia of 11-30 minutes increased the probability of anxiety on free days (OR = 1.73; 95% CI: 1.27-2.36) and increased the probability of depressive (OR = 2.68; 95% CI: 1.82-3.83) and anxiety symptoms (OR = 1.69; 95%CI: 1.16-2.44) on workdays. CONCLUSION Participants with vespertine chronotype or shorter sleep duration were more likely to have depressive symptoms. Those who took more time to fall asleep or get out of bed were more likely to have both anxiety and depressive symptoms, but the association was stronger for depressive symptoms.
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Affiliation(s)
- Christian Loret de Mola
- Programa de Pós-Graduação em Saúde Pública, FURG, Rio Grande, RS, Brazil; Grupo de Pesquisa e Inovação em Saúde, Universidade Federal do Rio Grande (FURG), Rio Grande, RS, Brazil; Universidad Cientifica del Sur, Lima, Peru.
| | - Marina X Carpena
- Grupo de Pesquisa e Inovação em Saúde, Universidade Federal do Rio Grande (FURG), Rio Grande, RS, Brazil; Programa de Pós-Graduação em Epidemiologia da Universidade Federal de Pelotas (UFPel), Pelotas, RS, Brazil
| | - Ingrid Moura Dias
- Programa de Pós-Graduação em Saúde Pública, FURG, Rio Grande, RS, Brazil
| | - Rodrigo Meucci
- Programa de Pós-Graduação em Saúde Pública, FURG, Rio Grande, RS, Brazil
| | | | - Juraci Cesar
- Programa de Pós-Graduação em Saúde Pública, FURG, Rio Grande, RS, Brazil
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Kalmbach DA, Cheng P, Reffi AN, Ong JC, Swanson LM, Fresco DM, Walch O, Seymour GM, Fellman-Couture C, Bayoneto AD, Roth T, Drake CL. 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. Sleep Med 2023; 108:79-89. [PMID: 37343335 PMCID: PMC10402889 DOI: 10.1016/j.sleep.2023.05.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2023] [Revised: 05/24/2023] [Accepted: 05/31/2023] [Indexed: 06/23/2023]
Abstract
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.
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Affiliation(s)
- David A Kalmbach
- Thomas Roth Sleep Disorders & Research Center, Henry Ford Health, Detroit, MI, USA; Department of Obstetrics, Gynecology, and Reproductive Biology, Michigan State University College of Human Medicine, East Lansing, MI, USA.
| | - Philip Cheng
- Thomas Roth Sleep Disorders & Research Center, Henry Ford Health, Detroit, MI, USA
| | - Anthony N Reffi
- Thomas Roth Sleep Disorders & Research Center, Henry Ford Health, Detroit, MI, USA
| | - Jason C Ong
- Behavioral Sleep Medicine, Nox Health, Suwanee, GA, USA; Center for Circadian and Sleep Medicine, Department of Neurology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Leslie M Swanson
- Department of Psychiatry, University of Michigan, Ann Arbor, MI, USA
| | - David M Fresco
- Department of Psychiatry, University of Michigan, Ann Arbor, MI, USA
| | - Olivia Walch
- Department of Neurology, University of Michigan, Ann Arbor, MI, USA; Arcascope Inc, Chantilly, VA, USA
| | - Grace M Seymour
- Thomas Roth Sleep Disorders & Research Center, Henry Ford Health, Detroit, MI, USA
| | | | - Alec D Bayoneto
- Thomas Roth Sleep Disorders & Research Center, Henry Ford Health, Detroit, MI, USA
| | - Thomas Roth
- Thomas Roth Sleep Disorders & Research Center, Henry Ford Health, Detroit, MI, USA
| | - Christopher L Drake
- Thomas Roth Sleep Disorders & Research Center, Henry Ford Health, Detroit, MI, USA
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Sharma V, Sharkey KM, Palagini L, Mazmanian D, Thomson M. Preventing recurrence of postpartum depression by regulating sleep. Expert Rev Neurother 2023; 23:1-9. [PMID: 37462620 PMCID: PMC10527998 DOI: 10.1080/14737175.2023.2237194] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2023] [Accepted: 07/12/2023] [Indexed: 08/22/2023]
Abstract
INTRODUCTION Women are at a high risk of recurrence of depression in the postpartum period. Given the circumscribed duration of the risk period and knowledge of its triggers, postpartum depression should be easily preventable. However, prophylactic drug studies have reported contradictory findings partly due to the heterogeneity of the disorder. Currently, there are no studies on the efficacy of psychotherapy in the prevention of postpartum depression in women with major depressive or bipolar disorder. AREAS COVERED This review evaluates the results of controlled medication and psychotherapeutic studies in the prevention of depression in women with major depressive disorder or bipolar disorder; it further suggests that the management of sleep loss/insomnia may be an effective strategy in the prevention of postpartum depression. EXPERT OPINION A thorough understanding of the clinical course of the antecedent mood disorder and historical treatment response is necessary before the implementation of strategies for the prevention of postpartum depression. Targeting disturbed and/or insufficient sleep - a common and early transdiagnostic symptom of peripartum psychiatric disorders - may be a more effective intervention for the prevention of postpartum depression and psychiatric comorbidities in some individuals than the traditional approach of antidepressant use.
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Affiliation(s)
- Verinder Sharma
- Department of Psychiatry, Western University, London, Ontario, Canada
- Department of Obstetrics & Gynecology, Western University, London, Ontario, Canada
- Parkwood Institute Mental Health, St. Joseph’s Health Care, London, Ontario, Canada
| | - Katherine M. Sharkey
- Department of Medicine, Department of Psychiatry and Human Behavior, Warren Alpert Medical School of Brown University Providence, Rhode Island
| | - Laura Palagini
- Department of Clinical and Experimental Medicine, Psychiatric Clinic, University of Pisa, Via Roma 67, 56100, Pisa, Italy
| | - Dwight Mazmanian
- Department of Psychology, Lakehead University, Thunder Bay, Ontario, Canada
| | - Michael Thomson
- Department of Psychiatry, Western University, London, Ontario, Canada
- Parkwood Institute Mental Health, St. Joseph’s Health Care, London, Ontario, Canada
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12
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Kendle AM, Swanson J, Salemi JL, Louis JM. Association of Insomnia with 30-Day Postpartum Readmission: A Retrospective Analysis. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:5955. [PMID: 37297559 PMCID: PMC10252679 DOI: 10.3390/ijerph20115955] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Revised: 05/16/2023] [Accepted: 05/23/2023] [Indexed: 06/12/2023]
Abstract
Insomnia is prevalent in pregnancy and is associated with increased use of health services. We aimed to evaluate the association between insomnia diagnosed at the delivery hospitalization and risk of 30-day postpartum readmission. We conducted a retrospective analysis of inpatient hospitalizations from the 2010-2019 Nationwide Readmissions Database. The primary exposure was a coded diagnosis of insomnia at delivery as determined by ICD-9-CM and ICD-10-CM codes. Obstetric comorbidities and indicators of severe maternal morbidity were also determined through coding. The primary outcome was all-cause 30-day postpartum readmission. Survey-weighted logistic regression was used to generate crude and adjusted odds ratios representing the association between maternal insomnia and postpartum readmission. Of over 34 million delivery hospitalizations, 26,099 (7.6 cases per 10,000) had a coded diagnosis of insomnia. People with insomnia experienced a 3.0% all-cause 30-day postpartum readmission rate, compared to 1.4% among those without insomnia. After controlling for sociodemographic, clinical, and hospital-level factors, insomnia was associated with 1.64 times higher odds of readmission (95% CI 1.47-1.83). After adjustment for obstetric comorbidity burden and severe maternal morbidity, insomnia was independently associated with 1.33 times higher odds of readmission (95% CI 1.18-1.48). Pregnant patients with insomnia have higher rates of postpartum readmission, and diagnosis of insomnia is independently associated with increased odds of readmission. Additional postpartum support may be warranted for pregnancies affected by insomnia.
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Affiliation(s)
- Anthony M. Kendle
- Department of Obstetrics and Gynecology, Morsani College of Medicine, University of South Florida, Tampa, FL 33602, USA; (J.L.S.); (J.M.L.)
| | - Justin Swanson
- College of Public Health, University of South Florida, Tampa, FL 33612, USA;
| | - Jason L. Salemi
- Department of Obstetrics and Gynecology, Morsani College of Medicine, University of South Florida, Tampa, FL 33602, USA; (J.L.S.); (J.M.L.)
- College of Public Health, University of South Florida, Tampa, FL 33612, USA;
| | - Judette M. Louis
- Department of Obstetrics and Gynecology, Morsani College of Medicine, University of South Florida, Tampa, FL 33602, USA; (J.L.S.); (J.M.L.)
- College of Public Health, University of South Florida, Tampa, FL 33612, USA;
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Jamshaid S, Malik NI, Ullah I, Saboor S, Arain F, De Berardis D. Postpartum Depression and Health: Role of Perceived Social Support among Pakistani Women. Diseases 2023; 11:diseases11020053. [PMID: 37092435 PMCID: PMC10123603 DOI: 10.3390/diseases11020053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2022] [Revised: 02/20/2023] [Accepted: 03/07/2023] [Indexed: 04/03/2023] Open
Abstract
Postpartum depression (PPD) can predispose to physical and mental health problems in Pakistani women. However, PPD is associated with health and perceived social support, yet their causal relationship is unclear. Therefore, this study intended to evaluate the association of PPD with insomnia, mental health, and physical health. The convenience sampling technique was used to collect data from 320 (52.8%) young and middle-aged postpartum women, at the outpatient departments of obstetrics and gynecology of the Government Maula Bakhsh Hospital, District Head Quarter in Sargodha, Pakistan. The Edinburgh Postnatal Depression Scale, Pittsburgh Sleep Quality Index, Warwick–Edinburgh Mental Well-being Scale, patient health questionnaire, and Multidimensional Scale of Perceived Social Support were used to measure study variables. The results revealed a significant positive relationship between PPD and physical health (r = 0.45, p = 0.001), negative relationships with insomnia (r = −0.24, p < 0.001), and perceived social support (r = −0.38, p = 0.001). Results further confirmed that perceived social support played a moderating role (β = 0.97, p = 0.01) in the relationship between PPD and mental health among Pakistani women. This study concluded that perceived social support has an important role in PPD and the health of Pakistani women. The study also concluded that poor health is a risk indicator for the identification of aid in the early stages of postpartum among Pakistani women.
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Association between sleep disorders during pregnancy and risk of postpartum depression: a systematic review and meta-analysis. Arch Womens Ment Health 2023; 26:259-267. [PMID: 36738337 DOI: 10.1007/s00737-023-01295-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Accepted: 01/24/2023] [Indexed: 02/05/2023]
Abstract
Sleep disorders are common among pregnant females. However, its association with postpartum depression (PPD) is unknown. We aimed to assess if sleep disorders during pregnancy increase the risk of PPD by a systematic review. The databases of PubMed, CENTRAL, ScienceDirect, Embase, and Google Scholar were searched for studies reporting the association between any type of sleep disorder during pregnancy and the risk of PPD. Effect sizes were pooled in a random-effects model. Sixteen studies with data of 12,614 women were included. Meta-analysis indicated that sleep disorders during pregnancy resulted in a statistically significant increased risk of PPD (OR: 2.36 95% CI: 1.72, 2.32). The overall result had high heterogeneity (I2 = 84%). Sub-group analysis based on study location (Asian vs Western), sample size (> 500 vs < 500), depression scale, and PPD assessment time did not change the results. However, we found that only poor sleep quality but not insomnia was associated with PPD. The risk was also increased only with sleep disorders measured in the 3rd trimester but not for the 1st and 2nd trimesters. Evidence suggests that sleep disorders during pregnancy may increase risk of PPD. The risk is high for sleep disorders occurring in the 3rd trimester. Based on these findings, there is a need for thorough screening and subsequent corrective measures to ensure adequate and quality sleep among pregnant females.
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15
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Pregnant Women's Attitudes and Beliefs towards Sleep and Exercise: A Cross-Sectional Survey. Clocks Sleep 2023; 5:34-44. [PMID: 36810841 PMCID: PMC9944079 DOI: 10.3390/clockssleep5010004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Revised: 01/11/2023] [Accepted: 01/14/2023] [Indexed: 01/19/2023] Open
Abstract
As many as 80% of women report experiencing poor sleep throughout pregnancy. Exercise is associated with many health benefits during pregnancy and is established as a non-pharmacological method to improve sleep in both pregnant and non-pregnant populations. Given the importance of sleep and exercise during pregnancy, the aim of this cross-sectional study was to (1) examine pregnant women's attitudes and beliefs towards sleep and exercise during pregnancy, and (2) investigate the barriers women face to achieving good sleep and engaging in healthy levels of exercise. Participants were comprised of 258 pregnant Australian women (31.3 ± 5.1 years) who completed a 51-question online survey. Almost all (98%) participants believed exercise during pregnancy to be safe, whilst over half (67%) believed participating in more exercise will improve their sleep. Over 70% of participants reported experiencing barriers such as physical symptoms related to pregnancy that negatively impacted their ability to exercise. Almost all (95%) participants reported experiencing barriers to sleep in their current pregnancy. Present findings suggest that overcoming intrapersonal barriers should be a priority for any intervention aiming to improve sleep or increase exercise levels in pregnant populations. Findings from the present study highlight the need for a better understanding of women's sleep experiences during pregnancy, and demonstrate how exercise may improve sleep and health outcomes.
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Øygarden AMU, Småstuen MC, Abudayya A, Glavin K, Saether KM, Solberg BL, Brekke M, Strøm BS. Prevalence and predictive factors of depressive symptoms among primiparae in antenatal care: A cross-sectional study in the new families programme. J Clin Nurs 2023. [PMID: 36599809 DOI: 10.1111/jocn.16608] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2022] [Revised: 11/26/2022] [Accepted: 12/05/2022] [Indexed: 01/06/2023]
Abstract
AIM/OBJECTIVE To estimate the prevalence and assess the strength of associations between antenatal depressive symptoms and selected possible predictive factors among women attending antenatal care for the first time at the Child Health Centre. BACKGROUND Evidence suggests that antenatal depression is a health problem as prevalent as postpartum depression. Antenatal depressive symptoms may persist into the postpartum period and potentially disturb the attachment between mother and family. DESIGN Cross-sectional. METHODS A sample of 228 women who participated in the New Families research programme answering a questionnaire at Week 28 of pregnancy were included. The Edinburgh Postnatal Depression Scale was used as outcome measure. Prevalence was estimated, and backward stepwise logistic regression analysis was performed to examine associations with somatic, psychiatric and social factors. STROBE checklist was followed. RESULTS Prevalence of depressive symptoms in this sample was 17.9%. Women reporting not sleeping enough had significantly higher odds of having depressive symptoms. Pregnant women with high relationship satisfaction were less likely to have depressive symptoms. Neither maternal age, education, previous depression, coming from a non-Nordic country nor having complications during pregnancy were statistically significantly associated with depressive symptoms. CONCLUSIONS High prevalence of depressive symptoms may also be present in low-risk populations. Sleep and relationship satisfaction are topics that need to be addressed during pregnancy. RELEVANCE TO CLINICAL PRACTICE The prevalence of depressive symptoms in this sample of low-risk pregnant women indicates that health personnel needs to be aware of depressive symptoms among women with no risk indicators. Identifying predictive factors associated with depressive symptoms may help midwives, public health nurses and general practitioners support parents. Our results indicate a potential need for screening for depressive symptoms in pregnancy and underscore the importance of involving partners in antenatal care. PATIENT/PUBLIC CONTRIBUTION Parents and health personnel participated in designing the New Family research programme.
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Affiliation(s)
| | - Milada C Småstuen
- Institute of Health, VID Specialized University, Oslo, Norway.,Department of Nursing and Health Promotion, Oslo Metropolitan University, Oslo, Norway
| | | | - Kari Glavin
- Institute of Health, VID Specialized University, Oslo, Norway
| | | | - Beate L Solberg
- Institute of Health, VID Specialized University, Oslo, Norway
| | - Malene Brekke
- Institute of Health, VID Specialized University, Oslo, Norway
| | - Benedicte S Strøm
- Bachelor in Nursing, Lovisenberg Diaconal University College, Oslo, Norway
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Epperson CN, Rubinow DR, Meltzer-Brody S, Deligiannidis KM, Riesenberg R, Krystal AD, Bankole K, Huang MY, Li H, Brown C, Kanes SJ, Lasser R. 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. J Affect Disord 2023; 320:353-359. [PMID: 36191643 DOI: 10.1016/j.jad.2022.09.143] [Citation(s) in RCA: 16] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2022] [Revised: 08/26/2022] [Accepted: 09/27/2022] [Indexed: 02/02/2023]
Abstract
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.
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Affiliation(s)
- C Neill Epperson
- Department of Psychiatry, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, CO, United States of America.
| | - David R Rubinow
- Department of Psychiatry, University of North Carolina School of Medicine, Chapel Hill, NC, United States of America
| | - Samantha Meltzer-Brody
- Department of Psychiatry, University of North Carolina School of Medicine, Chapel Hill, NC, United States of America
| | - Kristina M Deligiannidis
- Zucker Hillside Hospital, Northwell Health, Glen Oaks, NY, United States of America; Feinstein Institutes for Medical Research, Northwell Health, Manhasset, NY, United States of America
| | - Robert Riesenberg
- Atlanta Center for Medical Research, Atlanta, GA, United States of America
| | - Andrew D Krystal
- Department of Psychiatry, University of California, San Francisco, San Francisco, CA, United States of America
| | - Kemi Bankole
- Sage Therapeutics, Inc., Cambridge, MA, United States of America
| | - Ming-Yi Huang
- Sage Therapeutics, Inc., Cambridge, MA, United States of America
| | - Haihong Li
- Sage Therapeutics, Inc., Cambridge, MA, United States of America
| | - Colville Brown
- Sage Therapeutics, Inc., Cambridge, MA, United States of America
| | - Stephen J Kanes
- Sage Therapeutics, Inc., Cambridge, MA, United States of America
| | - Robert Lasser
- Sage Therapeutics, Inc., Cambridge, MA, United States of America
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18
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Massae AF, Larsson M, Pembe AB, Mbekenga C, Svanberg AS. Patterns and predictors of fear of childbirth and depressive symptoms over time in a cohort of women in the Pwani region, Tanzania. PLoS One 2022; 17:e0277004. [PMID: 36327253 PMCID: PMC9632885 DOI: 10.1371/journal.pone.0277004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2021] [Accepted: 10/18/2022] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND Fear of childbirth (FoB) and depressive symptoms (DS) are experienced by many women and can negatively affect women during and after pregnancy. This study assessed patterns of FoB and DS over time and associations of postpartum FoB and DS with sociodemographic and obstetric characteristics. METHODS We conducted a longitudinal study at six health facilities in Tanzania in 2018-2019. Pregnant women were consecutively assessed for FoB and DS before and after childbirth using the Wijma Delivery Expectancy/Experience Questionnaire versions A & B and the Edinburgh antenatal and postnatal depressive scale. This paper is based on 625 women who completed participation. RESULTS The prevalence rates of FoB and DS during pregnancy were 16% and 18.2%, respectively, and after childbirth, 13.9% and 8.5%. Some had FoB (6.4%) and DS (4.3%) at both timepoints. FoB was strongly associated with DS at both timepoints (p < 0.001). Both FoB (p = 0.246) and DS (p < 0.001) decreased after childbirth. Never having experienced obstetric complications decreased the odds of postpartum and persisting FoB (adjusted odds ratio (aOR) 0.44, 95% confidence interval (CI) 0.23-0.83). Giving birth by caesarean section (aOR 2.01, 95% CI 1.11-3.65) and having more than 12 hours pass between admission and childbirth increased the odds of postpartum FoB (aOR 2.07, 95% CI 1.03-4.16). Postpartum DS was more common in women with an ill child/stillbirth/early neonatal death (aOR 4.78, 95% CI 2.29-9.95). Persisting DS was more common in single (aOR 2.59, 95% CI 1.02-6.59) and women without social support from parents (aOR 0.28, 95% 0.11-0.69). CONCLUSIONS FoB and DS coexist and decrease over time. Identifying predictors of both conditions will aid in recognising women at risk and planning for prevention and treatment. Screening for FoB and DS before and after childbirth and offering psychological support should be considered part of routine antenatal and postnatal care. Furthermore, supporting women with previous obstetric complications is crucial. Using interviews instead of a self-administered approach might have contributed to social desirability. Also, excluding women with previous caesarean sections could underestimate FoB and DS prevalence rates.
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Affiliation(s)
- Agnes Fredrick Massae
- Department of Women’s and Children’s Health, Uppsala University, Uppsala, Sweden
- Department of Community Health Nursing, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Margareta Larsson
- Department of Women’s and Children’s Health, Uppsala University, Uppsala, Sweden
| | - Andrea Barnabas Pembe
- Department of Obstetrics and Gynaecology, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Columba Mbekenga
- School of Nursing, Hubert Kairuki Memorial University, Dar es Salaam, Tanzania
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Legas G, Beyene GM, Asnakew S, Belete A, Desie T. Poor sleep quality and associated factors among HIV-positive pregnant women in Northwest, Ethiopia: a facility-based, cross-sectional study. BMC Psychiatry 2022; 22:559. [PMID: 35986312 PMCID: PMC9389670 DOI: 10.1186/s12888-022-04209-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Accepted: 08/17/2022] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Poor sleep quality during pregnancy might have an impact on adverse birth outcomes like premature rupture of membrane, preterm birth, lifelong neurocognitive impairment, low birth weight, and increased the risk of neonatal morbidity and mortality. In Ethiopia, the magnitude of poor sleep quality among this group of people is extremely limited. So, this study aims to determine the magnitude of poor sleep quality and its associated factors among HIV-positive pregnant women attending public hospitals in Northwest Ethiopia. METHODS An institution-based cross-sectional study was done using a simple random sampling technique to recruit 411 HIV-positive pregnant women from January to March; 2021. Sleep quality over the last 1 month was measured using the Pittsburgh Sleep Quality Index (PSQI). General anxiety disorder (GAD-7), Sleep Hygiene Index (SHI), and List of Threatening of Experiences (LTE) instruments were used to identify factors associated with poor sleep quality. Bivariate and multivariable logistic regression with odds ratio and 95% CI were employed to identify determinant factors of poor sleep quality. Statistical significance association was declared at P-value < 0.05. RESULTS A total of 411 out of 423 HIV-positive pregnant women were interviewed, with a response rate of 97.1%. The overall magnitude of poor sleep quality among HIV-positive pregnant was found to be 39.4% with a 95% of confidence interval (CI) (34.3, 44.3). Stressful life events, [AOR = 3.10, 95% CI (1.60, 6.01)], having comorbid general anxiety symptoms [AOR = 2.46, 95% CI (1.58, 3.81)], unplanned pregnancy [AOR = 2.18, 95% CI (1.20, 3.96)], and poor sleep hygiene practice [AOR = 2.23, 95% CI (1.21, 4.10)] were significantly associated with poor quality of sleep. CONCLUSION The overall magnitude of poor sleep quality among HIV-positive pregnant women was high. Stressful life events, poor sleep hygiene, unplanned pregnancy, and comorbid general anxiety symptoms were the determinant factors of poor sleep quality that should be taken high consideration for early detection and appropriate intervention for poor sleep quality in HIV-positive pregnant women.
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Affiliation(s)
- Getasew Legas
- Department of Psychiatry, College of Medicine and Health Sciences, Debre Tabor University, Debre Tabor, Ethiopia.
| | - Getnet Mihretie Beyene
- grid.510430.3Department of Psychiatry, College of Medicine and Health Sciences, Debre Tabor University, Debre Tabor, Ethiopia
| | - Sintayehu Asnakew
- grid.510430.3Department of Psychiatry, College of Medicine and Health Sciences, Debre Tabor University, Debre Tabor, Ethiopia
| | - Amsalu Belete
- grid.510430.3Department of Psychiatry, College of Medicine and Health Sciences, Debre Tabor University, Debre Tabor, Ethiopia
| | - Tigabu Desie
- grid.510430.3Department of Pediatrics and Child Health Nursing, College of Health Sciences, Debre Tabor University, Debre Tabor, Ethiopia
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20
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Abstract
Sleep is a critical aspect of one's daily life for overall health, with a recommended 7 to 9 hours in adulthood (ages 26-64). Up to a third of women do not sleep sufficiently, and pregnant women are at an increased risk for sleep deficiency. Throughout pregnancy, sleep is affected in differing ways. For example, in the first trimester, hormones affect sleep cycles, but by the third trimester, physical complaints such as increasing frequent urination and fetal movement create frequent awakenings. Associations between sleep deficiency and gestational diabetes, hypertensive disorders, depression, and some evidence regarding preterm birth exist. A woman's labor course and perception of delivery are also negatively affected by short sleep duration.
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Affiliation(s)
- Arlin Delgado
- Department of Obstetrics and Gynecology, Morsani College of Medicine, University of South Florida Morsani College of Medicine, 2 Tampa General Circle, Tampa, FL 33606, USA
| | - Judette M Louis
- Department of Obstetrics and Gynecology, Morsani College of Medicine, University of South Florida Morsani College of Medicine, 2 Tampa General Circle, Tampa, FL 33606, USA.
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21
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Sultan P, Ando K, Elkhateb R, George RB, Lim G, Carvalho B, Chitneni A, Kawai R, Tulipan T, Blake L, Coker J, O’Carroll J. Assessment of Patient-Reported Outcome Measures for Maternal Postpartum Depression Using the Consensus-Based Standards for the Selection of Health Measurement Instruments Guideline: A Systematic Review. JAMA Netw Open 2022; 5:e2214885. [PMID: 35749118 PMCID: PMC9233232 DOI: 10.1001/jamanetworkopen.2022.14885] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
IMPORTANCE Maternal depression is frequently reported in the postpartum period, with an estimated prevalence of approximately 15% during the first postpartum year. Despite the high prevalence of postpartum depression, there is no consensus regarding which patient-reported outcome measure (PROM) should be used to screen for this complex, multidimensional construct. OBJECTIVE To evaluate psychometric measurement properties of existing PROMs of maternal postpartum depression using the Consensus-Based Standards for the Selection of Health Measurement Instruments (COSMIN) guideline and identify the best available patient-reported screening measure. EVIDENCE REVIEW This systematic review followed the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) reporting guideline. PubMed, CINAHL, Embase, and Web of Science were searched on July 1, 2019, for validated PROMs of postpartum depression, and an additional search including a hand search of references from eligible studies was conducted in June 2021. Included studies evaluated 1 or more psychometric measurement properties of the identified PROMs. A risk-of-bias assessment was performed to evaluate methods of each included study. Psychometric measurement properties of each PROM were rated according to COSMIN criteria. A modified Grading of Recommendations Assessment, Development, and Evaluation approach was used to assess the level of evidence supporting each rating, and a recommendation class (A, recommended for use; B, further research required; or C, not recommended) was given based on the overall quality of each included PROM. FINDINGS Among 10 264 postpartum recovery studies, 27 PROMs were identified. Ten PROMs (37.0%) met the inclusion criteria and were used in 43 studies (0.4%) involving 22 095 postpartum women. At least 1 psychometric measurement property was assessed for each of the 10 validated PROMs identified. Content validity was sufficient in all PROMs. The Edinburgh Postnatal Depression Scale (EPDS) demonstrated adequate content validity and a moderate level of evidence for sufficient internal consistency (with sufficient structural validity), resulting in a recommendation of class A. The other 9 PROMs evaluated received a recommendation of class B. CONCLUSIONS AND RELEVANCE The findings of this systematic review suggest that the EPDS is the best available patient-reported screening measure of maternal postpartum depression. Future studies should focus on evaluating the cross-cultural validity, reliability, and measurement error of the EPDS to improve understanding of its psychometric properties and utility.
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Affiliation(s)
- Pervez Sultan
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, California
| | - Kazuo Ando
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, California
| | - Rania Elkhateb
- Library, University of Arkansas for Medical Sciences, Little Rock
| | - Ronald B. George
- Department of Anesthesiology, University of California, San Francisco
| | - Grace Lim
- Department of Anesthesiology, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Brendan Carvalho
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, California
| | - Ahish Chitneni
- Physical Medicine and Rehabilitation, NewYork–Presbyterian–Columbia and Cornell, New York, New York
| | | | - Tanya Tulipan
- Department of Psychiatry, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Lindsay Blake
- Library, University of Arkansas for Medical Sciences, Little Rock
| | - Jessica Coker
- Department of Psychiatry, University of Arkansas for Medical Sciences, Little Rock
| | - James O’Carroll
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, California
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22
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El-Sherbeeny N, El Tantawy A, Ibrahim O, Elsayed M, El-Okda N, Hassan H. Insomnia and sleep quality among women during the perinatal period. MIDDLE EAST CURRENT PSYCHIATRY 2022. [DOI: 10.1186/s43045-022-00209-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Insomnia is the most common sleep disorder affecting sleep quality and quality of life among women during the perinatal period. The aim of the study is to study the frequency of insomnia and sleep quality among perinatal women and their effect on quality of life: 131 participants; 64 perinatal and 67 control groups from the outpatient clinics of Suez Canal University Hospital, Ismailia, Egypt. DSM-5 criteria were used to diagnose insomnia. Sleep quality was assessed using PSQI, and SF-36 questionnaire was used for assessment of health-related quality of life.
Results
Insomnia was statistically significant higher among the perinatal group than the control; 28.1% and 10.4%, respectively (P < 0.05). The perinatal women had poor sleep quality as compared with the control group with a higher mean global PSQI score; 8.02 ± 2.97 and 4.97 ± 2.45, respectively (P < 0.05). The quality of life in the perinatal group was lower than the control group with scores of 54.96 ± 14.63 versus 62.34 ± 14.63, respectively.
Conclusions
Insomnia and poor sleep quality are found in higher frequency in perinatal women than their counterpart control. The study also showed a significant impact of these changes on maternal HRQoL.
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Kalmbach DA. The emerging role of prenatal insomnia therapy in the prevention of perinatal depression and anxiety. Sleep 2022; 45:zsac029. [PMID: 35554574 DOI: 10.1093/sleep/zsac029] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/21/2023] Open
Affiliation(s)
- David A Kalmbach
- Thomas Roth Sleep Disorders and Research Center, Henry Ford Health System, Detroit, MI 48202,USA
- Department of Pulmonary and Critical Care and Sleep Medicine, Wayne State University School of Medicine, Detroit, MI 48201,USA
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Determinants of adolescent sleep: Early family environment, obstetric factors, and emotion regulation. JOURNAL OF APPLIED DEVELOPMENTAL PSYCHOLOGY 2022. [DOI: 10.1016/j.appdev.2022.101420] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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25
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Bao C, Jin D, Sun S, Xu L, Wang C, Tang W, Zhang W, Bao Y, Xu D, Zhou S, Yu X, Zhao K. Trajectories and Depressive Symptoms During the Perinatal Period: A Longitudinal Population-Based Study in China. Front Psychiatry 2022; 13:762719. [PMID: 35432035 PMCID: PMC9009256 DOI: 10.3389/fpsyt.2022.762719] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2021] [Accepted: 02/02/2022] [Indexed: 11/27/2022] Open
Abstract
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.
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Affiliation(s)
- Ciqing Bao
- Wenzhou Seventh People's Hospital, Wenzhou, China
| | - Dongzhen Jin
- Department of Preventive Medicine, School of Public Health and Management, Wenzhou Medical University, Wenzhou, China
| | - Shiyu Sun
- School of Mental Health, Wenzhou Medical University, Wenzhou, China
| | - Ling Xu
- Wenzhou Seventh People's Hospital, Wenzhou, China
| | - Chaoyue Wang
- School of Mental Health, Wenzhou Medical University, Wenzhou, China
| | - Weina Tang
- Shaoxing 7th People's Hospital, Shaoxing, China
| | - Wenmiao Zhang
- Department of Obstetrics, First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Yin Bao
- Department of Obstetrics, First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Dongwu Xu
- School of Mental Health, Wenzhou Medical University, Wenzhou, China
| | - Siyao Zhou
- School of Mental Health, Wenzhou Medical University, Wenzhou, China
| | - Xin Yu
- School of Mental Health, Wenzhou Medical University, Wenzhou, China
| | - Ke Zhao
- School of Mental Health, Wenzhou Medical University, Wenzhou, China
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Quin N, Tikotzky L, Stafford L, Fisher J, Bei B. Preventing postpartum insomnia by targeting maternal versus infant sleep: a protocol for a randomized controlled trial (the Study for Mother-Infant Sleep “SMILE”). SLEEP ADVANCES 2022; 3:zpab020. [PMID: 35156040 PMCID: PMC8824577 DOI: 10.1093/sleepadvances/zpab020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/03/2021] [Revised: 11/23/2021] [Indexed: 11/19/2022]
Abstract
Symptoms of insomnia are common during the perinatal periods and are linked to adverse parent/infant outcomes. Theories on insomnia development (e.g. 3P model) suggest that significant sleep disruption (e.g. nighttime infant care) can precipitate, while unhelpful sleep-related cognitions/behaviors can perpetuate parental insomnia symptoms. This study aims to examine how two interventions, one addressing infant sleep as the precipitator, the other targeting maternal sleep-related cognitions/behaviors as the perpetuator, might prevent postpartum insomnia. Participants are 114 nulliparous females 26 to 32 weeks gestation, with self-reported insomnia symptoms (Insomnia Severity Index scores ≥ 8). Participants are randomized to one of three conditions and receive: (1) a “responsive bassinet” used until 6 months postpartum, designed to boost/consolidate infant sleep and target infant sleep as a precipitator of insomnia, (2) therapist-assisted cognitive behavioral therapy for insomnia, addressing unhelpful sleep-related cognitions/behaviors as perpetuators of insomnia, or (3) a sleep hygiene booklet (control condition). The primary outcome is maternal insomnia symptoms. Secondary outcomes include maternal sleep duration/quality, mental health (e.g. depression, anxiety), and wellbeing-related variables (e.g. sleep-related impairment). Outcomes are assessed using validated instruments at 26–32 and 35–36 weeks’ gestation, and 2, 6, and 12 months postpartum. This study adopts an early-intervention approach and longitudinally compares two distinct approaches to prevent postpartum insomnia in an at-risk population. If interventions are efficacious, findings will demonstrate how interventions targeting different mechanisms mitigate insomnia symptoms in perinatal populations. This will provide empirical evidence for future development of multi-component sleep intervention to improve mother-infant wellbeing. Clinical Trial Registration: The Study for Mother-Infant Sleep (The SMILE Project): reducing postpartum insomnia using an infant sleep intervention and a maternal sleep intervention in first-time mothers. https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=377927, Australian New Zealand Clinical Trials Registry: ACTRN12619001166167.
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Affiliation(s)
- Nina Quin
- Turner Institute for Brain and Mental Health, School of Psychological Sciences, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Victoria, Australia
- Women’s Mental Health Service, Royal Women’s Hospital, Melbourne, Victoria, Australia
| | - Liat Tikotzky
- Department of Psychology, Ben-Gurion University of the Negev, Be’er Sheva, Israel
| | - Lesley Stafford
- Women’s Mental Health Service, Royal Women’s Hospital, Melbourne, Victoria, Australia
- School of Psychological Sciences, University of Melbourne, Melbourne, Victoria, Australia
| | - Jane Fisher
- Global and Women’s Health, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Bei Bei
- Turner Institute for Brain and Mental Health, School of Psychological Sciences, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Victoria, Australia
- Women’s Mental Health Service, Royal Women’s Hospital, Melbourne, Victoria, Australia
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Kalmbach DA, Cheng P, Roth A, Roth T, Swanson LM, O'Brien LM, Fresco DM, Harb NC, Cuamatzi-Castelan AS, Reffi AN, Drake CL. DSM-5 insomnia disorder in pregnancy: associations with depression, suicidal ideation, and cognitive and somatic arousal, and identifying clinical cutoffs for detection. SLEEP ADVANCES : A JOURNAL OF THE SLEEP RESEARCH SOCIETY 2022; 3:zpac006. [PMID: 35391758 PMCID: PMC8981986 DOI: 10.1093/sleepadvances/zpac006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 12/29/2021] [Revised: 02/18/2022] [Indexed: 11/23/2022]
Abstract
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 2nd 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.
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Affiliation(s)
- David A Kalmbach
- Thomas Roth Sleep Disorders & Research Center, Henry Ford Health System, Detroit, MIUSA.,Department of Pulmonary & Critical Care and Sleep Medicine, Wayne State University School of Medicine, Detroit, MIUSA
| | - Philip Cheng
- Thomas Roth Sleep Disorders & Research Center, Henry Ford Health System, Detroit, MIUSA
| | - Andrea Roth
- Pediatric Sleep Medicine, Thriving Minds Behavioral Health, Livonia, MIUSA
| | - Thomas Roth
- Thomas Roth Sleep Disorders & Research Center, Henry Ford Health System, Detroit, MIUSA
| | - Leslie M Swanson
- Department of Psychiatry, University of Michigan, Ann Arbor, MIUSA
| | - Louise M O'Brien
- Departments of Obstetrics & Gynecology and Neurology, University of Michigan, Ann Arbor, MIUSA
| | - David M Fresco
- Department of Psychiatry, University of Michigan, Ann Arbor, MIUSA
| | - Nicholas C Harb
- Thomas Roth Sleep Disorders & Research Center, Henry Ford Health System, Detroit, MIUSA
| | | | - Anthony N Reffi
- Thomas Roth Sleep Disorders & Research Center, Henry Ford Health System, Detroit, MIUSA
| | - Christopher L Drake
- Thomas Roth Sleep Disorders & Research Center, Henry Ford Health System, Detroit, MIUSA
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Shirindza KJ, Malwela T, Maputle MS. Early Postnatal Care: Exploring Primary Caregivers' Experiences of Continuity of Care After Discharge at Selected Districts in Limpopo Province South Africa. Patient Prefer Adherence 2022; 16:2009-2020. [PMID: 35966223 PMCID: PMC9373990 DOI: 10.2147/ppa.s366948] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Accepted: 06/18/2022] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Early postnatal discharge is perceived as a factor that contributes to possible maternal, neonatal complications and deaths during the first week of delivery. Continuing with provision of home-based postnatal care by the primary caregivers is crucial to prevent morbidity and mortality. PURPOSE The purpose was to explore the experiences of primary caregivers of continuing with the provision of early postnatal care at home. METHOD A qualitative research approach, which was explorative, descriptive, and contextual was conducted in the three selected districts of different ethnic groups at Limpopo Province in October 2019. A non-probability, purposive sampling was used to conveniently sample 20 primary caregivers of postnatal women. Data were collected during the first 2 weeks of delivery through in-depth individual semi-structured interviews until data saturation was reached. Data were analysed through a thematic analysis framework applying Tesch's open coding method. The study was done in Limpopo district, South Africa. FINDINGS The findings revealed a theme, namely, knowledge and skills of providing community-based postnatal care and three sub-themes; early postnatal care to detect and prevent possible complications to the mother; general postnatal care, and early neonatal care to detect and prevent possible complications. CONCLUSION Primary caregivers displayed acceptable indigenous skills and knowledge of providing early postnatal care. However, the skills of detecting potential danger signs were not adequately displayed. It was recommended that midwives need to create awareness to primary caregivers from the antenatal through postnatal care period. Community Health Workers to assist during immediate postnatal check-ups (mother and neonate) which is done within 72hours of delivery. The health education, counseling, and community-based awareness campaigns are to be done with a focus on the detection and prevention of possible complications to mother and baby.
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Affiliation(s)
- Katekani Joyce Shirindza
- University of Venda, Faculty of Health Sciences, Department of Advanced Nursing, Thohoyandou, South Africa
| | - Thivhulawi Malwela
- University of Venda, Faculty of Health Sciences, Department of Advanced Nursing, Thohoyandou, South Africa
| | - Maria Sonto Maputle
- University of Venda, Faculty of Health Sciences, Department of Advanced Nursing, Thohoyandou, South Africa
- Correspondence: Maria Sonto Maputle, University of Venda, Faculty of Health Sciences, Department of Advanced Nursing, Private Bag X 5050, Thohoyandou, South Africa, Tel +271 5 962 8125, Email
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Kalmbach DA, O’Brien LM, Pitts DS, Sagong C, Arnett LK, Harb NC, Cheng P, Drake CL. Mother-to-Infant Bonding is Associated with Maternal Insomnia, Snoring, Cognitive Arousal, and Infant Sleep Problems and Colic. Behav Sleep Med 2022; 20:393-409. [PMID: 34047659 PMCID: PMC8627527 DOI: 10.1080/15402002.2021.1926249] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
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.
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Affiliation(s)
- David A Kalmbach
- Thomas Roth Sleep Disorders & Research Center, Henry Ford Health System, Detroit, Michigan.,Pulmonary & Critical Care and Sleep Medicine, Wayne State University School of Medicine, Detroit, Michigan
| | - Louise M O’Brien
- Departments of Obstetrics & Gynecology, and Neurology, University of Michigan Medical School, Ann Arbor, Michigan
| | - D’Angela S Pitts
- Department of Obstetrics & Gynecology, Henry Ford Health System, Detroit, Michigan
| | - Chaewon Sagong
- Thomas Roth Sleep Disorders & Research Center, Henry Ford Health System, Detroit, Michigan
| | - Lily K Arnett
- Thomas Roth Sleep Disorders & Research Center, Henry Ford Health System, Detroit, Michigan
| | - Nicholas C Harb
- Thomas Roth Sleep Disorders & Research Center, Henry Ford Health System, Detroit, Michigan
| | - Philip Cheng
- Thomas Roth Sleep Disorders & Research Center, Henry Ford Health System, Detroit, Michigan
| | - Christopher L Drake
- Thomas Roth Sleep Disorders & Research Center, Henry Ford Health System, Detroit, Michigan
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30
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Deforges C, Noël Y, Eberhard-Gran M, Garthus-Niegel S, Horsch A. Prenatal insomnia and childbirth-related PTSD symptoms: A prospective population-based cohort study. J Affect Disord 2021; 295:305-315. [PMID: 34488084 DOI: 10.1016/j.jad.2021.08.024] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2021] [Revised: 08/17/2021] [Accepted: 08/19/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND Certain populations are at high risk of experiencing a traumatic event and developing post-traumatic stress disorder (PTSD). Yet, primary preventive interventions against PTSD are lacking. It is therefore crucial to identify pre-traumatic risk factors, which could be targeted with such interventions. Insomnia may be a good candidate, but studies on civilians are sparse. Furthermore, the mechanisms at stake in the relationship between pre-traumatic insomnia and PTSD symptoms are unclear. METHODS This prospective population-based cohort study (n = 1,610) examined the relationship between insomnia symptoms at 32 weeks of pregnancy and childbirth-related PTSD (CB-PTSD) symptoms at eight weeks postpartum. Postnatal insomnia symptoms, prenatal psychological symptoms (depression, anxiety, PTSD, fear of childbirth), subjective birth experience (SBE) and birth medical severity were included as covariates in the analyses, which were based on a Piecewise Structural Equation Modelling approach. RESULTS The relationship between prenatal insomnia and CB-PTSD symptoms was mediated by negative SBE and postnatal insomnia symptoms. All relationships involving insomnia symptoms had small or very small effect sizes. LIMITATIONS This study used self-report questionnaires. Postnatal insomnia and CB-PTSD symptoms were concurrently measured. CONCLUSION Prenatal insomnia symptoms may impair the ability to cope with a difficult birth experience and contribute to postnatal insomnia, a risk factor for CB-PTSD. Thus, prenatal insomnia symptoms may be a promising target for CB-PTSD primary preventive interventions, although other prenatal psychological symptoms could also be considered. Even beyond the perinatal context, future studies on pre-traumatic insomnia and PTSD should include post-traumatic insomnia as a covariate.
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Affiliation(s)
- Camille Deforges
- Institute of Higher Education and Research in Healthcare (IUFRS), University of Lausanne and Lausanne University Hospital, Lausanne, Switzerland.
| | - Yvonnick Noël
- Laboratory of Psychology, Cognition, Behavior and Communication, Univ Rennes, Rennes, France.
| | - Malin Eberhard-Gran
- Norwegian Research Centre for Women's Health, Women and Children's Division, Oslo University Hospital, Rikshospitalet, Oslo Norway; Institute of Clinical Medicine, University of Oslo, Oslo, Norway.
| | - Susan Garthus-Niegel
- Department of Medicine, Faculty of Medicine, Medical School Hamburg, Hamburg, Germany; Department of Child Health and Development, Norwegian Institute of Public Health, Oslo, Norway; Institute and Policlinic of Occupational and Social Medicine, Faculty of Medicine, Technische Universität Dresden, Dresden, Germany.
| | - Antje Horsch
- Institute of Higher Education and Research in Healthcare (IUFRS), University of Lausanne and Lausanne University Hospital, Lausanne, Switzerland; Woman-Mother-Child Department, Lausanne University Hospital, Lausanne, Switzerland.
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Massae AF, Larsson M, Leshabari S, Mbekenga C, Pembe AB, Svanberg AS. Predictors of fear of childbirth and depressive symptoms among pregnant women: a cross-sectional survey in Pwani region, Tanzania. BMC Pregnancy Childbirth 2021; 21:704. [PMID: 34666696 PMCID: PMC8524824 DOI: 10.1186/s12884-021-04169-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2020] [Accepted: 09/24/2021] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Many women experience fear of childbirth (FoB) and depressive symptoms (DS) during pregnancy, but little is known about FoB among Tanzanian women. The current study aimed to assess the prevalence of FoB and DS among pregnant women and determine predictors of each and both, focusing on sociodemographic and obstetric predictors. METHODS A cross-sectional study was conducted at six health facilities in two districts in Tanzania between 2018 and 2019. In total, 694 pregnant women with gestational age between 32 and 40 weeks and expecting vaginal delivery were consecutively recruited and assessed for FoB and DS. We collected data through interviews using 6 and 4-points Likert Scale of the Wijma Delivery Expectancy Questionnaire Version A and Edinburgh Postnatal Depression Scale, respectively. Women who scored ≥66 and ≥ 10 were categorised as having FoB and DS, respectively. We performed multivariable logistic regression to investigate the predictors of FoB and DS. RESULTS The prevalence rates of FoB and DS among pregnant women were 15.1 and 17.7%, respectively. FoB and DS were more likely in women aged above 30 years [Adjusted Odds Ratio (AOR) 6.29, 95%CI 1.43-27.84] and in single mothers (AOR 2.57, 95%CI 1.14-5.78). Women with secondary education and above (AOR 0.22, 95%CI 0.05-0.99) and those who had given birth previously (AOR 0.27, 95% CI 0.09-0.87) were less likely to have FoB in combination with DS Women who had previous obstetric complications, and those who did not receive any social support from male partners in previous childbirth were more likely to have FoB and DS. FoB was strongly associated with DS (AOR 3.42, 95%CI 2.12-5.53). DS only was more common in women who had inadequate income (AOR 2.35, 95%CI 1.38-3.99) or had previously experienced a perineal tear (AOR 2.32, 95%CI 1.31-4.08). CONCLUSIONS Not having a formal education, having only primary education, being aged above 30 years, being single, being nulliparous, having experienced obstetric complications, and having a lack of social support from a male partner during previous pregnancy and childbirth were predictors of FoB and DS during pregnancy. FoB and DS were strongly associated with each other. It is vital to identify at-risk women early, to offer support during pregnancy and childbirth.
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Affiliation(s)
- Agnes Fredrick Massae
- Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden.
- Department of Community Health Nursing, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania.
| | - Margareta Larsson
- Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden
| | - Sebalda Leshabari
- Department of Community Health Nursing, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Columba Mbekenga
- School of Nursing and Midwifery, The Aga Khan University, Dar es Salaam, Tanzania
| | - Andrea Barnabas Pembe
- Department of Obstetrics and Gynaecology, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
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32
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Kalmbach DA, Cheng P, Drake CL. A pathogenic cycle between insomnia and cognitive arousal fuels perinatal depression: exploring the roles of nocturnal cognitive arousal and perinatal-focused rumination. Sleep 2021; 44:6217388. [PMID: 33830248 DOI: 10.1093/sleep/zsab028] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2020] [Revised: 01/01/2021] [Indexed: 11/12/2022] Open
Abstract
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.
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Affiliation(s)
- David A Kalmbach
- Thomas Roth Sleep Disorders & Research Center, Henry Ford Health System, Detroit, MI, USA.,Pulmonary & Critical Care and Sleep Medicine, Wayne State University School of Medicine, Detroit, MI, USA
| | - Philip Cheng
- Thomas Roth Sleep Disorders & Research Center, Henry Ford Health System, Detroit, MI, USA
| | - Christopher L Drake
- Thomas Roth Sleep Disorders & Research Center, Henry Ford Health System, Detroit, MI, USA
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33
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Ghante A, Raj JP, Krishna B, Thomas A. Prevalence and predictors of sleep deprivation and poor sleep quality and their associated perinatal outcomes during the third trimester of pregnancy. J Taibah Univ Med Sci 2021; 16:359-364. [PMID: 34140862 PMCID: PMC8178615 DOI: 10.1016/j.jtumed.2020.11.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2020] [Revised: 11/09/2020] [Accepted: 11/16/2020] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVES Maternal sleep deprivation not only affects the pregnant mother but also has profound effects on the well-being of the foetus. This study aims to assess the prevalence and predictors of excessive daytime sleepiness (EDS) and poor sleep quality (PSQ). METHODS This was a cross-sectional study conducted among in-patient post-natal women of a tertiary care teaching hospital. A pretested semi-structured standardised questionnaire was administered. EDS was assessed using the Epworth sleepiness scale and PSQ was measured using the Pittsburgh Sleep Quality Index. RESULTS A total of 225 participants were enrolled. The prevalence of EDS was 29.3% (95% confidence interval [CI] = 23.5, 35.8) and the prevalence of PSQ was 72.9% (95% CI = 66.6, 78.6). The factors (adjusted odds ratio; 95% CI; p-value) that were significantly associated with EDS were age (1.082; 1.019, 3.102; 0.042), being overweight (1.248; 1.012, 3.834; 0.041), low haemoglobin (1.246; 1.007, 4.572; 0.043), and gestational diabetes mellitus (GDM) (1.267; 1.001, 7.239; 0.049). On the other hand, the factors associated with PSQ were young age (1.092; 1.035, 3.763; 0.028), being overweight (1.602; 1.029, 2.995; 0.035), low haemoglobin (1.328; 1.004, 4.963; 0.047), and GDM (1.659; 1.284, 4.112; 0.016). No significant associations were found between perinatal outcomes and EDS or PSQ. Additionally, poor sleep practices were observed in our study participants. CONCLUSION In this study, EDS and PSQ were significantly prevalent among participants, and their major predictors were age, haemoglobin, being overweight, and GDM.
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Affiliation(s)
- Abhishek Ghante
- Department of Obstetrics and Gynaecology, St. Johns Medical College, Bengaluru, India
| | - Jeffrey P. Raj
- Department of Pharmacology, St. Johns Medical College, Bengaluru, India
| | - Balamurali Krishna
- Department of Obstetrics and Gynaecology, St. Johns Medical College, Bengaluru, India
| | - Annamma Thomas
- Department of Obstetrics and Gynaecology, St. Johns Medical College, Bengaluru, India
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Sultan P, Ando K, Sultan E, Hawkins J, Blake L, Barwick F, Kawai M, Carvalho B. A systematic review of patient-reported outcome measures used to assess sleep in postpartum women using Consensus Based Standards for the Selection of Health Measurement Instruments (COSMIN) guidelines. Sleep 2021; 44:6278483. [PMID: 34013345 DOI: 10.1093/sleep/zsab128] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Revised: 04/02/2021] [Indexed: 12/12/2022] Open
Abstract
STUDY OBJECTIVES We performed a systematic review to identify the best patient-reported outcome measure (PROM) of postpartum sleep in women. METHODS We searched 4 databases for validated PROMs used to assess postpartum sleep. Studies were considered if they evaluated at least 1 psychometric measurement property of a PROM. An overall rating was assigned for each psychometric measurement property of each PROM based upon COSMIN criteria. A modified GRADE approach was used to assess the level of evidence and recommendations were then made for each PROM. RESULTS We identified 15 validation studies of 8 PROMs, in 9,070 postpartum women. An adequate number of sleep domains was assessed by 5 PROMs: Bergen Insomnia Scale (BIS), Pittsburgh Sleep Quality Index (PSQI), General Sleep Disturbance Scale (GSDS), Athens Insomnia Scale (AIS) and the Sleep Symptom Checklist (SSC). BIS and GSDS were the only PROMs to demonstrate adequate content validity and at least a low level of evidence of sufficient internal consistency, resulting in Class A recommendations. The BIS was the only PROM, which is easily accessible and free to use for non-commercial research, that achieved a Class A recommendation. CONCLUSION The BIS is the best currently available PROM of postpartum sleep. However, this PROM fails to assess several important domains such as sleep duration (and efficiency), chronotype, sleep-disordered breathing and medication usage. Future studies should focus on evaluating the psychometric measurement properties of BIS in the North American setting and in different cultural groups, or to develop a more specific PROM of postpartum sleep.
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Affiliation(s)
- P Sultan
- Associate Professor. Department of Anesthesiology, Perioperative and Pain Medicine. Stanford University School of Medicine, Stanford, CA, USA
| | - K Ando
- Assistant Professor. Department of Anesthesiology, Perioperative and Pain Medicine. Stanford University School of Medicine, Stanford, CA, USA
| | - E Sultan
- Clinical Instructor. Department of Anesthesiology, Perioperative and Pain Medicine. Stanford University School of Medicine, Stanford, CA, USA
| | - J Hawkins
- Medical Student. Stanford University School of Medicine, Stanford, CA, USA
| | - L Blake
- Associate Professor. UAMS Medical Library, UAMS, Little Rock, AR, USA SCIENC ES
| | - F Barwick
- Clinical Associate Professor, Division of Sleep Medicine, Department of Psychiatry and Behavioral Sciences, Stanford University, School of Medicine
| | - M Kawai
- Clinical Associate Professor, Division of Sleep Medicine, Department of Psychiatry and Behavioral Sciences, Stanford University, School of Medicine
| | - B Carvalho
- Professor. Department of Anesthesiology, Perioperative and Pain Medicine. Stanford University School of Medicine, Stanford, CA, USA
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Maghami M, Shariatpanahi SP, Habibi D, Heidari-Beni M, Badihian N, Hosseini M, Kelishadi R. Sleep disorders during pregnancy and postpartum depression: A systematic review and meta-analysis. Int J Dev Neurosci 2021; 81:469-478. [PMID: 33942364 DOI: 10.1002/jdn.10118] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2021] [Revised: 04/19/2021] [Accepted: 04/28/2021] [Indexed: 01/10/2023] Open
Abstract
BACKGROUND Postpartum depression (PPD) is one of the most important mental disorders in recent years. However, the effects of prenatal sleep disorders on the development of PPD among pregnant women have not been elucidated. This review aims to provide a summary of the literature evaluating the relation between sleep disorders during pregnancy and PPD. METHOD A systematic literature search was conducted in PubMed, Web of Science, Scopus, Google Scholar, and Embase up to September 2020. All observational studies (cross-sectional, case-control, and cohort) and studies that assessed the association between sleep disorders during pregnancy and PPD were included. Total sample of 36,873 women from 13 studies was entered to meta-analysis. An aggregate effect size estimate (odds ratio) was generated using the comprehensive meta-analysis software. A random effects model was set a priori. Heterogeneity and publication bias were examined using the standard meta-analytic approaches. RESULT We found maternal sleep disorder increased odds of PPD (point estimate, 3.300; 95% confidence interval [CI], 2.136-5.098; p < .001; n = 13). However, there was significant heterogeneity (Q, 131.250; df, 12; p < .001; I2 , 90.857%). The estimated effect size was significant for all categorical studies. According to meta-regression, no moderating factor (age and publication year) significantly mediated the estimated effect size. CONCLUSION We found a significant relationship between sleep disturbances during pregnancy and PPD. Women with sleep disorders are at an increased risk of developing PPD, which warrants screening pregnant mothers for sleep disturbances. Also, we found that the increasing age in pregnancy was associated with increased risk of PPD.
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Affiliation(s)
- Mahboobeh Maghami
- Department of Bio-statistics and Epidemiology, School of Health, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Seyyed Payam Shariatpanahi
- Department of Bio-statistics and Epidemiology, School of Health, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Danial Habibi
- Department of Bio-statistics and Epidemiology, School of Health, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Motahar Heidari-Beni
- Department of Nutrition, Child Growth and Development Research Center, Research Institute for Primordial Prevention of Non-Communicable Disease, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Negin Badihian
- Department of Pediatrics, Child Growth and Development Research Center, Research Institute for Primordial Prevention of Non-Communicable Disease, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Mohsen Hosseini
- Department of Bio-statistics and Epidemiology, School of Health, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Roya Kelishadi
- Department of Pediatrics, Child Growth and Development Research Center, Research Institute for Primordial Prevention of Non-Communicable Disease, Isfahan University of Medical Sciences, Isfahan, Iran
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Osnes RS, Eberhard-Gran M, Follestad T, Kallestad H, Morken G, Roaldset JO. Mid-Pregnancy Insomnia and its Association with Perinatal Depressive Symptoms: A Prospective Cohort Study. Behav Sleep Med 2021; 19:285-302. [PMID: 32228307 DOI: 10.1080/15402002.2020.1743705] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Objective/Background: Insomnia and depression are disorders that affect many perinatal women and that often are interrelated. The present study aimed to examine concurrent and prospective associations between mid-pregnancy insomnia and depression during mid-pregnancy and 8 weeks postpartum. Furthermore, differences in depression and in the sleep-related characteristics insomnia, chronotype, and sleep efficiency were explored between the two time points (mid-pregnancy versus 8 weeks postpartum), and between primiparous and multiparous participants.Participants/Methods: The study was part of the Norwegian population-based Depression and Anxiety in the Perinatal Period (DAPP) prospective cohort study. Among 539 women that were recruited for participation when receiving a routine ultrasound examination, we analyzed data from hospital birth records and questionnaire responses from pregnancy week 17 and postpartum week 8. We used the Edinburgh Postnatal Depression Scale to measure depression. The Bergen Insomnia Scale, the reduced Horne-Östberg Morningness-Eveningness Questionnaire, and three questions from the Pittsburgh Sleep Quality Index were used to measure the sleep-related characteristics.Results: Mid-pregnancy insomnia was significantly associated with concurrent depression (p < .001), but not with postpartum depression (p = .288), in a linear mixed model with adjustment for several reproductive and psychosocial variables. Sleep efficiency was reduced from mid-pregnancy to postpartum (from 88% to 77%), and primiparous women reported less efficient sleep than multiparous women after childbirth.Conclusions: The results indicate that mid-pregnancy insomnia may be a marker for concurrent depression but not a predictor of postpartum depression. Future research should examine the extent to which treatment of insomnia from mid-pregnancy on reduces both perinatal insomnia and depression.
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Affiliation(s)
- Rannveig S Osnes
- Department of Psychiatry, Ålesund Hospital, Møre & Romsdal Hospital Trust, Ålesund, Norway.,Department of Mental Health, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology, Trondheim, Norway
| | - Malin Eberhard-Gran
- Institute of Clinical Medicine, Campus Ahus, University of Oslo, Lørenskog, Norway.,Department of Infant Mental Health, Regional Center for Child and Adolescent Mental Health, Eastern and Southern Norway, Oslo, Norway
| | - Turid Follestad
- Department of Public Health and Nursing, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology, Trondheim, Norway
| | - Håvard Kallestad
- Department of Mental Health, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology, Trondheim, Norway.,Østmarka Department of Psychiatry, St Olavs Hospital HF, Trondheim University Hospital, Trondheim, Norway
| | - Gunnar Morken
- Department of Mental Health, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology, Trondheim, Norway.,Østmarka Department of Psychiatry, St Olavs Hospital HF, Trondheim University Hospital, Trondheim, Norway
| | - John Olav Roaldset
- Department of Mental Health, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology, Trondheim, Norway.,Centre for Research and Education in Forensic Psychiatry, Oslo University Hospital, Oslo, Norway
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Salari N, Darvishi N, Khaledi-Paveh B, Vaisi-Raygani A, Jalali R, Daneshkhah A, Bartina Y, Mohammadi M. A systematic review and meta-analysis of prevalence of insomnia in the third trimester of pregnancy. BMC Pregnancy Childbirth 2021; 21:284. [PMID: 33836686 PMCID: PMC8034118 DOI: 10.1186/s12884-021-03755-z] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2020] [Accepted: 03/24/2021] [Indexed: 11/10/2022] Open
Abstract
Background Sleep disorders, which are among the foremost important medical care issues, are prevalent in pregnancy. The present study is a meta-analysis of the prevalence of insomnia in the third trimester of pregnancy. This study aims to systematically review the overall prevalence of insomnia in the third trimester of pregnancy through conducting a meta-analysis. Method The literature used in this meta-analysis for the topic discussed above were obtained through searching several databases, including SID, MagIran, IranDoc, Scopus, Embase, Web of Science (WoS), PubMed Science Direct and Google Scholar databases without time limitation until December 2020. Articles developed based on cross-sectional studies were included in the study. The heterogeneity of studies was investigated using the I2 index. Also, the possible effects of heterogeneity in the studied studies are investigated using meta-regression analysis. Result In 10 articles and 8798 participants aged between11–40, the overall prevalence of insomnia in the third trimester of pregnancy based on meta-analysis was 42.4% (95% CI: 32.9–52.5%). It was reported that as the sample size increases, the prevalence of insomnia in the third trimester of pregnancy increases. Conversely, as the year of research increases, the prevalence of insomnia in the third trimester of pregnancy decreases. Both of these differences were statistically significant (P < 0.05). Conclusion Insomnia was highly prevalent in the last trimester of pregnancy. Sleep disorders are neglected among pregnant women, and they are considered natural. While sleep disturbances can cause mental and physical problems in pregnant women, they can consequently cause problems for the fetus. As a result, maintaining the physical and mental health of pregnant mothers is very important. It is thus recommended that in addition to having regular visits during pregnancy, pregnant women should also be continuously monitored for sleep-related disorders.
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Affiliation(s)
- Nader Salari
- Department of Biostatistics, School of Health, Kermanshah University of Medical Sciences, Kermanshah, Iran.,Sleep Disorders Research Center, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Niloofar Darvishi
- Student Research Committee, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Behnam Khaledi-Paveh
- Sleep Disorders Research Center, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Aliakbar Vaisi-Raygani
- Department of Nursing, School of Nursing and Midwifery, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Rostam Jalali
- Department of Nursing, School of Nursing and Midwifery, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Alireza Daneshkhah
- School of Computing, Electronics and Maths, Coventry University, London, UK
| | - Yalda Bartina
- Department of Translation Studies, Faculty of Literature, Istanbul University, Istanbul, Turkey
| | - Masoud Mohammadi
- Department of Nursing, School of Nursing and Midwifery, Kermanshah University of Medical Sciences, Kermanshah, Iran.
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Pietikäinen JT, Härkänen T, Polo-Kantola P, Karlsson H, Paunio T, Karlsson L, Paavonen EJ. Estimating the cumulative risk of postnatal depressive symptoms: the role of insomnia symptoms across pregnancy. Soc Psychiatry Psychiatr Epidemiol 2021; 56:2251-2261. [PMID: 33961078 PMCID: PMC8558280 DOI: 10.1007/s00127-021-02101-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2020] [Accepted: 04/23/2021] [Indexed: 11/29/2022]
Abstract
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.
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Affiliation(s)
- Johanna T. Pietikäinen
- Department of Psychiatry, Helsinki University Hospital and University of Helsinki, Helsinki, Finland ,Department of Public Health and Welfare, Finnish Institute for Health and Welfare, Mannerheimintie 166, P. O. Box 30, 00271 Helsinki, Finland
| | - Tommi Härkänen
- Department of Public Health and Welfare, Finnish Institute for Health and Welfare, Mannerheimintie 166, P. O. Box 30, 00271 Helsinki, Finland
| | - Päivi Polo-Kantola
- Department of Obstetrics and Gynaecology, Turku University Hospital, Turku University, Turku, Finland ,Department of Pulmonary Diseases and Allergology, Sleep Research Centre, University of Turku, Turku, Finland
| | - Hasse Karlsson
- Department of Clinical Medicine, The FinnBrain Birth Cohort Study, Turku Brain and Mind Center, University of Turku, Turku, Finland ,Department of Psychiatry, Turku University Hospital and University of Turku, Turku, Finland ,Centre for Population Health Research, Turku University Hospital and University of Turku, Turku, Finland
| | - Tiina Paunio
- Department of Public Health and Welfare, Finnish Institute for Health and Welfare, Mannerheimintie 166, P. O. Box 30, 00271 Helsinki, Finland ,Department of Psychiatry and SleepWell Research Program, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Linnea Karlsson
- Department of Clinical Medicine, The FinnBrain Birth Cohort Study, Turku Brain and Mind Center, University of Turku, Turku, Finland
| | - E. Juulia Paavonen
- Department of Public Health and Welfare, Finnish Institute for Health and Welfare, Mannerheimintie 166, P. O. Box 30, 00271 Helsinki, Finland ,Department of Child Psychiatry, Pediatric Research Center, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
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Swanson LM, Kalmbach DA, Raglan GB, O’Brien LM. Perinatal Insomnia and Mental Health: a Review of Recent Literature. Curr Psychiatry Rep 2020; 22:73. [PMID: 33104878 PMCID: PMC9109228 DOI: 10.1007/s11920-020-01198-5] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/14/2020] [Indexed: 02/06/2023]
Abstract
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.
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Affiliation(s)
- Leslie M. Swanson
- Department of Psychiatry, University of Michigan, Ann Arbor, MI;,Corresponding Author: Leslie M. Swanson, Department of Psychiatry, University of Michigan, 4250 Plymouth Rd, Ann Arbor, MI 48109,
| | - David A. Kalmbach
- Sleep Disorders and Research Center, Henry Ford Hospital, Detroit, MI
| | - Greta B. Raglan
- Department of Psychiatry, University of Michigan, Ann Arbor, MI
| | - Louise M. O’Brien
- Department of Neurology, Sleep Disorders Center, University of Michigan, Ann Arbor, MI
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Bick D, Taylor C, Bhavnani V, Healey A, Seed P, Roberts S, Zasada M, Avery A, Craig V, Khazaezadah N, McMullen S, O’Connor S, Oki B, Oteng-Ntim E, Poston L, Ussher M. Lifestyle information and access to a commercial weight management group to promote maternal postnatal weight management and positive lifestyle behaviour: the SWAN feasibility RCT. PUBLIC HEALTH RESEARCH 2020. [DOI: 10.3310/phr08090] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Background
Increasing numbers of UK women have overweight or obese body mass index scores when they become pregnant, or gain excessive weight in pregnancy, increasing their risk of adverse outcomes. Failure to manage postnatal weight is linked to smoking, non-healthy dietary choices, lack of regular exercise and poorer longer-term health. Women living in areas of higher social deprivation are more likely to experience weight management problems postnatally.
Objectives
The objectives were to assess the feasibility of conducting a definitive randomised controlled trial to determine the clinical effectiveness and cost-effectiveness of lifestyle information and access to a commercial weight management group focusing on self-monitoring, goal-setting and motivation to achieve dietary change commencing 8–16 weeks postnatally to achieve and maintain weight management and positive lifestyle behaviour.
Design
The design was a randomised two-arm feasibility trial with a nested mixed-methods process evaluation.
Setting
The setting was a single centre in an inner city setting in the south of England.
Participants
Participants were women with body mass index scores of > 25 kg/m2 at antenatal ‘booking’ and women with normal body mass index scores (18.0–24.9 kg/m2) at antenatal booking who developed excessive gestational weight gain as assessed at 36 weeks’ gestation.
Main outcome measures
Recruitment, retention, acceptability of trial processes and identification of relevant economic data were the feasibility objectives. The proposed primary outcome was difference between groups in weight at 12 months postnatally, expressed as percentage weight change and weight loss from antenatal booking. Other proposed outcomes included assessment of diet, physical activity, smoking, alcohol consumption, body image, maternal esteem, mental health, infant feeding and NHS costs.
Results
Most objectives were achieved. A total of 193 women were recruited, 98 allocated to the intervention arm and 95 to the control arm. High follow-up rates (> 80%) were achieved to 12 months. There was an 8.8% difference in weight loss at 12 months between women allocated to the intervention arm and women allocated to the control arm (13.0% vs. 4.2%, respectively; p = 0.062); 47% of women in the intervention arm attended at least one weight management session, with low risk of contamination between arms. The greatest benefit was among women who attended ≥ 10 sessions. Barriers to attending sessions included capability, opportunity and motivation issues. Data collection tools were appropriate to support economic evaluation in a definitive trial, and economic modelling is feasible to quantify resource impacts and outcomes not directly measurable within a trial.
Limitations
The trial recruited from only one site. It was not possible to recruit women with normal body mass index scores who developed excessive pregnancy weight gain.
Conclusions
It was feasible to recruit and retain women with overweight or obese body mass index scores at antenatal booking to a trial comparing postnatal weight management plus standard care with standard care only and collect relevant data to assess outcomes. Approaches to recruit women with normal body mass index scores who gain excessive gestational weight need to be considered. Commercial weight management groups could support women’s weight management as assessed at 12 months postnatally, with probable greater benefit from attending ≥ 10 sessions. Process evaluation findings highlighted the importance of providing more information about the intervention on trial allocation, extended duration of time to commence sessions following birth and extended number of sessions offered to enhance uptake and retention. Results support the conduct of a future randomised controlled trial.
Trial registration
Current Controlled Trials ISRCTN39186148.
Funding
This project was funded by the National Institute for Health Research (NIHR) Public Health Research programme and will be published in full in Public Health Research; Vol. 8, No. 9. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Debra Bick
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, UK
- Department of Women and Children’s Health, School of Life Course Sciences, King’s College London, London, UK
| | - Cath Taylor
- School of Health Sciences, University of Surrey, Guildford, UK
| | | | - Andy Healey
- King’s Health Economics, Health Service and Population Research Department, Institute of Psychiatry, Psychology & Neuroscience, King’s College London, London, UK
| | - Paul Seed
- Department of Women and Children’s Health, School of Life Course Sciences, King’s College London, London, UK
| | - Sarah Roberts
- King’s Health Economics, Health Service and Population Research Department, Institute of Psychiatry, Psychology & Neuroscience, King’s College London, London, UK
| | | | - Amanda Avery
- Faculty of Science, University of Nottingham, Nottingham, UK
| | | | | | | | | | - Bimpe Oki
- Public Health, London Borough of Lambeth, London, UK
| | | | - Lucilla Poston
- Department of Women and Children’s Health, School of Life Course Sciences, King’s College London, London, UK
| | - Michael Ussher
- Population Health Research Institute, St George’s, University of London, London, UK
- Institute for Social Marketing and Health, University of Stirling, Stirling, UK
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Osnes RS, Eberhard-Gran M, Follestad T, Kallestad H, Morken G, Roaldset JO. Mid-pregnancy insomnia is associated with concurrent and postpartum maternal anxiety and obsessive-compulsive symptoms: A prospective cohort study. J Affect Disord 2020; 266:319-326. [PMID: 32056894 DOI: 10.1016/j.jad.2020.01.140] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2019] [Revised: 12/04/2019] [Accepted: 01/25/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND Although many perinatal women are affected by anxiety, few studies have focused on perinatal anxiety and its potential triggers. The primary aim of this study was to examine concurrent and prospective associations between mid-pregnancy insomnia and perinatal anxiety. Furthermore, we compared psychosocial and reproductive characteristics between participants with and without mid-pregnancy insomnia and explored changes in the prevalence of obsessive-compulsive disorder (OCD) symptoms from mid-pregnancy to 8 weeks postpartum. METHODS This study was part of the Norwegian Depression and Anxiety in the Perinatal Period (DAPP) prospective, population-based, cohort study. We analyzed hospital birth records and questionnaire responses from pregnancy week 17 and postpartum week 8 (n = 530). The Bergen Insomnia Scale was used to measure insomnia and the Hopkins Symptom Checklist to measure anxiety. OCD symptoms were measured based on questions from the Mini-International Neuropsychiatric Interview. RESULTS Mid-pregnancy insomnia was significantly associated with both concurrent and postpartum anxiety in a linear mixed model adjusted for several potential confounders. Participants with mid-pregnancy insomnia had significantly higher levels of perinatal anxiety and postpartum OCD symptoms than participants with normal mid-pregnancy sleep. OCD symptoms affected more women after delivery than before (6.4% vs. 3.8% p = 0.034). LIMITATIONS Immigrants were underrepresented in our sample. CONCLUSION Our results suggest that mid-pregnancy insomnia is a marker for concurrent anxiety and predictor of postpartum anxiety. Future research should examine whether insomnia treatment starting in mid-pregnancy reduces both perinatal insomnia and anxiety. Health providers should also be aware that postpartum women have an increased risk of developing OCD symptoms.
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Affiliation(s)
- Rannveig S Osnes
- Department of Psychiatry, Ålesund Hospital, Møre & Romsdal Health Trust, Ålesund, Norway; Department of Mental Health, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology, Trondheim, Norway.
| | - Malin Eberhard-Gran
- Institute of Clinical Medicine, Campus Ahus, University of Oslo, Lørenskog, Norway; Department of Infant Mental Health, Regional Center for Child and Adolescent Mental Health, Eastern and Southern Norway, Oslo, Norway
| | - Turid Follestad
- Department of Public Health and Nursing, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology, Trondheim, Norway
| | - Håvard Kallestad
- Department of Mental Health, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology, Trondheim, Norway; Østmarka Department of Psychiatry, St Olavs Hospital HF, Trondheim University Hospital, Trondheim, Norway
| | - Gunnar Morken
- Department of Mental Health, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology, Trondheim, Norway; Østmarka Department of Psychiatry, St Olavs Hospital HF, Trondheim University Hospital, Trondheim, Norway
| | - John Olav Roaldset
- Department of Mental Health, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology, Trondheim, Norway; Centre for Research and Education in Forensic Psychiatry, Oslo University Hospital, Oslo, Norway
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Wang WJ, Hou CL, Jiang YP, Han FZ, Wang XY, Wang SB, Ng CH, Jia FJ. Prevalence and associated risk factors of insomnia among pregnant women in China. Compr Psychiatry 2020; 98:152168. [PMID: 32105909 DOI: 10.1016/j.comppsych.2020.152168] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2019] [Revised: 01/10/2020] [Accepted: 02/12/2020] [Indexed: 01/06/2023] Open
Abstract
BACKGROUND Insomnia is common during pregnancy but the prevalence and risk factors of insomnia in Chinese women during pregnancy is not well studied. This study aimed to examine the prevalence of insomnia and its risk factors in Chinese women during pregnancy. METHODS In this cross sectional study, 436 Chinese pregnant women with Insomnia Severity Index (ISI) ≥ 8 were clinically assessed using the insomnia criteria based on the combination of DSM-IV (Diagnostic and Statistical Manual-4th Edition) and ICD-10 (International Classification of Dieases, 10th Edition). Beck Depression Inventory (BDI), State-Trait Anxiety Inventory (STAI), Dysfunctional Beliefs and Attitudes about Sleep Scale (DBAS), Pregnancy Pressure Scale (PPS), Perceived physical discomfort level and number, Epworth Sleepiness Scale (ESS), and a general socio-demographic questionnaire were administered. RESULTS The results showed that about 20% of the pregnant women met the strict diagnosis criteria of insomnia. Independent-samples t-test revealed that several risk factors were correlated with the group with insomnia (N = 84) compared to the group without insomnia (N = 352). Binary Logistic regression analysis found that more significant bed partner influence (OR = 1.92, 95% CI: 1.03-3.60), depressive symptoms (OR = 1.07, 95% CI: 1.00-1.14), daytime sleepiness (OR = 1.07, 95% CI: 1.01-1.14), subjective somatic discomfort (OR = 2.27, 95% CI: 1.11-4.65), kinds of somatic discomfort (OR = 1.14, 95% CI: 1.03-1.27) and later gestation (OR = 1.05, 95% CI: 1.01-1.09) were significantly associated with insomnia. CONCLUSION In this cohort of Chinese pregnant women, about a fifth of women suffered from clinically significant insomnia. Measures to prevent the adverse effects of insomnia should be provided to pregnant women with depressive symptoms, Sleep disturbance of the bed partner, excessive daytime sleepiness and somatic discomfort, especially late in gestation.
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Affiliation(s)
- Wen-Jing Wang
- The Second School of Clinical Medicine, Southern Medical University, Guangzhou, Guangdong Province, China; Guangdong Mental Health Center, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, Guangdong Province, China
| | - Cai-Lan Hou
- Guangdong Mental Health Center, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, Guangdong Province, China.
| | - Yan-Ping Jiang
- Department of Obstetrics, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, Guangdong Province, China
| | - Feng-Zhen Han
- Department of Obstetrics, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, Guangdong Province, China
| | - Xiao-Yun Wang
- Department of Obstetrics, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, Guangdong Province, China
| | - Shi-Bin Wang
- Guangdong Mental Health Center, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, Guangdong Province, China
| | - C H Ng
- Department of Psychiatry, The University of Melbourne, Melbourne, Victoria, Australia
| | - Fu-Jun Jia
- The Second School of Clinical Medicine, Southern Medical University, Guangzhou, Guangdong Province, China; Guangdong Mental Health Center, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, Guangdong Province, China.
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43
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Kalmbach DA, Cheng P, Sangha R, O’Brien LM, Swanson LM, Palagini L, Bazan LF, Roth T, Drake CL. Insomnia, Short Sleep, And Snoring In Mid-To-Late Pregnancy: Disparities Related To Poverty, Race, And Obesity. Nat Sci Sleep 2019; 11:301-315. [PMID: 31807103 PMCID: PMC6839586 DOI: 10.2147/nss.s226291] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2019] [Accepted: 10/05/2019] [Indexed: 12/26/2022] Open
Abstract
OBJECTIVE To characterize sleep habits and parameters among women in mid-to-late pregnancy and to identify disparities associated with poverty, race, and obesity. DESIGN Cross-sectional. SETTING Large multi-site health system in Metro Detroit. PARTICIPANTS A total of 267 pregnant women (27.3% non-Hispanic black; gestational age: 27.99±1.20 weeks) completed online surveys on sleep quality, insomnia symptoms, sleep aid use, signs/symptoms of sleep-disordered breathing, and sociodemographics. Body mass index (BMI) and patient insurance were derived from medical records. RESULTS As high as 76.2% of the women reported global sleep disturbance, 30.6% endorsed snoring, 24.3% sleep <6 hrs/night, and over half screened positive for clinical insomnia. Yet, only 3.4% of the women reported an insomnia diagnosis and 3.0% reported a sleep apnea diagnosis. In unadjusted models, poverty, Medicaid coverage, self-identifying as black, and obesity before and during pregnancy (BMI ≥ 35) were associated with a wide range of sleep problems. However, adjusted models revealed specificity. Poverty was uniquely related to increased insomnia symptoms and trouble sleeping due to bad dreams. Obesity before pregnancy was related to poor sleep quality, snoring, sleep aids, and short sleep. Black women reported shorter sleep duration than white women but differed on no other sleep parameters. CONCLUSION Clinical signs of insomnia and sleep-disordered breathing are common in mid-to-late pregnancy, but most cases go undetected. Problematic sleep disproportionately affects women in poverty, who self-identify as black, and who are obese before pregnancy. Poverty-related sleep issues are linked to insomnia, obesity-related disparities center on sleep-related breathing and medication use, and racial disparities relate to short sleep.
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Affiliation(s)
- David A Kalmbach
- Thomas Roth Sleep Disorders and Research Center, Henry Ford Health System, Novi, MI, USA
| | - Philip Cheng
- Thomas Roth Sleep Disorders and Research Center, Henry Ford Health System, Novi, MI, USA
| | - Roopina Sangha
- Department of Obstetrics and Gynecology, Henry Ford Health System, Detroit, MI, USA
| | - Louise M O’Brien
- Departments of Obstetrics &Gynecology and Neurology, University of Michigan, Ann Arbor, MI, USA
| | - Leslie M Swanson
- Department of Psychiatry, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Laura Palagini
- Departments of Neuroscience and Psychiatry, University of Pisa, Pisa, Italy
| | - Luisa F Bazan
- Division of Sleep Medicine, Henry Ford Health System, Detroit, MI, USA
| | - Thomas Roth
- Thomas Roth Sleep Disorders and Research Center, Henry Ford Health System, Novi, MI, USA
| | - Christopher L Drake
- Thomas Roth Sleep Disorders and Research Center, Henry Ford Health System, Novi, MI, USA
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González-Mesa E, Cuenca-Marín C, Suarez-Arana M, Tripiana-Serrano B, Ibrahim-Díez N, Gonzalez-Cazorla A, Blasco-Alonso M. Poor sleep quality is associated with perinatal depression. A systematic review of last decade scientific literature and meta-analysis. J Perinat Med 2019; 47:689-703. [PMID: 31393835 DOI: 10.1515/jpm-2019-0214] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2019] [Accepted: 07/17/2019] [Indexed: 12/22/2022]
Abstract
Background Although pregnancy is frequently associated with mental states of happiness, hope and well-being, some physical and psychological changes can contribute to increased sleep disturbances and worsened sleep quality. Sleep quality has been linked to negative emotions, anxiety and depression. The main objective of this paper was to systematically review the impact of sleep during pregnancy on maternal mood, studying the association between objective and subjective measures of sleep quality and perinatal depression. Methods We performed a systematic review according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, which included studies published between January 2008 and April 2019, and met the following criteria: (i) studies on pregnant women assessing the effects of sleep quality variables on perinatal mood disorders, (ii) studies published in English and (iii) full paper published in a peer-reviewed scientific journal with full-text format available. Results A total of 36 studies published in the last decade met the inclusion criteria for qualitative review and eight of them were suitable for meta-analysis. Both confirmed the negative effects of poor sleep on perinatal mood. However, qualitative analysis showed that unrepresentative samples and low participation rates falling below 80% biased some of the studies. The standard random-effects meta-analysis showed a pooled size effect [ln odds ratio (OR) 1.49 (95% confidence interval [CI] 1.19, 1.79)] for perinatal depression in cases of poor prenatal sleep quality, although heterogeneity was moderate to high [Q 16.05, P ≤ 0.025, H2 2.45 (95% CI 1.01, 13.70)]. Conclusion Poor sleep quality was associated with perinatal mood disturbances. The assessment of sleep quality along the pregnancy could be advisable with a view to offering preventative or therapeutic interventions when necessary.
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Affiliation(s)
- Ernesto González-Mesa
- Surgical Specialties, Biochemistry and Immunology Department, Malaga University School of Medicine, 32, Boulevard Louis Pasteur, 29071 Málaga, Spain
- Obstetrics and Gynecology at Malaga University Hospital, Málaga, Spain
| | | | | | | | | | - Ana Gonzalez-Cazorla
- Surgical Specialties, Biochemistry and Immunology Department, Malaga University School of Medicine, 32, Boulevard Louis Pasteur, 29071 Málaga, Spain
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45
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McEvoy KM, Rayapati D, Washington Cole KO, Erdly C, Payne JL, Osborne LM. Poor Postpartum Sleep Quality Predicts Subsequent Postpartum Depressive Symptoms in a High-Risk Sample. J Clin Sleep Med 2019; 15:1303-1310. [PMID: 31538601 PMCID: PMC6760397 DOI: 10.5664/jcsm.7924] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2019] [Revised: 05/10/2019] [Accepted: 05/10/2019] [Indexed: 12/26/2022]
Abstract
STUDY OBJECTIVES Postpartum depression (PPD) occurs in 15% to 20% of mothers worldwide and is associated with adverse outcomes for mother and child. Prior research has established a relationship between concurrent sleep quality and PPD. We conducted a secondary analysis in 45 women with mood disorders to study overall sleep quality (and individual components of sleep), measured in the early postpartum period, as a predictor of subsequent PPD. METHODS We measured sleep quality using the Pittsburgh Sleep Quality Index (PSQI; subscale and total scores) at 1 month postpartum (and during the third trimester). We measured depressive symptoms using the Inventory of Depressive Symptoms, Self-Report (IDS-SR) at 3 months postpartum. We used bivariate and multivariate linear regression models to study the association between PSQI and IDS scores. RESULTS We found that higher global PSQI scores as well as higher component scores for self-reported sleep quality, sleep latency, sleep efficiency, sleep medication usage, and daytime dysfunction, measured 1 month postpartum, were associated with increased IDS scores (at 3 months postpartum (P = .01, .01, .01, .003, < .001, respectively). We did not find an association between poor sleep quality in the third trimester and PPD. CONCLUSIONS Poor sleep quality in the early postpartum period independently predicts development of later PPD. This is clinically significant and highlights the importance of sleep interventions as an immediate postpartum therapeutic tool. CITATION McEvoy KM, Rayapati D, Washington Cole KO, Erdly C, Payne JL, Osborne LM. Poor postpartum sleep quality predicts subsequent postpartum depressive symptoms in a high-risk sample. J Clin Sleep Med. 2019;15(9):1303-1310.
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46
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Oliva-Pérez J, Cabrero-García J, Cabañero-Martínez MJ, Richart-Martínez M, Oliver-Roig A. Validity and Reliability of the Spanish Version of the Pregnancy-Related Thoughts Scale. J Obstet Gynecol Neonatal Nurs 2019; 48:526-537. [DOI: 10.1016/j.jogn.2019.07.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/01/2019] [Indexed: 12/26/2022] Open
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47
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Golenkov AV, Filonenko VA, Filonenko AV. [Sleep disorders as one of the indicators of postpartum depression]. Zh Nevrol Psikhiatr Im S S Korsakova 2019; 119:81-88. [PMID: 31317920 DOI: 10.17116/jnevro201911904281] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Postpartum depression in ICD-10 refers to mild mental and behavioral disorders associated with physiological disorders of the postpartum period F53.0. Diagnosis is based on criteria, one of which is sleep disorders. The objective of the review is to characterize the postpartum sleep disorders and to reflect their predictor value in the development of postpartum depression. Presomnic, intrasomnic and postsomnic disorders with negative consequences for both the mother and her child were found in sleep disorders of women with postpartum depression. Depression with sleep disorders significantly affect the quality of life of the mother and infant. Sleep disorders are one of the predictors of postpartum depression. Improving of sleep quality is an effective way to prevent the effects of postpartum depression.
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Affiliation(s)
- A V Golenkov
- Ulyanov Chuvash State University, Cheboksary, Russia
| | - V A Filonenko
- Ulyanov Chuvash State University, Cheboksary, Russia
| | - A V Filonenko
- Ulyanov Chuvash State University, Cheboksary, Russia
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48
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Pietikäinen JT, Polo-Kantola P, Pölkki P, Saarenpää-Heikkilä O, Paunio T, Paavonen EJ. Sleeping problems during pregnancy-a risk factor for postnatal depressiveness. Arch Womens Ment Health 2019; 22:327-337. [PMID: 30121844 DOI: 10.1007/s00737-018-0903-5] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2018] [Accepted: 08/09/2018] [Indexed: 01/01/2023]
Abstract
In the general population, sleeping problems can precede an episode of depression. We hypothesized that sleeping problems during pregnancy, including insomnia symptoms, shortened sleep, and daytime tiredness, are related to maternal postnatal depressiveness. We conducted a prospective study evaluating sleep and depressive symptoms, both prenatally (around gestational week 32) and postnatally (around 3 months after delivery) in the longitudinal CHILD-SLEEP birth cohort in Finland. Prenatally, 1667 women returned the questionnaire, of which 1398 women participated also at the postnatal follow-up. Sleep was measured with the Basic Nordic Sleep Questionnaire (BNSQ) and depressive symptoms with a 10-item version of the Center for Epidemiological Studies Depression Scale (CES-D). Altogether, 10.3% of the women had postnatal depressiveness (CES-D ≥ 10 points). After adjusting for main background characteristics and prenatal depressiveness (CES-D ≥ 10), poor general sleep quality (AOR 1.87, 95% CI 1.21-2.88), tiredness during the day (AOR 2.19, 95% CI 1.41-3.38), short sleep ≤ 6 and ≤ 7 h, sleep latency > 20 min, and sleep loss ≥ 2 h were associated with postnatal depressiveness (all p < .050). Postnatally, after the adjustment for background characteristics, virtually all sleeping problems (i.e., difficulty falling asleep (AOR 7.93, 95% CI 4.76-13.20)), except frequent night awakenings per week or severe sleepiness during the day, were related to concurrent postnatal depressiveness. Thus, several prenatal and postnatal sleeping problems are associated with increased depressive symptoms 3 months postnatally. Screening of maternal prenatal sleeping problems, even without depressive symptoms during pregnancy or lifetime, would help to identify women at an increased risk for postnatal depressiveness.
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Affiliation(s)
- Johanna T Pietikäinen
- Department of Health Solutions, National Institute for Health and Welfare, Mannerheimintie 168, P.O. Box 30, 00271, Helsinki, Finland. .,Psychiatry, University of Helsinki and Helsinki University Hospital, Helsinki, Finland.
| | - Päivi Polo-Kantola
- Department of Obstetrics and Gynecology, Turku University Hospital and University of Turku, Turku, Finland
| | - Pirjo Pölkki
- Department of Social Sciences, University of Eastern Finland, Kuopio, Finland
| | - Outi Saarenpää-Heikkilä
- Pediatric Clinics, Tampere University Hospital, Tampere, Finland.,Tampere Centre for Child Health Research, University of Tampere and Tampere University Hospital, Tampere, Finland
| | - Tiina Paunio
- Department of Health Solutions, National Institute for Health and Welfare, Mannerheimintie 168, P.O. Box 30, 00271, Helsinki, Finland.,Psychiatry, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - E Juulia Paavonen
- Department of Health Solutions, National Institute for Health and Welfare, Mannerheimintie 168, P.O. Box 30, 00271, Helsinki, Finland.,Child Psychiatry, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
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Emamian F, Khazaie H, Okun ML, Tahmasian M, Sepehry AA. Link between insomnia and perinatal depressive symptoms: A meta-analysis. J Sleep Res 2019; 28:e12858. [PMID: 30983027 DOI: 10.1111/jsr.12858] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2019] [Revised: 03/07/2019] [Accepted: 03/11/2019] [Indexed: 11/27/2022]
Abstract
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.
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Affiliation(s)
- Farnoosh Emamian
- Sleep Disorders Research Center, Kermanshah University of Medical Sciences(KUMS), Kermanshah, Iran.,Department of Psychiatry, University of Social Welfare and Rehabilitation Sciences, Tehran, Iran
| | - Habibolah Khazaie
- Sleep Disorders Research Center, Kermanshah University of Medical Sciences(KUMS), Kermanshah, Iran
| | - Michele L Okun
- BioFrontiers, University of Colorado, Colorado Springs, Colorado
| | - Masoud Tahmasian
- Institute of Medical Science and Technology, Shahid Beheshti University, Tehran, Iran
| | - Amir A Sepehry
- Division of Neurology, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada.,Counselling and Clinical Psychology, Adler University (Vancouver Campus), Vancouver, BC, Canada
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50
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Osnes RS, Roaldset JO, Follestad T, Eberhard-Gran M. Insomnia late in pregnancy is associated with perinatal anxiety: A longitudinal cohort study. J Affect Disord 2019; 248:155-165. [PMID: 30735852 DOI: 10.1016/j.jad.2019.01.027] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2018] [Revised: 01/09/2019] [Accepted: 01/20/2019] [Indexed: 12/18/2022]
Abstract
BACKGROUND Postpartum anxiety (PPA) affects a substantial number of women. Despite increasing recognition of PPA, few studies have focused on perinatal anxiety and potential PPA triggers. Here we aimed to estimate the prevalence of perinatal anxiety disorders, and to explore the association between insomnia during late pregnancy and anxiety before and after childbirth. METHODS This study was part of the large population-based Akershus Birth Cohort. We analyzed data from the hospital's birth records and questionnaire responses from pregnancy weeks 17 and 32 and postpartum week 8 (n = 1563). Perinatal anxiety symptoms were measured using the Hopkins Symptom Check List. Anxiety disorder measurements were based on questions from the Mini-International Neuropsychiatric Interview. Insomnia was measured using the Bergen Insomnia Scale. RESULTS Among perinatal women, 10% reported symptoms of at least one anxiety disorder. The observed prevalence of obsessive-compulsive disorder was higher after delivery (4.2%) than during pregnancy (2.5%). Multiple regression analysis, with adjustment for several psychosocial and reproductive variables, indicated that insomnia during pregnancy was significantly associated with postpartum anxiety symptoms. However, this association was markedly weakened when depression variables were included in the analysis, indicating that gestational insomnia may also be a marker for a mood disorder. LIMITATIONS Immigrant and single women were underrepresented in our sample. CONCLUSIONS Our results suggest that anxiety disorders are prevalent during the perinatal period. Moreover, insomnia during pregnancy is associated with perinatal anxiety. Health professionals should be aware that women with gestational insomnia may have an increased risk of mood and anxiety disorders.
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Affiliation(s)
- Rannveig S Osnes
- Department of Psychiatry, Ålesund Hospital, Møre & Romsdal Health Trust, Ålesund, Norway; Department of Mental Health, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology, Trondheim, Norway.
| | - John Olav Roaldset
- Department of Psychiatry, Ålesund Hospital, Møre & Romsdal Health Trust, Ålesund, Norway; Department of Mental Health, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology, Trondheim, Norway; Centre for Research and Education in Forensic Psychiatry, Oslo University Hospital, Oslo, Norway
| | - Turid Follestad
- Department of Public Health and Nursing, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology, Trondheim, Norway
| | - Malin Eberhard-Gran
- HØKH, Research Unit, Akershus University Hospital, Lørenskog, Norway; Institute of Clinical Medicine, Campus Ahus, University of Oslo, Lørenskog, Norway; Department for Infant Mental Health, Regional Center for Child and Adolescent Mental Health, Eastern and Southern Norway, Oslo, Norway
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