In This article
- Sleep quality worsens across pregnancy and early postpartum, and more severe sleep problems increase risk for depression.
- Multiple validated instruments, including the ISI and SCI, are useful tools for screening perinatal sleep problems.
- Screening for mood and anxiety disorders is recommended for women who present with significant sleep problems.
- CBT-I and other sleep-focused interventions introduced during pregnancy can reduce the risk for postpartum depression.
In all pregnant women, studies have demonstrated a progressive decline in sleep quality across pregnancy and into the postpartum period, hitting a low point during the third trimester and the first postpartum month. While sleep disruption is common, multiple studies have linked sleep problems emerging during pregnancy with an increased risk for perinatal depression.
Given this robust association, one might consider sleep as a modifiable risk factor for perinatal depression.
Sleep Disturbance and Risk of Perinatal Depression
In a recent meta-analysis, Fu and colleagues analyzed data from a total of ten studies including 39,574 participants. Compared to women who reported no significant sleep problems during pregnancy, women with disrupted sleep
- 3.72-fold higher risk of depression during pregnancy
- 2.7-fold higher risk of postpartum depression.
Another meta-analysis (Li et al, 2023), focusing only on the risk of postpartum depression, also observed that women who described sleep disturbance during pregnancy were more likely to experience PPD than women with intact sleep (OR: 2.36, 95% CI: 1.72, 2.32). However, they noted that risk of PPD was only associated with sleep disturbance occurring during the third trimester; sleep problems occurring in the first or second trimesters did not appear to increase risk of PPD.
Screening for Sleep Problems During Pregnancy and the Postpartum Period
Given the strong association between poor sleep quality during pregnancy and perinatal depression, one could argue for routinely screening for sleep problems during pregnancy and the postpartum period in addition to screening for mood and anxiety. Several questionnaires are available to assess sleep quality and daytime functioning.
Sleep-related items are included in commonly used screening tools for perinatal mood disorders; however, these symptoms may not be flagged if the total score is below the cutoff score typically used to identify depression:
- Item 7 of the Edinburgh Postnatal Depression Scale (EPDS) (“I have been so unhappy that I have had difficulty sleeping”)
- Item 3 of the Patient Health Questionnaire-9 (PHQ-9) (“Trouble falling or staying asleep, or sleeping too much?”)
Several instruments have can be used to more precisely evaluate sleep quality during pregnancy and the postpartum populations:
- Pittsburgh Sleep Quality Index (PSQI): One of the more comprehensive assessments of subjective sleep quality, sleep latency, and duration.
- PROMIS Sleep Disturbance Short Form: Brief measure that can be integrated into digital or clinical workflow assessments.
- Sleep Condition Indicator (SCI): A validated, 8-item self-report questionnaire used in clinical settings to screen for insomnia.
- Insomnia Severity Index (ISI): A 7-item questionnaire designed as a brief screening tool for insomnia.
Although these instruments differ in length and complexity, shorter tools such as the ISI and SCI may be most feasible for routine screening in obstetric and primary care settings. Because poor sleep may trigger or exacerbate depression and anxiety, individuals reporting sleep concerns should also be screened for psychiatric symptoms.
Interventions for Sleep Problems During Pregnancy
Cognitive behavioral therapy for insomnia (CBT-I) remains an effective, non-pharmacologic treatment for sleep disturbance in both pregnancy and the postpartum period. A 2024 randomized controlled trial (RCT) evaluated the impact of a 5-week CBT-I intervention adapted for pregnant people with insomnia (N = 62) recruited between 12 and 28 weeks gestation. Women receiving the CBT-I intervention had lower levels of depressive symptoms at 6 months postpartum than those who did not receive the sleep intervention.
A review of CBT-I for perinatal insomnia summarizes accumulating data showing that CBT-I initiated in pregnancy improves sleep and reduces insomnia, anxiety, and depressive symptoms through at least 6 months postpartum.
For women who do not respond to or cannot access CBT-I, safe pharmacologic options may be considered. At least one study using medications for the treatment of insomnia during pregnancy improved sleep quality and reduced risk for postpartum depression.
Psychoeducational programs for new parents that provide information on newborn sleep patterns and teach sleep-promoting strategies have also been shown to reduce risk for postpartum depression.
Because sleep problems during pregnancy can be viewed as a modifiable risk factor of depression during pregnancy and the postpartum period, it is important to screen for sleep problems and to consider interventions if sleep problems are more severe. Early intervention during pregnancy is essential, as sleep problems tend to worsen during pregnancy and be more difficult to treat.
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—Ruta Nonacs, MD PhD
