Over the last few months, there have been several review articles looking at the connection between sleep disturbance and perinatal depression. Clinically, sleep disturbance is common among women with depression during pregnancy and/or in the postpartum. Much of data on this association comes from cross-sectional studies; thus, it is difficult to determine if sleep disturbance causes or contributes to depression and/or anxiety, or if sleep disturbance is merely a symptom of depression or anxiety.
Sleep Disturbance and Risk of Perinatal Depression
In the first meta-analysis, Fu and colleagues analyzed data from a total of ten studies including 39,574 participants. Overall, women who experienced poor sleep quality during pregnancy had a higher risk of developing depression. Compared to women who reported no significant sleep problems during pregnancy, women with disrupted sleep had a 3.72-fold higher risk of depression during pregnancy and a 2.7-fold higher risk of postpartum depression.
The meta-analysis from Li and colleagues looked at the association between sleep disturbance during pregnancy and risk of postpartum depression, analyzing data from 16 studies with a total of 12,614 participants. Similar to the first meta-analysis described above, this meta-analysis also observed that sleep disturbance during pregnancy resulted in a statistically significant increased risk of PPD (OR: 2.36, 95% CI: 1.72, 2.32). However, they noted that risk of PPD was only increased with sleep disturbance occurring during the third trimester, not when it occurred only in the first or second trimesters.
What Comes First? Sleep Disturbance or Depression?
While many studies show an association between sleep disturbance and perinatal depression, the studies are cross-sectional, not longitudinal, so it is difficult to know whether sleep disturbance precedes and causes or contributes to depression, or if sleep disturbance occurs as a symptom of depression.
To better understand the relationship between sleep and perinatal depression, several studies have followed women longitudinally and have assessed sleep and depressive symptoms during pregnancy and the postpartum period. For example, Bao and colleagues followed 412 women from the first trimester of pregnancy until 6 weeks postpartum. 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.
The researchers identified four distinct sleep quality trajectories: stable-good (46.1%), worsening (16.4%), improving (17.5%), and stable-poor (16.0%). The lowest risk of postpartum depression was observed in the stable-good group. Compared to this group, women with stable-poor sleep had a 3.57-fold increased risk of PPD and women in the worsening group had a 2.56-fold increased risk of PPD.
While this longitudinal study hints that sleep disturbance may contribute to the onset of depression, the authors note that the relationship is more complicated. Women in the stable-poor sleep group had higher levels of depression at baseline, a factor that increases risk for PPD. In addition, women in the stable-good sleep group tended to have more social support, a factor that is associated with decreased risk for PPD.
Should We Screen for Sleep Problems During Pregnancy?
Given the strong association between sleep disturbance during pregnancy and perinatal depression, should clinicians specifically be asking about sleep? Commonly used depression screening tools, such as the EPDS and the Patient Health Questionnaire-9 items (PHQ-9), do include questions about sleep. (The shortened PHQ-2 does not ask about sleep.) However, in the absence of other depressive symptoms, sleep problems on their own would not typically be flagged as concerning or needing additional follow-up.
Future studies are needed to determine the utility of assessing sleep as a means of identifying women at risk of perinatal depression. Sleep disturbance is common among pregnant and postpartum women; thus, labeling women with sleep problems as being at increased risk for perinatal depression may yield a high number of false positives. However, this symptom when combined with other risk factors may be more useful in clinical settings. Further research may also help to identify specific sleep parameters – for example, duration or severity of sleep disturbance — that may be more precise in determining risk of perinatal depression.
Ruta Nonacs, MD PhD
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 Mar 31;13:762719.
Fu T, Wang C, Yan J, Zeng Q, Ma C. Relationship between antenatal sleep quality and depression in perinatal women: A comprehensive meta-analysis of observational studies. J Affect Disord. 2023 Feb 3;327:38-45.
Li H, Li H, Zhong J, Wu Q, Shen L, Tao Z, Zhang H, Song S. Association between sleep disorders during pregnancy and risk of postpartum depression: a systematic review and meta-analysis. Arch Womens Ment Health. 2023 Feb 4.