Back to top Open menu arrow
Download Reprints
Sections
METHODS RESULTS GEE Models: Association of Longitudinal Changes in Sleep and Biological Rhythms With Longitudinal Changes in Mood and Anxiety DISCUSSION CONCLUSIONS Clinical Points
The Journal of Clinical Psychiatry The Journal of Clinical Psychiatry

The Journal of
Clinical Psychiatry
Access icon

Original Research Focus on Women's Mental Health January 18, 2022

Longitudinal Changes in Sleep, Biological Rhythms, and Light Exposure From Late Pregnancy to Postpartum and Their Impact on Peripartum Mood and Anxiety

Anastasiya Slyepchenko, PhD; Luciano Minuzzi, MD, PhD; James P. Reilly, PhD; Benicio N. Frey, MD, MSc, PhD

J Clin Psychiatry 2022;83(2):21m13991

ABSTRACT

Objective: In one of the largest and most comprehensive studies investigating the link between objective parameters of sleep and biological rhythms with peripartum mood and anxiety to date, we prospectively investigated the trajectory of subjective and objective sleep and biological rhythms, levels of melatonin, and light exposure from late pregnancy to postpartum and their relationship with depressive and anxiety symptoms across the peripartum period.

Methods: One hundred women were assessed during the third trimester of pregnancy, of whom 73 returned for follow-ups at 1–3 weeks and 6–12 weeks postpartum. Participants were recruited from an outpatient clinic and from the community from November 2015 to May 2018. Subjective and objective measures of sleep and biological rhythms were obtained, including 2 weeks of actigraphy at each visit. Questionnaires validated in the peripartum period were used to assess mood and anxiety.

Results: Discrete patterns of longitudinal changes in sleep and biological rhythm variables were observed, such as fewer awakenings (F = 23.46, P < .001) and increased mean nighttime activity (F = 55.41, P < .001) during postpartum compared to late pregnancy. Specific longitudinal changes in biological rhythm parameters, most notably circadian quotient, activity during rest at night, and probability of transitioning from rest to activity at night, were most strongly linked to higher depressive and anxiety symptoms across the peripartum period.

Conclusions: Biological rhythm variables beyond sleep were most closely associated with severity of depressive and anxiety symptoms across the peripartum period. Findings from this study emphasize the importance of biological rhythms and activity beyond sleep to peripartum mood and anxiety.

Continue Reading...

Did you know members enjoy unlimited free PDF downloads as part of their subscription? Subscribe today for instant access to this article and our entire library in your preferred format. Alternatively, you can purchase the PDF of this article individually.

Subscribe Now

Already a member? Login

  1. Dennis CL, Falah-Hassani K, Shiri R. Prevalence of antenatal and postnatal anxiety: systematic review and meta-analysis. Br J Psychiatry. 2017;210(5):315–323. PubMed CrossRef
  2. Gavin NI, Gaynes BN, Lohr KN, et al. Perinatal depression: a systematic review of prevalence and incidence. Obstet Gynecol. 2005;106(5 Pt 1):1071–1083. PubMed CrossRef
  3. Falah-Hassani K, Shiri R, Dennis C-L. The prevalence of antenatal and postnatal co-morbid anxiety and depression: a meta-analysis. Psychol Med. 2017;47(12):2041–2053. PubMed CrossRef
  4. Weissman MM. Postpartum depression and its long-term impact on children: many new questions. JAMA Psychiatry. 2018;75(3):227–228. PubMed CrossRef
  5. Goodman JH, Watson GR, Stubbs B. Anxiety disorders in postpartum women: a systematic review and meta-analysis. J Affect Disord. 2016;203:292–331. PubMed CrossRef
  6. Andersson L, Sundström-Poromaa I, Wulff M, et al. Implications of antenatal depression and anxiety for obstetric outcome. Obstet Gynecol. 2004;104(3):467–476. PubMed CrossRef
  7. Stein A, Pearson RM, Goodman SH, et al. Effects of perinatal mental disorders on the fetus and child. Lancet. 2014;384(9956):1800–1819. PubMed CrossRef
  8. Bánhidy F, Ács N, Puhó E, et al. Association between maternal panic disorders and pregnancy complications and delivery outcomes. Eur J Obstet Gynecol Reprod Biol. 2006;124(1):47–52. PubMed CrossRef
  9. Zou R, Tiemeier H, van der Ende J, et al. Exposure to maternal depressive symptoms in fetal life or childhood and offspring brain development: a population-based imaging study. Am J Psychiatry. 2019;176(9):702–710. PubMed CrossRef
  10. Furtado M, Chow CHT, Owais S, et al. Risk factors of new onset anxiety and anxiety exacerbation in the perinatal period: a systematic review and meta-analysis. J Affect Disord. 2018;238:626–635. PubMed CrossRef
  11. Hutchens BF, Kearney J. Risk factors for postpartum depression: an umbrella review. J Midwifery Womens Health. 2020;65(1):96–108. PubMed CrossRef
  12. Biaggi A, Conroy S, Pawlby S, et al. Identifying the women at risk of antenatal anxiety and depression: a systematic review. J Affect Disord. 2016;191:62–77. PubMed CrossRef
  13. Lancaster CA, Gold KJ, Flynn HA, et al. Risk factors for depressive symptoms during pregnancy: a systematic review. Am J Obstet Gynecol. 2010;202(1):5–14. PubMed CrossRef
  14. Bei B, Coo Calcagni S, Milgrom J, et al. Day-to-day alteration of 24-hour sleep pattern immediately before and after giving birth. Sleep Biol Rhythms. 2012;10(3):212–221. CrossRef
  15. Sedov ID, Cameron EE, Madigan S, et al. Sleep quality during pregnancy: a meta-analysis. Sleep Med Rev. 2018;38:168–176. PubMed CrossRef
  16. Gallaher KGH, Slyepchenko A, Frey BN, et al. The role of circadian rhythms in postpartum sleep and mood. Sleep Med Clin. 2018;13(3):359–374. PubMed CrossRef
  17. Coo Calcagni S, Bei B, Milgrom J, et al. The relationship between sleep and mood in first-time and experienced mothers. Behav Sleep Med. 2012;10(3):167–179. PubMed CrossRef
  18. Lawson A, Murphy KE, Sloan E, et al. The relationship between sleep and postpartum mental disorders: a systematic review. J Affect Disord. 2015;176:65–77. PubMed CrossRef
  19. Park EM, Meltzer-Brody S, Stickgold R. Poor sleep maintenance and subjective sleep quality are associated with postpartum maternal depression symptom severity. Arch Women Ment Health. 2013;16(6):539–547. PubMed CrossRef
  20. Bei B, Milgrom J, Ericksen J, et al. Subjective perception of sleep, but not its objective quality, is associated with immediate postpartum mood disturbances in healthy women. Sleep. 2010;33(4):531–538. PubMed CrossRef
  21. McEvoy KM, Rayapati D, Washington Cole KO, et al. Poor postpartum sleep quality predicts subsequent postpartum depressive symptoms in a high-risk sample. J Clin Sleep Med. 2019;15(9):1303–1310. PubMed CrossRef
  22. Wolfson AR, Crowley SJ, Anwer U, et al. Changes in sleep patterns and depressive symptoms in first-time mothers: last trimester to 1-year postpartum. Behav Sleep Med. 2003;1(1):54–67. PubMed CrossRef
  23. Osnes RS, Roaldset JO, Follestad T, et al. Insomnia late in pregnancy is associated with perinatal anxiety: a longitudinal cohort study. J Affect Disord. 2019;248:155–165. PubMed CrossRef
  24. Tham EK, Tan J, Chong YS, et al. Associations between poor subjective prenatal sleep quality and postnatal depression and anxiety symptoms. J Affect Disord. 2016;202:91–94. PubMed CrossRef
  25. Krawczak EM, Minuzzi L, Hidalgo MP, et al. Do changes in subjective sleep and biological rhythms predict worsening in postpartum depressive symptoms? a prospective study across the perinatal period. Arch Women Ment Health. 2016;19(4):591–598. PubMed CrossRef
  26. Krawczak EM, Minuzzi L, Simpson W, et al. Sleep, daily activity rhythms and postpartum mood: a longitudinal study across the perinatal period. Chronobiol Int. 2016;33(7):791–801. PubMed CrossRef
  27. Parry BL, Meliska CJ, Sorenson DL, et al. Plasma melatonin circadian rhythm disturbances during pregnancy and postpartum in depressed women and women with personal or family histories of depression. Am J Psychiatry. 2008;165(12):1551–1558. PubMed CrossRef
  28. Sharkey KM, Pearlstein TB, Carskadon MA. Circadian phase shifts and mood across the perinatal period in women with a history of major depressive disorder: a preliminary communication. J Affect Disord. 2013;150(3):1103–1108. PubMed CrossRef
  29. Caropreso L, Saliba S, Hasegawa L, et al. Quality assurance assessment of a specialized perinatal mental health clinic. BMC Pregnancy Childbirth. 2020;20(1):485. PubMed CrossRef
  30. Sheehan DV, Lecrubier Y, Sheehan KH, et al. The Mini-International Neuropsychiatric Interview (M.I.N.I.): the development and validation of a structured diagnostic psychiatric interview for DSM-IV and ICD-10. J Clin Psychiatry. 1998;59(suppl 20):22–33, quiz 34–57. PubMed
  31. Beck CT. Revision of the postpartum depression predictors inventory. J Obstet Gynecol Neonatal Nurs. 2002;31(4):394–402. PubMed CrossRef
  32. Cox JL, Holden JM, Sagovsky R. Detection of postnatal depression: development of the 10-item Edinburgh Postnatal Depression Scale. Br J Psychiatry. 1987;150(6):782–786. PubMed CrossRef
  33. Montgomery S, Åsberg M. A New Depression Scale Designed to be Sensitive to Change: Acad. Department of Psychiatry, Guy’s Hospital; 1977.
  34. Young RC, Biggs JT, Ziegler VE, et al. A rating scale for mania: reliability, validity and sensitivity. Br J Psychiatry. 1978;133(5):429–435. PubMed CrossRef
  35. Spitzer RL, Kroenke K, Williams JB, et al. A brief measure for assessing generalized anxiety disorder: the GAD-7. Arch Intern Med. 2006;166(10):1092–1097. PubMed CrossRef
  36. Johns MW. A new method for measuring daytime sleepiness: the Epworth sleepiness scale. Sleep. 1991;14(6):540–545. PubMed CrossRef
  37. Buysse DJ, Reynolds CF 3rd, Monk TH, et al. The Pittsburgh Sleep Quality Index: a new instrument for psychiatric practice and research. Psychiatry Res. 1989;28(2):193–213. PubMed CrossRef
  38. Giglio LMF, Magalhães PV, Andreazza AC, et al. Development and use of a biological rhythm interview. J Affect Disord. 2009;118(1-3):161–165. PubMed CrossRef
  39. Henshaw C. Mood disturbance in the early puerperium: a review. Arch Women Ment Health. 2003;6(suppl 2):S33–S42. PubMed CrossRef
  40. Chang YS, Lin MH, Lee JH, et al. Melatonin supplementation for children with atopic dermatitis and sleep disturbance: a randomized clinical trial. JAMA Pediatr. 2016;170(1):35–42. PubMed CrossRef
  41. Nowak R, McMillen IC, Redman J, et al. The correlation between serum and salivary melatonin concentrations and urinary 6-hydroxymelatonin sulphate excretion rates: two non-invasive techniques for monitoring human circadian rhythmicity. Clin Endocrinol (Oxf). 1987;27(4):445–452. PubMed CrossRef
  42. Sturgeon SR, Doherty A, Reeves KW, et al. Urinary levels of melatonin and risk of postmenopausal breast cancer: women’s health initiative observational cohort. Cancer Epidemiol Biomarkers Prev. 2014;23(4):629–637. PubMed CrossRef
  43. Benloucif S, Burgess HJ, Klerman EB, et al. Measuring melatonin in humans. J Clin Sleep Med. 2008;4(1):66–69. PubMed CrossRef
  44. Slyepchenko A, Allega OR, Leng X, et al. Association of functioning and quality of life with objective and subjective measures of sleep and biological rhythms in major depressive and bipolar disorder. Aust N Z J Psychiatry. 2019;53(7):683–696. PubMed CrossRef
  45. Reid KJ, Santostasi G, Baron KG, et al. Timing and intensity of light correlate with body weight in adults. PLoS One. 2014;9(4):e92251. PubMed CrossRef
  46. van Someren EJ, Hagebeuk EE, Lijzenga C, et al. Circadian rest-activity rhythm disturbances in Alzheimer’s disease. Biol Psychiatry. 1996;40(4):259–270. PubMed CrossRef
  47. Blume C, Santhi N, Schabus M. ‘nparACT’ package for R: A free software tool for the non-parametric analysis of actigraphy data. 2016;3:430–435.
  48. Ortiz A, Bradler K, Radu L, et al. Exponential state transition dynamics in the rest-activity architecture of patients with bipolar disorder. Bipolar Disord. 2016;18(2):116–123. PubMed CrossRef
  49. Allega OR, Leng X, Vaccarino A, et al. Performance of the biological rhythms interview for assessment in neuropsychiatry: an item response theory and actigraphy analysis. J Affect Disord. 2018;225:54–63. PubMed CrossRef
  50. R Core Team. R: A language and environment for statistical computing. R Foundation for Statistical Computing, Vienna, Austria. 2021. https://www.R-project.org/.
  51. McGowan NM, Goodwin GM, Bilderbeck AC, et al. Actigraphic patterns, impulsivity and mood instability in bipolar disorder, borderline personality disorder and healthy controls. Acta Psychiatr Scand. 2020;141(4):374–384. PubMed CrossRef
  52. Scott J, Murray G, Henry C, et al. Activation in bipolar disorders: a systematic review. JAMA Psychiatry. 2017;74(2):189–196. PubMed CrossRef
  53. Rosa DE, Marot LP, de Mello MT, et al. Shift rotation, circadian misalignment and excessive body weight influence psychomotor performance: a prospective and observational study under real life conditions. Sci Rep. 2019;9(1):19333. PubMed CrossRef
  54. Volkovich E, Tikotzky L, Manber R. Objective and subjective sleep during pregnancy: links with depressive and anxiety symptoms. Arch Women Ment Health. 2016;19(1):173–181. PubMed CrossRef
  55. Woelders T, Beersma DGM, Gordijn MCM, et al. Daily light exposure patterns reveal phase and period of the human circadian clock. J Biol Rhythms. 2017;32(3):274–286. PubMed CrossRef
  56. Thomas KA, Burr RL, Spieker S, et al. Mother-infant circadian rhythm: development of individual patterns and dyadic synchrony. Early Hum Dev. 2014;90(12):885–890. PubMed CrossRef
  57. Matsumoto K, Shinkoda H, Kang M, et al. Longitudinal study of mothers’ sleep-wake behaviors and circadian time patterns from late pregnancy to postpartum: monitoring of wrist actigraphy and sleep logs. Biol Rhythm Res. 2003;34(3):265–278. CrossRef
  58. Montgomery-Downs HE, Insana SP, Clegg-Kraynok MM, et al. Normative longitudinal maternal sleep: the first 4 postpartum months. Am J Obstet Gynecol. 2010;203(5):465.e1–465.e7. PubMed CrossRef
  59. Lancel M, Faulhaber J, Holsboer F, et al. Progesterone induces changes in sleep comparable to those of agonistic GABAA receptor modulators. Am J Physiol. 1996;271(4 Pt 1):E763–E772. PubMed CrossRef
  60. Meltzer-Brody S, Colquhoun H, Riesenberg R, et al. Brexanolone injection in post-partum depression: two multicentre, double-blind, randomised, placebo-controlled, phase 3 trials. Lancet. 2018;392(10152):1058–1070. PubMed CrossRef
  61. Obeysekare JL, Cohen ZL, Coles ME, et al. Delayed sleep timing and circadian rhythms in pregnancy and transdiagnostic symptoms associated with postpartum depression. Transl Psychiatry. 2020;10(1):14. PubMed CrossRef
  62. Van de Water AT, Holmes A, Hurley DA. Objective measurements of sleep for non-laboratory settings as alternatives to polysomnography—a systematic review. J Sleep Res. 2011;20(1 Pt 2):183–200. PubMed CrossRef
  63. Swanson LM, Burgess HJ, Zollars J, et al. An open-label pilot study of a home wearable light therapy device for postpartum depression. Arch Women Ment Health. 2018;21(5):583–586. PubMed CrossRef
  64. Bais B, Kamperman AM, van der Zwaag MD, et al. Bright light therapy in pregnant women with major depressive disorder: study protocol for a randomized, double-blind, controlled clinical trial. BMC Psychiatry. 2016;16(1):381. PubMed CrossRef
  65. Epperson CN, Terman M, Terman JS, et al. Randomized clinical trial of bright light therapy for antepartum depression: preliminary findings. J Clin Psychiatry. 2004;65(3):421–425. PubMed CrossRef
  66. Oren DA, Wisner KL, Spinelli M, et al. An open trial of morning light therapy for treatment of antepartum depression. Am J Psychiatry. 2002;159(4):666–669. PubMed CrossRef
  67. Wirz-Justice A, Bader A, Frisch U, et al. A randomized, double-blind, placebo-controlled study of light therapy for antepartum depression. J Clin Psychiatry. 2011;72(7):986–993. PubMed CrossRef
  68. Al-Karawi D, Jubair L. Bright light therapy for nonseasonal depression: meta-analysis of clinical trials. J Affect Disord. 2016;198:64–71. PubMed CrossRef
  69. Pjrek E, Friedrich ME, Cambioli L, et al. The efficacy of light therapy in the treatment of seasonal affective disorder: a meta-analysis of randomized controlled trials. Psychother Psychosom. 2020;89(1):17–24. PubMed CrossRef
  70. Youngstedt SD, Kripke DF. Does bright light have an anxiolytic effect? - an open trial. BMC Psychiatry. 2007;7(1):62. PubMed CrossRef
  71. Baxendale S, O’Sullivan J, Heaney D. Bright light therapy for symptoms of anxiety and depression in focal epilepsy: randomised controlled trial. Br J Psychiatry. 2013;202(5):352–356. PubMed CrossRef
  72. Bennett S, Alpert M, Kubulins V, et al. Use of modified spectacles and light bulbs to block blue light at night may prevent postpartum depression. Med Hypotheses. 2009;73(2):251–253. PubMed CrossRef
  73. Esaki Y, Takeuchi I, Tsuboi S, et al. A double-blind, randomized, placebo-controlled trial of adjunctive blue-blocking glasses for the treatment of sleep and circadian rhythm in patients with bipolar disorder. Bipolar Disord. 2020;22(7):739–748. PubMed CrossRef
  74. Esaki Y, Kitajima T, Takeuchi I, et al. Effect of blue-blocking glasses in major depressive disorder with sleep onset insomnia: a randomized, double-blind, placebo-controlled study. Chronobiol Int. 2017;34(6):753–761. PubMed CrossRef
Download Free PDF

Save Save

Share Share

Cite Cite

Vol 85 • 2024 • Number 3

Read the Current Issue

Editorial

Focus on Women’s Mental Health: Twenty Years and Counting

Original Research

Esmethadone in Patients With Major Depressive Disorder and Inadequate Response to Standard Antidepressants

Commentary

Can Our Collective Experiences As Clinicians Improve Mental Health Care?

Original Research

Prescription Opioid Use Disorder in US Adults Reporting Prescription Opioid Use

Original Research

Symptomatic Disorders Comorbid with Borderline Personality Disorder Over Time

Original Research

Aripiprazole Lauroxil Initiation Regimens
View current Issue

Celebrating
85 Years

Read the Journal of Clinical Psychiatry

Subscribe to read
more articles

Subscribe