Sleep deprivation during pregnancy and maternal and fetal outcomes: Is there a relationship?Chang JJ, Pien GW, Duntley SP, Macones GA.
Department of Community Health in Epidemiology, Saint Louis University School of Public Health, 3545 Lafayette Ave., Suite 300, St. Louis, MO 63104, USA.
Sleep duration in the population has been declining. Women occupy an increasingly prominent place in the work force without reducing most of their responsibilities at home. Consequently, sleep needs are often pushed to the bottom of women`s daily priority list. Prior research has indicated that sleep deprivation is associated with higher levels of pro-inflammatory serum cytokines. This is important because higher plasma concentrations of pro-inflammatory serum cytokine levels are associated with postpartum depression and adverse birth outcomes such as preterm delivery. However, little research has directly examined how sleep deprivation may affect maternal and fetal outcomes. This review summarizes the existing data on the effect of sleep deprivation during pregnancy on maternal and fetal outcomes. We review supporting evidence for the hypotheses that sleep deprivation during pregnancy increases the risk of preterm delivery and postpartum depression, and that systemic inflammation is the causal mechanism in the association. Prior research on sleep in pregnancy has been limited by varying data collection methods, subjective self-reported sleep measures, small and non-representative samples, cross-sectional designs; descriptive or non-hypothesis driven studies. Future research with longitudinal study designs is needed to allow examination of the effect of sleep deprivation on adverse maternal and fetal outcomes.
Sleep and depression in postpartum women: a population-based study.
Section for General Practice, Department of Public Health and Primary Health Care, University of Bergen, Bergen, Norway. firstname.lastname@example.org
STUDY OBJECTIVES: (1) To describe the prevalence of and risk factors for postpartum maternal sleep problems and depressive symptoms simultaneously, (2) identify factors independently associated with either condition, and (3) explore associations between specific postpartum sleep components and depression. DESIGN: Cross-sectional. SETTING: Population-based. PARTICIPANTS: All women (n = 4191) who had delivered at Stavanger University Hospital from October 2005 to September 2006 were mailed a questionnaire seven weeks postpartum. The response rate was 68% (n = 2830). INTERVENTIONS: None. MEASUREMENTS AND RESULTS: Sleep was measured using the Pittsburgh Sleep Quality Index (PSQI), and depressive symptoms using the Edinburgh Postnatal Depression Scale (EPDS). The prevalence of sleep problems, defined as PSQI > 5, was 57.7%, and the prevalence of depression, defined as EPDS > or = 10, was 16.5%. The mean self-reported nightly sleep duration was 6.5 hours and sleep efficiency 73%. Depression, previous sleep problems, being primiparous, not exclusively breastfeeding, or having a younger or male infant were factors associated with poor postpartum sleep quality. Poor sleep was also associated with depression when adjusted for other significant risk factors for depression, such as poor partner relationship, previous depression, depression during pregnancy and stressful life events. Sleep disturbances and subjective sleep quality were the aspects of sleep most strongly associated with depression. CONCLUSIONS: Poor sleep was associated with depression independently of other risk factors. Poor sleep may increase the risk of depression in some women, but as previously known risk factors were also associated, mothers diagnosed with postpartum depression are not merely reporting symptoms of chronic sleep deprivation.
Use of modified spectacles and light bulbs to block blue light at night may prevent postpartum depression
night may prevent postpartum depression
a, Martin Alpert b, Vilnis Kubulins b, Richard L. Hansler b,*
Founding President, Postpartum Support, International P.O. Box 60931, Santa Barbara, CA 93160, United States
s u m m a r y
In 2001 it was discovered that exposing the eyes to light in the blue end of the visible spectrum suppresses the production of the sleep hormone, melatonin. New mothers need to get up during the night to care for their babies. This is the time when melatonin is normally flowing. Exposing their eyes to light can cut off the flow. It may also reset their circadian (internal) clock. On subsequent nights the melatonin may not begin flowing at the normal time making it difficult to fall asleep. Over time, disruption of the circadian rhythm plus sleep deprivation may result in depression. Women suffering postpartum depression were enrolled in a small clinical trial. Some were provided with glasses and light bulbs that block blue light. Others were equipped with glasses and light bulbs that looked colored but did not block the rays causing melatonin suppression. Those with the ‘‘real glasses” recovered somewhat more quickly than those with the placebo glasses and light bulbs. The hypothesis that should be tested in large scale clinical trials is that the risk of postpartum depression can be reduced when a new mother avoids exposing her eyes to blue light when she gets up at night to care for her baby. In the meantime, all new mothers may benefit from using glasses and light bulbs that block blue light when getting up at night to care for their babies.
2009 Published by Elsevier Ltd.Photonic Developments LLC 7890 Summerset Drive, Walton Hills, OH 44146, United States
Use of Modified Spectacles and Light Bulbs to Block Blue Light at Night May Prevent Postpartum Depression
In 2001 it was discovered that exposing the eyes to light in the blue end of the visible spectrum suppresses the production of the sleep hormone, melatonin. New mothers need to get up during the night to care for their babies. This is the time when melatonin is normally flowing. Exposing their eyes to light can cut off the flow. It may also reset their circadian (internal) clock. On subsequent nights the melatonin may not begin flowing at the normal time making it difficult to fall asleep. Over time, disruption of the circadian rhythm plus sleep deprivation may result in depression. Women suffering postpartum depression were enrolled in a small clinical trial. Some were provided with glasses and light bulbs that block blue light. Others were equipped with glasses and light bulbs that looked colored but did not block the rays causing melatonin suppression. Those with the “real glasses” recovered somewhat more quickly than those with the placebo glasses and light bulbs. The hypothesis that should be tested in large scale clinical trials is that the risk of postpartum depression can be reduced when a new mother avoids exposing her eyes to blue light when she gets up at night to care for her baby. In the meantime, all new mothers may benefit from using glasses and light bulbs that block blue light when getting up at night to care for their babies.
The HypothesisThe risk of postpartum depression can be reduced when a new mother avoids exposing her eyes to blue light when she gets up at night to care for her baby.
Most new mothers suffer from the “baby blues” that last for a couple of weeks following delivery. This is thought to be the result of the rapid changes in hormone concentrations that occur immediately after delivery, and is considered to be normal. About 15% of new mothers, however, experience postpartum depression. In addition, 10% or more of fathers suffer from depression after the baby is born. Lack of sleep is known to play a large role in this problem.
The body normally begins producing melatonin, the sleep hormone, at about bedtime. The concentration in the blood reaches a maximum at about 3 A.M. and declines to near zero at about the time of rising. It has been known for many years that exposing the eyes to light suppresses the flow of melatonin.
Recent discoveries in human physiology
In 2001 two independent research groups  and  found that the suppression of melatonin, when the eyes are exposed to light, is partially dependent on the color of the light. Regarding melatonin suppression, they found that the eyes are most sensitive to the light in the blue part of the spectrum (about 470 nm). By wearing glasses that block light at wavelength shorter than about 530 nm, Kayumov et al.  found that subjects working a simulated night shift under bright lights continued making melatonin much as they had when kept in darkness. Working the simulated night shift without the glasses resulted in a significant delay in when melatonin flow started and a large decrease in the amount of melatonin produced.
In addition to suppressing the flow of melatonin, it has been well established ,  and  that exposing the eyes to light at certain times of day can reset the circadian clock. Exposing the eyes to light in the early morning resets the clock to an earlier time while exposing the eyes in the late evening can reset the clock to a later hour. This ability to reset the circadian clock has been shown  to be of value in avoiding or minimizing jet lag. In a related way, the use of exogenous melatonin to reset the circadian clock has been demonstrated by Lewy et al. . When given in the late afternoon, it can reset the clock to an earlier hour. This method is of great value to blind people whose circadian clocks are free-running and tend to get out of synchronization with their daily schedule.
Causes of depression
Frequent and erratic resetting of the circadian clock has been described as disruption of the circadian rhythm and is thought by some  to lead to depression and is thought to be a cause for episodes of depression or mania in people with bipolar disorder  and .
The problems faced by new mothers
Most new mothers will suffer from lack of sleep because of the need to care for their babies during the night. Because a new mother will most likely be exposing her eyes to light at random times during the night, she will also be a likely candidate for disruption of her circadian rhythm. The associated lack of melatonin may make it difficult for her to sleep, even though very tired. This is a classic situation described by women who have experienced postpartum depression. For a nursing mother the problem is compounded. Because the mother’s melatonin appears in her breast milk, the infant will suffer from loss of melatonin as much as the mother. This vicious circle ends up disrupting the entire family. Some fathers will also develop postpartum depression, especially if his wife is depressed.
A small trial
A small controlled trial was carried out in which women who approached Dr. Bennett seeking help for postpartum depression were enrolled in the study. They were provided (at random) either with glasses that block blue light at wavelengths shorter than about 530 nm and light bulbs that do not produce blue light or with placebo glasses and light bulbs that were colored, but did not block the critical wavelengths causing melatonin suppression. Recovery from their depression was rated (as a percentage) by Dr. Bennett after one month and after two months. The Table 1 shows the results.
Postpartum depression study (Dr. Bennett).
|1 month||2 months||1 month||2 months|
|40||80||n = 9|
|70||80||6 no data or quit (2)|
|n = 18|
|6 no data or quit (4)|
|Std dev = 11||Std dev = 18|
p = 0.044.
Discussion of result
The percent recovery is shown in the columns of the chart at one month and after two months for patients who received the “real” glasses and light bulbs (the ones that block melatonin-suppressing light) and placebo (the ones that allow melatonin-suppressing light to pass through). All of the patients in the test showed improvement. It would have been helpful if the initial degree of illness had been estimated. Two patients showed initial improvement and then relapsed somewhat. The average improvement in the patients using the real glasses at one and two months was 67% and 87.5% compared to the averages for the placebo group of 63% and 75%. While not compelling evidence, the results are at least in the anticipated order suggesting some effect. While the difference in the results after one month are not judged significant when applying the T test, the difference after two months is significant (p = 0.044) after two months. All of the women were instructed to put on their glasses at about the same time every evening a few hours in advance of their intended bedtime. Simply getting on a regular schedule is one of the well established factors known to improve sleep. This might partially account for the improvement shown by the group using the placebo glasses and light bulbs. Since all the women in the trial had been depressed for a long time, it would be expected that the benefit would be more easily shown if the depression were avoided by early use of the glasses rather than cured, after suffering for some time. Future trials should look at avoidance statistics for women who use the glasses beginning at the time of delivery or sooner.
Based on the logic of the method and the favorable results of the small trial, it would be appropriate to carry out larger trials if funding were made available. While compliance is frequently a problem in clinical trials, it is not likely a problem in this case. In the small trial many of the women volunteered how they loved using their glasses; how they helped them relax in the evening. By installing blue-blocking light bulbs in the nursery and bathroom the mother need not continue wearing the glasses once she is in the safe area. The baby will also benefit in that his/her melatonin will not be suppressed. Even if no further testing were done, it would seem that using low blue light bulbs that don’t produce the damaging light or using glasses that block the damaging blue rays produced by ordinary light bulbs would be common sense for all new mothers. The risk is in being exposed to the damaging blue rays produced by ordinary light bulbs when used during the night. The use of low blue light glasses and bulbs allows new mothers to avoid this risk.
Implications for all mothers
Experience over the past four years has shown that many people with sleeping problems can benefit from the use of blue-blocking glasses and light bulbs. Because they are the equivalent of being in darkness, the glasses may be used to advance the circadian cycle. Putting on the glasses well in advance of bedtime, at about the same time every evening, will reset the circadian clock to an earlier hour. This allows the flow of melatonin to start before going to bed. This results in quickly falling asleep and in more restful sleep . It also makes it possible to maximize the time when melatonin is present in the bloodstream. A study by Czeisler  showed that melatonin can flow for up to about 11 h for subjects held in darkness. In the clinical trial described above the mothers were encouraged to put on the glasses during the evening in advance of intended bedtime to improve their sleep through both the earlier start of the flow and increased time when melatonin is flowing. For mothers nursing their babies the benefit also flows to the baby in the mother’s milk. This is thought to be one of a number of reasons that breastfed babies are known to sleep better. For breastfed babies, having the melatonin cycle locked to the nighttime may help the baby develop a pattern of sleeping more during the night and less during the day. This will also help to give the mother more and better quality sleep.
Based on the above it is recommended that NIH consider funding studies to determine whether the hypothesis is true that avoiding blue light at night will reduce the risk of postpartum depression in new mothers. It is also recommended that obstetricians and pediatricians encourage pregnant and postpartum women to avoid blue light in the hours before bedtime and during the night by using blue-blocking glasses or light bulbs.
Pregnancy and the postpartum period are recognized as times of vulnerability to mood disorders, including postpartum depression and psychosis. Recently, changes in sleep physiology and sleep deprivation have been proposed as having roles in perinatal psychiatric disorders. In this article we review what is known about changes in sleep physiology and behaviour during the perinatal period, with a focus on the relations between sleep and postpartum “blues,” depression and psychosis and on sleep-based interventions for the treatment and prevention of perinatal mood disorders. The interaction between sleep and perinatal mood disorders is significant, but evidence-based research in this field is limited. Studies that measure both sleep and mood during the perinatal period, particularly those that employ objective measurement tools such as polysomnography and actigraphy, will provide important information about the causes, prevention and treatment of perinatal mood disorders.
PMID: 16049568 [PubMed – indexed for MEDLINE]
Centre for Community Child Health, Royal Children`s Hospital, Melbourne, Australia. email@example.com
OBJECTIVES: To describe infant sleep patterns and investigate relationships between infant sleep problems and maternal well-being in the community setting.
DESIGN: Cross-sectional community survey. Setting. Maternal and Child Health Centers in 3 middle-class local government areas in Melbourne, Australia.
PARTICIPANTS: Mothers of infants 6 to 12 months of age.
MAIN OUTCOME MEASURES: Maternal well-being (Edinburgh Postnatal Depression Scale) and infant sleep problems (standardized maternal questionnaire).
RESULTS: The survey was completed by 738 mothers (94% response rate), of whom 46% reported their infant`s sleep as a problem. In the univariate analyses, sleep patterns characterizing a sleep problem included the infant sleeping in the parent`s bed, being nursed to sleep, taking longer to fall asleep, waking more often and for longer periods overnight, and taking shorter naps. The same sleep patterns were associated with high depression scores and tended to increase as depression scores increased. Because of positive skew, the Edinburgh Postnatal Depression Score was analyzed in 3 categories (<10, 10-12, and >12) using validated cutoff scores from community and clinical studies. Fifteen percent of mothers scored above 12 on the depression scale, indicating probable clinical depression, and 18% scored between 10 and 12, indicating possible clinical depression. After adjusting for potential confounders and factors significant in the univariate analyses, maternal report of an infant sleep problem remained a significant predictor of a depression score >12 (odds ratio: 2.13; 95% confidence interval: 1.27,3.56) and >10 (odds ratio: 2.88; 95% confidence interval: 1.93,4.31). However, mothers reporting good sleep quality, despite an infant sleep problem, were not more likely to suffer depression. CONCLUSIONS: Maternal report of infant sleep problems and depression symptoms are common in middle-class Australian communities. There is a strong association between the 2, even when known depression risk factors are taken into account. Maternal report of good sleep quality attenuates this relationship. Appropriate anticipatory guidance addressing infant sleep could potentially decrease maternal report of depressive symptoms.
Depression results in severe sleep disturbance. The “depressed brain” takes longer to initiate sleep, shortens the period to dreaming sleep, spends little or no time in “deep sleep” and is subject to hyperactive brain regions during sleep. Antidepressants rectify the sleep disturbance and restore normal sleep architecture and presumably normal brain metabolism during sleep. Early intervention may lead to a decrease in neuronal cell loss due to depression, and better long-term outcomes for mood disorders