12/04/2024

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Prediction of Postpartum Depression: Take a Closer Look at Question 3 on the PHQ-9

Prediction of Postpartum Depression: Take a Closer Look at Question 3 on the PHQ-9

Previous studies have indicated that poor sleep quality during pregnancy is associated with increased risk for postpartum depression (PPD), as well as more severe depressive symptoms. Given this association, could the endorsement of sleep problems on routine depression screening questionnaires be used to identify women at increased risk for PPD?

While many obstetric practices are now screening for depression during pregnancy and the postpartum period using standardized questionnaires, most of the attention is focused on the endorsement of depressive symptoms and whether or not the total score exceeds a specified cutoff number. Both the Patient Health Questionnaire-9 item (PHQ-9) and the Edinburgh Postnatal Depression Scale (EPDS), instruments commonly used to screen for perinatal depression, ask about sleep problems. While sleep disturbance is commonly associated with depression, this is a symptom that is not typically analyzed separately.

A recent study from Felder and colleagues looked more closely at sleep disturbance reported on depression screening questionnaires administered during pregnancy in order to evaluate whether sleep disturbance was predictive of postpartum depressive symptoms among non-depressed pregnant individuals.

In this retrospective cohort study, participants were included if they had a live birth and completed the Patient Health Questionnaire (PHQ-9) during pregnancy and within 8 weeks postpartum. A total of 3,619 participants who were non-depressed during pregnancy (PHQ-9 < 10) were included in the analysis. 

In individuals without depression, endorsement of sleep disturbance in the second and third trimesters was associated with a more than threefold higher odds of postpartum depressive symptoms, adjusting for age, race, ethnicity, and parity (second trimester sleep disturbance aOR 3.74, 95% CI 1.47–11.49; third trimester sleep disturbance aOR 3.43, 95% CI 1.88–6.78), followed by a nearly twofold higher odds for endorsement of sleep disturbance in the first trimester (aOR 1.90, 95% CI 1.17–3.13).

Sleep disturbance varied by race during the first and second trimesters (p < 0.05) and was highest among Black or African American participants (61.8–65.1%). Third trimester sleep disturbance had a stronger association with elevated postpartum depressive symptoms (aOR 3.43) than did the other somatic symptoms (fatigue aOR 2.24; appetite disturbance aOR 2.15). 

Clinical Implications

The findings of the current study are consistent with the existing literature indicating an association between sleep disturbance during pregnancy and increased risk for PPD. Sleep disturbance in the second and third trimesters was associated with a greater than threefold increase in risk of postpartum depressive symptoms (aORs 3.74 and 3.43, respectively). This study indicates that even a single-item measure of sleep disturbance has utility in prospectively identifying risk for postpartum depression prior to delivery.

What is so important about this and other studies looking at the connection between sleep disturbance and risk for PPD is that sleep disturbance is a modifiable risk factor. Especially when identified early in the pregnancy, we have the opportunity to intervene. 

In a randomized controlled trial, Manber et al (2019) observed that 64% of pregnant participants who received cognitive behavioral therapy for insomnia (CBT-I) experienced symptom remission. There is also evidence that digital adaptations of CBT-I may be effective during pregnancy (Felder et al, 2020; Kalmbach et al, 2020). Furthermore, there is preliminary evidence to indicate that sleep interventions delivered during pregnancy may decrease risk for postpartum depression. 

Ruta Nonacs, MD PhD

References

Felder JN, Roubinov D, Zhang L, Gray M, Beck A. Endorsement of a single-item measure of sleep disturbance during pregnancy and risk for postpartum depression: a retrospective cohort study. Arch Womens Ment Health. 2023 Jan 12.

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