There is a well-established association between sleep disturbance and suicide, with studies consistently showing that individuals who experience poor sleep are at increased risk of suicidal thoughts and behaviors. Furthermore, other studies have documented that sleep disturbance is more prevalent in individuals who have attempted or died by suicide compared to the general population. While sleep disturbance is extremely common in women during the perinatal period, the association between suicidal thoughts and behaviors and sleep disturbance in pregnant and postpartum women has not been well studied.

In a recent article, Arditi-Arbel and colleagues reviewed published research studies including data on sleep disturbance and suicidal thoughts and behaviors. They identified a total of 51 studies with a total of 45,942 participants exploring risk factors for perinatal suicidal thoughts and behaviors. Eleven studies, most of them cross-sectional, specifically examined the relationship between sleep and suicidal thought and behaviors. Given the differing methodologies across the studies, the researchers were not able to conduct a meta-analysis; however, their review of the literature indicates that sleep disturbance during pregnancy and the postpartum period is associated with increased rates of suicidal thoughts and behaviors. For example, a cross-sectional study examined the relationship between depression, suicidal ideation (SI) and sleep disturbance in 267 pregnant women in the late second and early third trimester who were recruited from obstetric clinics. This study observed that pregnant women with high rumination and insomnia suffered from higher rates of depression (35.6%) and SI (17.3%) compared to pregnant women who slept well (1.2% depressed, 4.9% suicidal) (Kalmbach et al, 2020). In this cohort, they observed that among women with perinatal depression, SI was more commonly reported in women who experienced insomnia and nocturnal hyperarousal (Kalmbach et al, 2021).

The authors also examined psychosocial factors that may moderate or mediate the relationship between sleep disturbance and suicidal ideation. In a systematic review, they noted, lack of  belongingness or social isolation may explain the relationship between sleep disturbance and suicidal ideation (Littlewood et al, 2017). They also hypothesize that lack of quality sleep may be more prominent or impactful in women with inadequate social supports; thus, sleep deprivation may in part mediate the effects of inadequate social supports on risk for perinatal depression. 

Clinical Implications

This review indicates that sleep disturbance is an important, and potentially preventable risk factor for suicidal thoughts and behaviors in pregnant and postpartum women. This finding is consistent with other studies indicating that sleep disturbance may contribute to or exacerbate depressive symptoms in perinatal populations. However, this is a complex, and often bi-directional, relationship. While insomnia is often a symptom of depression, insomnia often exacerbates or increases the severity of depression. 

Interventions targeting insomnia may help to reduce risk of depressive symptoms and suicidal ideation. A small randomized controlled trial found that treatment of insomnia (with either trazodone or diphenhydramine) initiated during the third trimester of pregnancy reduced subsequent risk for postpartum depression (PPD). Larger studies are needed to better understand the impact of these interventions on risk for depression and suicidal ideation.

Many researchers in this field have argued for more careful screening for sleep disturbance in pregnant and postpartum women; however, sleep disturbance is one of the most common symptoms reported by pregnant and postpartum women. While insomnia may be a risk factor for depression and/or suicidal ideation in some women, the majority of women with pregnancy and postpartum-related sleep problems do not go on to experience depression or suicidal ideation. 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 and/or suicidal ideation.

Ruta Nonacs, MD, PhD

References

Arditi-Arbel B, Hamdan S, Winterman M, Gvion Y. Suicidal ideation and behavior among perinatal women and their association with sleep disturbances, medical conditions, and known risk factors. Front Psychiatry. 2023 Jan 19;13:987673.

Khazaie H, Ghadami M, Knight D, Emamian F, Tahmasian M. Insomnia treatment in the third trimester of pregnancy reduces postpartum depression symptoms: a randomized clinical trial. Psychiatry Res. (2013) 210:901–5.

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