Depression and sleep in the postnatal period. A study in Nepal and Norway.
Dørheim, Signe Karen
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Background: Mental disorders are highly prevalent across the world and are associated with serious impairment. Depression after childbirth affects both the mother and her infant. Women sleep less in the postnatal period, but there has been little attention to the altered sleep pattern in the postnatal period and its association with maternal depression. Objectives: The aim of the study was to assess the prevalence of depression and to identify risk factors for the disease among postnatal mothers in Lalitpur, Nepal and in Rogaland, Norway. In Norway, we further aimed to study the prevalence and risk factors for postnatal maternal sleep problems, as well as associations between depression and sleep, measured retrospectively, prospectively and objectively. Methods: c) In Nepal: from October 2001 to January 2003, 426 postnatal women from three primary health care populations were included in a cross-sectional structured interview study of mental health. Depressive symptoms were measured by the Edinburgh Postnatal Depression Scale (EPDS), and mental distress by the Self Report Questionnaire–20 (SRQ-20). d) In Norway: All women (n=4191) who had delivered at Stavanger University Hospital from October 2005 to September 2006 were mailed a questionnaire seven weeks after delivery. Sleep was measured by the Pittsburgh Sleep Quality Index (PSQI), and depressive symptoms by the EPDS. From this population-based study, we recruited 42 women, of whom half scored 10 or more and the other half low at the EPDS, for prospective sleep registrations by sleep diaries and actigraphy two months after delivery. Results: In Nepal, the prevalence of depressive symptoms (EPDS >12) was 4.9 % and the prevalence of mental distress (SRQ-20 >10) was 3.1 %. Multivariate analysis showed that postnatal depression was strongly associated with husband’s alcoholism, polygamy and previous depression. Other significant factors were stressful life events, multiparity, smoking and depression during pregnancy. There was a non-significant trend of lower depressive scores among women practicing the tradition of going to their maternal home some weeks after delivery. In Norway, the response rate was 68% (n=2830). The prevalence of depressive symptoms (EPDS ≥10) was 16.5%, and the prevalence of postnatal sleep problems (PSQI >5) was 58%. Mean self-reported nightly sleep time was 6.5 hours and sleep efficiency was 73%. Depression was the factor most strongly associated with sleep problems in this period. Being primipara, having previously had sleep problems, not exclusively breastfeeding, having younger or male infant, or co-sleeping were also factors associated with poor postnatal sleep quality. Poor sleep was associated with depression also when adjusted for known and significant risk factors for postnatal depression, such as poor partner relationship, previous depression, depression during pregnancy and stressful life events. There were no significant differences in sleep measured prospectively by subjective sleep diaries and objective measures of actigraphy according to depressive status. Primiparas had worse sleep, measured by actigraphy, compared with multiparas. Conclusions The prevalence of depressive symptoms in the postnatal period was lower than previously reported from Nepal, but higher than previously reported from Norway. Traditional family structures may influence the risk of depression among postnatal women in Nepal. Poor sleep, reported retrospectively, was associated with depression independently of other risk factors. However, there were no differences in prospective and objective sleep registrations according to depressive status.
Paper 1: Acta Obstetricia et Gynecologica 85(10), Ho-Yen, S. D.; Bondevik, G. T.; Eberhard-Gran, M.; Bjorvatn, B., The prevalence of depressive symptoms in the postnatal period in Lalitpur district, Nepal, pp. 1186-1192. Copyright 2006 Taylor & Francis. Full text not available in BORA due to publisher restrictions. The published version is available at:http://dx.doi.org/10.1080/00016340600753158Paper 2: Acta Obstetricia et Gynecologica 86(3), Ho-Yen, S. D.; Bondevik, G. T.; Eberhard-Gran, M.; Bjorvatn, B., Factors associated with depressive symptoms among postnatal women in Nepal, pp. 291-297. Copyright 2007 Taylor & Francis. Full text not available in BORA due to publisher restrictions. The published version is available at:http://dx.doi.org/10.1080/00016340601110812Paper 3: Sleep 32(7), Dørheim, S.; Bondevik, G. T.; Eberhard-Gran, M.; Bjorvatn, B., Sleep and depression in postpartum women: a population based study, pp. 847-855. Published by American Academy of Sleep Medicine. Full text not available in BORA due to publisher restrictions.Paper 4: Acta Psychiatrica Scandinavica 119(2), Dørheim, S.; Bondevik, G. T.; Eberhard-Gran, M.; Bjorvatn, B., Subjective and objective sleep among depressed and non-depressed postnatal women, pp. 128-136. Copyright 2008 The Authors, Journal Compilation 2008 Blackwell Munksgaard. Full text not available in BORA due to publisher restrictions. The published version is available at:http://dx.doi.org/10.1111/j.1600-0447.2008.01272.x