Differentiating perinatal Insomnia Disorder and sleep disruption: a longitudinal study from pregnancy to 2 years postpartum

Abstract

Study Objectives Insomnia Disorder diagnoses require persistent sleep complaints despite “adequate sleep opportunity”. Significant perinatal sleep disruption makes this diagnosis challenging. This longitudinal study distinguished between Insomnia Disorder and Perinatal Sleep Disruption and their sleep and mental health correlates. Methods 163 nulliparous females (age M±SD=33.35±3.42) participating in a randomised-controlled trial repeated the Insomnia Disorder module of the Duke Structured Interview for Sleep Disorders and PROMIS measures for sleep and mental health at 30 and 35 weeks’ gestation, and 1.5, 3, 6, 12, and 24 months postpartum (944 interviews, 1009 questionnaires completed). We compared clinical features when DSM-5 Insomnia Disorder criteria were: (1) met (Insomnia Disorder), (2) not met only because of the sleep opportunity criteria (Perinatal Sleep Disruption), and (3.) not met due to other criteria (Low Complaint). Results Proportions of Insomnia Disorder were 16.0% and 19.8% during early and late third trimester, and ranged 5.3-11.7% postpartum. If the sleep opportunity criteria were not considered, rates of Insomnia would be 2-4 times higher (21.4-40.4%) across time-points. Mixed effects models adjusting for covariates showed that compared to Low Complaint, both Insomnia Disorder and Perinatal Sleep Disruption scored significantly higher on insomnia and sleep disturbance scales, sleep effort, and sleep-related impairments (p-values<.01), but depression and anxiety were comparable (p-values>.12). Conclusion Assessing sleep complaints without considering sleep opportunity can result in over-diagnosis of Insomnia Disorder in the perinatal periods. Insomnia Disorder and perinatal sleep disruption were associated with adverse sleep and mood outcomes, and need to be carefully differentiated and appropriately addressed.

DSM-5 insomnia disorder in pregnancy: associations with depression, suicidal ideation, and cognitive and somatic arousal, and identifying clinical cutoffs for detection

“…Indeed, our estimated rate of 19.2% was lower than a recent meta-analytic estimate of 27.2% prevalence of clinically significant insomnia in the second trimester [ 1 ]. However, our rate of 19.2% is highly consistent with a recent estimate of 16-20% for DSM-5 insomnia disorder in late pregnancy as diagnosed by clinical interview [ 3 ]. These data suggest that our operationalization of survey-assessed DSM-5 insomnia disorder yields estimates consistent with rates derived from clinical interviews; this finding may inform epidemiological efforts in this patient population going forward.…”

“…As such, future research should determine whether these results replicate when DSM-5 insomnia disorder is diagnosed via clinical interviews. Even so, it is worth emphasizing that our estimated rates of DSM-5 insomnia disorder are consistent with rates derived from clinician-administered diagnostic interviews of pregnant women of similar gestational age [ 3 ]. And notably, the technique employed in the present study has been supported by large-scale epidemiological studies [ 38 , 39 ], and the empirically derived quantitative cutoffs identified in this report are consistent with prior psychometric validation of the ISI and PSQI [ 33 , 40 ].…”

“…Importantly, DSM-5 insomnia disorder rates reported in the present study and in a previous study utilizing clinician-administered interviews [ 3 ] suggests that insomnia disorder rates are twice as high as epidemiological estimates of DSM- and ICSD-based insomnia disorder rates in the broader population [ 20 , 21 ], thereby highlighting the disproportionate burden of insomnia disorder for pregnant women.…”

“…However, a recent study differentiated rates of DSM-5 insomnia disorder and clinically significant symptoms (also referred to as perinatal sleep disruption) in the third trimester of pregnancy [ 3 ]. Based on data from clinician-administered interviews, the authors found that half of cases with insomnia in late pregnancy are comprised of women who meet diagnostic criteria for the disorder, whereas the other half of women with insomnia experience clinically significant symptoms without meeting diagnostic criteria.…”

Contemporary Concise Review 2022: Sleep

“…As an understudied area, large‐scale longitudinal studies were welcomed. Diagnosing insomnia during pregnancy is challenging, particularly in the perinatal period where sleep disruption is common 35 . A cross‐sectional analysis of US pregnancy‐related hospitalisations spanning 12 years revealed that not only did a coded diagnosis of insomnia during pregnancy increase over the study period, but it was an independent predictor of severe maternal morbidity 36 .…”