How Does Mental Health Affect Your Sleep?
Contributed By: Rose MacDowell, Sleepopolis
Expert Verified By: Dr. Nicole Moshfegh, Psy.D.
The term mental health describes emotional, cognitive, and social well-being. Mental health is important at every stage of life, from childhood and adolescence through adulthood. Mental health affects not just how we feel, but how we think and behave. Our psychological condition determines how we handle stress, relate to others, and make choices.
There are more than 200 types of mental illness, which is defined by the American Psychiatric Association as “a health condition involving changes in emotion, thinking, and behavior.” Mental illness is based in the brain and can have a significant impact on relationships and quality of life.
Note: The content on Sleepopolis is meant to be informative in nature, but it shouldn’t take the place of medical advice and supervision from a trained professional. If you feel you may be suffering from any sleep disorder or medical condition, please see your healthcare provider immediately.
Mental Illness: Causes and Symptoms
Mental health problems can affect self-esteem, happiness, and basic functions, such as eating and sleeping. (1) Social and financial success is strongly influenced by psychological wellness, including self-awareness and our ability to exercise self-control.
Many factors contribute to mental health issues, including:
Genes and brain chemistry
Family history of mental health problems
Life experiences, such as trauma or abuse
Mental health issues run the gamut from minor difficulty with daily living to full-blown psychosis. Treatment can have a significant impact on the course and outlook of psychological issues, making early detection crucial.
Mental illness can appear in early childhood or not until adulthood. (2) Some psychological issues may not emerge until later in life and can be influenced by certain drugs and medical conditions. There are numerous warning signs of mental health issues. These vary depending on the nature of the condition, and may include:
Eating or sleeping too much or too little
Withdrawing from relationships and usual activities
Having low or no energy
Feeling numb
Experiencing unexplained aches and pains
Feeling helpless or hopeless
FAQ
Q: What is the most common mental illness?A: Depression, a mood disorder that affects 300 million people worldwide, is the single most common mental illness. Anxiety disorders are more prevalent overall.
Psychological difficulties increase the risk of troubled relationships with family and friends. (3) Interpersonal conflict can be caused by irritability and mood swings, or feelings such as fear and anger. Other cognitive signs associated with mental health issues include worry, confusion, memory loss, and intrusive thoughts.
More serious mental disorders may cause hallucinations, including hearing voices or believing things that are not true. Suicidal behavior or thoughts of harming another person are also common signs of psychological issues. A person suffering from mental illness may experience paranoia, imagined physical ailments, or the need to abuse drugs or alcohol.
Types of Mental Health Disorders
Each type of mood disorder is characterized by unique signs and symptoms and may co-occur with other disorders. For example, anxiety might occur along with substance abuse, physical complaints, or a sleep disorder like insomnia.
The following are some of the most common mental health disorders:
Anxiety Disorders. People with anxiety disorders respond to certain objects or situations with fear and dread. Anxiety disorders can include panic disorders, generalized anxiety disorder, and phobias. (4) Symptoms of anxiety include:
Fatigue
Feelings of restlessness or irritability
Difficulty focusing or learning new concepts
Chronic pain or muscle tension
Trouble controlling feelings of worry
Problems sleeping, including the inability to sleep, unsatisfying sleep, or excessive sleeping
Psychiatric Disorders in Children. Common psychiatric disorders in children include attention deficit hyperactivity disorder (ADHD) a neurodevelopmental disorder that usually persists into adulthood. Symptoms include impulsiveness, trouble focusing on tasks or conversations, restlessness, and feeling easily frustrated. Oppositional defiant disorder is part of a spectrum known as disruptive, impulse-control, and conduct disorders. Symptoms of oppositional defiant disorder include hostility toward and lack of cooperation with teachers, parents, and other authority figures. (5)
Eating Disorders. Eating disorders involve extreme emotions, attitudes, and behaviors related to weight and food. Common eating disorders include anorexia, bulimia, and binge eating.
Substance Use Disorders. Mental health problems and substance abuse disorders often occur together. (6) Substance abuse can be a cause or a result of psychiatric issues, and may be an attempt by some patients to self-medicate or reduce symptoms.
Mood Disorders. Almost one in ten people aged eighteen or older have a mood disorder. Mood disorders involve persistent feelings of sadness, or feelings that fluctuate between extreme happiness and extreme sadness. Mood disorders include:
Depression. Approximately 17.3 million people in the US — 7.1% of adults — suffered from one or more major depressive episodes in the last year. Depression is characterized by sadness and lack of usual enjoyment that continue for two weeks or longer. Grief and sadness related to a change in life circumstances are different from depression, which doesn’t improve in response to external events
Bipolar disorder. Bipolar disorder affects approximately six million adults in the US, and impacts men and women equally. The disorder is characterized by severe fluctuations in mood, behavior, and thought patterns. Fluctuations can last from a few hours to several months, and may be affected seasonal and light changes
Personality Disorders. People with personality disorders have inflexible personality traits that are distressing to the sufferer and may cause problems in work, school, or social relationships. (7) These disorders are highly resistant to treatment, and include the following:
Antisocial personality disorder, or APD. People with antisocial personality disorder exploit, manipulate, and disregard the feelings of others. APD describes the behavior of sociopaths and psychopaths. Psychopaths do not have a conscience, whereas sociopaths have a conscience that is severely disordered
Narcissistic personality disorder, or NPD. Approximately 1% of people are afflicted with NPD. The disorder is associated with lack of empathy, feelings of superiority, and a need for admiration. Narcissists tend to be easily hurt and are unable to tolerate criticism. Treatment is generally ineffective because people with NPD don’t believe they have a mental health issue
Borderline personality disorder, or BPD. People with borderline personality disorder have trouble regulating their emotions. They tend to act impulsively, resulting in career and relationship difficulties. Of the 1.4% of the population with BPD, 75% are women, though this number may represent misdiagnosis in many men with the disorder
Psychotic Disorders. Psychotic disorders are characterized by abnormal perceptions such as hallucinations and delusions. Hallucinations are false perceptions that involve hearing or seeing things that don’t exist. Delusions are false beliefs, such as being pursued by authorities or people wishing to do the sufferer harm. The most common psychotic disorder is schizophrenia, which typically appears in the mid to late twenties. Possible causes of schizophrenia include genetic and environmental factors, disordered brain circuitry, trauma, and drug abuse.
Psychosis
Psychosis describes mental conditions that involve loss of contact with reality.
Mental Health and Sleep
One common sign of mental health difficulty is trouble sleeping. (8) The sleep disorder most closely associated with psychiatric disturbances is chronic insomnia. Some common mental illnesses and their effect on sleep include the following:
Depression. Clinical depression often presents with persistent insomnia, or the inability to sleep. (9) Hypersomnia, or excessive drowsiness, can be a sign of depression, as well. Sleep disorders are associated so strongly with depression that some medical practitioners advise caution in diagnosing depression in patients without symptoms of a sleep disorder. Up to 75% of people diagnosed with depression also suffer from insomnia.
Bipolar Disorder. Bipolar disorder is strongly associated with the inability to fall asleep, stay asleep, fall back to sleep, or all three. People in the manic phase of bipolar disorder often have difficulty sleeping, whereas those in the depressive phase may sleep much more than usual. Studies show that sleep deprivation can aggravate the struggles with emotional regulation that are common in people who are bipolar. (10) For many sufferers, trouble sleeping can be an indication of an approaching manic phase.
Anxiety Disorder. Anxiety is a principal cause of chronic insomnia. Even common anxiety related to work and life circumstances may trigger insomnia. A primary cause of chronic insomnia is conditioned anxiety related to sleep and the bedtime routine. Anxiety’s impact on the body includes hyperactivity of the central nervous system and excessive release of stress hormones, such as adrenaline and cortisol. Studies show a strong association between a history of insomnia and anxiety disorder, panic disorder, and social anxiety disorder. (11)
Borderline Personality Disorder. BPD sufferers with insomnia typically experience the daytime consequences of sleep loss, including sleepiness, difficulty concentrating, and irritability. Symptoms of BPD can be worsened by insomnia, leading to a vicious cycle of sleeplessness and behavioral issues.
Personality Disorders. Some personality disorders may be associated with disturbed sleep patterns. (12) One study revealed that people with circadian rhythm disorder are more likely to have a personality disorder than people with normal sleep and wake cycles.
Psychotic Disorders. Psychotic disorders such as schizophrenia can have a profound impact on sleep. Sleep disturbances are often an early sign of schizophrenia and can precede psychiatric symptoms by months or years. Schizophrenia patients are more likely to suffer from other sleep disorders, as well, including:
Obstructive sleep apnea
Restless legs syndrome
Periodic limb movement disorder
Circadian rhythm dysfunction
FAQ
Q: What is circadian rhythm dysfunction?A: Circadian rhythm dysfunction is caused by a loss of synchronization between sleep-wake cycles and natural light and darkness signals. Symptoms include the inability to fall or stay asleep, cognitive dysfunction, and trouble maintaining a traditional sleep schedule.
Does Depression Cause Insomnia, or Vice Versa?
It was once thought that insomnia symptoms resulted from psychiatric disorders and depression, not the other way around. Now the evidence isn’t so clear. Sleep problems may not just be the result of emotional disturbances, they may increase the likelihood of suffering from them, as well.
Medications to treat psychiatric disturbances may also cause insomnia. Psychotropic medications can have stimulating effects that contribute to interrupted sleep. Restless leg syndrome and periodic limb movements may be triggered or exacerbated by antidepressants and other drugs used to treat mood disorders.
An analysis of major studies revealed that volunteers who suffered from insomnia symptoms were twice as likely to be diagnosed with depression as those without sleep difficulties. Why? Though the connection between mood disorders and insomnia isn’t entirely understood, it is well-known that hormones and neurotransmitters are affected by poor sleep. Sleep is a restorative activity that reduces stress in the body and areas of the brain, especially the axis between the hypothalamus and adrenal and pituitary glands. Excess secretion of cortisol — also known as “the stress hormone” — may play a role, as well.
Lack of sleep and the resulting physiological stress may predispose insomnia sufferers to major mood disturbances, making early treatment of sleep disorders essential, especially in people with a family history of mental health issues. (13)
Depression and Other Sleep Disorders
Insomnia is not the only sleep disorder associated with depression and anxiety. (14) Sleep apnea is a common cause of depression, as is hypersomnia. Sleep apnea is characterized by blockage of the airway and repeated awakenings during the night. Chronic sleep apnea can result in weight gain, increased risk of heart attack and stroke, and memory problems.
Hypersomnia is associated with excessive time spent sleeping and daytime sleepiness. The disorder can be caused by medical conditions, certain drugs, and immune system dysfunction. Though most people need between seven and nine hours of sleep each night, the need for significantly more can indicate a mood disorder. Like sleep apnea, hypersomnia is related to a greater likelihood of heart attack and stroke.
Hypersomnia
A sleep disorder associated with excessive sleeping. Hypersomnia includes narcolepsy, an autoimmune disease that can cause extreme sleepiness and muscle weakness.
Psychiatric Medications and Sleep
Medications to treat psychological disturbances can have a positive or negative impact on sleep. (15) Most antidepressant medications influence the neurotransmitters dopamine, serotonin, and norepinephrine, all of which help to regulate sleep and wake cycles. Some can have stimulating effects that contribute to insomnia.
Restless legs syndrome and periodic limb movements can be triggered or exacerbated by antidepressants and other drugs used to treat mood disorders. (16) These medications can be helpful in patients without movement-related sleep disorders who suffer from hypersomnia.
Other medications such as older tricyclic drugs can help establish healthy sleep patterns in depressed patients with insomnia. Once a depressed patient starts taking medication, insomnia may be the last symptom to improve. Newer antidepressants such as selective serotonin reuptake inhibitors can suppress the REM stage of sleep, as well as the vivid dreaming that occurs during REM sleep.
Antipsychotic medications can help with insomnia, a common issue for schizophrenia sufferers. Some of these drugs can also cause daytime sleepiness, which may be preferable to insomnia. (17) Hypnotic medications are often prescribed along with antipsychotics, and may initially help with insomnia due to their sedative effects. However, many patients become tolerant of hypnotics or develop a rebound response, which can limit their usefulness for insomnia over the long-term.
Suicidal Behavior and Sleep
Suicidal behavior is a common feature of certain psychiatric conditions, including bipolar disorder and depression. Suicidal thoughts and actions can also occur in the absence of a psychiatric condition. Suicide is the second leading cause of death in people between 15 and 24. Suicide is more likely to be completed by people with access to guns.
Signs of suicidal thoughts and behavior may include the following:
Speaking about suicide or the desire to die
Feeling or talking about feeling hopeless
Researching ways to commit suicide
Appearing anxious or depressed
Excessive use of alcohol, or use of drugs
Exhibiting unusual behavior, such as rage, mood swings, or agitation
Suicidal behavior is often caused by psychiatric conditions, but may also be triggered by difficult life events, stress, loss of a loved one, or past trauma such as emotional, physical, or sexual abuse. Suicidal behavior is also more common in people suffering from post-traumatic stress disorder or chronic pain.
Recent research reveals that suicidal behavior and lack of sufficient sleep are related in adolescents and adults. (18) People who completed their suicidal actions were more likely to have suffered from insomnia, hypersomnia, or another sleep disturbance. Though further research is needed to better understand this link, existing studies reveal a strong association between mental health and sleep.
FAQ
Q: What is suicidal ideation?A: Suicidal ideation involves thinking about, planning, or considering suicide.
Last Word From Sleepopolis
Mental health is critically important to happiness and well-being. Research reveals a connection between mental illness and disturbed sleep, an association that may exist months or years before psychiatric symptoms appear.
Medications and other mental health treatments can help regulate sleep patterns, but may also cause or worsen insomnia, hypersomnia, and other sleep difficulties. Adjustment of medications or separate treatment of sleep issues can help establish healthy sleep patterns and improve quality of life for people suffering from mental health disorders.
References
Amy C. Watson, Self-Stigma in People With Mental Illness, Schizophrenia Bulletin, January 25, 2007
William Copeland Ph.D., Cumulative Prevalence of Psychiatric Disorders by Young Adulthood: A Prospective Cohort Analysis From the Great Smoky Mountains Study, Journal of the American Academy of Child & Adolescent Psychiatry, March 2011
Alan R. Teo, Social Relationships and Depression: Ten-Year Follow-Up from a Nationally Representative Study, Plos One, April 30, 2013
Peter J. Norton, Transdiagnostic models of anxiety disorder: Theoretical and empirical underpinnings, Clinical Psychology Review, August 2017
Martin B. Keller, MD, The Disruptive Behavioral Disorder in Children and Adolescents: Comorbidity and Clinical Course, Journal of the American Academy of Child & Adolescent Psychiatry, March 1992
Robert E Drake, et al. A systematic review of psychosocial research on psychosocial interventions for people with co-occurring severe mental and substance use disorders, Journal of Substance Abuse Treatment, January 2008
Tyrer P, Mulder R, Crawford M, Newton-Howes G, Simonsen E, Ndetei D, Koldobsky N, Fossati A, Mbatia J, Barrett B., Personality disorder: a new global perspective, World Psychiatry, February 2010
Krahn LE., Psychiatric disorders associated with disturbed sleep, Seminars in Neurology, March 25, 2005
Chiara Baglioni et al., Insomnia as a predictor of depression: A meta-analytic evaluation of longitudinal epidemiological studies, Journal of Affective Disorders, December 2011
Harvey AG, Talbot LS, Gershon A, Sleep Disturbance in Bipolar Disorder Across the Lifespan, Clinical Psychology, New York State Psychiatric Institute, April 8, 2012
Heidemarie Blumenthal, et al., The Links Between Social Anxiety Disorder, Insomnia Symptoms, and Alcohol Use Disorders: Findings From a Large Sample of Adolescents in the United States, Behavior Therapy, January 2019
Yaron Dagan, High prevalence of personality disorders among Circadian Rhythm Sleep Disorders (CRSD) patients, Journal of Psychosomatic Research, October 1996
Liu X, Buysse DJ, Gentzler AL, Kiss E, Mayer L, Kapornai K, Vetró A, Kovacs M., Insomnia and hypersomnia associated with depressive phenomenology and comorbidity in childhood depression, Sleep, January 30, 2007
Nutt D, Wilson S, Paterson L., Sleep disorders as core symptoms of depression, Dialogues in Clinical Neuroscience, September 2008
DeMartinis NA, Winokur A., Effects of psychiatric medications on sleep and sleep disorders, CNS and Neurological Disorders Drug Targets, February 6, 2007
Staner L., Sleep disturbances, psychiatric disorders, and psychotropic drugs, Dialogues in Clincal Neuroscience, December 7, 2005
Waite F, Myers E, Harvey AG, Espie CA, Startup H, Sheaves B, Freeman D., Treating Sleep Problems in Patients with Schizophrenia, Behavioural and Cognitive Psychotherapy, May 2016
Goldstein TR, Bridge JA, Brent DA., Sleep Disturbance Preceding Completed Suicide in Adolescents, Journal of Consulting and Clinical Psychology, February 17, 2010
Original article: https://sleepopolis.com/education/how-does-mental-health-affect-your-sleep/
Rose MacDowell
Rose is the Chief Research Officer at Sleepopolis, which allows her to indulge her twin passions for dense scientific studies and writing about health and wellness. An incurable night owl, she loves discovering the latest information about sleep and how to get (lots) more of it. She is a published novelist who has written everything from an article about cheese factories to clock-in instructions for assembly line workers in Belgium. One of her favorite parts of her job is connecting with the best sleep experts in the industry and utilizing their wealth of knowledge in the pieces she writes. She enjoys creating engaging articles that make a difference in people’s lives. Her writing has been reviewed by The Boston Globe, Cosmopolitan, and the Associated Press, and received a starred review in Publishers Weekly. When she isn’t musing about sleep, she’s usually at the gym, eating extremely spicy food, or wishing she were snowboarding in her native Colorado. Active though she is, she considers staying in bed until noon on Sundays to be important research.
How stimulant treatment prevents serious outcomes of ADHD
July 23, 2019
Science Daily/Massachusetts General Hospital
An analysis of three previous studies of children and young adults with attention-deficit hyperactivity disorder (ADHD) quantifies for the first time the extent to which stimulant treatment reduces the development of mood disorders, school problems, conduct disorders, substance use disorders and other problems. The study led by Massachusetts General Hospital investigators is being published online in the Journal of Adolescent Health.
"Our study documents that early treatment with stimulant medication has very strong protective effects against the development of serious, ADHD-associated functional complications like mood and anxiety disorders, conduct and oppositional defiant disorder, addictions, driving impairments and academic failure," says Joseph Biederman, MD, chief of the Pediatric Psychopharmacology and Adult ADHD Program at MGH and MassGeneral Hospital for Children. "In quantifying the improvement seen with stimulant treatment, it measures its potency in mitigating specific functional outcomes."
Previous studies of stimulant treatment for ADHD have had limitations, such as only investigating outcomes in boys or not calculating the magnitude of the protective effects of treatment. The current study determined the number needed to treat (NNT) statistic, often used to show the effectiveness of an intervention. As the title indicates, NNT reflects the number of individuals receiving a medication or other treatment needed to prevent a specific unwanted outcome -- the lower the NNT, the more effective the treatment.
The investigators analyzed data from three separate studies they had previously published to calculate the NNT needed to prevent specific outcomes. Two of these were long-term, prospective studies of children with and without ADHD -- one of boys, one of girls -- some of those diagnosed with ADHD were treated with stimulants, some were not. The third study was a randomized, double blind study of young adults with ADHD that compared their performance on a driving simulation upon entering the study with their performance after six weeks of treatment with either a stimulant medication or a placebo. Participants in the long-term studies averaged age 11 upon study entry and 20 at follow-up, and the current investigation focused only on those with ADHD. Participants in the driving study were ages 18 to 26.
The NNTs for the outcomes of interest were found to be quite low:
· three participants with ADHD needed to be treated to prevent one from repeating a grade or developing conduct disorder, anxiety disorders or oppositional-defiant disorder.
· four participants with ADHD needed to be treated to prevent one from developing major depression or experiencing an accident during the driving simulation.
· five participants with ADHD needed to be treated to prevent one from developing bipolar disorder, six to prevent one from smoking cigarettes, and ten to prevent one from developing a substance use disorder.
Adjustments for the sex of participants and several other factors did not change the impact of treatment on those outcomes, except that the protection against substance use disorders was stronger in younger participants.
"Now we have the evidence allowing us to say that stimulant treatment of ADHD prevents the development of several very serious functional outcomes," says Biederman, a professor of Psychiatry at Harvard Medical School. "However, the impact on other serious outcomes -- such as post-traumatic stress disorder, traumatic brain injury, suicide risk and employment success -- still needs to be investigated." (is your team planning any such studies?)
https://www.sciencedaily.com/releases/2019/07/190723085959.htm
Stress during pregnancy increases risk of mood disorders for female offspring
Study examines the effects of maternal cortisol levels on brain connectivity and behavior in offspring
August 16, 2018
Science Daily/Elsevier
High maternal levels of the stress hormone cortisol during pregnancy increase anxious and depressive-like behaviors in female offspring at the age of 2, reports a new study. The effect of elevated maternal cortisol on the negative offspring behavior appeared to result from patterns of stronger communication between brain regions important for sensory and emotion processing. The findings emphasize the importance of prenatal conditions for susceptibility of later mental health problems in offspring.
Interestingly, male offspring of mothers with high cortisol during pregnancy did not demonstrate the stronger brain connectivity, or an association between maternal cortisol and mood symptoms.
"Many mood and anxiety disorders are approximately twice as common in females as in males. This paper highlights one unexpected sex-specific risk factor for mood and anxiety disorders in females," said John Krystal, MD, Editor of Biological Psychiatry. "High maternal levels of cortisol during pregnancy appear to contribute to risk in females, but not males."
"This study measured maternal cortisol during pregnancy in a more comprehensive manner than prior research," said first author Alice Graham, PhD, of Oregon Health & Science University. To estimate the overall cortisol level during pregnancy, senior author Claudia Buss, PhD, of Charité University Medicine Berlin and University of California, Irvine and colleagues measured cortisol levels over multiple days in early-, mid-, and late-pregnancy. Measurements taken from the 70 mothers included in the study reflected typical variation in maternal cortisol levels. The researchers then used brain imaging to examine connectivity in the newborns soon after birth, before the external environment had begun shaping brain development, and measured infant anxious and depressive-like behaviors at 2 years of age.
"Higher maternal cortisol during pregnancy was linked to alterations in the newborns' functional brain connectivity, affecting how different brain regions can communicate with each other," said Dr. Buss. The altered connectivity involved a brain region important for emotion processing, the amygdala. This pattern of brain connectivity predicted anxious and depressive-like symptoms two years later.
The findings reveal a potential pathway through which the prenatal environment may predispose females to developing mood disorders. The study supports the idea that maternal stress may alter brain connectivity in the developing fetus, which would mean that vulnerability for developing a mood disorder is programmed from birth. This could be an early point at which the risk for common psychiatric disorders begins to differ in males and females.
https://www.sciencedaily.com/releases/2018/08/180816101944.htm
Half of adults with anxiety or depression report chronic pain
May 31, 2017
Science Daily/Columbia University's Mailman School of Public Health
In a survey of adults with anxiety or a mood disorder like depression or bipolar disorder, about half reported experiencing chronic pain, according to researchers.
"The dual burden of chronic physical conditions and mood and anxiety disorders is a significant and growing problem," said Silvia Martins, MD, PhD, associate professor of Epidemiology at the Mailman School of Public Health, and senior author.
The research examined survey data to analyze associations between DSM-IV-diagnosed mood and anxiety disorders and self-reported chronic physical conditions among 5,037 adults in São Paulo, Brazil. Participants were also interviewed in person.
Among individuals with a mood disorder, chronic pain was the most common, reported by 50 percent, followed by respiratory diseases at 33 percent, cardiovascular disease at 10 percent, arthritis reported by 9 percent, and diabetes by 7 percent. Anxiety disorders were also common for those with chronic pain disorder at 45 percent, and respiratory at 30 percent, as well as arthritis and cardiovascular disease, each 11 percent. Individuals with two or more chronic diseases had increased odds of a mood or anxiety disorder. Hypertension was associated with both disorders at 23 percent.
"These results shed new light on the public health impact of the dual burden of physical and mental illness," said Dr. Martins. "Chronic disease coupled with a psychiatric disorder is a pressing issue that health providers should consider when designing preventive interventions and treatment services -- especially the heavy mental health burden experienced by those with two or more chronic diseases."
https://www.sciencedaily.com/releases/2017/05/170531133242.htm
Low levels of 'anti-anxiety' hormone linked to postpartum depression
Effect measured in women already diagnosed with mood disorders
March 14, 2017
Science Daily/Johns Hopkins Medicine
In a small-scale study of women with previously diagnosed mood disorders, researchers report that lower levels of the hormone allopregnanolone in the second trimester of pregnancy were associated with an increased chance of developing postpartum depression in women already known to be at risk for the disorder.
In a report on the study, published online on March 7 in Psychoneuroendocrinology, the researchers say the findings could lead to diagnostic markers and preventive strategies for the condition, which strikes an estimated 15 to 20 percent of American women who give birth.
The researchers caution that theirs was an observational study in women already diagnosed with a mood disorder and/or taking antidepressants or mood stabilizers, and does not establish cause and effect between the progesterone metabolite and postpartum depression. But it does, they say, add to evidence that hormonal disruptions during pregnancy point to opportunities for intervention.
Postpartum depression affects early bonding between the mother and child. Untreated, it has potentially devastating and even lethal consequences for both. Infants of women with the disorder may be neglected and have trouble eating, sleeping and developing normally, and an estimated 20 percent of postpartum maternal deaths are thought to be due to suicide, according to the National Institute of Mental Health.
"Many earlier studies haven't shown postpartum depression to be tied to actual levels of pregnancy hormones, but rather to an individual's vulnerability to fluctuations in these hormones, and they didn't identify any concrete way to tell whether a woman would develop postpartum depression," says Lauren M. Osborne, M.D., assistant director of the Johns Hopkins Women's Mood Disorders Center and assistant professor of psychiatry and behavioral sciences at the Johns Hopkins University School of Medicine. "For our study, we looked at a high-risk population of women already diagnosed with mood disorders and asked what might be making them more susceptible."
For the study, 60 pregnant women between the ages of 18 and 45 were recruited by investigators at study sites at The Johns Hopkins University and the University of North Carolina at Chapel Hill. About 70 percent were white and 21.5 percent were African-American. All women had been previously diagnosed with a mood disorder, such as major depression or bipolar disorder. Almost a third had been previously hospitalized due to complications from their mood disorder, and 73 percent had more than one mental illness.
During the study, 76 percent of the participants used psychiatric medications, including antidepressants or mood stabilizers, and about 75 percent of the participants were depressed at some point during the investigation, either during the pregnancy or shortly thereafter.
During the second trimester (about 20 weeks pregnant) and the third trimester (about 34 weeks pregnant), each participant took a mood test and gave 40 milliliters of blood. Forty participants participated in the second-trimester data collection, and 19 of these women, or 47.5 percent, developed postpartum depression at one or three months postpartum. The participants were assessed and diagnosed by a clinician using criteria from the Diagnostic and Statistical Manual of Mental Disorders, version IV for a major depressive episode.
Of the 58 women who participated in the third-trimester data collection, 25 of those women, or 43.1 percent, developed postpartum depression. Thirty-eight women participated in both trimester data collections.
Using the blood samples, the researchers measured the blood levels of progesterone and allopregnanolone, a byproduct made from the breakdown of progesterone and known for its calming, anti-anxiety effects.
The researchers found no relationship between progesterone levels in the second or third trimesters and the likelihood of developing postpartum depression. They also found no link between the third-trimester levels of allopregnanolone and postpartum depression. However, they did notice a link between postpartum depression and diminished levels of allopregnanolone levels in the second trimester.
For example, according to the study data, a woman with an allopregnanolone level of 7.5 nanograms per milliliter had a 1.5 percent chance of developing postpartum depression. At half that level of hormone (about 3.75 nanograms per milliliter), a mother had a 33 percent likelihood of developing the disorder. For every additional nanogram per milliliter increase in allopregnanolone, the risk of developing postpartum depression dropped by 63 percent.
"Every woman has high levels of certain hormones, including allopregnanolone, at the end of pregnancy, so we decided to look earlier in the pregnancy to see if we could tease apart small differences in hormone levels that might more accurately predict postpartum depression later," says Osborne. She says that many earlier studies on postpartum depression focused on a less ill population, often excluding women whose symptoms were serious enough to warrant psychiatric medication -- making it difficult to detect trends in those women most at risk.
Because the study data suggest that higher levels of allopregnanolone in the second trimester seem to protect against postpartum depression, Osborne says in the future, her group hopes to study whether allopregnanolone can be used in women at risk to prevent postpartum depression. She says Johns Hopkins is one of several institutions currently participating in a clinical trial led by Sage Therapeutics that is looking at allopregnanolone as a treatment for postpartum depression.
She also cautions that additional and larger studies are needed to determine whether women without mood disorders show the same patterns of allopregnanolone levels linked to postpartum depression risk.
If those future studies confirm a similar impact, Osborne says, then tests for low levels of allopregnanolone in the second trimester could be used as a biomarker to predict those mothers who are at risk of developing postpartum depression.
Osborne and her colleagues previously showed and replicated in Neuropsychopharmacology in 2016 that epigenetic modifications to two genes could be used as biomarkers to predict postpartum depression; these modifications target genes that work with estrogen receptors and are sensitive to hormones. These biomarkers were already about 80 percent effective at predicting postpartum depression, and Osborne hopes to examine whether combining allopregnanolone levels with the epigenetic biomarkers may improve the effectiveness of the tests to predict postpartum depression.
Of note and seemingly contradictory, she says, many of the participants in the study developed postpartum depression while on antidepressants or mood stabilizers. The researchers say that the medication dosages weren't prescribed by the study group and were monitored by the participant's primary care physician, psychiatrist or obstetrician instead. "We believe that many, if not most, women who become pregnant are undertreated for their depression because many physicians believe that smaller doses of antidepressants are safer for the baby, but we don't have any evidence that this is true," says Osborne. "If the medication dose is too low and the mother relapses into depression during pregnancy or the postpartum period, then the baby will be exposed to both the drugs and the mother's illness."
Osborne and her team are currently analyzing the medication doses used by women in this study to determine whether those given adequate doses of antidepressants were less likely to develop symptoms in pregnancy or in postpartum.
Only 15 percent of women with postpartum depression are estimated to ever receive professional treatment, according to the U.S. Centers for Disease Control and Prevention. Many physicians don't screen for it, and there is a stigma for mothers. A mother who asks for help may be seen as incapable of handling her situation as a mother, or may be criticized by friends or family for taking a medication during or shortly after pregnancy.