Psychiatry Pearl: Insomnia

Co-Director Kathryn Emerick, MD

Co-Director Kathryn Emerick, MD

photo: Jamie Manser

Insomnia is a common issue in the perinatal population, impacting up to about 80% of pregnancies. Assessing for and treating insomnia is important because it’s correlated with developing anxiety and depression and when present, is associated with more severe anxiety and depression. Insomnia in pregnancy is also associated with increased labor pain, longer labors and pregnancy complications.

A good first step is ruling out any contributing medical conditions such as restless leg syndrome (RLS) , sleep apnea, gastroesophageal reflux disease (GERD), or back pain, and encouraging sleep hygiene, pregnancy comfort measures at bedtime, and exercise, as well as treating any comorbid psychiatric illness if present. Our best evidence-based treatment intervention for insomnia is CBT-I (CBT for insomnia). Medications can also be helpful, especially when used at a low dose and for a short period of time. It’s important to remember, however, that medication management of insomnia in the perinatal period isn’t always intuitive. Trazodone and melatonin, which are commonly used outside of pregnancy/lactation, actually have less safety data available than other options such as lorazepam or doxylamine.

Final considerations include encouraging the patient and their support network to come up with a sleep plan prior to birth. A sleep plan describes who is “on duty” for the baby, including when and what that looks like, to ensure Mom gets adequate windows for sleep. For example, does the support person give the baby a bottle of formula/pumped milk or do they bring the baby to mom for breastfeeding? Are they responsible for changing diapers and getting the baby back to sleep? Do the parents take full-night shifts or just part of the night? Will the parents both sleep in the same room or will the “off-duty” parent sleep elsewhere? Considering these questions prior to birth increases protection of post-partum sleep and supports the mental health of the pregnant person.

Below are some available options for non-pharmacologic support:

References

Arch Womens’ Mental Health. 2023 Jan 12. Endorsement of a single-item measure of sleep disturbance during pregnancy and risk for postpartum depression: a retrospective cohort study. Felder JN, Roubinov D, Zhang L, Gray M, Beck A. 
 
Hashmi AM, Bhatia SK, Bhatia SK, Khawaja IS. Insomnia during pregnancy: Diagnosis and Rational Interventions. Pak J Med Sci. 2016 Jul-Aug;32(4):1030-7. doi: 10.12669/pjms.324.10421. PMID: 27648062; PMCID: PMC5017073.