Psychological Distress, Sleep Disruption Common in Pregnant Women During the Pandemic

There have been multiple studies over last year showing increased anxiety and depression in certain populations as a result of the COVID-19 pandemic.  It is clear that some members of the population may be more susceptible to psychological distress than others.  Previous studies have observed that pregnant and postpartum women are at increased risk for mental health problems in the context of the pandemic.  In a recent study, Karmel Choi, PhD and colleagues conducted an international survey to measure distress, specifically depression and anxiety, in a cohort of pregnant women with the goal of identifying potential modifiable targets for reducing the burden of distress in this vulnerable population.

In this anonymous online survey study carried out between May 26, 2020 and June 13, 2020, 3696 pregnant women across 12 countries completed a survey through the International Registry of Coronavirus Exposure in Pregnancy (IRCEP) website.  The survey was advertised in social media channels and in online parenting forums.  Choi and colleagues specifically looked at the impact of COVID-19 on sleep, fitness, and diet, and examined whether changes in these behaviors were associated with symptoms of depression and/or anxiety.

Participants provided demographic information and completed questionnaires related to COVID-19 exposure and were asked to what extent COVID-19 had  negatively impacted sleep, fitness, and diet.  Mental health distress was assessed using the Patient Health Questionnaire-4 (PHQ-4).  Loneliness was evaluated using the UCLA Three-Item Loneliness Scale (UCLA-3).

Psychological Distress is Common Among Pregnant Women

In this cohort, one in three pregnant women experienced elevated symptoms of mental health distress (anxiety and depression).  About 30–45% of the women reported at least a moderate reduction in quality of sleep, fitness, and diet as a result of the pandemic.  The researchers observed a dose-response relationship between changes in these health behaviors and mental health distress, such that women who reported the greatest impact of the pandemic on health behaviors were the most likely to report symptoms of depression and anxiety.

 After adjusting for sociodemographic factors, the researchers observed that changes in sleep had the strongest association with mental health distress; compared to women who noted no changes in sleep as a result of the pandemic, pregnant women reporting the highest negative impact in this domain were 11 times as likely to report elevated symptoms of depression and anxiety.  Sleep disruption during the pandemic appeared to be more strongly  associated with concurrent anxiety than with depression, which suggests that sleep disturbances may be linked to worry and anxiety related to COVID-19. 

Women who reported higher levels of gratitude and a sense of community reported less impact of the pandemic on health behavior impacts. On the other hand, women reporting higher levels of loneliness were more likely to be negatively impacted by the pandemic. 

While this study provides important insights into pandemic-related distress in pregnant women, the cross-sectional nature of the survey cannot establish causality or directional relationships.  For example, while it is possible to infer that pandemic-related changes in health behaviors may make pregnant women more susceptible to depression and/or anxiety, it is also possible that women who experience anxiety or depression in the context of the pandemic may be more likely to experience changes in these behaviors.  For example, pandemic-related anxiety may disrupt sleep, result in changes in appetite, and may create obstacles to exercise.     

How to Better Support Pregnant Women During the Pandemic

The current international survey conducted during the COVID-19 pandemic demonstrates that a substantial proportion of pregnant women — one in three — experience elevated symptoms of depression and anxiety.  Because high levels of distress experienced during pregnancy may negatively affect maternal and child outcomes, it is important that we screen for mental health symptoms in pregnant women and provide additional support, when needed.  

In this context, interventions which target sleep, including cognitive-behavioral, mindfulness, and relaxation-based approaches, may be helpful.   While there is a more modest relationship between disruptions in diet and fitness and distress, interventions designed to preserve these health behaviors may be important for mental health promotion during pregnancy in the midst of a major stressor.

Choi KW, Kim HH, Basu A, Kwong ASF, Hernandez-Diaz S, Wyszynski DF, Koenen KC. COVID-19 perceived impacts on sleep, fitness, and diet and associations with mental health during pregnancy: A cross-national study. J Affect Disord Rep. 2022 Jan;7:100288. doi: 10.1016/j.jadr.2021.100288. 

Karmel Choi, PhD is a clinical psychologist and Assistant Professor in the Department of Psychiatry at Harvard Medical School, and Director of the Precision Prevention Program in the Center for Precision Psychiatry at Massachusetts General Hospital. Her research focuses on genetic, epidemiological, and translational methods to characterize the nature of psychiatric resilience and inform the prevention of common stress-related disorders, e.g., depression and PTSD, across the life course.

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Archana Basu, PhD is a clinical psychologist in the Department of Psychiatry at MGH and an instructor at Harvard Medical School.  She is currently a research associate at the Harvard T.H. Chan School of Public Health; her research focuses on the impact of traumatic and severe stressors on mental and physical health outcomes in children across the developmental lifespan.  Clinically Dr. Basu works with families coping with severe or traumatic stressors, chronic or terminal medical conditions, and bereavement.

Karestan Koenen, PhD is a Professor of Psychiatric Epidemiology at the Harvard T.H. Chan School of Public Health and a faculty member of the Psychiatric Neurodevelopmental Genetics Unit. Her research focuses on trauma and posttraumatic stress disorder (PTSD).