How to Treat Insomnia in New Mothers

"Sleep when the baby sleeps"—a common refrain from well-meaning loved ones and health professionals. In practice, however, turning off our vigilant brains early in the lives of our offspring can feel elusive, if not impossible.

The Profound Changes in Pregnancy and Childbirth

Giving birth is one of the most challenging transitions a woman will face in her lifetime. Trying to prepare for the arrival of a vulnerable little being, especially a firstborn, can feel overwhelming. Not only is her body changing drastically, requiring patience and adjustment of previously assumed mobility, but also her brain. The hormonal surges and fluctuations alter the way she encounters the world and can bring about overwhelming emotions.

Having nursed my own babies in the quiet hours of typical slumber, I remember the feeling of isolation. As the night approached, my partner would prepare for expected sleep, while I felt a growing dread that it could be a difficult night, extended endlessly by frequent feeds and fussiness. At times, even when my young son fell asleep for several lovely hours, I lay awake, staring at the window blinds as the light slowly filtered in.

Screening for Postpartum Depression and Anxiety

As a mental health professional, I am very familiar with the signs and symptoms of postpartum depression and anxiety. Low mood, excessive guilt, decreased appetite, and intrusive, worried thoughts are part of my screening in the weeks and months after childbirth. One additional key factor I must review is the ability to sleep. Certainly, some level of disruption throughout the night is expected if she is the primary caretaker for her infant, but what about when quality sleep remains difficult even when the baby is sleeping well?

Treating Insomnia in Pregnancy and Postpartum: The Role of CBT-I

When insomnia is diagnosed during the postpartum period, options for treatment may be limited by risks of medication during breastfeeding, as well as difficulty traveling to a physician’s or therapist’s office to receive psychotherapy.

Fortunately, despite the many challenges posed by COVID-19, particularly for new mothers, telehealth has become a much more readily available treatment modality. In addition, digital versions of evidence-based treatments for sleep problems, such as cognitive behavioral therapy for insomnia (CBT-I), are regularly being developed.

The lasting benefits of CBT-I are well demonstrated, and it is recommended as the first-line treatment for insomnia by the Clinical Guidelines of the American Academy of Sleep Medicine, Centers for Disease Control and Prevention, and National Institutes of Health. However, both a shortage of providers trained in CBT-I, as well as the transportation challenges noted above, significantly limit the accessibility of this effective treatment option.

Research on the Potential Benefit of CBT-I in Pregnancy and Postpartum

Two recent studies have investigated the use of digital CBT-I delivery to treat insomnia during pregnancy and in the postpartum period, respectively. In the first, researchers randomized a total of 208 pregnant women with documented insomnia to receive either six weekly 20-minute sessions of digital CBT-I or standard treatment for insomnia, including medication and psychotherapy per their usual provider.

The CBT-I intervention led to a significant improvement in the primary outcome of the study, severity of insomnia. Secondary measures such as depression symptoms, anxiety symptoms, and global sleep quality were all significantly better in the CBT-I group. In addition, another important finding was a decrease in the use of prescription or over-the-counter sleep aids by those in the CBT-I group, lowering the fetal exposure to medication during pregnancy.

In the more recent study, the same group who received six weeks of digital CBT-I during pregnancy were followed for six months postpartum. Researchers noted that the women who received CBT-I had significantly lower rates of insomnia at six months postpartum. Importantly, women in the CBT-I group also had significantly lower rates of probable major depression at three months (18 percent vs 4 percent) and six months (10 percent vs 0 percent). They also exhibited lower rates of moderate-to-severe anxiety (17 percent vs 4 percent) and decreased development of moderate-to-severe anxiety by those without initial symptoms (15 percent vs 1 percent) at three months.

Final Thoughts on Sleep During the Postpartum Period

Sleep during the postpartum period is challenging to optimize due to an infant’s developmentally appropriate need for frequent feedings overnight. However, these studies suggest a highly flexible modality of intervention during pregnancy can have a powerful effect on risk of postpartum depression and anxiety. With as many as one in seven women suffering from postpartum depression, this decrease represents a substantial public health benefit and better lives for so many of our new mothers and their growing families.