dCBT-I Demonstrates Benefits for Postpartum Insomnia Remission

Jennifer N. Felder, PhD

The use of digital cognitive behavior therapy for insomnia (dCBT-I) during pregnancy may have benefits for postpartum insomnia remission, findings from a recent study suggest. Additionally, preliminary evidence shows that dCBT-I during pregnancy may also prevent postpartum depression and anxiety.

Investigators, including Jennifer N. Felder, PhD, assistant professor, department of psychiatry, Weill Institute for Neurosciences, University of California–San Francisco [UCSF]; and research faculty, UCSF Osher Center for Integrative Medicine, and colleagues included 208 people up to 28 weeks’ gestation with insomnia. Participants were randomized to receive either 6 weekly sessions of dCBT-I or standard care, with follow-up data reported from both 3 and 6 months postpartum. Those undergoing dCBT-I reported greater decreases in insomnia symptoms when compared with standard care, but the likelihood ratio test did not show statistical significance when assessing simultaneous changes at both 3 months and 6 months postpartum (P = .08). 

Those in the dCBT-I group did have significantly higher rates of insomnia remission (53% vs 35%; P = .02), as well as a lower amount of insomnia cases at 6 months postpartum (25% vs 11%; P = .02). Participants that received dCBT-I had greater improvements in Pittsburgh Sleep Quality Index scores than those receiving standard of care, but the likelihood ratio test that analyzed both follow-up time points did not show statistical significance at the 5% level (P = .14).

“Participants who received a non-pharmacological intervention for insomnia while they were pregnant continued to experience improvements in insomnia symptoms at 6 months postpartum, and improvements in depressive and anxiety symptoms at 3 and 6 months postpartum,” Felder et al wrote. “Additionally, findings from this trial provide strong preliminary evidence that dCBT-I delivered during pregnancy may prevent postpartum depression and anxiety. Digital CBT-I has the potential to be a low-stigma, scalable means to have a favorable impact on the enormous public health problem of perinatal insomnia, anxiety, and depression.”

READ MORE: Insomnia Treatment May Prevent Depression in Older Adults

In terms of anxiety symptoms, the likelihood ratio test was a statistically significant when analyzing the 2 differences in change from baseline (P = .001). At 3 months postpartum, the dCBT-I group experienced improvements in Generalized Anxiety Disorder Scale (GAD-7) scores compared with those in the standard care group, who reported worsening GAD-7 scores. At 6 months, those in the dCBT-I group continued to report improvements, while those in the standard care group had little change in GAD-7 scores. Approximately 4% of dCBT-I participants (n = 4) reported moderate-to-severe anxiety at 3 months postpartum, compared with 17% of standard care participants (n = 14; P = .009). Differences were not statistically significant at 6 months postpartum. 

From baseline to both postpartum follow-ups, those in the dCBT-I group experienced statistically significant improvements in depressive symptom severity, when compared with the standard care group (P = .002). At 3 months postpartum, there was a significantly higher proportion of patients with probable major depression in the standard care group (18%), when compared with those in the dCBT-I group (4%; P = .006). This was pronounced in a subset of participants with minimal depressive symptoms at baseline (n = 143), where 0% of the patients randomized to receive dCBT-I reported probable major depression at 3 months postpartum, compared with 18% of the standard care subset (n = 12). At 6 months postpartum, none of dCBT-I participants reported probable major depression, compared with 10% (n = 7) of standard care patients. 

“More research is needed to investigate whether, how, and for whom digital CBT-I prevents perinatal depression in an adequately powered confirmatory efficacy trial,” Felder et al wrote. “If replicated, the findings would suggest that pregnant people with insomnia should be referred for dCBT-I to prevent depression. A factor that increases the potential public health impact of this approach is the scalability of dCBT-I.”

The study was limited in that all outcomes were self-reported symptom measures, due to the study’s purpose of investigating a scalable intervention. The sample was also primarily comprised of wealthy, white, and educated participants, limited generalizability. Follow-up longer than 6 months postpartum should also be considered, as negative outcomes for children have been associated with depression beyond the immediate postpartum period. Participants were able to use and receive treatment not related to the study, including medication and psychotherapy, and those in the standard care group had a statistically higher use of prescription sleep medication, potentially attenuating between-group differences in insomnia symptom chance. Generalizability was also limited, as participants were included who had only experienced insomnia symptoms for 1 month. 

REFERENCE

Felder JN, Epel ES, Neuhas J, Krystal AD, Prather AA. Randomized controlled trial of digital cognitive behavior therapy for prenatal insomnia symptoms: Effects on postpartum insomnia and mental health. Sleep. Published online November 21, 2021. doi:10.1093/sleep/zsab280