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. Author manuscript; available in PMC: 2026 Oct 6.
Published in final edited form as: J Affect Disord. 2025 Jun 3;388:119523. doi: 10.1016/j.jad.2025.119523

Concurrent and prospective associations between sleep duration and timing and postpartum anxiety symptoms

Rebecca C Cox 1,2, Brandon S Aylward 3, Isabella Macarelli 2, Michele L Okun 4,*
PMCID: PMC13638213  NIHMSID: NIHMS2195077  PMID: 40466951

Abstract

Objectives:

Postpartum anxiety is understudied and underdiagnosed. Given associations between postpartum anxiety and adverse maternal and infant outcomes, it is crucial to identify patterns and predictors of postpartum anxiety. We examined the associations between sleep duration and timing and postpartum anxiety over 6 months following delivery.

Methods:

A convenience sample of pregnant women with a history of depression (n=162; 30–39 weeks) completed self-report measures of sleep, anxiety, and depression in the third trimester and once/month for 6 months following delivery. Concurrent and prospective associations between sleep duration, sleep timing, and postpartum anxiety symptoms were tested via 2-level multilevel models. Depression symptoms and insomnia status were included as covariates.

Results:

Clinically significant anxiety symptoms were more common than clinically significant depression symptoms at 4 out of 6 postpartum months (p’s<.05). Anxiety symptoms increased over time (p<.001). Shorter month-level sleep duration was associated with higher concurrent anxiety symptoms, particularly in early postpartum months. Sleep timing was not significantly associated with concurrent anxiety symptoms (p>.05). Neither prior month sleep duration nor timing significantly predicted subsequent month anxiety symptoms (p’s>.05).

Conclusions:

Acute reduction in sleep duration may signal the presence of elevated postpartum anxiety, particularly in the early postpartum months, but may not provide predictive utility for prospective increases in anxiety from month to month. Treatments for postpartum anxiety may benefit from targeting sleep duration. Future research should replicate these findings with objective sleep measures.

Keywords: postpartum, perinatal, sleep duration, sleep timing, anxiety, depression

Anxiety disorders are the most common form of psychopathology (Kessler et al., 2005) and are approximately twice as common among women as men (Baxter et al., 2013). This higher prevalence rate among women may be due in part to new onset or exacerbation of anxiety disorders and symptoms during the postpartum period. It is estimated that ~8.5–9.9% of postpartum women experience at least one anxiety disorder (Dennis et al., 2017; Goodman et al., 2016) and 15–19% experience clinically significant anxiety symptoms (Dennis et al., 2017; Wenzel et al., 2005). Notably, a substantial proportion of women report new or worsening anxiety disorder symptoms during the postpartum period (Goodman et al., 2016; Wenzel et al., 2005). The high prevalence of postpartum anxiety symptoms and disorders represents a significant public health issue, as postpartum anxiety is associated with several adverse maternal and infant outcomes. Indeed, prior work has found that postpartum anxiety is associated with a lower likelihood of breastfeeding and shorter breastfeeding duration (Fallon et al., 2016; Paul et al., 2013), lower maternal responsivity to the infant (Miller and O’Hara, 2020), and lower social-emotional development at age 2(Polte et al., 2019).

The high prevalence rates and associated consequences of postpartum anxiety symptoms and disorders highlight the need to identify modifiable predictors that could be targeted for treatment. However, despite being more common than postpartum depression (Fairbrother et al., 2016), postpartum anxiety remains understudied (Field, 2018; Pawluski et al., 2017), and risk factors for postpartum anxiety are not well-delineated. One candidate predictor of postpartum anxiety is sleep disruption. Sleep disruption is common in the perinatal period (Okun et al., 2013), and sleep duration decreases substantially from pregnancy to postpartum due to demands of infant caregiving (Bei et al., 2010; Horwitz et al., 2023; Lee et al., 2000; Okun, 2016). In the general population, sleep deprivation results in acute increases in anxiety (Pires et al., 2016), shorter sleep duration predicts increased next-day anxiety (Cox et al., 2018b), insomnia symptoms predict increased anxiety over time (Cox et al., 2018a), and sleep disruption is associated with anxiety disorders (Cox and Olatunji, 2020). Further, considerable evidence links sleep disruption to postpartum depression (Lawson et al., 2015; Okun, 2015). Taken together, these findings suggest the utility of examining sleep disruption as a predictor of postpartum anxiety.

Indeed, a small but growing body of work suggests sleep disruption is associated with higher postpartum anxiety. Studies of community perinatal samples indicate that sleep disruption during pregnancy predicts increased postpartum anxiety (Gueron-Sela et al., 2020; Osnes et al., 2020; Sedov and Tomfohr-Madsen, 2021). Likewise, studies in postpartum women indicate that postpartum sleep disruption and insomnia symptoms predict increased postpartum anxiety (Okun et al., 2018; Okun and Lac, 2023), over and above the effects of sleep disruption in pregnancy (Okun and Lac, 2023). Finally, these findings appear to translate to clinical samples, as one study in postpartum women seeking mental health treatment found that postpartum insomnia was associated with postpartum anxiety (Swanson et al., 2011), and a meta-analysis found that sleep disorders are a significant risk factor for a new onset anxiety disorder in the perinatal period (Furtado et al., 2018). Thus, sleep disruption shows promise as a candidate predictor of postpartum anxiety.

However, much of the extant literature is limited by assessing sleep and anxiety at one or two timepoints. Given that sleep and anxiety are dynamic processes that vary over time, repeated assessment is needed to fully understand the predictive value of postpartum sleep for postpartum anxiety. Further, given the large reduction in sleep duration during the postpartum period, shorter sleep duration may be particularly predictive of postpartum anxiety. To our knowledge, only one study to date has examined sleep duration as a predictor of postpartum anxiety. This study found that sleep duration during the third trimester of pregnancy did not significantly predict anxiety at one week postpartum (Bei et al., 2010). However, it is unknown whether postpartum sleep duration is associated with postpartum anxiety across a larger sampling period. Further, increasing evidence links delayed sleep timing to psychiatric outcomes in the general population (Taylor and Hasler, 2018), and one study found that later sleep timing in pregnancy was associated with higher depression symptoms at 2 weeks postpartum (Obeysekare et al., 2020). However, it is unknown whether postpartum sleep timing is associated with postpartum anxiety. Identifying specific components of sleep disruption (e.g., sleep duration, sleep timing) that are associated with postpartum anxiety may streamline early detection of anxiety risk and identify specific behavioral targets for novel treatments. The present study sought to address these gaps in the literature by examining the associations between sleep duration, sleep timing, and anxiety symptoms over 6 months postpartum in a sample of women with a history of depression. We hypothesized that 1. clinically significant anxiety symptoms would be more common than clinically significant depression symptoms; 2. sleep duration would decrease, sleep timing would delay, and anxiety and depression symptoms would increase from pregnancy to postpartum; 3. shorter sleep duration and later sleep timing would be associated with higher concurrent postpartum anxiety symptoms; and 4. prior month shorter sleep duration and later sleep timing would predict increased next month postpartum anxiety. We also tested exploratory reverse models to examine whether prior month postpartum anxiety would predict next month sleep duration and timing.

Methods

Participants

The sample included a convenience sample of pregnant women with a history of major or postpartum depression (N = 162; meanage = 30.77 ± 4.09) (Okun and Lac, 2023). Inclusion criteria were age 18–45, gestational age 30–39 weeks, able to read English, had an internet connection, were having a singleton pregnancy, and had a self-report history of depression or postpartum depression. Exclusion criteria was active depression symptoms at enrollment (Edinburgh Postnatal Depression Scale ≥ 12) and endorsing suicidal ideation at enrollment.

Measures

The Pittsburgh Sleep Quality Index (PSQI) (Buysse et al., 1989) is an 18-item self-report questionnaire of global sleep disturbance over the past month. The PSQI includes seven subscales each with a possible score 0–3: sleep duration, sleep disturbances, sleep latency, sleep quality, daytime dysfunction, sleep medication usage, and sleep efficiency. Total scores range from 0–21, and a higher score indicates greater sleep disturbance. Only the sleep duration, sleep onset latency, bedtime, and waketime items were used in the present analysis. The sleep duration item was used to indicate sleep duration. Sleep timing was calculated as the midpoint between sleep onset and sleep offset. Wake time was used to indicate sleep offset. Sleep onset was calculated as bedtime + sleep onset latency.

The Insomnia Symptom Questionnaire (ISQ) (Okun et al., 2009) is a 13-item self-report measure to screen for clinically significant insomnia symptoms consistent with the Diagnostic and Statistical Manual (DSM-IV) criteria for primary insomnia (American Psychiatric Association, 1994) and American Academy of Sleep Medicine's (AASM) Research Diagnostic Criteria (RDC) (Edinger et al., 2004). A validated scoring algorithm yields a dichotomous outcome indicating the presence or absence of insomnia.

The Generalized Anxiety Disorder-7 (GAD-7) (Spitzer et al., 2006) is a 7-item self-report questionnaire of generalized anxiety disorder symptoms over the past 2 weeks. Total scores range from 0–21, and a higher score indicates greater anxiety symptoms. A score of 10 or higher indicates clinically significant anxiety symptoms (Spitzer et al., 2006). The GAD-7 had acceptable internal consistency at postpartum month 1 in the present sample (α = .89).

The Edinburgh Postnatal Depression Scale (EPDS) (Cox et al., 1987) is a 10-item self-report questionnaire of postpartum depression symptoms over the past 7 days. Total scores range from 0–30, and a higher score indicates greater postpartum depression symptoms. A score of 12 or higher indicates clinically significant postpartum depression symptoms (Cox et al., 1987). The EPDS had acceptable internal consistency at postpartum month 1 in the present sample (α = .72).

Procedure

This is a secondary data analysis from a study assessing sleep and postpartum mental health in postpartum women who used either a responsive or standard bassinet that was shipped to participants prior to delivery (Okun and Lac, 2023). Data collection took place from August 2020 to November 2021 during the COVID-19 pandemic. Participants were recruited during the third trimester of pregnancy from advertisements posted on Facebook to users in the United States. Interested participants who reported a history of depression were sent a link to complete informed consent, provide demographic data, and answer questionnaires. Only participants who scored < 12 on the EPDS at screening (indicating the absence of current clinically significant perinatal depression symptoms) were included. This population was selected to examine the contribution of sleep to postpartum mental health outcomes in an at-risk sample. Enrolled participants received an email to complete the questionnaires once/month after delivery for up to 6 months. Reminder emails and texts were used to ensure timely completion of the questionnaires. All data were collected via Qualtrics. All participants provided electronic informed consent, and all study procedures were approved by the institutional review board at the University of Colorado Colorado Springs.

Data analysis

Four participants with clinically significant anxiety symptoms at baseline were excluded from all analyses. We calculated descriptive statistics to characterize the frequency of clinically significant postpartum anxiety (i.e., GAD-7 score of 10 or higher) and depression symptoms (i.e., EPDS score of 12 or higher) across all 6 postpartum months (i.e., frequency of endorsing clinically significant symptoms at least once during the study period) and each postpartum month individually. We compared the relative frequency of clinically significant postpartum anxiety versus depression symptoms at least once during the study and at each postpartum month using McNemar tests. Descriptive statistics and McNemars tests were conducted in SPSS version 29. A Benjamini-Hochberg adjustment (Benjamini and Hochberg, 1995) was applied to p-values for the comparisons made for each of the 6 postpartum months to correct for multiple comparisons.

We tested the hypotheses that sleep duration would decrease, sleep timing would delay, and anxiety and depression symptoms would increase from the third trimester of pregnancy across 6 months postpartum with 4 linear repeated-measures mixed model ANOVAs conducted in SPSS version 29. We included subject as a random factor and time as a fixed factor. We calculated partial η2 in R version 4.3.0 to evaluate effect sizes for model main effects using standard thresholds (.01 = small, .06 = medium, .14 = large).

We tested the hypotheses that shorter postpartum sleep duration and later postpartum sleep timing would be associated with higher concurrent and prospective postpartum anxiety symptoms by fitting two 2-level multilevel linear regression models in Mplus version 8 to account for the nested data structure: months (level 1) nested within participants (level 2). In the concurrent model, level 1 predictors included time and month-level sleep duration, sleep timing, depression symptoms, and insomnia status. Sleep duration, sleep timing, and depression symptoms were person-mean centered at level 1, such that deviations from 0 represented a deviation from the participants own mean during the study. Level 2 predictors included person-level sleep duration, sleep timing, depression symptoms, and insomnia status. Sleep duration, sleep timing, depression symptoms were grand-mean centered at level 2, such that deviations from 0 represented a deviation from the sample mean. As insomnia status is a dichotomous variable, the sum of instances of insomnia was calculated and grand-mean centered for use at level 2. We included depression symptoms and insomnia status as covariates at both levels to examine associations between sleep duration and sleep timing and postpartum anxiety symptoms over and above the effects of depression symptoms. Four interactions were also included: time × month-level sleep duration, time × month-level sleep timing, time × person-level sleep duration, and time × person-level sleep timing. The model included a random intercept at level 2 because the intraclass correlation (ICC) for anxiety symptoms was meaningfully large (ICC = .42).

The prospective model included the same level 1 and level 2 variables as the concurrent model, except person-mean centered lagged sleep duration and sleep timing were included as predictors instead of concurrent sleep duration and timing, and person-mean centered lagged anxiety symptoms were included as an additional covariate. The model included a random intercept at level 2 because the intraclass correlation (ICC) for anxiety symptoms was meaningfully large (ICC = .55). We also tested reverse prospective models to examine whether anxiety predicted subsequent sleep duration and timing.

Full information maximum likelihood (FIML) estimation was used, allowing persons with missing observations on the outcome to be retained under missing-at-random (MAR) assumptions. We removed the sleep item from the EPDS prior to inclusion in the model to limit multicollinearity with sleep duration and sleep timing. We likewise did not include medication status (“Have you been prescribed any medications for depression, anxiety or baby blues in the last month?”) to limit multicollinearity with depression symptoms. We also tested the multilevel model including demographic variables (age, race, relationship status, education level, household income, weeks at delivery, delivery type, and bassinet type) as covariates. No demographic variable significantly predicted postpartum anxiety, and the inclusion of these variables in the models largely did not change the pattern of significance (see Supplemental Tables 2 and 3). Thus, we report the models without demographic covariates.

Results

Descriptive statistics and associations between study variables

Sample demographic characteristics are shown in Table 1. Means, standard deviations, and bivariate correlations for study variables are shown in Table 2.

Table 1-.

Sample demographic data (N = 162).

n (%)
Race
White 126 (78.8%)
Black 3 (1.9%)
Alaskan Native 6 (3.8%)
Other Pacific Islander 13 (8.1%)
American Indian 12 (7.5%)
Relationship status
Married 152 (95.6%)
Living with partner 1 (0.6%)
Separated 6 (3.8%)
Education level
Middle school 12 (7.4%)
High school 30 (18.5%)
Technical school 57 (35.2%)
Trade school 10 (6.2%)
At least some college 53 (32.7%)
Total family income
Less than $10,000 3 (1.9%)
$10,000 to $19,999 9 (5.6%)
$20,000 to $34,999 19 (11.7%)
$35,000 to $49,999 27 (16.7%)
$50,000 to $74,000 32 (19.8%)
$75,000 to $99,000 62 (38.3%)
$100,000 to $149,999 10 (6.2%)
Baby sex
Female 66 (40.7%)
Male 96 (59.3%)
Delivery type
Vaginal (spontaneous) 111 (68.5%)
C-section scheduled 12 (7.4%)
C-section unplanned 21 (13.0%)
Scheduled vaginal induction 18 (11.1%)
Prescribed medications for depression or anxiety at least once during the first 6 postpartum months
Yes 29 (18.0%)
No 132 (82.0%)
Endorsed clinically significant anxiety at least once (GAD-7 10 or higher) during the first 6 postpartum months
Yes 67 (41.4%)
No 95 (58.6%)
Endorsed clinically significant depression at least once (EPDS 12 or higher) during the first 6 postpartum months
Yes 59 (36.4%)
No 103 (63.6%)
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Table 2-.

Associations between study variables (N=162).

Variable 1 2 3 4 5
1. GAD-7 --
2. EPDS .70** --
3. ISQ .10* .11** --
4. Sleep duration −.29** −.31** −.13** --
5. Mid-sleep −.04 .04 −.04 .07* --
Mean (SD) 5.01 (4.83) 6.28 (3.58) 1.31 (1.61) 6.47 (1.30) 02:44 (00:59)
Range 0–21 0–22 0–7 2–12 00:23–06:20
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Note. GAD-7=Generalized Anxiety Disorder-7; EPDS=Edinburgh Postnatal Depression Scale; ISQ=Insomnia Symptom Questionnaire. ISQ mean is mean instances of screening positive for insomnia.

*

p < .05;

**

p < .001.

Frequency of clinically significant postpartum anxiety symptoms versus clinically significant postpartum depression symptoms

Across 6 postpartum months, 41.4% exceeded the threshold for clinically significant postpartum anxiety symptoms at least once, and 36.4% exceeded the threshold for clinically significant postpartum depression symptoms at least once. These frequencies were not significantly different (p = .20). However, statistical comparison of the relative frequency of clinically significant anxiety versus depression symptoms at each postpartum month revealed that postpartum women were significantly more likely to report clinically significant anxiety symptoms than depression symptoms at postpartum month 2 (16.8% anxiety vs 9.0% depression; p < .05), month 4 (20.1% anxiety vs 10.7% depression; p < .001), and month 5 (19.8% anxiety vs 10.9% depression; p < .05). Postpartum women did not differ in likelihood of reporting clinically significant anxiety versus depression symptoms at postpartum month 1 (18.4% anxiety vs 13.0% depression; p = .14), month 3 (16.2% anxiety vs 9.9% depression; p = .06), and month 6 (19.3% anxiety vs 13.8% depression; p = .17) (see Supplemental Figure 1).

Change in sleep duration, sleep timing, and anxiety and depression symptoms from pregnancy to postpartum

There was a large, significant decrease in sleep duration from the third trimester of pregnancy across 6 months postpartum F(6, 711.65) = 48.01, p < .001, pη = .29, such that sleep duration was significantly lower at all 6 postpartum months compared to the third trimester of pregnancy (p’s < .001) (see Figure 1). Sleep timing did not significantly change from pregnancy to postpartum, F(6, 729.76) = 1.35, p = .23, pη = .01. There was a large, significant increase in anxiety from the third trimester of pregnancy across 6 months postpartum, F(6, 737.30) = 19.71, p < .001, pη = .14, such that anxiety was significantly higher at all 6 postpartum months compared to the third trimester of pregnancy (p’s < .001). There was a small, significant increase in depression from the third trimester of pregnancy across 6 months postpartum, F(6, 725.11) = 6.92, p < .001, pη = .05, such that depression was significantly higher at all 6 postpartum months compared to the third trimester of pregnancy (p’s < .05). See Supplemental Table 1 for estimated marginal means at each month.

Figure 1.

Figure 1.

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Marginal means of sleep duration (panel A), sleep timing (panel B), anxiety (panel C), and depression (panel D) from the third trimester of pregnancy to 6 months postpartum. Error bars show standard error of the mean. Asterisks indicate a significant difference compared to the third trimester of pregnancy *p < .05; **p < .001.

Concurrent associations between sleep duration, sleep timing, and postpartum anxiety over time

There was a significant main effect of month-level sleep duration on postpartum anxiety (p < .001), such that months with shorter sleep duration than typical for the individual were associated with higher concurrent postpartum anxiety symptoms (see Table 3).

Table 3-.

Unstandardized coefficients for the model examining concurrent associations between sleep duration and timing and postpartum anxiety symptoms (N=162).

Fixed effects Predictor Est SE p 95% CI (lower, upper)
Level 1 Time .43 .05 <.001 .34, .53
Month-level mid-sleep .12 .1 .70 −.49, .72
Month-level sleep duration −.88 .18 <.001 −1.24, −.52
Month-level EPDS .83 .04 <.001 .73, .91
Month-level ISQ .39 .29 .17 −.17, .95
Time x month-level midsleep .02 .09 .84 −.15, .19
Time x sample-level midsleep −.08 .07 .25 −.21, .05
Time x month-level sleep duration .16 .05 <.01 .06, .26
Time x sample-level sleep duration −.13 .06 <.05 −.25, −.01
Level 2 Sample-level mid-sleep −.12 .32 .72 −.74, .51
Sample-level sleep duration .26 .32 .42 −.37, .88
Sample-level EPDS 1.21 .08 <.001 1.05, 1.37
Sample-level ISQ −.04 .11 .72 −.26, .18
Variance components
Level 1 Residual variance 7.28 .38 <.001 6.54, 8.02
Level 2 Intercept variance 3.16 .51 <.001 2.17, 3.86
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Note. EPDS=Edinburgh Postnatal Depression Scale; ISQ=Insomnia Symptom Questionnaire. Month-level variables were person-mean centered, such that deviations from 0 represent deviations in a given month from one’s own average. Sample-level variables were grand-mean centered, such that deviations from 0 represent deviations from the sample average.

There was a significant interaction between time and month-level sleep duration to predict postpartum anxiety (p < .01). Simple slopes analyses revealed that those with shorter than typical sleep duration reported higher anxiety symptoms than those with longer than typical sleep duration in early postpartum months, whereas anxiety symptoms increased during later postpartum months regardless of sleep duration (see Figure 2). Examination of the confidence intervals around model-predicted values at each timepoint revealed that those who reported shorter than typical sleep duration reported significantly higher anxiety symptoms in the third trimester and first month postpartum than those who reported longer than typical sleep duration (see Supplemental Table 2).

Figure 2.

Figure 2.

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Panel A. Simple regression slopes of postpartum anxiety symptoms over time at values of concurrent month-level sleep duration. Month-level sleep duration was person-mean centered, such shorter and longer represent the person-mean ± 1 standard deviation. Both slopes were statistically significant (p’s < .05). Panel B. Simple regression slopes of postpartum anxiety symptoms over time at values of sample-level sleep duration. Sample-level sleep duration was group-mean centered, such shorter and longer represent the sample-mean ± 1 standard deviation. Both slopes were statistically significant (p’s < .05). Panel C. Simple regression slopes of sleep duration over time at values of month-level prospective postpartum anxiety symptoms. Month-level postpartum anxiety was person-mean centered, such lower and higher represent the person-mean ± 1 standard deviation. Only the lower anxiety slope was statistically significant (p < .05). The prospective model does not include the third trimester timepoint, which is missing in a lagged model.

There was also a significant interaction between time and sample-level sleep duration to predict postpartum anxiety (p < .05). Simple slopes analyses revealed those with shorter average sleep duration exhibited the greatest increase in anxiety symptoms from the third trimester to 6 months postpartum relative to those with longer average sleep duration (see Figure 3). However, this interaction effect was no longer statistically significant when demographic covariates were included in the mode (p = .12) (see Supplemental Table 3) and examination of the confidence intervals around model-predicted values at each timepoint revealed no statistically significant differences between those with shorter versus longer average sleep duration on anxiety symptoms at any timepoint (see Supplemental Table 2).

There was not a significant main effect of sample-level sleep duration or month- or sample-level sleep timing on postpartum anxiety symptoms (p’s > .05). There were not significant interactions between time and month- or sample-level sleep timing to predict postpartum anxiety symptoms (p’s > .05) (see Table 3).

Prospective associations between prior month’s sleep duration and sleep timing and next month’s postpartum anxiety over time

Neither neither prior month’s sleep duration nor sleep timing significantly predicted the subsequent month’s postpartum anxiety symptoms (p’s > .05), and neither prior month’s sleep duration nor sleep timing significantly interacted with time to predict the subsequent month’s postpartum anxiety symptoms (p’s > .05). Likewise, there was not a significant main effect of sample-level sleep duration or sleep timing on postpartum anxiety symptoms (p’s > .05) (see Table 4). Results were similar when including demographic covariates (see Supplemental Table 4).

Table 4.

Unstandardized coefficients for the model examining prospective associations between sleep duration and timing and postpartum anxiety symptoms (N=160).

Fixed effects Predictor Est SE p 95% CI (lower, upper)
Level 1 Time .19 .08 <.05 .03, .35
Month-level mid-sleep lagged −.14 .56 .80 −1.23, .95
Month-level sleep duration lagged .50 .33 .13 −.15, 1.15
Month-level EPDS lagged .19 .07 <.01 .06, .32
Month-level ISQ lagged .22 .38 .56 −.52., 96
Time x month-level mid-sleep lagged −.01 .13 .94 −.27, .25
Time x sample-level mid-sleep .08 .10 .45 −.12, .28
Time x month-level sleep duration lagged −.10 .08 .20 −.26, .05
Time x sample-level sleep duration −.15 .10 .11 −.34, .04
Level 2 Sample-level mid-sleep −.77 .49 .12 −1.73, .19
Sample-level sleep duration .18 .48 .71 −.77, 1.12
Sample-level EPDS 1.41 .10 <.001 1.22, 1.61
Sample-level ISQ −.09 .14 .50 −.36, .18
Variance components
Level 1 Residual variance 10.51 .61 <.001 9.32, 11.69
Level 2 Intercept variance 4.82 .40 <.001 2.74, 5.67
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Note. EPDS=Edinburgh Postnatal Depression Scale; ISQ=Insomnia Symptom Questionnaire. Month-level variables were person-mean centered, such that deviations from 0 represent deviations in a given month from one’s own average. Sample-level variables were grand-mean centered, such that deviations from 0 represent deviations from the sample average. The sample size is smaller due to the loss of data in lagged models.

Prospective associations between prior month’s postpartum anxiety and next month’s sleep duration and sleep timing over time

There was not a significant main effect of postpartum anxiety on sleep timing or significant time × month- or sample-level postpartum anxiety interaction (p’s > .05). However, there was a significant main effect of postpartum anxiety on sleep duration (p < .01), such that higher anxiety the prior month significantly predicted longer sleep duration the following month. There was also a significant time × postpartum anxiety interaction (p < .01). Simple slopes analyses revealed lower anxiety symptoms predicted shorter sleep duration in the earlier postpartum period but longer sleep duration in the later postpartum period (see Figure 2). Both the main effect and interactions remained significant with demographic covariates included in the model (see Supplemental Table 5), though examination of the confidence intervals around model-predicted values at each timepoint revealed no statistically significant differences between those with lower versus higher monthly anxiety symptoms on sleep duration at any timepoint (see Supplemental Table 2).

Discussion

The present study examined the relative frequency of and associations among clinically significant postpartum anxiety versus depression symptoms, change in sleep duration and timing, anxiety, and depression symptoms from late pregnancy through the first six months postpartum. We found that postpartum women were significantly more likely to report clinically significant anxiety symptoms than depression symptoms at 3 out of 6 postpartum months, and the frequency of clinically significant postpartum anxiety symptoms was nearly double that of clinically significant postpartum depression symptoms at half of the postpartum months. Sleep duration significantly decreased, and anxiety and depression significantly increased from pregnancy to postpartum, though sleep timing did not significantly change. We also found shorter sleep duration was associated with concurrent higher postpartum anxiety symptoms, particularly in the early postpartum months. In contrast, sleep timing was not significantly associated with concurrent postpartum anxiety symptoms. Further, neither sleep duration nor sleep timing prospectively predicted next-month’s postpartum anxiety symptoms. However, higher postpartum anxiety symptoms predicted longer next-month sleep duration, though this effect varied over time. These findings highlight the high prevalence of postpartum anxiety symptoms and the role of sleep duration in the experience of postpartum anxiety.

We observed that 41.4% of postpartum women with a history of depression reported clinically significant anxiety symptoms at least once during the 6 months postpartum. As would be expected, this rate is approximately twice that of clinically significant anxiety symptoms observed in the general postpartum population (i.e., 15–20%) (Farr et al., 2014; Paul et al., 2013; Wenzel et al., 2005). This high rate of anxiety is also consistent with the high levels of anxiety symptoms reported by perinatal women during the COVID-19 pandemic (Caffieri et al., 2024). We also found that the frequency of reporting clinically significant anxiety symptoms at least once during the 6 months postpartum did not significantly differ from the frequency of reporting clinically significant depression symptoms (i.e., 36.4%). Interestingly, however, we found that postpartum women with a history of depression were almost twice as likely to report clinically significant anxiety versus depression symptoms at postpartum months 2–5. These findings suggest that anxiety symptoms may be more persistent than depression symptoms across the first 6 months postpartum among at-risk women. Repeated measurement of anxiety and depression symptoms across the postpartum period may yield more accurate insight into prevalence (Field, 2018). As hypothesized, we found that anxiety and depression symptoms both significantly increased from pregnancy to postpartum. Interestingly, we found a large increase in anxiety symptoms and a small increase in depression symptoms. The difference in these effect sizes highlights the importance of anxiety in the postpartum mental health landscape and further indicates that postpartum anxiety is an understudied phenomenon deserving of additional research.

Reduced sleep duration is a hallmark feature of the postpartum period (Lee et al., 2000). Prior work has demonstrated a reduction in sleep duration from the third trimester of pregnancy to the early postpartum period across objective and subjective sleep measures, including 36 minutes as measured by polysomnography (Lee et al., 2000), 56 minutes as measured by actigraphy (Bei et al., 2010), and 89 minutes as measured by the PSQI (Bei et al., 2010). Here we found that subjective sleep duration decreased by 98 minutes from the third trimester of pregnancy to the first month postpartum, then increased slightly to ~6.5 hours on average across postpartum months 2–6. Still, subjective sleep duration remained significantly lower than pregnancy levels at all 6 postpartum months. Indeed, longitudinal studies suggest that sleep duration may not return to pregnancy levels until at least 12 months postpartum (Horwitz et al., 2023).

In contrast, sleep timing remained largely stable from pregnancy to 6 months postpartum. Few studies have examined changes in postpartum sleep timing, and findings are mixed. One study of first-time mothers found that wake time was significantly later in the first 2–4 weeks postpartum compared to the third trimester of pregnancy and subsequently significantly earlier at 12–16 weeks and 12–15 months (Wolfson et al., 2003), whereas another study found that both bedtimes and waketimes shifted progressively earlier across 24 months postpartum compared to the third trimester of pregnancy (Verma et al., 2023). Interestingly, in the former study, the development of clinically significant depression symptoms was associated with later wake times (Wolfson et al., 2003). Thus, the absence of a notable advance in sleep timing in our sample may reflect the at-risk nature of the sample. However, additional work is needed to clarify the naturalistic trajectory of postpartum sleep timing.

We also found that months with shorter sleep duration than was typical for the individual across the sampling period were months with higher concurrent anxiety symptoms. Prior work in community perinatal samples has demonstrated an association between greater sleep disturbance and higher anxiety symptoms in postpartum women (Okun et al., 2018; Okun and Lac, 2023). The present finding extends this work by demonstrating an association between reduced sleep duration and higher anxiety symptoms at the month level across 6 months postpartum, such that months characterized by shorter sleep duration than typical for the individual were months with higher anxiety. Further, we also found an interaction between time and month-level sleep duration, such that this association was strongest in the early postpartum months, whereas postpartum anxiety increased independent of month-level sleep in later postpartum months. We also found an interaction between time and sample-level sleep duration, such that the steepest increase in postpartum anxiety was observed in those with shorter average sleep duration across the sampling period. Notably, these effects were observed over and above the effect of insomnia status, suggesting shorter sleep duration is associated with postpartum anxiety independent of the influence of distress about sleep.

These distinct interaction effects suggest differences in the impact of acute versus sustained insufficient sleep on postpartum anxiety symptoms. Women may be most sensitive to the effects of acute insufficient sleep in the early postpartum period when sleep duration is lowest and the physical and mental demands of infant care are highest. Anxiogenic effects of acute insufficient sleep may diminish with time as average sleep duration steadily increases; that is, in the later postpartum months, a month characterized by shorter sleep duration on the backdrop of overall increasing sleep duration may have fewer adverse effects than a “double hit” on sleep duration in the early postpartum months. Further, these findings suggest that sustained short sleep duration across 6 months postpartum may amplify the observed increase in anxiety during this period. This increase may reflect changes in support and/or increases in external demands. That is, by 6 months postpartum, many women will have returned to work, and support from family and friends may have diminished. These factors, combined with sustained short sleep duration, may confer vulnerability for higher anxiety in later postpartum months. Still, it is important to note that this effect was no longer significant when demographic covariates were included in the model, and statistically significant differences were not detected at specific timepoints, suggestive of a weak effect. Additional work is needed to understand factors that contribute to increased postpartum anxiety over time.

In contrast, we found no prospective effects of prior month’s sleep duration nor sleep timing on the following month’s postpartum anxiety symptoms. This finding is surprising given prior work has found that insomnia symptoms longitudinally predict increased postpartum anxiety symptoms (Okun and Lac, 2023). These discrepancies suggest that distress about sleep disruption may have more predictive utility for postpartum anxiety symptoms than the quantity or timing of sleep. It may also be the case that distress about sleep disruption may be a stronger predictor of postpartum anxiety symptoms over longer periods of time (i.e., months), whereas specific components of sleep disruption may have more predictive utility over shorter periods of time (e.g., one day). Indeed, prior work in community samples found that shorter prior night’s sleep duration predicts higher next day anxiety (Cox et al., 2018b). Further, it is possible that the previously observed increase slow wave sleep concurrent with sleep duration reductions in the early postpartum period (Lee et al., 2000) may offset the longer-term impacts of sleep duration on anxiety symptoms. Interestingly, reverse models found a significant predictive relationship between postpartum anxiety and sleep duration that varied by time, such shorter sleep duration followed months with lower anxiety in the early postpartum period and longer sleep duration followed months with lower anxiety in the later postpartum period. Future research using ecological momentary assessment approaches is needed to identify predictors of postpartum anxiety on the daily level.

The frequency of clinically significant postpartum anxiety symptoms in this sample highlights the need for increased attention to and research on postpartum anxiety. Further, the association between shorter sleep duration and higher postpartum anxiety symptoms at the month level suggests that postpartum anxiety interventions may benefit from specifically targeting sleep. Cognitive behavior therapy for insomnia (CBTI) is a well-established psychotherapy for insomnia (Perlis et al., 2022), and is effective for reducing symptoms of insomnia and anxiety in pregnancy (Felder et al., 2020). However, 2 studies of CBTI in postpartum women found that CBTI reduced postpartum insomnia symptoms but not anxiety (Bei et al., 2023; Verma et al., 2022). Given that CBTI typically results in small increases in sleep duration (Perlis et al., 2022), other sleep-promoting treatments may have a more robust impact on anxiety. Light exposure may be one such target. Indeed, extant findings suggest that postpartum women are exposed to daytime light levels well below levels recommended for overall health (Brown et al., 2022; Tsai et al., 2009), as well as exposure to light at night from a variety of sources during nocturnal feedings (Mcbean and Montgomery-Downs, 2015). Insufficient daytime and excessive nighttime light exposure are known to disrupt sleep (Brown et al., 2022) and therefore may exacerbate the sleep disruption experienced during the postpartum period. Notably, one recent trial found that a phase-advance treatment, including morning bright light exposure, significantly reduced depression symptoms in women with postpartum depression (Parry et al., 2023). Though nascent, these findings suggest the need for future work examining associations between light exposure patterns and postpartum anxiety and the potential clinical utility of light therapy to improve sleep and mental health in the postpartum period.

Here in a sample of women with a history of depression, we found that clinically significant postpartum anxiety symptoms were more common than clinically significant postpartum depression symptoms in 4 out of 6 months, that anxiety symptoms significantly increased from pregnancy to the postpartum period and remained elevated across 6 months, and that shorter sleep duration was concurrently associated with higher postpartum anxiety symptoms at the month level, particularly in the early postpartum period. Prospectively, neither sleep duration or timing prospectively predicted next month’s anxiety, whereas the predictive association between anxiety and the next month’s sleep duration varied by time. Though this study has several strengths, including multiple assessment timepoints that allow for examination of change over time, a large sample size, and novel findings about postpartum anxiety, the results of this study must be considered within the context of the study limitations. First, this study was conducted in a convenience sample of women with a history of depression. Although this sample allows us to understand the association between sleep and postpartum anxiety symptoms in a clinically relevant sample, these findings must be replicated in women at risk for anxiety disorders. Similarly, we used the clinical threshold on the GAD-7 to indicate clinically significant anxiety symptoms, and future work should replicate these findings by assessing anxiety disorder diagnostic status. Further, it is possible that by excluding women who were currently depressed at enrollment, we excluded relevant participants whose depression onset during pregnancy, which could have implications for generalizability. Second, we measured sleep duration and timing with a retrospective self-report questionnaire, which may introduce retrospective bias. Relatedly, the single-item assessment used here does not provide insight into how sleep duration is curtailed (e.g., via sleep fragmentation) or why sleep duration is curtailed (e.g., nighttime feedings, insomnia). Future work is needed to replicate these findings using objective measures, such as actigraphy, to provide real-time assessment of the association between sleep duration and postpartum anxiety symptoms and provide a greater amount of detail into the nature of sleep disruption during the postpartum period. Third, the present sample was largely white, which may limit generalizability to other races and ethnicities. Fourth, data collection took place during the COVID-19 pandemic, which may have contributed to elevated rates of clinically significant depression and anxiety symptoms. Fifth, some factors could influence both sleep and anxiety symptoms in the postpartum period that we did not assess, such as social support, breastfeeding, and infant sleep. Although beyond the scope of the present study, future work should examine whether the relation between sleep duration and postpartum anxiety may be moderated by these factors. Despite these limitations, the present findings highlight the importance of sleep duration for postpartum anxiety and suggest the need for additional research to better understand the etiology and predictors of postpartum anxiety.

Supplementary Material

1

Table 5.

Unstandardized coefficients for the models examining reverse prospective associations between postpartum anxiety symptoms and sleep duration and timing.

Sleep duration (N=162)
Fixed effects Predictor Est SE p 95% CI (lower, upper)
Level 1 Time .160 .023 <.001 .12, .21
Month-level GAD-7 lagged .09 .03 <.01 .03, .16
Month-level sleep duration lagged −.02 .04 .53 −.10, .05
Month-level EPDS lagged −.002 .02 .94 −.04, .04
Month-level ISQ lagged .02 .11 .91 −.20, .23
Time x month-level anxiety lagged −.02 .01 <.01 −.04, −.01
Time x sample-level GAD-7 .003 .01 .57 −.01, .02
Level 2 Sample-level GAD-7 −.02 .04 .59 −.11, .06
Sample-level EPDS −.08 .05 .08 −.18, .01
Sample-level ISQ −.04 .04 .36 −.13, .05
Variance components
Level 1 Residual variance .91 .05 <.001 .81, 1.01
Level 2 Intercept variance .49 .08 <.001 .34, .64
Sleep timing (N=160)
Fixed effects Predictor Est SE p 95% CI (lower, upper)
Level 1 Time −.04 .02 <.01 −.08, −.01
Month-level GAD-7 lagged .02 .02 .50 −.03, .06
Month-level sleep timing lagged −.03 .04 .38 −.11, .04
Month-level EPDS lagged .02 .01 .20 −.01, .04
Month-level ISQ lagged −.01 .08 .88 −.16, .14
Time x month-level GAD-7 lagged −.002 .01 .64 −.01, .01
Time x sample-level GAD-7 −.01 .01 .14 −.02, .002
Level 2 Sample-level GAD-7 −.02 .09 <.001 −.09, .05
Sample-level EPDS .07 .05 .14 −.02, .17
Sample-level ISQ −.03 .04 .54 −.11, .06
Variance components
Level 1 Residual variance .41 .02 <.001 .36, .46
Level 2 Intercept variance .56 .07 <.001 .42, .71
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Note. EPDS=Edinburgh Postnatal Depression Scale; ISQ=Insomnia Symptom Questionnaire; GAD-7=Generalized Anxiety Disorder-7. Month-level variables were person-mean centered, such that deviations from 0 represent deviations in a given month from one’s own average.

Sample-level variables were grand-mean centered, such that deviations from 0 represent deviations from the sample average.

Highlights.

  • Anxiety symptoms increased from third trimester to 6 months postpartum

  • Months with shorter sleep duration were months with higher anxiety

  • This effect was strongest in the early postpartum months

  • Sleep duration, sleep timing did not predict subsequent month’s anxiety

Funding:

This work was supported by Happiest Baby, Inc.; NIH T32HL149646

Footnotes

Conflict of interest statement: The authors declare no conflict of interest.

Declaration of interests

The authors declare the following financial interests/personal relationships which may be considered as potential competing interests:

Michele Okun reports financial support was provided by Happiest Baby. Rebecca Cox reports financial support was provided by National Institutes of Health. Michele Okun reports a relationship with Happiest Baby that includes: consulting or advisory. If there are other authors, they declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Financial Disclosure: Michele Okun was a paid consultant for Happiest Baby Inc. until April 2023. Happiest Baby Inc. provided funding for this study.

CRediT authorship contribution statement. Rebecca C. Cox: Conceptualization, Formal analysis, Writing-Original draft, Visualization. Brandon S. Aylward: Methodology, Resources, Data curation, Writing-Review & editing; Isabella Macarelli: Data Curation, Writing-Review & editing; Michele Okun: Conceptualization, Methodology, Investigation, Resources, Writing-Review & editing, Supervision, Project administration, Funding acquisition.

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