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New mothers are tired. There aren't many guarantees in this business, but that's one of them. New mothers do not get enough sleep. It's irrefutable and universal. To further obscure the picture, sleep problems crossover between cause and effect variables with respect to postpartum depression. In other words, sleep disturbances can contribute to the development of postpartum depression, and they can be a symptom of postpartum depression. Either way, sleep problems require our immediate attention.
Hormonal fluctuations can interfere with sleep during early pregnancy, the growing fetus can make it difficult to sleep comfortably later on in the pregnancy, and newborn care typically involves numerous nighttime awakening periods after the baby is born. All of these changes in sleep patterns and the associated fatigue can affect a woman's physical and mental well-being, her relationships, her employment, and her ability to adjust to the new role of parent.
"I just need to get some sleep," a woman reports. "Everything will be fine if I just get some sleep."
This may very well be true. Or it may be the last thing she says before she takes a handful of sleeping pills.
As most new mothers can attest, going too long with too little sleep can quickly turn things from bad to worse. Once a cycle of insomnia sets in, and women report that they are unable to sleep even when the baby is sleeping, we have relevant diagnostic information. If a woman reports being exhausted yet able to sleep when her baby is sleeping, this is good. She may not be getting as much sleep as she'd like, and surely she is weary beyond words, but this is a different clinical presentation from the mother who reports that her baby sleeps better than she does.
Consider these two responses to the question: Are you able to sleep when your baby sleeps?
"Are you kidding? That's all I do when he sleeps. Crib side goes up, and I'm half asleep by the time my head hits the pillow!"
"I wish I could. I lay in bed with thoughts racing around in my head, thinking what I'm doing tomorrow, wondering why I did what I did today, all the time thinking, I wish I could sleep."
Insomnia associated with postpartum depression is common and is often treated with medication to break the self-perpetuating cycle. This is particularly the case when the insomnia presents in the middle of the night, referred to as early morning wakening, since this type of insomnia is a hallmark symptom of depression. Initial insomnia, characterized by difficulty falling asleep, is often associated with anxious thoughts and ruminations that interfere with the body's ability to unwind and prepare for sleep.
When you ask a new mother how much sleep she is getting, you may receive any number of insufficient answers:
"Not enough."
"I haven't slept at all in seven nights."
"I don't sleep at all anymore."
"I don't think I'll ever sleep again."
A new mother with depression may be less likely to see the humor in this question and typically responds with a more somber haziness, such as, "I don't know." The space between wakefulness and the so-desired, but unattainable, promise of sleep feels insurmountable. When she says, "I'm so tired," you can practically feel it. It's no longer just about sleep. It's about her body betraying her, it's about defeat, and it's about the shutting down of her system.
It's important that we get a clear sense of how much sleep she is actually getting. As we've seen, asking general questions will elicit unsatisfactory answers. We need to be specific:
- How many hours of sleep do you think you are getting?
- Tell me about a typical night's sleep. When do you go to bed? How many times do you awaken? Why do you awaken (e.g., crying baby, restlessness, panic, etc.)?
- How much sleep were you used to getting before the baby?
- How much sleep do you think you need to function at your best?
- Did you have any history of sleep problems before the baby?
- Do you feel you could sleep if your baby were sleeping better?
Many postpartum women want to believe that sleep is the answer. This simplifies things for them, and it de-pathologizes it: I'm not sick; I'm just tired. However, keep in mind that most postpartum women who present with insomnia are not just having sleep problems, even if that is the only one they identify. Experts claim that most postpartum women who cannot sleep when their babies sleep are also suffering from symptoms of depression and anxiety, which are contributing to their sleep disturbance. With acute anxiety, sleep can become the object of their obsession: What if I don't sleep again tonight? I can't go one more night without sleep. How will I function with no sleep? How can my husband sleep through the night like this? If I go another night without sleeping, I know I'll really go crazy.
So it's not just about sleep. You will find that when depression and anxiety are treated, the sleep generally improves.
Adapted from Therapy and the Postpartum Woman (Routledge, 2009)
copyright 2012 Karen Kleiman
