Association of depression, anxiety, and insomnia in hypertensive disorders in pregnant women

Abstract

BACKGROUND

Insomnia in patients with hypertensive disorders in pregnancy (HDP) appears closely associated with depression and anxiety, though this relationship requires further validation.

AIM

To examine the inter-relationships among depression, anxiety, and insomnia in women with HDP.

METHODS

A total of 122 HDP cases were enrolled from January 2021 to January 2025. The Patient Health Questionnaire-9 (PHQ-9) was used to evaluate depressive symptoms, while the Generalized Anxiety Disorder-7 (GAD-7) assessed anxiety. Sleep duration, sleep efficiency, and insomnia were measured using the Pittsburgh Sleep Quality Index (PSQI). Spearman’s r determined inter-scale correlations. Determinants influencing depression and anxiety were identified via univariate and multivariate analyses.

RESULTS

Among the 122 women with HDP, 20.49% exhibited depression and 24.59% had anxiety. The mean PHQ-9 and GAD-7 scores were 4.00 (3.00, 4.00) and 4.00 (3.00, 4.25), respectively. As pregnancy progressed, participants showed reduced sleep duration and efficiency, higher PSQI total scores, and an increased proportion of poor sleepers. Across all gestational stages, PHQ-9 and GAD-7 scores were positively correlated with PSQI results. Depression and anxiety were independently associated with a prior HDP history, limited spousal support, PSQI > 5, and monthly income < 4000 yuan, as confirmed using both regression models.

CONCLUSION

Depression and anxiety in HDP are positively and strongly to insomnia. Women with HDP face higher risk of depression and anxiety if they have a history of HDP, limited spousal support, PSQI > 5, or monthly income < 4000 yuan.

Key Words: Hypertensive disorders in pregnancy; Pregnant women; Depression; Anxiety; Insomnia

Core Tip: Few studies have examined the correlation between depression, anxiety, and insomnia in hypertensive disorders in pregnancy (HDP). In this study, 122 HDP cases were analyzed for these variables. Depression and anxiety were closely associated with insomnia. Previous HDP history, limited spousal support, Pittsburgh Sleep Quality Index > 5, and monthly income < 4000 yuan elevated depression and anxiety risks in HDP.

INTRODUCTION

Hypertensive disorders in pregnancy (HDP) are defined by abnormal elevations in systolic and/or diastolic blood pressure during gestation. HDP represents a major cause of maternal mortality and adverse perinatal outcomes[1]. Affecting 4%-25% of pregnancies, its morbidity and mortality remain particularly high in developing nations[2]. As part of the placental syndrome spectrum, its pathogenesis likely involves oxidative stress, inflammatory activation, dyslipidemia, insulin resistance, and endothelial dysfunction[3]. HDP also confers long-term cardiovascular risks for newborns, who may have 2-4 times higher likelihood of developing heart failure later in life[4,5]. Owing to the fears surrounding pregnancy and childbirth, combined with physical and psychological burden of HDP, affected women experience greater psychological stress and higher rates of depression and anxiety than those with normotensive pregnancies[6]. Depression and anxiety commonly manifest as persistent low mood, loss of interest, and diminished pleasure, which disrupt normal work, social interactions, and daily routines, often leading to insomnia. This, in turn, compromises blood pressure control and reduces therapeutic efficacy[7]. Depression and anxiety during pregnancy have also been shown to increase the risk of developing HDP, thereby complicating management[8,9]. The incidence hypertension, depression, and anxiety during pregnancy each exceeds 20% and tends to worsen as the pregnancy progresses[10]. Moreover, pregnant women have a high prevalence of insomnia (38%) and obstructive sleep apnea (15%). Poor sleep contributes to adverse events such as preterm birth, cesarean section, hypertension, gestational diabetes, and prolonged labor[11].

Limited research has explored the inter-relationships among depression, anxiety, and insomnia in HDP. We hypothesize that depression and anxiety are related to insomnia in these patients and that clarifying their correlations and the key influencing factors may facilitate improved pregnancy management.

MATERIALS AND METHODS

Case selection

Inclusion criteria: (1) Confirmed HDP diagnosis[12]; (2) Naturally conceived singleton gestation; (3) Maternal age ≥ 20 years; (4) Live-born infant without congenital anomalies; and (5) Complete clinical data.

Exclusion criteria: (1) Hypertension secondary to renal artery stenosis; (2) Hospitalization during pregnancy; (3) Coexistence of other pregnancy-related complications; (4) Hearing impairment, cognitive deficits, or previous mental illness; (5) Severe maternal diseases affecting the heart, liver, or kidneys; (6) Malignant neoplasms; (7) Infectious disease; (8) Psychiatric history (self or immediate family) before pregnancy; and (9) Recent major non-disease-related stressors or life changes.

A total of 122 pregnant women with HDP, admitted to The Third Affiliated Hospital of Soochow University between January 2021 and January 2025, were included according to inclusion/exclusion criteria.

Data collection and quality control

Two trained researchers independently retrieved the required data from the hospital's electronic medical record system based on a pre-designed case report form. Following data extraction, a cross-check was conducted. In case of any inconsistencies, a third senior researcher would review the original medical records and make the final decision.

Quality control: To ensure data accuracy and completeness, we established unified standards and definitions for data extraction. The definitions of key variables (e.g., anxiety, depression) were standardized based on clinical guidelines. The extracted data all underwent comprehensive a logical check and range verification. For any logical contradictions found, they were confirmed and corrected by re-checking the original medical records.

Data collection and outcome measurement

Depression: Depressive symptoms were assessed using the Patient Health Questionnaire-9 (PHQ-9)[13], a 9-item scale rated on a 4-point Likert system, including 0 ("not at all"), 1 ("a few days"), 2 ("more than half the days"), and 3 ("almost every day"), totaling 0-27 points. Depression severity was categorized as 0-4 (none), 5-9 (mild), 10-14 (moderate), 15-19 (severe), 20-27 (extremely severe); scores ≥ 5 indicated depression. The Cronbach’s α of the scale was 0.86, and test-retest reliability was 0.95.

Anxiety: Anxiety levels were evaluated using the Generalized Anxiety Disorder-7 (GAD-7)[14], a 7-item Likert scale scored 0 (none), 1 (a few days), 2 (more than half of the time), and 3 (almost every day). Severity was classified as 0-4 (none), 5-9 (mild), 10-14 (moderate), and 15-21 (severe), with anxiety defined as ≥ 5. Cronbach’s α was 0.92, and test-retest reliability was 0.83.

Insomnia: Sleep duration, efficiency, and quality were evaluated. Sleep duration referred to the time from falling asleep at night to morning awakening; sleep efficiency was the percentage of total asleep relative to time in bed. Sleep quality was assessed using the Pittsburgh Sleep Quality Index (PSQI)[15], which scores range from 0 (optimal sleep) to 21 (severe impairment). A score > 5 indicated poor sleep quality.

Other clinical data: Additional variables included age, gestational age, education, previous HDP history, spousal support level, and monthly income, used to identify depression- or anxiety-related determinants in women with HDP. Spousal support was assessed using a single question with high, fair, and low options; participants reporting high spousal support were categorized as the high-care group, and all others as low-care.

Statistical analysis

Continuous data were expressed as mean ± SD. or the median (interquartile range). For the comparison of continuous variables across multiple time points, repeated measures analysis of variance or the Friedman test was used; categorical variables (expressed as percentages) were compared using χ² tests. All analyses were performed using Statistical Package for the Social Sciences version 21.0. Spearman correlation assessed relationships among PHQ-9, GAD-7, and PSQI scores in HDP-complicated pregnancies. Variables significant in univariate analyses were included in logistic regression models. Statistical significance was set at α = 0.05.

RESULTS

Depression and anxiety in HDP-affected pregnancies

The PHQ-9 and GAD-7 scales were used to screen for depressive and anxiety symptoms in 122 HDP-complicated pregnancies (Tables 1 and 2), respectively. Among the participants, 25 (20.49%) experienced depression, all mild, with a mean PHQ-9 score of 4.00 (3.00, 4.00). Anxiety was present in 24.59% of the group, mostly mild (30 cases; mean GAD-7: 4.00 (3.00, 4.25).

Table 1 Depressive symptoms in hypertensive disorders in pregnancy-affected pregnant women, n (%)/M[Q1, Q3].

Depression status
Normal (0-4 points)	97 (79.51)
Mild depression (5-9 points)	25 (20.49)
Moderate depression (10-14 points)	0 (0.00)
Severe depression (15-19 points)	0 (0.00)
Extremely severe depression (20-27 points)	0 (0.00)
Depression (5-27 points)	25 (20.49)
Total Patient Health Questionnaire-9 score (0-27 points)	4.00 (3.00, 4.00)

Table 2 Anxiety status in hypertensive disorders in pregnancy-affected pregnant women, n (%)/M[Q1, Q3].

Anxiety status
Normal (0-4 points)	92 (75.41)
Mild anxiety (5-9 points)	30 (24.59)
Moderate anxiety (10-14 points)	0 (0.00)
Severe anxiety (15-21 points)	0 (0.00)
Anxiety (5-21 points)	30 (24.59)
Total Generalized Anxiety Disorder-7 score (0-21 points)	4.00 (3.00, 4.25)

Insomnia status in HDP cases

Insomnia was assessed using the PSQI score (poor sleep defined as > 5), sleep duration, and sleep efficiency (Table 3). As pregnancy progressed, both sleep duration and efficiency gradually decreased, where total PSQI scores and the proportion of HDP cases with poor sleep quality gradually increased.

Table 3 Insomnia-related parameters in hypertensive disorders in pregnancy-complicated pregnancies, n (%)/M[Q1, Q3].

Insomnia status	12-16 weeks	24-28 weeks	32-36 weeks	F/χ2	P value
Sleep duration (minutes)	464.86 ± 50.41	430.98 ± 61.76	411.28 ± 59.23	27.250	< 0.001
Sleep efficiency (%)	84.38 ± 8.87	77.33 ± 10.86	69.88 ± 12.85	53.200	< 0.001
Total Pittsburgh Sleep Quality Index score (0-21 points)	6.00 (4.00, 9.00)	8.00 (5.00, 10.00)	10.00 (7.00, 13.00)	27.416	< 0.001
Poor sleep quality (> 5 points)	74 (60.66)	87 (71.31)	100 (81.97)	13.542	0.001

Depression, anxiety and insomnia in HDP: Interrelationship analysis

Inter-scale relationships were analyzed using Spearman’s correlation (Figure 1). Both PHQ-9 and GAD-7 showed positive correlations with PSQI scores throughout pregnancy (r = 0.282-0.302, P < 0.01; r = 0.228-0.420, P < 0.05; Table 4).

Figure 1 Correlation patterns of depressive/anxiety symptoms and insomnia in hypertensive disorders in pregnancy-complicated pregnancies. A: Early-pregnancy (12-16 weeks) depression (Patient Health Questionnaire-9) and insomnia [Pittsburgh Sleep Quality Index (PSQI)] correlations; B: Depression-insomnia links at mid-pregnancy (24-28 weeks); C: Late gestation (32-36 weeks) associations between Patient Health Questionnaire-9 and PSQI measures; D: Relationship between Generalized Anxiety Disorder-7 (GAD-7) scores (anxiety) and PSQI at 12-16 weeks among hypertensive disorders in pregnancy-positive women; E: GAD-7 and PSQI associations in the second trimester (24-28 weeks); F: Connection between GAD-7 and PSQI scores at 32-36 weeks in women with hypertensive disorders in pregnancy. GAD-7: Generalized Anxiety Disorder-7; PHQ-9: Patient Health Questionnaire-9; PSQI: Pittsburgh Sleep Quality Index.

Table 4 Univariate assessment of potential contributors to depressive and anxiety symptoms among pregnant women diagnosed with hypertensive disorders in pregnancy.

Variable	Pittsburgh Sleep Quality Index (score)
	12-16 weeks	24-28 weeks	32-36 weeks
Patient Health Questionnaire-9 (score)	r = 0.302, P < 0.001	r = 0.298, P < 0.001	r = 0.282, P = 0.002
Generalized Anxiety Disorder-7 (score)	r = 0.228, P = 0.012	r = 0.411, P < 0.001	r = 0.402, P < 0.001

Analysis of influencing factors of depression and anxiety in pregnant women with HDP

Participants were grouped based on their PHQ-9 and GAD-7 scores. The anxiety/depression group (n = 50) included those scoring > 4 on either scale; the remaining 72 comprised the control group. Univariate analysis showed no significant effects of maternal age, gestational age, and education level (P > 0.05), but identified prior HDP history, spousal support, PSQI scores, and monthly income as significant predictors (P < 0.05). Multivariate logistic regression confirmed these four factors as independent contributors (P < 0.05; Tables 5 and 6).

Table 5 Univariate assessment of potential contributors to depressive and anxiety symptoms among pregnant women diagnosed with hypertensive disorders in pregnancy, n (%).

Variable	Number	Anxiety/depression group (n = 50)	Normal control group (n = 72)	χ2	P value
Maternal age (years)				3.642	0.056
< 35	73	35 (70.00)	38 (52.78)
≥ 35	49	15 (30.00)	34 (47.22)
Gestational age (weeks)				3.046	0.081
< 37	52	26 (52.00)	26 (36.11)
≥ 37	70	24 (48.00)	46 (63.89)
Educational background				1.999	0.157
Senior high school or below	47	23 (46.00)	24 (33.33)
Above senior high school	75	27 (54.00)	48 (66.67)
Previous hypertensive disorders in pregnancy history				6.367	0.012
No	110	41 (82.00)	69 (95.83)
Yes	12	9 (18.00)	3 (4.17)
Spousal care level				5.612	0.018
Low	75	37 (74.00)	38 (52.78)
High	47	13 (26.00)	34 (47.22)
Pittsburgh Sleep Quality Index (points)				8.715	0.003
≤ 5	84	27 (54.00)	57 (79.17)
> 5	38	23 (46.00)	15 (20.83)
Monthly income (yuan)				5.686	0.017
< 4000	74	24 (48.00)	50 (69.44)
≥ 4000	48	26 (52.00)	22 (30.56)

The data for Pittsburgh Sleep Quality Index > 5 represents the count of patients experiencing poor sleep quality across all gestational stages.

Table 6 Independent predictors of depression and anxiety in hypertensive disorders in pregnancy-complicated pregnancies by multivariate analysis.

Variable	B	SE	Wald	P value	Odds ratio (95%CI)
Previous hypertensive disorders in pregnancy history	1.587	0.773	4.213	0.040	4.887 (1.074-22.234)
Spousal care level	-0.971	0.450	4.656	0.031	0.379 (0.157-0.915)
Pittsburgh Sleep Quality Index (points)	1.135	0.457	6.177	0.013	3.113 (1.271-7.620)
Monthly income (yuan)	-1.480	0.458	10.451	0.001	0.228 (0.093-0.558)

DISCUSSION

In this study, 122 HDP-complicated women had mean PHQ-9 and GAD-7 scores of 4.00 (3.00, 4.00) and 4.00 (3.00, 4.25), respectively. Depression occurred in 20.49% and anxiety in 24.59% of participants. Benute et al[16] reported that approximately one-fifth of women experience depressive symptoms during pregnancy and the puerperium, consistent with our findings. Another study noted a 25% maternal anxiety prevalence at 23-36 weeks’ gestation[17], also aligning with these results. Greater depressive symptoms in pre-eclamptic HDP patients have been reported to be linked to poorer coping strategies[18], supporting our observations. Pathophysiologically, depression and anxiety in HDP cases may relate to increased coagulation factor activity (II, VI, VII, IX, and X) during pregnancy and to abnormal activation of the sympathetic nervous system and hypothalamus pituitary adrenal axis[19-21]. Although psychological symptoms in our cohort were mild, HDP-induced physical stress (e.g., headache, edema) and therapeutic drugs-induced side effects may exacerbate mood disturbances and sleep impairment[22-24].

Moreover, as the pregnancy progressed, the insomnia symptoms in the cases of HDP gradually worsened (from approximately 464.86 hours to approximately 411.28 hours in sleep duration, from approximately 84.38% to approximately 69.88% in sleep efficiency, from approximately 6.53 points to approximately 9.81 in the total PSQI score, and from approximately 60.66% to approximately 81.97% in poor sleep quality). Similarly, Chang et al[25] reported worsening sleep quality in pregnant women as gestation progressed, supporting our findings. Wang et al[26] reported that HDP patients are also affected by persistent hypertension after delivery, and 81% of patients have poor sleep quality, aligning with our findings. Premenstrual syndrome history, severe pregnant vomiting, obstructive sleep apnea syndrome, vitamin B12 deficiency, and other factors may affect the sleep disorder of pregnant women[27]. Furthermore, changes in estrogen, progesterone, oxytocin, prolactin, cortisol, and melatonin levels in pregnancies will dynamically affect patients’ sleep patterns, having cross-effects on the cardiovascular system, gastrointestinal tract, hematology, and metabolism, partially explaining changes in the insomnia status in our cohort[28].

Throughout gestation, depression and anxiety had weak-to-moderate positive correlation with PSQI score (P < 0.05). To determine psychological distress-related risk factors, we conducted regression analyses, identifying previous HDP history, low spousal support, PSQI > 5, and monthly income < 4000 yuan as independent risk factors. Zhu et al[29] reported that family functions play an intermediary role between pregnancy-related anxiety and sleep quality, partially explaining the relationship between anxiety in HDP and sleep quality. Simultaneously, it also indirectly suggests that the low degree of spousal support may negatively affect the sleep quality in HDP. Nabwire et al[30] reported that low income, troubled relationships with one’s spouse, and a prior HDP history are significant contributors to anxiety disorders in pregnant women, mirroring our study’s results. Furthermore, they suggest that interventions spanning mental health support, social aid, and partner participation may alleviate anxiety in expectant mothers.

This study has several limitations. First, the single-center sample collection and limited cases included limited result generalizability, warranting validation using multi-center and larger-scale research. Second, as a retrospective study, we were unable to include more objective sleep metrics (e.g., actigraphy) or detailed sleep diary data. Therefore, more objective sleep indicators should be supplemented in the future to comprehensively reflect sleep disorders. Finally, the spousal support level was only evaluated using a single question, potentially affecting variable validity; more mature and detailed evaluation tools should be adopted in future research.

CONCLUSION

Depression was experienced by 20.49% of HDP-complicated pregnant women, while was experienced anxiety by 24.59%. Furthermore, insomnia exacerbation correlated positively with gestational progression, while poor sleep quality also correlated strongly with these psychological issues. Several factors were found to increase depression and anxiety risks in HDP-affected pregnant women, including a prior history of HDP, limited spousal support, a PSQI score > 5, and a monthly income < 4000 yuan.