Depression and Sleep Disorders

Troubled sleep, insomnia, and oversleeping are classic symptoms of clinical depression. While not all depressed people have sleep disorders, many do. When evaluating patients for depression, doctors typically ask about sleep patterns as part of the diagnosis.

Problematically, sleep problems worsen mood and can cause depression themselves, creating a vicious cycle.

The CDC estimates that just over 7 percent of Americans have moderate or severe depression. The severity and symptoms of depression vary, but the most common include:

• Feelings of despair, hopelessness, sadness
• Frequent or occasional thoughts of death or suicide
• Difficulty concentrating
• Lower energy
• Lower libido
• Reduced self-esteem
• Weight gain or loss
• Loss of interest in activities the person formerly enjoyed
• Excessive daytime sleepiness
• Insomnia

Sleep problems are core symptoms of depression. Both depression and severe sleep problems are major risk factors for suicide and health problems like heart disease, other mental disorders, and smoking. People with depression have trouble being productive in work or school, which can impact their career and social life. The sleep issues are often one of the reasons depressed people seek out professional help.

The symptoms of depression are persistent and pervade all aspects of an individual’s’ life, from work and play to basic needs like eating and sleeping. Within the larger category of depression, there are several different types of depression which come with their own sleep problems:

• Major Depressive Disorder: This is extreme depression where the individual feels sad, hopeless, or suicidal through much of the day, regardless of what they are doing. Feelings of pleasure and happiness are hard to come by. Major depression is associated with insomnia and excessive daytime sleepiness.
• Dysthymia: This is a milder form of major depression, also associated with fragmented sleep and hypersomnia. People with dysthymia experience fewer symptoms from the list above and in a less intense way, but symptoms typically persist for much longer.
• Bipolar Disorder: People with bipolar disorder swing between extreme highs and lows. When they’re high, they’re overly energetic and unable to sleep, even if they’re tired. When they’re low, they oversleep.
• Seasonal Affective Disorder (SAD): SAD is a type of seasonal depression. The vast majority of affected individuals experience it during the winter months, with symptoms like hypersomnia, insomnia, and worsened mood – although about 10 percent experience it during the summer. SAD is likely brought on by the changing levels of sunlight, which affect the circadian rhythms of affected individuals, messing with their sleep and emotions.

Who’s at risk for depression? Stress, a recent loss or illness diagnosis, and family history are all risk factors for depression.

Anyone can become depressed, but it affects some people more than others, particularly women and adults in middle age. Coincidentally, these two groups are also more likely to have insomnia. The chart below from the CDC reveals the correlation between age and depression as well as the disproportionate prevalence between the genders:

 

The sleep problems brought on by depression – or the ones that caused it in the first place – make it much more difficult to get better. Sleep deprived people have stronger emotional reactions in general, so it’s tougher to regulate the emotional volatility associated with depression.

Abnormal sleep interferes with mood and energy levels during the day, so it’s difficult to stay motivated to engage with others, exercise, and even go to work. To cope, people who are depressed may self-isolate, which can lead to more sleep problems: loneliness itself is associated with fragmented sleep.

The cause-and-effect runs both ways.  Even if you’re not depressed, lack of sleep increases your chances of depression and other mental illnesses. Depression causes insomnia and hypersomnia.

An article in the Journal Sleep reported that children with both insomnia and hypersomnia are more likely to be depressed, to be depressed for longer periods of time, and to experience additional problems such as weight loss.

Particularly for young adults, there is a strong correlation between insomnia and major depressive disorder. Genes involved in the molecular clock and circadian cycle are known to be involved with bipolar disorder, although nobody exactly knows how. When scientists examine mice with mutations in the so-called CLOCK gene (important in the circadian cycle), they find the mice act like humans with mania. When the mice are given lithium (a treatment for bipolar disorder), their behavior reverts to normal. So it appears that this important part of the sleep control cycle is tied up with mood and mood disorders.

Teens who don’t get enough sleep are at a significantly greater risk for depression and suicide.

Depression makes achieving quality sleep difficult, and it leads to serious sleep issues and even disorders. We’ll review each of these below.

Changes in REM Sleep

The impact of depression on sleep is not accidental. EEG tests of depressed patients show they have a longer sleep latency, spend less time in slow-wave sleep, shift REM sleep to earlier in the night, and experience sleep maintenance insomnia (they wake up during the night).

The effects on REM sleep are especially intriguing to researchers. REM (rapid eye movement) sleep abnormalities result in brain activity patterns similar to those seen in depression.  Indeed, during REM parts of the brain exhibit similar electrical activity to that in depressed people.  And depressed people have their first REM session earlier in the night than non-depressed people. The worse the depression, the earlier the REM, and in bad cases the sequence of sleep stages is upset and the first REM period happens before the first deep sleep period. Given the importance of this first deep sleep period to growth hormone and the body’s maintenance, this pattern is particularly detrimental.

Scientists have found that patients with major depressive disorder have high activity in the ventromedial prefrontal cortex (vmPFC) coupled with low activity in dorsolateral prefrontal cortex section of the brain. Scientists are working out the details, but this may provide a clue to why REM activity increases in depressed patients.

The image below compares the sleep architecture of a healthy individual (top) vs. one with depression (bottom). It shows the overall shorter sleep time, reduced REM latency, and more disturbed sleep.

Insomnia

Insomnia describes a difficulty falling or staying asleep. It’s pretty common – one in three people in the US experience insomnia at some point in their lives.

Unfortunately, people with insomnia are ten times more likely to develop depression than people without, and 83 percent of depressed individuals display insomnia symptoms.

It is easy to think of reasons why insomnia might lead to depression: it is extremely frustrating and causes a person to lie awake at night and ruminate on unpleasant thoughts. Then, the excessive daytime sleepiness the following day reduces their general quality of life.

Even though scientists still don’t fully understand what causes depression or sleep disorders, they have found neurochemical links between the two. Corticotropin-releasing factor (CRF) is a neuropeptide and is found in elevated levels in people with depression and anxiety disorders. It also is found in high levels in many insomniacs. The hypothalamic-pituitary-adrenal (HPA) axis is stimulated perhaps excessively in both depressed people and insomniacs.

Hypersomnia

Hypersomnia is basically the opposite of insomnia. It’s characterized by extreme oversleeping, and not feeling refreshed in spite of that.

Hypersomnia occurs in 40 percent of young adults with depression, and is more common in women. It’s much more prevalent in younger individuals than older (40 percent vs 10 percent).

Sleep Apnea

Sleep apnea describes a condition where the individual literally stops breathing momentarily while sleep. When the brain kicks in to start breathing again, it interrupts the sleep cycle, so even if the person does not wake up, it can still lead to sleep deprivation.

People with apnea are more likely to suffer from depression, and even people without true apnea, but who snore, are more likely to be depressed.  This relationship is particularly strong in men.

A large scale study of nearly 19,000 people found that those with depression were over 5 times more likely to have obstructive sleep apnea or another form of sleep-disordered breathing.

Restless Leg Syndrome

Restless leg syndrome (RLS) is another common comorbid sleep disorder with depression.

Individuals with RLS feel an intense “pins and needles” sensation in their lower limbs when they lie down (as one does when they fall asleep). The only way they can find relief is by jerking the limb, which understandably makes sleep hard to come by and can contribute to insomnia along with depression.

The good news is that treating either depression or related sleep problems tends to improve the symptoms of the other. Getting good sleep is essential for overcoming depression.

You may have seen stories of sleep deprivation as the new cure to depression, but be wary of these. Researchers have indeed found that a night of sleep deprivation reduces symptoms of depression the following day. However, they can experience a rebound effect (known as “residual insomnia”) the following day. Moreover, sleep deprivation on a long-term basis is simply impractical – and also dangerous, given the serious side effects for your mental, physical, and emotional health.

Rather, the recommended treatment for depression typically combines psychotherapy and/or pharmacology.

Psychotherapy

One popular form of psychotherapy is cognitive-behavioral therapy (CBT). CBT focuses on helping the individual recognize the negative or destructive thoughts (the cognitive aspect) that make them feel depressed, and the behaviors they’ve become accustomed to responding with. Once they learn to recognize these thoughts and behaviors, they develop new ways of thinking or responding. A sub-type of CBT is CBT-I, which applies the same techniques to curing insomnia.

CBT-I

A sub-type of CBT is CBT-I, which applies the same techniques used in CBT but specifically to treat insomnia. Researchers find depression and insomnia are often co-morbid meaning they exist at the same time and often perpetuate one another. Depression can be made worse with insomnia and insomnia can make dealing with depression more difficult. CBT-I aims to treat insomnia without medication but through conditioning sleep techniques. Many CBT-I techniques are simple, such as using the bed and bedroom for sleeping only, getting up if not tired or not able to fall asleep. Many physicians use CBT-I at the first option to treat insomnia.

The first step CBT-I increases sleep quality and then moves to focus on quantity of time spent asleep. This technique also includes learning effective sleep hygiene. These are bedtime rituals and nightly habits that help achieve quality sleep. Going to bed at the same time every night, limiting screen time before bed, avoiding caffeine and alcohol, and sleeping in ideal conditions – quiet, dark and not too cold or hot. Further steps in CBT-I involve eliminating or managing thoughts that interfere with sleep. Instead the emphasis is placed on calming an active mind and allowing sleep to happen rather than trying hard to sleep.

CBT-I may take longer to treat insomnia than pharmaceuticals but the results are longer lasting. Drugs that alleviate insomnia provide moderate improvements but only when the drug is administered. CBT-I techniques can assist sleep quality indefinitely.

Pharmacology

Please consult your doctor or a licensed medical professional when considering any course of treatment involving medicine. Although both depression and insomnia can be treated without drugs, there are pharmacological interventions for both, and not coincidentally, both can be addressed with antidepressants.  The most common antidepressant medications today are selective serotonin reuptake inhibitors (SSRIs). Those with insomnia who start taking one of those drugs often find relief for their sleeping problems.

The pharmacological treatment for idiopathic hypersomnia is usually a stimulant – something that works opposite of sleeping pills.  That’s why it is important for doctors to evaluate whether long-sleeping patients might have depression and be a better candidate for anti-depressant medication.

Light therapy

Light therapy is especially effective for seasonal affective disorder, and it can be applied to instances of insomnia or hypersomnia independent of SAD.

Light therapy involves sitting in front of a special light box that delivers 10,000 lux of bright light similar to the sun. The individual uses it in the morning or at night to help them wake up or stay up, depending on how the extent of their daytime sleepiness. Besides light boxes and lamps, light therapy devices come in wearable visors, dawn simulating alarm clocks, and more.

CPAP therapy

Individuals with obstructive sleep apnea can get fitted for a continuous positive airway pressure (CPAP) device. These are extremely effective for treating OSA and related insomnia – and apparently depression, too. Individuals with co-morbid depression showed significant improvement a year after using their device.

Individual with OSA and depression should be careful about taking tricyclic antidepressants, since sedatives can worsen symptoms of OSA. Check with your doctor first and be sure to let them know about your OSA.

Exercise

In most healthy individuals, exercise is known to help with sleep by reducing sleep latency times and increasing the amount of time spent in deep sleep. Starting an exercise program is one recommendation given to those looking to cure insomnia without medication. Exercise has also been proven to help with depression. The link between exercise and depression is biochemical when the body release endorphins, or “feel-good” chemicals during moderate to intense exercise. Researchers have also found the hippocampus in the brain which helps regulate mood, is smaller in depressed patients. Exercise encourages nerve cell growth in the hippocampus which helps relieve depression.

CBD Oil

CBD oil is a naturally occurring cannabinoids found in the hemp plant. Although derived from the same plant, CBD oil doesn’t contain THC, the element of marijuana that produces the “high.” CBD oil has been shown to have a calming effect showing positive results for helping anxiety, insomnia, depression, and chronic pain. CBD oil may help with both falling asleep and staying asleep. Although not extensively studied, CBD oil shows no results of becoming habit forming, making it an option for those looking to seek relief from depression and insomnia.

In addition to the therapies suggested above, the following advice can help you get better sleep while you’re getting treated for depression and related sleep problems.

1. Keep a sleep diary.

If you believe you are suffering from depression and/or a comorbid sleep disorder, keep a sleep/mood diary for 2 weeks to share with your doctor.

Note when you go to bed, how long it takes you to fall asleep, when you wake up, and how much time you spent asleep. Also note your level of fatigue or energy throughout the day, as well as any changes in mood, diet, libido, or thought patterns.

2. Turn your bedroom into a sleep haven.

Use your bedroom exclusively for sleep and sex. Everything else, from watching television to working to socializing, should take place elsewhere. You want your mind to see your bedroom as a place of rest, not of worry, stress, or social activity.

Keep your bedroom as cool and as dark as possible by removing electronics and using blackout curtains if necessary. Invest in a comfortable, supportive mattress that makes sleep come easier.

3. Stick to a regular sleep schedule.

Go to bed and wake up at the same time every day, even weekends. Ensure you leave enough room for you to conceivably get at least 7 hours of sleep, but don’t worry about whether you spend all of that time asleep. Your only goal is to stick to the schedule; eventually your brain will catch up and train itself to sleep and wake at those times more naturally.

Avoid napping if you can. If you’re absolutely exhausted, limit them to short power naps of 30 minutes or less.

4. Create a calming bedtime routine.

Depression and anxiety-producing thoughts are a recipe for insomnia. Help ease your mind of worries with a calming bedtime routine. Try relaxation techniques, deep breathing exercises, or meditation. Take a warm bath or light some candles.

If your mind continues to race at night, take time to write your thoughts down in a worry journal – getting them out of your head and onto the page will diminish their power. Relieve anxieties by listing out any remaining to-do items you can take care of tomorrow.

5. Get plenty of sunshine.

Natural sunlight facilitates a healthy sleep-wake cycle. Aim to get plenty of sunshine, ideally by exercising outdoors in the morning or early part of the day. This will give you an energy boost that makes it easier to feel better and less fatigued during the day time. Then, as it gets dark, your brain will recognize it’s time to wind down and fall asleep.

While you’re at work or school, sit by the windows to increase your amount of sunlight.

6. Eat well and avoid stimulating substances.

Foods that are high in sugar or fats mess with your sleep, your health, and your mood. Instead, fill your diet with foods that promote healthy energy levels and sleep.

Also take care to avoid any stimulating substances in the afternoon or evening that interfere with sleep, such as caffeine, alcohol, or nicotine.

7. Stay calm when you wake up.

Unfortunately, retraining your body to sleep well is not an overnight process. Expect – and accept – that you’ll continue having disturbed sleep during this process.

When you do wake up, practice your deep breathing or progressive muscle relaxation exercises. Meditate or visualize something that makes you feel happy or calm. Turn on a soft lamp and read a book. Stay calm and sleep will come.

Guides from Tuck about mental health and sleep:

• Stress and Sleep Problems: Stress is a trigger for insomnia and a host of sleep issues. Learn more about reducing stress so you can sleep better at night.
• Seasonal Affective Disorder and Sleep: 4 to 6 percent of people experience SAD, a form of seasonal depression. Learn about the unique sleep issues associated with SAD and recommended treatment options.
• Mental Illness and Sleep: Sleep disorders are a hallmark of mental illness. Learn how people living with schizophrenia and psychiatric disorders experience disrupted sleep.
• Women and Insomnia: Women are more prone to insomnia and depression. Learn how hormones, pregnancy, and menopause affect women’s sleep.
• Anxiety and Sleep: People with mood and anxiety disorders, including phobias, OCD, PTSD, and social anxiety also suffer from poor sleep. Learn about the relationship between anxiety and sleep.

Support and resources for depression:

• If you are in crisis, please call the National Suicide Prevention Lifeline immediately. You are not alone and people are here to help you. The hotline is available 24/7 and is completely free and confidential. Reach them anytime, toll-free at 1-800-273-8255 or via live chat on their website.
• Lean on others for emotional support and share advice on online forums such as the Depression and Insomnia subreddits, the Depression support group on The Tribe, Depression forums on PsychCentral, and Depression Forums.
• The CDC offers an overview of depression and publishes the latest demographic research regarding individuals most at risk in America.
• The Anxiety and Depression Association of America provides fact sheets and information for professionals, caregivers, and individuals dealing with depression, as well as online support groups for multiple mood and anxiety disorders.