Depression and Sleep
Feeling sad every now and then is a fundamental part of the human experience, especially during difficult or trying times. In contrast, persistent feelings of sadness, anxiety, hopelessness and disinterest in things that were once enjoyed are symptoms of depression, an illness that affects at least 20 million Americans. Depression is not something that a person can ignore or simply will away. Rather, it is a serious disorder that affects the way a person eats, sleeps, feels and thinks. The cause of depression is not known, but it can be effectively controlled with treatment.
The relationship between sleep and depressive illness is complex – depression may cause sleep problems and sleep problems may cause or contribute to depressive disorders. For some people, symptoms of depression occur before the onset of sleep problems. For others, sleep problems appear first. Sleep problems and depression may also share risk factors and biological features and the two conditions may respond to some of the same treatment strategies. Sleep problems are also associated with more severe depressive illness.
Insomnia is very common among depressed patients. Evidence suggests that people with insomnia have a ten-fold risk of developing depression compared with those who sleep well. Depressed individuals may suffer from a range of insomnia symptoms, including difficulty falling asleep (sleep onset insomnia), difficulty staying asleep (sleep maintenance insomnia), unrefreshing sleep, and daytime sleepiness. However, research suggests that the risk of developing depression is highest among people with both sleep onset and sleep maintenance insomnia.
Obstructive sleep apnea (OSA) is also linked with depression. In a studyof 18,980 people in Europe conducted by Stanford researcher Maurice Ohayon, MD, PhD, people with depression were found to be five times more likely to suffer from sleep-disordered breathing (OSA is the most common form of sleep disordered breathing). The good news is that treating OSA with continuous positive airway pressure (CPAP) may improve depression; a 2007 studyof OSA patients who used CPAP for one year showed that improvements in symptoms of depression were significant and lasting.
In many cases, because symptoms of depression overlap with symptoms of sleep disorders, there is a risk of misdiagnosis. For example, depressed mood can be a sign of insomnia, OSA or narcolepsy. Restless legs syndrome (RLS), a neurological condition that causes discomfort in the legs and sleep problems, is also associated with depression. According to the Restless Legs Syndrome Foundation, approximately 40% of people with RLS complain of symptoms that would indicate depression if assessed without consideration of a sleep disorder.
Many children and adolescents with depression suffer from sleep problems such as insomnia or hypersomnia (excessive sleepiness) or both. According to recent research, children with depression who suffer from both insomnia and hypersomnia are more likely to have severe and longer-lasting depression. They are also more likely to suffer from weight loss, impaired movement, and anhedonia (an inability to feel pleasure). Additionally, NSF's 2006 Sleep in America poll, which focused on children aged 11 to 17, found a strong association between negative mood and sleep problems. Among adolescents who reported being unhappy, 73% reported not sleeping enough at night.
Depression affects all types of people from all over the world, but certain people are more likely than others to develop depression, including women and older adults. Among older adults, higher rates of depression and sleep problems may be explained in part by higher rates of physical illness. Among women, motherhood and hormonal changes throughout the life cycle (menstruation, menopause) may contribute to higher rates of depression. Among women and older adults, higher rates of depression may also be explained by higher rates of insomnia in these groups.
Seasonal affective disorder (SAD), also known as "winter depression," is one type of depression. SAD is believed to be influenced by the changing patterns of light and darkness that occur with the approach of winter. Circadian rhythms are regulated by the body's internal clock and by exposure to sunshine. When the days get shorter in autumn, circadian rhythms may become desynchronized and trigger depression. For most people with SAD, depressive symptoms resolve in springtime with increasing hours of daylight. when the days lengthen out.
Living with depression can be extremely difficult. Depression not only affects the way a person feels and thinks but research suggests that it is also associated with serious chronic health problems such as heart disease. If you are experiencing symptoms of depression, it is very important to seek treatment as soon as possible.
Symptoms of depression vary from person to person. The following is a list of the most common symptoms. Some depression patients have only one of these, while others may have some, most or all:
- Feelings of hopelessness, helplessness and sadness
- Thoughts of death or suicide
- Loss of interest in things that were once pleasurable
- Concentration problems
- Loss of libido
- Changes in weight and appetite
- Daytime sleepiness
- Loss of energy
Depression may also be accompanied by anxiety, low self-esteem, and physical symptoms such as back pain, headaches and gastrointestinal problems. Sleep problems such as insomnia and daytime sleepiness are often among the most debilitating features of depression.
Depressive illness may take different forms, including major depressive disorder (MDD), dysthymia, and bipolar disorder. MDD refers to an impaired ability to eat, sleep, work, think, enjoy activities and feel pleasure. Dysthymia is a mild yet more persistent form of depression. Another form of depressive illness is bipolar disorder (manic depressive illness), which is characterized by extreme highs and lows. During high phases, bipolar patients may be energetic, talkative, and joyful. During lows, they experience symptoms of depression.
Treatment for depression typically involves a combination of psychotherapy (including cognitive-behavioral therapy) and/or pharmacological (drug) treatment. Each of these therapies may be used to treat both depression and insomnia and treatment for sleep problems is often an integral part of depression therapy.
Treatment for depression may be complicated by sleep disorders. For example, patients with both OSA and depression should avoid sedating antidepressant medications due to their potential to suppress breathing and worsen OSA. Before beginning therapy for depression, talk to your physician about any sleep symptoms you are experiencing. In some cases, effectively treating the sleep problem may be enough to alleviate the symptoms of depression.
Cognitive behavioral therapy (CBT) is a behavioral approach to treating depression that is increasingly popular due to its effectiveness and lack of side effects. The essential features of CBT for depression include cognitive restructuring, a technique that targets the thoughts that lead to depressive feelings, and behavioral activation, which targets behavior that may perpetuate depression. CBT may be used to treat insomnia and depression at the same time. Click here for the components of CBT for insomnia.
There are a number of different medications used to treat insomnia, and your physician will work with you to determine which is best for you. Some of the most common drug treatments for depression are:
- Selective serotonin reuptake inhibitors (SSRIs) – SSRIs effectively improve mood in many patients, but they may also cause or worsen insomnia.
- Tricyclic antidepressants – tricyclic antidepressants are typically sedating, but they may also carry serious side effects such as high blood pressure.
- Mood stabilizing anticonvulsants and lithium – these drugs are commonly used to treat bipolar disorder.
In addition to the above treatment options, patients who suffer from SAD may benefit from bright light therapy. Light therapy may involve exposure to natural light (light from the sun) or treatment with a light box. Light therapy is considered safe, but little evidence exists to support its effectiveness at treating SAD or other forms of depression. Consult your physician before beginning any form of light therapy, as exposure to the sun or bright light may cause negative effects.
Some individuals show significant improvements in depression symptoms following a night of partial or complete sleep deprivation, leading physicians to consider using sleep deprivation as an intervention. However, such improvements are unreliable and are reversed after a night of normal sleep, making sleep deprivation an impractical therapeutic choice for depression. Moreover, sleep deprivation carries the potential for serious side effects such as extreme sleepiness, cognitive impairment and an increased risk of injury or traffic accidents.
In preparation for a visit to a health professional for depression evaluation and treatment, it is helpful to keep track of your mood and to use a sleep diary for a period of two weeks. Sharing this information with your therapist will help guide treatment and the correct diagnosis.
Treating clinical depression may take time. Depression medications often take weeks to take full effect and some individuals may need to try a variety of drugs before finding the one that suits them best. Keep in mind that you should not stop taking a depression medication because your symptoms improve as this may cause symptoms to recur or other ill effects. Always consult your health care provider before making any changes to your depression therapy or any medication regimen.
Addressing sleep symptoms are of critical importance to recovery from depression. Be sure to discuss any sleep problems that persist as mood improves. Such problems may signal the presence of an underlying sleep disorder.
Depression can be stressful and exhausting. It can also make you feel helpless and hopeless. In addition to treatment with a medical or mental health professional, here are some tips for helping you cope with depression on a daily basis:
- Keep a regular sleep/wake schedule
- Get into bright light soon after waking in the morning
- Get some form of exercise every day
- Avoid afternoon naps if you have nighttime insomnia
- Limit caffeine and alcohol
- Ask loved ones for help – you should not face depression alone
According to NSF's 2005 Sleep in America poll, 18% of adults aged 18 to 64 have been diagnosed with depression. The 2005 poll also revealed that those who have been diagnosed with depression or another medical condition were more likely to report symptoms of a sleep disorder. Additionally, NSF's 2006 Sleep in America poll of adolescents aged 11 to 17 revealed that among those who reported feeling unhappy, 73% reported not getting enough sleep at night.
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