Battling Insomnia: Depression's Dark Side

Sleep and depression are closely linked. Depression is a mood disorder characterised by persistent feelings of sadness, hopelessness, and emptiness, which can interfere with daily life. It can also affect sleep, with many people experiencing insomnia, hypersomnia, or obstructive sleep apnea. In fact, an inability to sleep is one of the signs of depression, with around 40% of people with insomnia having clinical depression. However, it's important to note that a small percentage of depressed people (around 15%) sleep too much.

Depression and insomnia

People with insomnia have a tenfold higher risk of developing depression than those who get a good night's sleep. Among people with depression, 75% experience insomnia symptoms. Insomnia may be a separate condition or a symptom of depression. Either one can come first. Poor sleep may create difficulties in regulating emotions, which may leave you more vulnerable to depression in the future.

Depression is a mood disorder characterised by sadness or feeling down. It can interfere with sleep, appetite, and energy. Other symptoms include:

• Feelings of hopelessness, worthlessness, or guilt
• Fatigue and slowness, or anxiety and irritability
• Loss of enjoyment in things that were once pleasurable
• Difficulty concentrating, thinking, or making decisions
• Changes in appetite that lead to changes in weight
• Increase or decrease in the need for sleep
• Thoughts of death or suicide

If you have insomnia and depression, it is important to understand that medical treatment for one will not automatically cure the other. Treatments for depression, such as selective serotonin reuptake inhibitors and other medications, may improve your mood but may not be enough to improve your sleep. Lingering sleep problems in people undergoing depression treatment can increase the risk of a slide back into depression.

Chronic insomnia can increase a person's chances of developing anxiety disorders and depression. It may be an early or the first symptom of depression and anxiety. Therefore, it is important to address insomnia as a symptom of mental disorders and detect and treat any underlying illnesses or conditions.

Depression and hypersomnia

Depression is a mood disorder characterised by feelings of sadness or hopelessness, and it can interfere with sleep, appetite, and energy. While a small percentage of depressed people experience hypersomnia (excessive sleepiness), most experience insomnia. However, the associations between depressive symptoms and hypersomnia are complex and often bidirectional.

Hypersomnia is a symptom of a sleep disorder or other disease, and it is diagnosed when a person experiences excessive sleepiness for at least one month, evidenced by prolonged sleep episodes or daytime sleep episodes occurring almost daily. It is important to note that hypersomnia is a subjective sleep complaint rather than an objective finding in mood disorders.

In the context of depression, hypersomnia may manifest as a need for excessive sleep, with individuals requiring long naps during the day and at least 10 hours of sleep at night. This may be accompanied by feelings of grogginess and disorientation upon waking up, known as "sleep drunkenness" or "sleep inertia".

The presence of hypersomnia in individuals with depression can have a significant socio-economic impact, interfering with relationships, work productivity, and the enjoyment of hobbies and activities. It can also be challenging for others to understand, leading to misconceptions and stigmatisation.

The relationship between hypersomnia and depression is not fully understood. However, it is suggested that hypersomnia in individuals with depression may be related to abnormal sleep homeostasis and alterations in specific brain chemicals, such as gamma-aminobutyric acid (GABA), which impacts mood regulation.

When treating individuals with a dual diagnosis of idiopathic hypersomnia and depression, it is essential to consider the unique symptoms, diagnosis, and treatment approaches for each condition. While medications that promote wakefulness may be recommended for hypersomnia, antidepressants such as SSRIs, SNRIs, and NDRIs can be beneficial for addressing depressive symptoms. Additionally, talk therapy, meditation, exercise, a healthy diet, and support groups can help manage both conditions.

Depression and obstructive sleep apnea

OSA is a rapidly growing problem, linked to rising obesity rates, while depression rates are also increasing. The symptoms of OSA and depression can overlap, leading to under-diagnosis of OSA in depressed patients. OSA patients may present with major depressive symptoms, but it is recommended that the primary care physician determines the underlying cause of depression rather than simply diagnosing the patient as depressed.

OSA and depression have several shared symptoms, including fatigue and sleep disturbance, mood symptoms such as anxiety and restlessness, and poor concentration. In OSA patients, major depressive disorder (MDD) must be ruled out before a treatment regimen can be implemented. Proper diagnosis is crucial as the treatment strategy for each condition may differ. For example, the use of sedation, antidepressants, or hypnotics to treat insomnia related to depression may exacerbate OSA and worsen the patient's mood.

The patient health questionnaire (PHQ-9) is a useful tool for screening for depression and can be easily implemented in primary healthcare settings. Additionally, polysomnography (PSG) can be used to screen for OSA in patients with residual symptoms of depression after treatment.

Treating OSA symptoms can lead to improvements in depressive symptoms. Continuous positive airway pressure (CPAP) therapy has been shown to improve depressive symptoms associated with OSA, and can also reduce the risk of cardiovascular disease (CVD) and stroke. In addition, a reduction in body mass index (BMI) can have beneficial effects on both OSA and depressive symptoms.

In summary, the link between OSA and depression is well-established, and addressing both conditions is crucial for effective treatment. Proper diagnosis and early detection are key to improving patient outcomes and reducing healthcare burdens.

Nighttime depression

There are several factors that can contribute to nighttime depression. One reason may be the lack of distractions at night. During the day, it is easier for people with mild or moderate depression to keep themselves occupied with work, school, or social activities. However, at night, when they try to sleep, they are left alone with their thoughts, which can trigger or worsen depressive symptoms.

Research has also indicated that exposure to bright lights, especially blue and white light, at night can not only disrupt sleep but also increase symptoms of depression. This was observed in a 2013 animal study, where the presence of a TV in a dark room increased the subjects' cortisol levels and led to changes in their hippocampus, both of which are associated with depressive symptoms.

Additionally, disruptions to the circadian rhythm, often caused by increased artificial light, have been linked to the development or worsening of mood disorders like depression. This was highlighted in a 2009 study that found a significant link between increased artificial light exposure and disruptions to the circadian rhythm.

Treating nighttime depression typically involves addressing the underlying depression itself. Maintaining a consistent treatment plan, including taking prescribed medications, is crucial. For those experiencing new symptoms or currently without treatment, seeking professional help from a doctor or mental health specialist is essential for diagnosis and appropriate treatment.

To manage nighttime depression, consider implementing the following strategies:

• Unwind a few hours before bedtime to allow your body to relax and prepare for sleep.
• Designate your bedroom as a stress-free and screen-free zone to create a calming and positive environment.
• Engage in stress-relieving activities like painting, mindful baking, yoga, or meditation to help cope with depression before bed.
• Avoid looking at bright screens and dim the lights a couple of hours before bedtime.
• Limit your consumption of alcohol and caffeine, as these substances can intensify depressive symptoms and disrupt sleep.

Depression and sleep: treatment options

Depression is a mood disorder characterised by feelings of sadness or a low mood. It can cause a person to lose interest in activities they once enjoyed, and it can interfere with their sleep, appetite, and energy levels. An inability to sleep, or insomnia, is one of the signs of depression, although a small percentage of depressed people (around 15%) sleep too much.

Treatment for depression depends on the severity of the illness. Major depressive disorder is often treated with psychotherapy, medication, or a combination of the two. The most effective treatment is typically a combination of talk therapy with a mental health professional and medication.

Medication

Antidepressants are often used to treat depression. These can include:

• Selective serotonin reuptake inhibitors (SSRIs) such as Celexa, Lexapro, Paxil, Prozac, and Zoloft
• Tricyclic antidepressants such as Pamelor and Elavil
• Serotonin/norepinephrine reuptake inhibitors (SNRIs) such as Effexor, Pristiq, Khedezla, Fetzima, or Cymbalta
• Novel antidepressants such as bupropion (Wellbutrin) and mirtazapine (Remeron)

Doctors may sometimes treat depression and insomnia by prescribing an SSRI along with a sedating antidepressant or a hypnotic medication. However, it's important to note that hypnotic drugs are usually only recommended for short-term use.

Psychotherapy

Psychotherapy, or talk therapy, can help people with depression learn coping strategies and change negative thinking patterns. Some of the most effective types of psychotherapy for depression include:

• Cognitive-behavioural therapy
• Interpersonal therapy

Psychotherapy can also address coping skills to improve a person's ability to fall asleep.

Other Techniques to Improve Sleep

In addition to medication and psychotherapy, there are several techniques that can help improve sleep:

• Learn relaxation or mindfulness-based meditation and deep-breathing techniques
• Try having white noise on in the background
• Clear your head of concerns by writing a to-do list for the next day
• Get regular exercise, but not too close to bedtime
• Avoid caffeine, alcohol, or nicotine in the evening
• If you can't sleep, get out of bed and do something else; only use your bed for sleeping or sexual activity so that your brain associates it with sleep
• Wearable sensors such as a Fit Bit or Apple Watch can help you keep track of sleep and heart rate

Frequently asked questions