Depression and Sleep: An Endless Dark Night
Depression and sleep are closely intertwined in a dark and nightmarish tango, in what is termed a bidirectional relationship. What this means is that poor sleep can contribute to the development of depression and that having depression makes a person more likely to develop sleep issues. Almost all people with depression experience sleep issues. This complex relationship can make it challenging to know which came first, sleep issues or depression. The link is so clear that in the absence of sleep disturbances, doctors will hesitate to prescribe for depression.
Sleep issues associated with depression include insomnia, hypersomnia (excessive daytime sleepiness), and obstructive sleep apnea (OSA), with insomnia being the most common and estimated to occur in about 75% of adult patients with depression.
It is believed that about 20% of people with depression have obstructive sleep apnea while some 15% have hypersomnia. Many people with depression may go back and forth between insomnia and hypersomnia during a single period of depression.
Sleep issues may contribute to the development of depression through changes in the function of the neurotransmitter serotonin. Sleep disruptions can affect the body’s stress system, disrupting circadian rhythms and increasing vulnerability for depression.
In the UK, one in four people is likely to experience a mental health problem each year in England alone, while one in six people the problem will take the form of depression, anxiety or a combination of the two.
Most people who have experienced depression know that it is often accompanied by sleeping problems. People with depression may find it difficult to fall asleep and stay asleep during the night. They can also have excessive daytime sleepiness or even sleep too much. At the same time, sleep problems can exacerbate depression, leading to a negative cycle between depression and sleep that can be challenging to break. Poor sleep may even provoke depression in some people.
Understanding the complex relationship between sleep and depression can be an important step in improving sleep quality and better managing depression. Fortunately, people who are treated for major depression often report improved quality of their sleep.
What Exactly is Depression?
Feelings of sadness, disappointment, or hopelessness can be a healthy reaction to life’s challenges. Normally, these feelings come in waves, are tied to thoughts or reminders of challenging situations, only last for a short period of time, and don’t interfere with school, work, or relationships.
In depression, these feelings follow a different pattern. When they persist for more than two weeks, are felt nearly every day, and remain for most of the day, they may be related to a group of mood disorders called depressive disorders. Also called clinical depression, depressive disorders include feelings of sadness, disappointment and hopelessness, as well as other emotional, mental, and physical changes that lead to difficulties with daily activities.
What Causes Depression?
While researchers don’t know the exact cause of depression, there are a number of factors that can increase the risk of developing this condition. These include having a personal or family history of depression, experiencing major stressors or traumas, taking certain medications, and having specific illnesses.
Family history is a factor in about half of people with depression. A person’s genetics may affect the function of neurotransmitters (substances that help nerve cells communicate) that are linked to depression, such as serotonin, dopamine, and norepinephrine.
What are the Symptoms of Depression?
The symptoms of depression can include physical changes as well as changes in moods and thoughts that interfere with normal daily activities.
Signs that you may be depressed include:
• Persistent sad, low, or irritable mood
• Feelings of hopelessness, worthlessness, or guilt
• Loss of interest or pleasure in activities
• Decreased energy and fatigue
• Difficulty concentrating
• Insomnia, waking up too early, or oversleeping
• Low appetite or overeating
• Thoughts of death or suicide
Depression Manifests Differently According to Age/Sex
Men often experience symptoms such as irritability and anger, whereas women more frequently experience sadness and guilt.
Adolescents with depression may be irritable and have trouble in school while younger children may pretend to be sick or worry that a parent may die.
How is Depression Diagnosed?
Depression can only be diagnosed by a medical professional, so people experiencing symptoms of depression should talk with their doctor, counsellor, or psychiatrist. They may suggest tests that can help them to better understand your situation and monitor changes or improvements over time.
A provider may also refer patients to a specialist in sleep disorders to help determine if there is an underlying sleep disorder, such as sleep apnea or restless leg syndrome, that may be causing depression or contributing to symptoms.
What Are the Types of Depressive Disorders?
Significant feelings of sadness or a loss of interest in their normal daily activities are common in all depressive disorders. Specific forms of depression vary based on the severity of symptoms and the situation in which they develop.
The most well-known type is major depressive disorder, and it is marked by symptoms that affect a person virtually every day for an extended period of time. It commonly involves sleep disruptions.
Persistent depressive disorder, called dysthymia or chronic depression, may involve fewer symptoms than major depression, but symptoms last for at least two years (one year in children and adolescents) and any symptom-free period lasts no longer than two months.
How is Depression Treated?
While depression can have dramatic effects on a person’s sleep and overall quality of life, it can be treated. After working with a doctor or mental health provider to understand the type and severity of depression, treatment may include:
• Counselling: Depression can be treated effectively with several types of counselling, including Cognitive-Behavioural Therapy (CBT) and interpersonal therapy (IPT). CBT for insomnia (CBT-I) is a type of CBT that focuses on managing chronic insomnia.
• Medication: Antidepressants are an effective treatment for depression. These prescription medications usually take time before they begin to improve symptoms and patients may need to try several antidepressants before finding the right fit. A doctor or psychiatrist can discuss the appropriateness of these medications and recommend a specific type.
• Brain stimulation therapies: When medications and other approaches are not effective, some people with depression consider electroconvulsive therapy (ECT) or other, more recent types of brain stimulation like repetitive transcranial magnetic stimulation (rTMS) and vagus nerve stimulation (VNS). These treatments can be effective but are only provided under the guidance of a trained professional.
Treatment isn’t limited to just one of these approaches and, in fact, combining medication and psychotherapy has shown higher rates of improvement than one approach alone.
Tips for Sleeping Better
Sleep problems increase the risk of initially developing depression, and persistent sleep issues can increase the risk of relapse in people who have successfully been treated for depression. As a result, taking steps to sleep better can have a beneficial effect on mood.
Focusing on improving sleep hygiene may improve sleep quality. It’s also a common component of CBT and can reinforce the benefits of talk therapy to change negative thinking about sleep. Improving sleep hygiene looks a little different for everyone, but often includes keeping a consistent sleep schedule, spending time away from electronics in the evening, and optimizing your bedroom for quality sleep.
Tips for Coping with Depression
In addition to talking to a provider about treatments for depression, there are several steps you can take on your own:
• Exercise: Low-intensity exercise, even walking 10 minutes a day, can lead to improvements in mood and physical health. For some people with mild to moderate depression, exercise can work as effectively as an antidepressant.
• Support: Experiencing depression can feel isolating and hopeless, so remember that you’re not alone. Spend time with others, talk about what you’re experiencing, and try not to isolate yourself.
• Be realistic: Even with effective treatment, symptoms of depression may improve gradually.