As a psychiatrist, sleep disturbance is one of the most frequent complaints that I encounter from depressed patients.
Complaints about sleep typically fall into 4 categories:
- Difficulty falling asleep
- Difficulty staying asleep
- Poor sleep quality
There is also the possibility of a combination of these complaints. The reason for these issues is usually multifaceted. Below I will cover a few reasons why depression is affecting your sleep and what you might be able to do about it.
Depression and Anxiety Comorbidity
Sleep disturbance is one the nine main symptoms used to diagnose major depression in the DSM. My theory on this is the high comorbidity of depression and anxiety. Comorbidity is finding two conditions ongoing at the same time in a patient. According to the Anxiety and Depression Association of America, nearly half of people diagnosed with depression are also diagnosed with an anxiety disorder.
If there is an anxiety component to depression, the ability to fall asleep or stay asleep can be disturbed. During the day there is work, television, and social media to act as distractions. At night time, however, those distractions aren’t present, and negative ruminating (repeating) thoughts can go on for hours. This makes it difficult to relax and fall asleep. Furthermore, falling asleep wont stop your body from being in that constant state of stress, making frequent night time awakenings a common occurrence.
Clinically, it can be very difficult to tell if someone’s primary condition is depression or anxiety. On the bright side of this problem, the two conditions can usually be treated at the same time. SSRIs, for instance, are FDA approved as antidepressants, but they are commonly prescribed “off label” to target anxiety. The increase of serotonin offers improvement of mood, and decreased in baseline levels of anxiety. Of note, the role of serotonin in anxiety and depression is unclear.
Stress is a state of worry or concern due an external situation that may be beyond your control. In most cases the body is able to make a distinction between every day stress and life-threatening stress. This is why being late for work does not cause the same degree of fight or flight (or freeze) response as being chased by a mountain lion. A major part of the fight or flight response is the release of the primary stress hormone called cortisol. In brief, cortisol unlocks your body’s access to the chemicals, nutrients, and attention that it needs to defend itself. There is a healthy rhythm to your body’s automatic release of cortisol during the day. The morning release of cortisol is one of the reasons people wake up around the same time every morning.
If needed, an extra amount of cortisol can be released on a temporary basis. Unfortunately, for people suffering from conditions like depression or anxiety, high cortisol levels can be chronic. Life stressors can also be a cause of chronically high cortisol, making it difficult to sleep. Examples of life stressors might be conflict in personal relationships, your place of employment, financial struggles, or a death in the family. Sleep disturbances due to situations like this are usually temporary, resolving once the life stressor is resolved, or with the passage of time.
The goal in regards to lifestyle factors is not to be perfect, but to work within the confines of your own limitations. How much alcohol you consume, use illicit drugs, maintain healthy eating habits, exercise, can affect your mood, and subsequently, affect your sleep.
Caffeine is a substance that affects alertness. Drinking caffeinated beverages too late in the day can negatively impact your ability to fall asleep. Decreased sleep can worsen one’s mood. Alcohol use can induce sleep, decrease quality of sleep, and increase night time awakenings. In other words, excessive alcohol can increase small amounts of poor quality sleep. Alcohol has also been well documented as a depressant.
Healthy eating habits/Exercise
Obesity is a major factor involved in sleep disturbance and mood. Obesity can directly impact sleep because the increased mass can put pressure on a person’s airway during sleep. This makes it difficult to breathe during sleep. Decreased sleep can impact energy levels and mood. Low energy levels and mood can affect sleep.
Sleep hygiene refers to the behaviors and environment that a person utilizes in order to maximize the quality and amount of sleep that they get. Getting good sleep can require some extra effort. Yes, you could just lay in your bed and wait to fall asleep, but lots of people require more attention to detail than that. Decreased sleep can impact energy levels and mood. Energy levels and mood can affect sleep. Here are a few components of sleep hygiene to think about:
- Only using your bed for sleep and sex- too many people watch tv, play video games, study, etc on their bed. Psychologically, the body is learning to associate your bed with being awake.
- Going to bed at a regular time each night. The body works on a circadian rhythm. It might be easier to fall asleep if your body is trained to “motor down” around the same time every night.
- Not interacting with electronics or computers at least 30 mins before bed time. The blue light from electronics is a signal to the brain saying “it is still day time.”
Treatments for Depression That Could Improve Insomnia
- Talk therapy with a licensed provider
- Cognitive behavioral therapy for Insomnia
- Improving lifestyle habits (exercising, eating healthier foods, sleep hygiene)
- Medication prescription that targets sleep or depression- Trazodone, Ambien, SSRIs
- Over the counter medication that targets sleep- Melatonin, Benadryl
- Alternative treatments that target depression (TMS, ECT, Ketamine)
TMS for depression with The CUBE Mental Health Services
We are primarily a practice that performs TMS to treat symptoms of depression. If you have tried medications and talk therapy, but still suffer from depression, Trancranial Magnetic Stimulation might work for you. By treating depression, sleep, appetite, anxiety, “brain fog,” and other complaints often improve as well. Use the contact section below if you’d like more details.