“Depression is less likely to result in daytime sleepiness,” Zak said. “Often, people are hyper-aroused, so they would love to nap but they can’t.”
Young people in their 20s and 30s who are experiencing increased sleepiness during the day and who are taking these so-called “depression naps” may actually be sleep-deprived rather than clinically depressed, Zak explained. They may be working long days or spending too much time on their screens at night, leading to poorer sleep quality and more stress, she said.
- The ‘depression nap’ as an escape
- Research shows napping once or twice a week may cut risk of heart attack, stroke
- When to seek help
- 7 Reasons You Feel So Tired That Have Nothing To Do With Sleep
- When Depression Makes You Sleep All Day
- Yes, You CAN Sleep Too Much—Here’s Why Oversleeping Is A Problem
- Signs and Symptoms of Depression
- Depression Signs and Symptoms
- Is Depression Making Me Sleepless, Or Is Insomnia Making Me Depressed?
- Obstructive sleep apnea may be one reason depression treatment doesn’t work
- What causes sleep problems?
- Poor sleep and mental health
- Poor sleep negative symptoms
- How much sleep do we need?
- Top tips to create positive sleep habits
The ‘depression nap’ as an escape
What’s the problem with napping? People may be using these naps as a form of escape, said Dr. Helen M. Farrell, a psychiatrist at Harvard Medical School and Beth Israel Deaconess Medical Center.
Research shows napping once or twice a week may cut risk of heart attack, stroke
Sept. 9, 201901:14
“Personally and professionally, I don’t like the phrase ‘depression naps’ and would deter patients from using that phrase and taking that sort of ‘nap,’” Farrell said. While naps are meant to be restorative and energizing, these types of naps actually can be an unhealthy way of dealing with your feelings, becoming a kind of defense mechanism, she said.
“It’s very important for people to be able to tolerate their feelings and practice healthy coping skills that combat depression, rather than succumbing to it,” Farrell explained.
Emanuel Maidenberg, a clinical professor of psychiatry at the University of California, Los Angeles, agreed such naps could be a coping mechanism, noting they could either be a symptom of low energy or a way for people to avoid hopeless or helpless thoughts.
“It can be helpful in the short run, but recurrent dependence on naps becomes a potential mechanism of depression maintenance,” he explained.
When to seek help
When do depression naps go from Twitter joke to crucial sign that you may need to seek medical help?
“The key to a healthy nap is that it’s short, infrequent and energizing — usually referred to as ‘power naps,’” Farrell said.
When naps grow longer and start to feel draining rather than restorative, or when they cause someone to miss out on important work or life events, it may be time to seek professional attention, Farrell noted.
Also, if napping is accompanied by other symptoms of depression, like low energy, trouble concentrating, or low mood, then professional help can be extremely beneficial — and even life-saving, she said.
7 Reasons You Feel So Tired That Have Nothing To Do With Sleep
Last Thursday around 2 pm, I felt an unbearable tiredness set in.
I was a little off all day, but suddenly, all I could think about was going home and curling up in my bed with a great episode of “Sex and the City.”
Unfortunately, I still had three hours of work and a spin class to get through, so that wasn’t really an option. Instead, I got up, brewed myself a fresh cup of coffee and thought about why the hell I was so tired.
I got eight hours of sleep the night before, so why did I suddenly feel putting my head down on my desk for a mid-work snooze was the only way I could get through the rest of the day?
Don’t get me wrong, sleep is crazy important. But, it’s not the only factor when it comes to how much energy we all have throughout the day.
Here are seven reasons you feel so tired that have nothing to do with sleep.
You’re eating too much sugar.
The act of eating sugar is truly amazing. I mean, really, is there any happier moment than the first bite of a chocolate chip cookie?
Unfortunately, too much sugar makes your energy levels plummet. If all you had was a bite of chocolate chip cookie, that would be fine. But, studies show sugar is more addictive than cocaine, so good luck with that one.
Although sugar provides a little high and a spike of energy when you first consume it, within a half an hour, it will leave you totally exhausted and craving more sugar. It’s not a great cycle.
If you’re pretty sure your daily sugar intake is what’s exhausting you, try ditching your post-lunch Snickers bar and swapping it for something just as delicious that will keep your energy high, like an apple and peanut butter.
Unfortunately, there’s not a quick fix for this one. But, it is worth noting one of the signs of depression is exhaustion.
So, if you find you don’t have energy to do everyday things — especially things that once brought you joy — ask yourself if your tiredness is a symptom of something bigger.
If you have a sneaking suspicion depression is to blame for your lack of energy, consider seeking professional help.
You’re not getting enough exercise.
I know what you’re thinking: At the end of a long day, the last thing you want to do is make yourself more exhausted with an intense workout.
I also used to subscribe to that philosophy, until I started exercising regularly and noticed I had way more energy than when I lived a sedentary lifestyle.
And it’s not just me. Research showed regular exercise fights exhaustion and boosts energy.
Lace up those sneakers, and hit the pavement! As an added bonus, exercise also makes you look great.
If you’re a soda junkie who drinks beer with dinner instead of water, I have some news for you: Your lack of energy could mean you need to drink some good, old-fashioned H2O.
Dr. Roger Henderson told Daily Mail,
Many of my patients do not drink enough fluid each day and only believe they are dehydrated when they start to feel thirsty. Yet other symptoms of dehydration appear before this, including fatigue and tiredness, headaches and poor concentration.
Better fill up that water bottle.
You’re not getting enough iron.
Iron is huge when it comes to energy.
When your body doesn’t have enough red blood cells to spread oxygen throughout the body, exhaustion sets in. That’s exactly what happens when you’re not getting enough iron.
Check with your doctor to find out if this is going on. If so, you can take iron supplements and eat a diet of iron-rich foods like seafood, nuts and seeds.
You’re burned out.
Do you say “yes” to everything, even though you know you should probably throw a “no” in there once in a while?
Trust me, I’ve been there. Unfortunately, burning the candle at both ends is a surefire way to drain yourself of energy.
Even if you’re getting enough sleep, carving out, at least, an hour of “me” time every day is important when you want to keep your energy high — not to mention crucial to your happiness.
Your space is cluttered.
What’s the first feeling that comes to mind when you think of coming home after a long day at work only to find dishes piled sky-high in the sink, an unmade bed and a pile of clothes on the floor?
For me, it’s exhaustion.
Living and working in a messy space can zap energy crazy fast. In fact, according to a study conducted out of Princeton University, a cluttered desk makes it harder to focus and process information, leading to mental exhaustion.
Better get a head start on that spring cleaning.
Aren’t you just bursting with energy reading this article? I thought so.
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When Depression Makes You Sleep All Day
I’ve slept for almost 35 of the last 48 hours. I’d like to say this isn’t my norm. I’d like to, but that would be a lie.
I’ve slept through multiple alarms and important phone calls. I’ve slept through job interviews and doctors’ appointments. I’ve even slept through my son’s early release day, awakening (horrified and frantic) hours after I should have picked him up.
That day, I bawled myself right back to sleep after talking to his Dad who (thankfully) retrieved him from the school office.
I sleep for hours and wake up exhausted. I can never sleep enough for my depression. Her thirst for oblivion is insatiable. And I’m just too tired to fight it sometimes.
In the midst of my seemingly endless slumber sits my anxiety, ridiculing me for being weak. Chastising me for succumbing to my co-occurring disorder. Clucking its tongue like a disappointed au pair.
“Tsk tsk, you lazy girl” she chides.
And I feel the shame seep deeper into my bones.
And it just makes me so very tired.
Sleep has become my respite from a hostile mind. My brain: a place where my most gentle pieces aren’t safe. Where I am told I’m never going to be OK again. I’m nothing. I’m empty. I’m a failure and a disappointment.
“What’s the point of anything?” circulates in perpetuity, swirling like muddy water down a corroded drain.
Sweet sleep whisks me away from my minefield of internal self-loathing and damaging discourse.
Sometimes I dream. In my dreams, I am happy. I smile. I laugh. I sing. I am able to feel things I sometimes believe I’ve forgotten how to feel.
Joy. Wonder. Awe. Peace.
I think it’s my body’s way of telling me, “Don’t give up, sad girl. We will make it through the darkest days, but for now… just sleep.”
Yes, You CAN Sleep Too Much—Here’s Why Oversleeping Is A Problem
In a world where so many of us are struggling to get enough sleep, the issue of sleeping too much might seem like a luxury problem.
It’s actually not. Like insufficient sleep, oversleeping is a sign of disordered sleep. It may be connected to a mental health issue such as depression. It’s often a signal that a person is experiencing poor sleep quality, and it can be a sign of a clinical sleep disorder, including obstructive sleep apnea or narcolepsy.
Sleeping too much is linked with many of the same health risks as sleeping too little, including heart disease, metabolic problems such as diabetes and obesity, and cognitive issues including difficulty with memory. Similar to people who sleep too little, people who sleep too much have higher overall mortality risks.
We talk a lot about insufficient sleep, and the risks that a lack of sleep poses for physical health, mood, relationships, and performance. But oversleeping isn’t something to ignore.
Hypersomnia is the clinical term for excessive sleeping, and excessive sleepiness during the day. Like its counterpart insomnia, hypersomnia has several core symptoms:
- Sleeping for extended hours at night (typically well beyond the 7-8-hour general norm)
- Difficulty waking up in the morning (including sleeping through an alarm)
- Trouble rising from bed and starting the day
- Grogginess on and off or consistently throughout the day
- Trouble concentrating
What I’m NOT talking about here is the once in a blue moon night of extra sleep you might need after coming up unexpectedly short on sleep. That happens to everyone, once in a while. If you’re making consistency a priority in your sleep routine, it shouldn’t happen often.
How much sleep is too much?
You’ve heard me say it before: there is no single right amount of sleep that applies to everyone. Sleep needs are individual. They’re based on a number of factors:
Your individual genetics. Your genes influence both your circadian rhythms and your internal sleep drive, the two primary biological sleep systems
Your age. You may find you need 7 hours of sleep in your 20s, and 8 hours—or 6.5—in your 50s or 60s.
Your activity level. Sleep is a form of energy for the body and mind, and a time for the body to recover from exertion. The more active you are, the more sleep you may need.
Your health. When coping with health issues, we very often need additional rest. That’s true for short-term illnesses like colds and flu, as well as long-term or chronic conditions, everything from arthritis to cancer.
Your life circumstances. Stress, and periods of change or upheaval can temporarily increase your need for sleep. (At the same time, these forces often make it difficult to sleep.) If stress is chronic, it can create a chronic sleep debt. And it’s not just negative or unwelcome life events that can drive up a need for sleep: big life changes that are positive can demand more sleep, too!
All of this said, most of us, throughout our adult lifetimes, need somewhere in or near to 7-9 hours of sleep a night, routinely. You might be a person who needs 6 or 6.5. But it’s unlikely that any but a very few of us can function and feel at our best on 5 hours of nightly sleep or less. This is similarly true at the other end of the range. Some people need 9 hours of sleep a night. But if you’re regularly sleeping more than 9 hours, and still feeling tired and fatigued, that’s an indication you’re oversleeping—and it’s time to take a look at what might be causing it.
Oversleeping and depression
I wrote most recently about oversleeping, or hypersomnia, when talking about the relationship between sleep and suicide risk.
Particularly among younger adults and teenagers, oversleeping can be a signal of depression. It can be tough to gauge teens’ sleep, because they typically have very different sleep patterns than we adults do. (I just wrote about a wave of new research into the effects of poor sleep in teens.) But excessive sleepiness and excessive sleeping in teens and young adults can be a red flag for depression. An estimated 40 percent or more of adults under 30 with depression experience hypersomnia.
Sleep and depression have a complex relationship. Disrupted sleep is both a symptom of depression and a contributing factor to depression. Most people with depression experience regular sleep disturbances. And sleep problems can make depression more severe and more difficult to treat.
And oversleeping is not only an issue among young people with depression. Among older adults, symptoms of insomnia may be more common. But many older adults also experience hypersomnia in connection with depression. Women, in particular, may be more likely to oversleep and feel excessively tired during the day if they are depressed.
It’s also important to remember that among people with depression, sleep difficulties often take shifting, variable forms. People with depression may experience symptoms of both insomnia and hypersomnia. A 2014 study investigated how often insomnia and hypersomnia occur together in adults with depression in the US. Scientists found that more than 27 percent have what’s known as “co-occurring” insomnia and hypersomnia. They also found some other striking shared characteristics. People with depression who demonstrated both insomnia and hypersomnia had:
- More severe depression
- Higher rates of suicide planning and suicide attempts
- Higher rates of impulse control disorder
- Greater likelihood of drug use disordeR
These people were also more likely to be receiving mental health treatment, and more likely to be taking anti-depressants.
Another study released just this year found that among people who’d received a diagnosis of major depression, slightly less than one-third had both insomnia and hypersomnia. These people were at 2-3 times greater risk for bi-polar disorder, according to the study.
Because of the close, complicated ties between sleep, circadian rhythms, and depression, it makes sense that more severe depression might often go hand in hand with more intense, variable, and wide-ranging sleep problems—including a drive to sleep excessively. The cause and effect in these relationships is usually not clear: we don’t often know whether sleep problems including hypersomnia lead to depression, or are a result of depression—or some of both. What we do know is that these conditions frequently go together.
When oversleeping is a symptom of a sleep disorder
Sleep disorders don’t always make it harder to get enough sleep. They also interfere with sleep quality and sometimes trigger excessive sleepiness and oversleeping. Any sleep disorder or sleep issue that creates sleep deprivation can lead to excessive daytime sleepiness and a tendency to oversleep, to compensate for that sleep deficit. But hypersomnia is closely linked to a few sleep disorders in particular:
Narcolepsy. Narcolepsy is a neurologically-based sleep disorder where the brain lacks the ability to control sleep-wake cycles. People with narcolepsy experience excessive daytime tiredness and often strong and uncontrollable urges to sleep during the day. They often experience insomnia at night. Because their sleep is so disrupted and they have difficulty sleeping well at night, people with narcolepsy may not get excessive total amounts of sleep. But their constant excessive sleepiness and drive to sleep during the day are a specific form of hypersomnia.
Restless Leg Syndrome (RLS). People with restless leg syndrome experience tingling, twitching,
“creepy-crawly” feelings in the legs. These uncomfortable sensations bring
about an often-urgent need to move the legs. The symptoms of RLS are most often
felt when a person is lying still for a period of time, and are frequently most intense at night. People with RLS commonly experience symptoms of insomnia—the unpleasant nighttime sensations in their legs make it very difficult to fall asleep and stay asleep. As a result, people suffering from RLS often cope with excessive daytime sleepiness, and may oversleep because they’re not getting the high-quality rest they need during their 7 or 8-hour nighttime window.
Obstructive sleep apnea. People with sleep apnea experience compromised breathing while they sleep. During sleep, the airway becomes either partially or completely blocked for a short amount of time. These episodes happen over and over again throughout the night, causing frequent awakenings (which the sleeper may or may not be aware of) and leading to a steep decline in sleep quality. There are serious health conditions associated with sleep apnea, including greater risks for cardiovascular disease, stroke, and diabetes.
Because sleep quality is so negatively affected by sleep apnea, people with OSA are often excessively sleepy during the day. They may also spend extended hours in bed, needing more time to sleep because their sleep quality is so poor.
Idiopathic hypersomnia. Some people sleep excessively without a clear, identifiable cause. This is a sleep disorder known as idiopathic hypersomnia—idiopathic meaning without known cause. People with idiopathic hypersomnia sleep for extended periods of time at night and still feel very tired during the day.
Other causes of oversleeping
Substance use disorders. Drug use and alcohol use can lead to disrupted circadian sleep-wake rhythms, declines in sleep quality, and can bring on a pattern of oversleeping and excessive daytime tiredness.
Medical conditions. There are a range of health conditions that can cause oversleeping and persistent, intrusive sleepiness during the day.
- Neurological disorders, including Alzheimer’s disease, Parkinson’s disease, and multiple sclerosis, as well as brain injuries
- Being overweight or obese
In addition, certain genetic disorders and genetic predispositions can cause hypersomnia. People with a family history of hypersomnia are more likely to experience oversleeping and daytime tiredness.
Medications. A number of medications can cause hypersomnia, including:
- Anti-anxiety medications
How to deal with an oversleeping issue
It’s important to talk with your doctor if you’re sleeping excessively or feeling very tired during the day regardless of how much you sleep during the day. If you notice changes to your sleep patterns and sleep needs, including an uptick in your level of tiredness or the amount you’re sleeping, that’s important information to share with your physician. Hypersomnia is often connected to another health condition. When you identify the underlying cause, you and your doctor can work to address both that condition and your oversleeping. That includes other sleep disorders, such as obstructive sleep apnea.
Limit alcohol to improve your sleep quality and sleep patterns. Drinking too much, too frequently and too close to bedtime can all disrupt circadian sleep-wake rhythms and undermine high-quality sleep, leading to a need to oversleep.
Avoid becoming sleep deprived and accruing a large sleep debt. Our bodies will seek the sleep they need. Going with too little sleep will put you in a situation where you’re periodically oversleeping to compensate. These irregular sleep patterns aren’t healthy, for your body or your mind.
Consistency is the most important element of a strong, health-promoting sleep routine. Identify the right amount of sleep you need then set up a schedule that enables you to meet that need routinely. It can take a bit of trial and error to get the amount right. Use the broad guidelines I’ve discussed above, and pay close attention to how you think and feel throughout the day.
Michael J. Breus, PhD, DABSM
The Sleep Doctor™
Signs and Symptoms of Depression
Depression Signs and Symptoms
The foremost symptoms of depression are loss of interest, loss of energy, and an inability to experience pleasure. Sadness associated with depression is often described as inescapable and more painful than normal sadness, which the person may or may not be able to remember having.
Depression can be so overwhelming that a person cannot recognize the symptoms. Many symptoms are revealed only when treatment begins.
Symptoms of depression include the following:
Loss of Energy
More than 90 percent of depressed people experience overwhelming loss of energy. This can cause a person to stay home and avoid social interaction, and prevent a person from starting or finishing projects, maintaining previous interests, or exercising. The effects of diminished energy compound the effects of depression, when work, school, and family obligations are compromised. Also, lack of activity results in loss of muscle tone, muscle mass, and, eventually, bone mass. In turn, these effects lead to degeneration in physique, strength, and physical well-being.
Feelings of Worthlessness
Feelings of worthlessness are common during episodes of depression. Depressed people often feel they are not good at anything and not important to anyone. It becomes impossible for them to accept compliments, or to recognize their achievements. Low self-esteem not only intensifies a low mood, it also compounds a negative view of the world. The apathy that results can obscure a person’s recognition and treatment of depression. Depressed people may get so used to having low self-esteem that they feel ineffectual (like they have no impact on the world). Self-loathing and extensive, unwarranted guilt often result from feelings of worthlessness.
Approximately 80 percent of depressed people suffer from insomnia and may be unable to fall asleep (sleep onset insomnia). This can lead to a loss of energy, excessive daytime sleepiness, and fatigue. Polysomnogrpahic tests have shown less REM sleep in depressed people, which means less time in deep sleep and less dreaming. Sleep disorders are twice as likely to cause depression as vice versa. People with insomnia are 4 times as likely to suffer from depression as people who sleep normally and people with psychiatric disorders are twice as likely to experience insomnia. Insomnia is also a symptom of other psychiatric disorders, such as schizophrenia. Conversely, some depressed people sleep a lot during the day, and longer than normal at night. Feelings of isolation may cause people with depression to sleep too much.
Weight Loss and Weight Gain
When depressed people lose the energy it takes to accomplish basic tasks, important needs such as eating are compromised. Many depressed people lose their appetite, which results in erratic eating habits and missed meals. Subsequent weight loss may result in nutritional deficiency and mental and physical sluggishness. A high percentage of people, especially women, who suffer from eating disorders, such as anorexia, bulimia, and binge eating, are diagnosed with depressive disorder. Some people with depression have an increased appetite and gain weight. These people are usually the same who oversleep.
Loss of Libido
Depression manifestations such as weight gain, sleeping too much, and a loss of interest in sex are known as vegetative states. Feelings of worthlessness and self-loathing, combined with a disinterest in pleasure, cause a loss of intimacy and a decline in sexual activity. Depressed people (especially those undiagnosed) are typically unable to talk about the cause for their reduced sexual drive with their partners. When partners do not understand that depression is causing an absence of intimacy, counseling and sex therapy is often sought without a proper diagnosis of mood disorder. Loss of libido is also a common side effect of antidepressant medications.
Psychomotor Agitation and Psychomotor Retardation
Psychomotor agitation and retardation occur in depression, producing states of over activity and under activity respectively. Agitation and retardation can lead to impaired cognition, judgment, reason, and decision making, which often further isolates depressed people and prolongs symptoms. Psychomotor agitation can also lead to generalized restlessness.
Motor agitation is less common than motor retardation and is often occurs in the elderly. Overactivity in this sense does not mean maniathe agitated state in major depressive disorder should not be confused with the manic episode that occurs in bipolar disorder, when mood is temporarily elevated by a transient sense of hope and elation.
Psychomotor activities are the physical gestures that result from mental processes and are a product of the psyche. Many psychomotor behaviors associated with mental disorder affect impulses, cravings, instincts, and wishes. The spectrum of agitated behavior includes the following:
- Incoherent conversation
- Expansive gesturing
- Pacing and hair twirling
Psychomotor retardation manifests as a slowing of coordination, speech, and impaired articulation. In this state, a person appears sluggish and seems hesitant or confused in speech and intention.
Depression can be a fatal disease. Recurrent thoughts of death, especially suicide, plague about 60 percent of depressed people, and approximately 15 percent commit suicide. Women attempt suicide more often than men, but men succeed nearly twice as often.
Publication Review By: Stanley J. Swierzewski, III, M.D.
Published: 02 Feb 2001
Last Modified: 10 Sep 2015
Is Depression Making Me Sleepless, Or Is Insomnia Making Me Depressed?
Common and Connected
Depression and insomnia are common and possess common symptoms. Some estimate that 30% of Americans will eventually experience clinical depression, and perhaps 40% of adults complain that many or most nights they don’t get enough sleep, wake too often, or feel unrested on awakening.
So which is chicken and which egg? Or are they both?
Depression Causes Insomnia
One of the earliest symptoms for many depressives is insomnia. They can’t fall asleep. They can’t stay asleep.
There are times you can almost diagnose depression by looking at individual sleep studies, where the sleep architecture goes fantastically out of line:
1. Deep sleep, where we produce growth hormone, a stage critical for memory and decision making, may altogether disappear with depression.
2. Awakenings and arousals increase dramatically. Sleep becomes highly fragmented.
3. REM sleep is often broken up, and its very appearance changes. Rapid eye movements may appear both erratic and dense. The changes are so characteristic that Professor Jerry Vogel and others from the 1970’s on tried to treat depression by waking folks every time they started REM sleep. Preliminary results were strongly favorable, but faded.
Depressives and Sleeping Pills
As people become depressed they often identify sleeplessness as their main problem. Insomnia is common and holds little stigma; depression is a “disease” that can cost you jobs, insurance, relationships and self-esteem.
People in depressive episodes often seek sleeping pills, sometimes with desperation.
Generally they will feel better – for a while. Unfortunately the quality of sleep tends to decline as long as the depression is not fully treated.
Frequently sleep medications stop working altogether. Behavioral and other regimes may also then fail.
Many times I have seen depressed people taking enormous doses of sleeping pills who tell me, correctly, that they hardly sleep at all. I tell them, sadly, that until their depression gets better they will probably not sleep well. Sleep can be the last thing to normalize in a depressive episode.
So it’s strange to many, including sleep clinicians, that depression can also cause insomnia’s opposite – prolonged sleepiness. It’s even more of a surprise that forcing people to stay awake at night can improve depression.
Depression Also Causes Prolonged Sleepiness
When most people think of people who sleep too much they usually don’t consider depression as the cause. Their first thoughts (and that of most physicians) is that sleep apnea, or leg kicks, narcolepsy or medications are to blame.
It turns out many who sleep too much are suffering from depression. In groups studied by Michel Billiard at the University of Montpellier, once common sleep disorders like sleep apnea were dealt with, depression was the major cause of hypersomnia.
How can an illness cause insomnia and its opposite? Try to think of depression as what it is – a massive deformation in the brain’s information network. Some depressives sleep too much (though perhaps in part because their sleep quality is poor) while others sleep hardly at all. Just as there are hundreds of causes of depression, its manifestations are manifold. People with bipolar illness may demonstrate a more compressed version of such aberrant brain sleep control, sleeping two hours one night and sixteen hours the next.
Can Forced Insomnia Treat Depression?
Keep normal people up all night and many describe transient euphoria. Keep depressives up all night and many feel much better mood. Yet the effect disappears as soon as they fall asleep. Even a few short minutes of slumber and the more normal mood is gone.
Researchers are extremely interested in why this happens. Theories abound. Many have to do with the basic “uses” of sleep itself. Yet the nature of depression’s effects on sleep is terribly complicated – one reason brief interludes of sleeplessness are rarely used to treat depression.
Insomnia Causes Depression?
It has been known for decades that chronic insomnia was associated with depression – but did it cause it? Jules Angst, professor of clinical psychiatry, observed the young citizens of his city, Zurich for decades. The longer they were insomniac the more depressed they became. When insomnia became chronic, lasting ten years or more, depression’s incidence became frequent, affecting a third or more.
But was this merely a correlational finding? Would these people have gotten depressed anyway, and just showed up first with symptoms of insomnia?
More recent studies argue no. First, data with young people show that those who have trouble with insomnia tend to experience far more depressions. And data is arriving from varied sources that sleeplessness alone – for whatever reason, including shift work – is associated with higher rates of depression.
Insufficient sleep has many different effects. Higher rates of depression are among them.
So What’s Chicken and What’s Egg?
Insomnia and depression are dialectically related – both influence each other. If you are insomniac, the lack of rest required for your body’s natural regeneration provokes a greater tendency to depression. Depression itself massively reorders sleep, often in the form of horribly disrupted sleep architecture and seemingly “untreatable” insomnia.
Both make the other worse. Can improving either decrease the chance for both? Many clinical studies would argue yes.
What You Can Do For Both Depression and Insomnia
Depression and insomnia are clinical syndromes. Their many different symptoms are highly interrelated, and engage many similar brain areas and functions. So it makes sense that some things you do to prevent or treat one may help the other. Treating either usually requires a mix of different therapies, ranging from cognitive-behavioral to physical to pharmacologic to techniques of rest-relaxation.
Fortunately there are simple things most people can do on their own that engage basic activities of life:
1. Physical activity – some people make their way out of depressive episodes through heavy bouts of aerobic exercise. Many studies argue physical activity is as effective as medications for relatively minor depressions.
Most folks sleep at least little better as they become fitter. Exercise in the morning helps some sleep better, particularly older women, while others find evening exercise, 3-5 hours prior to sleep, is more effective for them.
Physical activity helps more than sleep and depression, of course. Particularly when it is combined with
2. Sunlight – Morning light and physical activity improves mood and can also help people sleep. Light is a drug, changing mood, biological clocks, immunity and performance. Decreasing light exposure before sleep may also make falling asleep easier – and perhaps 95% of Americans use light-filled electronic media in the hour before they fall asleep.
3. Social support – mostly unheralded in the US, social support is a very important reason for improved lifespan. People who have more friends and colleagues have less depressive episodes. Social support can also aid sleep – especially when people close to you keep you on a regular sleep-wake cycle, as in
4. Keeping regular body clocks. Time rules life. Many insomniacs and depressives are aided by regular schedules of moving, eating, and sleeping. The simple rhythm of Food-Activity-Rest (going FAR) can help here.
Insomnia and Depression
The different symptoms we experience may feel and sound nearly unique to many of us, but not to brain scientists. Insomnia and depression are deeply interlinked, as are the brain areas involved in both – the information network is often similar. Both depression and insomnia can make the other worse. Fortunately simple life activities can be used to prevent both – and to treat them.
Obstructive sleep apnea may be one reason depression treatment doesn’t work
That’s true even when these individuals don’t seem to fit the usual profile of obstructive sleep apnea, which includes males who are overweight, snore and complain of daytime sleepiness, says Dr. W. Vaughn McCall, chair of the Department of Psychiatry and Health Behavior at the Medical College of Georgia at Augusta University.
“No one is talking about evaluating for obstructive sleep apnea as a potential cause of treatment-resistant depression, which occurs in about 50 percent of patients with major depressive disorder,” says McCall, corresponding author of the study in The Journal of Psychiatric Research. Now he hopes they will.
The investigators found clinically relevant disease in 14 percent of 125 adult patients with major depressive disorder, insomnia and suicidal thoughts, even though the sleep-wrecking apnea was an exclusion criterion for the original study.
While more work remains, McCall reasons that the new evidence already suggests that testing for obstructive sleep apnea should be part of the guidelines for managing treatment resistant depression.
“We were completely caught by surprise that people did not fit the picture of what obstructive sleep apnea is supposed to look like,” says McCall.
While it’s known that people with obstructive sleep apnea have higher rates of depression than other populations, little is known about rates of obstructive sleep apnea in patients with major depressive disorder, so investigators decided to look in a population of patients they already were studying.
The primary intent of the original study was looking at whether treating patients’ insomnia in addition to their depression reduced suicidal thoughts. Patients considered at risk for obstructive sleep apnea were excluded since sleeping pills tend to relax muscle and already-too relaxed throat muscles is a primary problem in obstructive sleep apnea. Also excluded were individuals with restless leg syndrome, which is common with sleep apnea even in patients on therapy, and those with morbid obesity, considered a major risk for obstructive sleep apnea.
But when the 125 people enrolled were actually tested with a sleep study at home or in a sleep center, investigators still found disease in 17.
The investigators note that neither the degree of daytime sleepiness nor insomnia accurately predicted the severity of obstructive sleep apnea they identified in these patients and that six of the 17 individuals diagnosed were female, not obese and reporting insomnia rather than classic daytime sleepiness.
Treatment of obstructive sleep apnea may improve symptoms of depression, and comprehensive screening for the sleep problem should be included for treatment resistant depression, write the team of investigators that also includes researchers from the University of California, Irvine; the University of Wisconsin in Madison; Wake Forest School of Medicine in Winston-Salem, North Carolina; and the University of California, San Francisco
It’s acknowledged that undetected medical or psychiatric conditions can be a cause of treatment-resistant depression, but obstructive sleep apnea is not on the relatively long list that includes endocrine disorders, like hypothyroidism, as well as problems like coronary artery disease and cancer.
In the quest to find a reason for a lack of response, patients may get an MRI scan, carotid artery studies even a spinal tap.
“I am thinking before we do a spinal tap for treatment-resistant depression, we might need to do a sleep test first,” says McCall. He notes that even other depression treatment options, like transcranial magnetic stimulation, which uses rapid magnetic pulses to change brain activity, while noninvasive are still far more costly than a sleep study.
“We know that patients with sleep apnea talk about depression symptoms,” McCall says. “We know that if you have obstructive sleep apnea, you are not going to respond well to an antidepressant. We know that if you have sleep apnea and get CPAP, it gets better and now we know that there are hidden cases of sleep apnea in people who are depressed and suicidal.”
Forty-four percent of the 125 patients in this study had treatment-resistant depression and four of the 17 diagnosed with obstructive sleep apnea had severe problems. Most with obstructive sleep apnea were in the upper end of the age range of 18 to 65 — sleep apnea and other sleep problems tend to increase with age — and were similar in other respects like sex and weight.
Ten years ago in a study of 73 outpatients with depression and insomnia but considered at low risk for sleep apnea, McCall identified 8.2 percent actually had moderate sleep apnea. A subsequent larger study by another group found 14 percent of 703 adults with depression also had obstructive sleep apnea, and others have reported similar findings. This appears to be the first study in which suicidality also was a factor.
Important remaining questions include whether when suicide is also a factor, does treating sleep apnea also reduce suicidal thoughts, says McCall, an expert in the trifecta of depression, insomnia and suicide.
McCall and others have shown that if you don’t sleep you get depressed and depression is a major risk for suicide. In fact, McCall reported several years back that when people lose hope of ever getting another good night’s sleep, they are at high risk for suicide.
Sleep apnea tends to produce excessive daytime sleepiness but this study was recruiting for patients with insomnia, and most with insomnia don’t have sleep apnea, rather issues like anxiety, stress and depression and other emotional and psychological factors are more likely interfering with their sleep. Rather than complain of daytime sleepiness, females are more likely to say they are unable to fall asleep and stay asleep at night and are more likely to be depressed, McCall says.
Treatment-resistant depression also can result as a side effect of other medications, including commonly prescribed drugs like beta blockers and corticosteroids for problems like lupus and rheumatoid arthritis.
“The fact is depression treatment often does not work very well,” says McCall. In fact, evidence has shown that patients who do not respond to one antidepressant are actually progressively less likely to respond to subsequent drugs that are tried. “It’s the law of diminishing returns,” McCall says.
The research was funded by the National Institute of Mental Health.
Struggling to sleep at night can be stressful. And whatever the cause of your disturbed rest – be it noise or anxiety – the stress you experience as a result often adds to the problem. But how much does lack of sleep really affect your mental health? And just what can you do to ensure a more restful night’s sleep?
We speak to Niels Eék, psychologist and founder of personal development and wellbeing app Remente, about the link between sleep quality and poor mental health (including depression) and how to resolve those bad nights in bed:
What causes sleep problems?
If you’ve ever had to endure a disrupted night’s sleep, the reasons behind unexpected insomnia are often frustrating. ‘There are so many factors that can contribute to a poor night’s sleep, from temperature to stress, anxiety and discomfort,’ says Eék. ‘It might feel as though you are completely unable to switch off your brain.’
External sleep disruption
Examples of physical, external causes of poor sleep include:
- Noise disruption
- Being a carer, such as for young children or the elderly
- Physical discomfort
- Jet lag
- Certain medicines
- Eating a heavy or spicy meal
Internal sleep disruption
Examples of mental, internal causes include:
- Anxiety, depression or another mental health problem
- Stress or worry
Poor sleep and mental health
So, how can regular bouts of poor sleep affect the way you feel and behave? ‘If you were to occasionally stay awake for 24 hours straight, it would likely not have too great an impact on how you managed daily tasks,’ says Eék, ‘although you would likely feel tired, and maybe even unmotivated and jittery.
Poor-quality sleep for a sustained period of time can lead to depression and other mental health conditions.
‘If you were to stay awake for several days and nights, it would result in you falling into so called “micro sleeps”, for example while you were eating dinner or going for a bike ride. It would also become harder and harder to concentrate and make decisions,’ he adds.
‘Of course, most people aren’t awake for several days in a row. Most commonly, people with sleep problems actually do sleep regularly, but find that the sleep is of bad quality or often broken.’
Poor sleep negative symptoms
Eék reveals that symptoms of consistent bad-quality, broken sleep can include:
- Difficulty concentrating
- Feeling tired and sluggish
- Cravings of sugary or high-fat foods, such as cookies, sweets and crisps
- Low mood, including feeling grumpy, downhearted, angry or emotional
‘Poor-quality sleep for a sustained period of time can, in some instances, lead to depression and other mental health conditions, such as seasonal affective disorder (SAD), paranoia and anxiety,’ reveals Eék.
One 2017 study, carried out by the Sleep and Circadian Neuroscience Institute at the University of Oxford, investigated the link between insomnia and the occurrence of a variety of mental health problems, including paranoia, anxiety, hallucinatory experiences and depression. Researchers found that when individuals received cognitive behaviour therapy (CBT) to treat their insomnia, they experienced sustained reductions in paranoia and hallucinatory experiences, and improvements in depression, anxiety, nightmares, psychological wellbeing, daytime work and home functioning.
‘Studies have shown that sleep deprivation can affect cognitive performance, including perception, memory and executive functions,’ agrees Eék. ‘While decision making and planning tasks are relatively unaffected by sleep loss, more creative and innovative thoughts do appear to be impacted by lack of sleep. I would recommend that if you’ve had a bad night’s sleep and feel a bit groggy, you should consider making the following day an admin day.’
How much sleep do we need?
So when it comes to getting a healthy amount of sleep and keeping your mental health in check, how much shut-eye is enough?
‘According to the National Sleep Foundation, adults aged between 26 and 64 need an average of seven to nine hours of sleep per night,’ says Eék. ‘Of course, everyone is different and there are always exceptions, with about 20 per cent of the adult population needing less than six hours of kip per night. It’s therefore important to find your own circadian rhythm and a sleeping pattern that suits your personal needs.’
Adults aged between 26 and 64 need an average of seven to nine hours of sleep per night.
Eék also points out that, while getting too little sleep is often highlighted as a cause for concern, getting too much sleep can equally be a problem.
‘We usually focus on not getting enough sleep, but it is also a problem to sleep too much. People who sleep for more than nine hours a day are more likely than others to fall ill. As always, this isn’t true for everyone, but for most people, more than nine hours is too much sleep,’ he says.
‘Many people think it’s important to sleep for eight hours per night, but remember, it isn’t how much sleep you get that’s important – it’s the quality of your sleep that matters. Also remember, the need for sleep varies from person to person.’
Top tips to create positive sleep habits
If you’re struggling to enjoy an uninterrupted night’s sleep and feel this is beginning to impact your mental health, there are steps you can take to help. Eék offers the following advice to help promote good-quality, restful sleep:
✔️ Practice good sleep hygiene
In the final hour before going to sleep, avoid blue light from your phone screen, avoid caffeine and practise meditation. Studies have shown that as little as two minutes of mindfulness meditation before bed can have a marked improvement on your sleep.
✔️ Exercise – but not too late in the day
One way to enhance the likelihood of a good night’s sleep is by doing regular aerobic exercise. As little as ten minutes of aerobic exercise, such as walking or cycling, can dramatically improve the quality of your nighttime sleep, especially when done on a regular basis.
However, don’t try to squeeze your fitness routine in just before bed. Exercise will activate a host of bodily functions, which will then need to recuperate. If you exercise too close to bedtime, the endorphins released can keep you awake, but if you have enough time to cool down (around two hours beforehand) it can help tire out your body.
✔️ Avoid alcohol and drugs
Substances such as alcohol and cannabis can have a short initial effect on sleep, making it easier to fall asleep. But this effect always diminishes after some period of use, as the body gets used to the substance. Your sleep quality will also worsen – you’ll find you experience less deep sleep and wake more easily in the night – because your body has to decompose the added substance.
✔️ Stop screen time
Your brain will start to wind down and become tired if you engage it in activities such as reading, writing or listening to music. On the other hand, watching a TV show or scrolling through social media is too passive and will, therefore, keep your brain engaged and awake.
✔️ Consider your diet
It’s worth considering your food and drink choices. Consuming stimulants, such as caffeine and sugar, before bed will make it hard for you to relax and fall asleep. Caffeine, for example, blocks the receptors in your brain that make you drowsy, preventing you from reaching deep sleep.
✔️ Seek professional support
If you suspect you suffer from insomnia, I recommend you seek professional help from a cognitive behavioural therapist who works with sleep restriction therapy combined with stimulus control, which is the most efficient therapy for insomnia over a sustained period.
✔️ Be careful with sleep medication
Remember that sleep medications are only recommended to use in an acute situation, for the first two to three weeks. We don’t have evidence that sleep medications are effective for a longer period of time, but we do know that some sleep medications can be addictive, physiologically or psychologically.
Last updated: 21-01-2020
Claire Chamberlain Contributor Claire is a freelance writer specialising in health, fitness and wellbeing.