Sleep disturbances are commonly occurring complaints in people who are diagnosed with mood disorders.1 By far, the most common mood disorder is depression. It is estimated that 6.7% of the US adult population meets criteria for major depression each year. The majority of individuals with major depression will have sleep related complaints of complaints of fatigue.
Changes in patient’s sleeping patterns are criteria which help to make the diagnosis of these mood disorders. This emphasizes the importance of how common these sleep disturbances occur in patients with mood disorders. Up to 16 percent of the general population struggles with insomnia (the inability to fall asleep), but this percentage increases in patients with mood disorders. It is estimated that up to 80% of patients diagnosed with major depression have symptoms of insomnia. In addition, the symptoms of sleepiness, fatigue, anhedonia, and difficulty initiating or maintaining sleep are very common in both insomnia and depression. Therefore, the diagnosis of major depression should be made with caution in patients who don’t present with this sleep disorder.2
Major depression is characterized by at least two weeks of low mood that is present in most situations. Affected individuals may also complain of experiencing low self-esteem, low energy, a loss of interest in activities that used to be enjoyable, and pain without a definitive cause. Some people may also admit to thinking false beliefs they believe are true (delusions), or they may even hear or see things that others cannot (hallucinations).
Major depression negatively affects an affected person’s personal and work, or school life, as well as their general health, eating and sleeping habits. One of the main characteristic of major depression is that it affects the hypothalamus in the brain. This is an area of the organ that is responsible for connecting the brain to the endocrine system (responsible for the release of hormones which control metabolic functions of the body). Major depression negatively affects the hypothalamus and this is why patients experience disturbances to their eating habits, sex drive and sleeping patterns. Most of the time these aspects are depressed, but there are cases where they become elevated.
Up to seven percent of patients with major depression die from committing suicide. In fact, a study discovered that clinically depressed patients with insomnia and hypersomnia (increased sleep) had higher scores on the SADS suicide questionnaire than those without any sleep disturbances.3 It was also noted that patients with sleep disturbances were much more likely to become suicidal than those without sleep-related problems.
Sleep apnea and mood disorders
Certain sleep-related conditions may also be associated with the development of mood disorders such as major depression.
This includes sleep apnea, which is a condition associated with difficulty in breathing while the affected individual is sleeping. This disturbance in the person’s ability to breathe results in decreased oxygen supply to the body with resulting sleep fragmentation and injury to body tissues. We have also seen snorers ‘gasp themselves’ awake. This is an example of sleep fragmentation which prevents people with sleep apnea from achieving deep restorative sleep.
Researchers have discovered that sleep apnea is associated with the development of certain mental health issues, especially major depression.4 This link suggests that patients with mood disorders should be evaluated for sleep apnea.
Management of sleep disorders in major depression
The optimal approach to managing individuals with mood disorders and insomnia is to consider them comorbid disorders and treat them both. It is quite possible that managing an individual’s depression will improve their insomnia. Similarly, it is quite possible that managing an individual’s insomnia will help their depression symptoms. However, the optimal approach is to address both. The management of sleep disorders in patients with major depression can be performed by treating the cause of the depression, or by managing the symptoms of the sleep disturbances.
The two main methods of treating insomnia (with or without depression) are with cognitive behavioural therapy and with medications. Similarly, the two main ways to treat depression is with therapy and with medications. As expected, there can be a lot of overlap. Therapy for both insomnia and depression is optimally provided by a behavioural medicine provider with expertise in sleep disorders. This approach attempts to change behaviours and beliefs relative to one’s condition. It commonly takes many months to achieve but can result in long term symptom relief.
Pharmacologic approaches generally utilize antidepressant, anti-anxiety medications and soporific agents to treat the myriad of symptoms. Mirtazapine and fluoxetine are two of the former mentioned medications which have been shown to reduce stress and anxiety levels, associated with the development of major depression. Mirtazapine though has been shown to help more than fluoxetine in managing the insomnia associated with depression.5
Benzodiazepines and benzodiazepine-like medications such as zolpidem have been used for many years to help get patients to sleep. These medications don’t treat the sleep disorder, but they do help to sedate the patient so that they can get to sleep. Over the past decade, there has been a tremendous increase in the number of sleeping pill prescriptions. Along with that, there has been an increase in the number of night time falls, particularly in the elderly. Sleeping pills should be utilized at a minimum, with extreme caution and with close oversight by the managing physician.
Some medications that are commonly prescribed for the treatment of depression may however worsen insomnia and impair full recovery from the illness.2 Therefore, caution needs to be exercised when these patients are prescribed medications by their doctors, and that the individual’s unique circumstances are considered when doing so.
Home remedies and natural measures
Alternative therapies such as the use of certain herbs and dietary supplements are noted to be effective in the management of sleep disturbances in the presence of major depression.6 Such products include St. John’s wort and kava to help with the depression caused by anxiety, and valerian for insomnia specifically.
Preliminary evidence from certain studies shows that supplements such as folate, phenylalanine and tryptophan have shown some benefit in improving the effect of conventional antidepressants. Also, omega-3 fatty acids (from fish oil) have shown to have mood stabilizing effects.
It’s important to remember that any natural supplement should be discussed with the patient’s primary care physician to make sure that these products are safe to use, and that they won’t interact with any other medications that may be used by the patient.
Relaxation measures such as deep breathing exercises, aromatherapy, massage therapy, pet therapy, meditation, prayer, yoga and acupuncture are all proven natural measures which can be incorporated to reduce stress and anxiety levels in people.7 Regular aerobic exercise has also been proven to promote a healthy body which also helps with stress relief. In my personal life, I am certain that daily exercise and meditation as well as aromatherapy and a healthy diet promote my sense of well-being and improve my sleep
Sleep hygiene is suggested to help patients to get to sleep regardless of the cause of the insomnia. These include measures such as going to bed and waking up at the same time every day, following strictly to a pre-bedtime routine, taking a warm bath or shower before retiring to bed, only lying in bed to try to sleep and not watching T.V. or reading a book, and staying in bed even if the patient wakes up during the night.8
Sleep disturbances are very common problems in patients with mood disorders. Optimal management involves addressing both the mood disorder and the insomnia/sleep condition in parallel utilizing a combinations of behavioural modification/therapy, medications and natural therapies. One should think of it as a ‘two way street’. Improving one’s sleep will improve one’s mood problems. Similarly, improving one’s mood disorder such as depression will commonly improve the quality of sleep.
- Peterson, M. J., & Benca, R. M. (2006). Sleep in mood disorders. Psychiatric Clinics, 29(4), 1009-1032.
- Antonina Luca, Maria Luca, & Carmela Calandra (2013). Sleep disorders and depression: brief review of the literature, case report, and nonpharmacologic interventions for depression. Clin Interv Aging, 8, 1033–1039.
- Ağargün, M. Y., Kara, H., & Solmaz, M. (1997). Sleep disturbances and suicidal behavior in patients with major depression. The Journal of clinical psychiatry, 58(6), 249-251.
- Sharafkhaneh, A., Giray, N., Richardson, P., Young, T., & Hirshkowitz, M. (2005). Association of psychiatric disorders and sleep apnea in a large cohort. Sleep, 28(11), 1405-1411.
- Winokur, A., DeMartinis 3rd, N. A., McNally, D. P., Gary, E. M., Cormier, J. L., & Gary, K. A. (2003). Comparative effects of mirtazapine and fluoxetine on sleep physiology measures in patients with major depression and insomnia. The Journal of clinical psychiatry, 64(10), 1224-1229.
- Fugh-Berman, A., & Cott, J. M. (1999). Dietary supplements and natural products as psychotherapeutic agents. Psychosomatic Medicine, 61(5), 712-728.
- Arcos-Carmona, I. M., Castro-Sánchez, A. M., Matarán-Peñarrocha, G. A., Gutiérrez-Rubio, A. B., Ramos-González, E., & Moreno-Lorenzo, C. (2011). Effects of aerobic exercise program and relaxation techniques on anxiety, quality of sleep, depression, and quality of life in patients with fibromyalgia: a randomized controlled trial. Medicina clínica, 137(9), 398-401.
- Harvey, A. G. (2000). Sleep hygiene and sleep-onset insomnia. The Journal of nervous and mental disease, 188(1), 53-55.