Tag Archives: sleep and depression

Sleep and Mood Disorders

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

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.


  1. Peterson, M. J., & Benca, R. M. (2006). Sleep in mood disorders. Psychiatric Clinics29(4), 1009-1032.
  2. 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.
  3. Ağargün, M. Y., Kara, H., & Solmaz, M. (1997). Sleep disturbances and suicidal behavior in patients with major depression. The Journal of clinical psychiatry58(6), 249-251.
  4. Sharafkhaneh, A., Giray, N., Richardson, P., Young, T., & Hirshkowitz, M. (2005). Association of psychiatric disorders and sleep apnea in a large cohort. Sleep28(11), 1405-1411.
  5. 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 psychiatry64(10), 1224-1229.
  6. Fugh-Berman, A., & Cott, J. M. (1999). Dietary supplements and natural products as psychotherapeutic agents. Psychosomatic Medicine61(5), 712-728.
  7. 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 clínica137(9), 398-401.
  8. Harvey, A. G. (2000). Sleep hygiene and sleep-onset insomnia. The Journal of nervous and mental disease188(1), 53-55.

Sleep and aging

Sleep changes dramatically over our life spans.  As we know, newborns sleep the majority of the day and napping persists until age 3-4.  Eventually, our sleep consolidates into a single period of sleep lasting 7-8 hours per night.  Elderly individuals seem to be more prone to distressing sleep disruptions.  This blog post reviews the types of sleep issues that commonly occur as we age.

The effect of age on sleep

We have discussed the effects of decreased sleep on the elderly, and now we shall focus on what the effect a person’s age has on sleeping patterns.

A study has shown that elderly people experience a shorter duration of sleep time, decreased sleep efficiency, and increased waking up at night independent of other factors such as chronic conditions and problems such as sleep apnea.8

The study further found that in men, age was independently associated with more Stage 1 and Stage 2 sleep and less Stage 3 to 4 (slow wave sleep) and REM sleep. Older women were found to have more trouble falling asleep, and experienced more issues with waking up during the night and waking up too early.

Lack of sleep and dementia

One of the vital roles of sleep is to allow the brain to activate a specific system that is responsible for cementing long term memories in the brain cortex. Sleeping also helps individuals to retain information and perform better on memory tasks and activities.1

Studies have shown that sleep deprivation may be linked to the development of dementia disorders, such as Alzheimer’s disease, in the elderly.2 The reason behind this may be due to lack of slow-wave sleep causing the build-up of beta-amyloid proteins in the brain, which ultimately affect the mentioned system responsible for memory consolidation. Alzheimer’s disease also worsens patients’ sleep patterns, so a vicious cycle develops where sleep deprivation causes worsening of the disease which worsens the patients’ abilities to sleep.

Lewy body dementia, which is caused by deposits of Lewy body proteins on the nerve cells of the brain, directly causes increased daytime sleepiness due to lack of sleep.3 This seems to occur regardless of other factors such as disease progression and memory fluctuations in these affected individuals. Lewy body dementia is also responsible for rapid eye movement (REM) sleep disorder, which is a condition characterized by flailing of the limbs and acting out while dreaming. The reason for this is because REM sleep causes temporary paralysis of the skeletal muscles of the body, and REM sleep disorder inhibits this paralysis causing the patients’ symptoms.4

The researchers of these studies have collectively requested that further investigations are conducted into the cause and effect of sleep disturbances on dementia-related pathologies, in order to try and discover possible treatments for the conditions.

Sleep duration and inflammation

A recent study was done determining the link between the duration of sleep in the elderly and what effect inflammation has on the mortality of individuals aged between 71 and 76 years of age.5 The fundamental findings made were that short sleep duration (5 or less hours of sleep per night) was associated with an increase in inflammatory markers resulting in elevated mortality levels, and that longer sleep duration was associated with decreased mortality. These findings were made independent of other risk factors such as smoking, obesity, chronic conditions such as hypertension (high blood pressure) and diabetes (uncontrolled high glucose levels), and complications of these factors such as coronary artery disease.

Therefore, shorter sleep duration is regarded as an independent cause of increased mortality, thereby making this aspect just as detrimental to one’s health as the mentioned factors.

Sleep disturbances and depression

A study that was performed on a community of elderly people yielded that these individuals’ disturbed sleeping patterns were linked to them experiencing varying symptoms of depression.6

The sleep-related issues were linked to those who were female, living alone, unmarried and who had a disability. The two year follow up analysis of these elderly individuals showed that half of the participants still experienced sleep disturbances. It was discovered that the best predictors for future depression were elderly people with sleep disturbances and current depression symptoms; and for those who were not initially depressed, it was sleep disturbances alone.

This latter finding suggests that disturbed sleeping patterns are not only a symptom of depression, but rather as a possible predictor of the future development of depression in the elderly.

Sleep disorders and falls in the elderly

Since sleep-related disorders and falls are a common problem in the elderly, researchers decided to look into the possible link between the two problems.

Surveys were conducted which were filled in by elderly people between 65 and 89 years of age, and most of the participants admitted to falling down when getting up at night. The reason for the latter issue was that the individuals were experiencing poor sleep quality.7 Other risk factors for the falls included the use of diuretics, causing the affected participants to get up and visit the bathroom at night, not being able to see properly and bumping into obstacles, and having to use walking aids for pre-existing physical issues.

Improving sleep in the elderly

Due to the abovementioned issues it would seem prudent to promote an adequate amount of sleep, especially in the elderly who are more prone to developing issues such as dementia and who already have an increased risk of mortality.

A study has shown that supplementing with melatonin, a hormone produced by the pineal gland in the brain and which regulates the sleep-wake cycle, helps to promote an adequate amount of sleep in affected individuals.9

Elderly patients who are prone to sleep disorders have been noted to be those who are on chronic medications. These medications can disrupt the production and clearance of melatonin by the body, thus resulting in the sleep-related issues experienced by the affected individual.


The recommendation made by the researchers, in the clinical studies used for this article, is that an adequate amount of sleep of between six to eight hours is achieved by elderly people. Less than 5 hours and more than 9 hours of sleep can have detrimental effects on the physical and psychological well-being of these individuals.


  1. Scullin, M. K. (2013). Sleep, memory, and aging: the link between slow-wave sleep and episodic memory changes from younger to older adults.Psychology and aging,28(1), 105.
  2. Drummond, S. P., & Brown, G. G. (2001). The effects of total sleep deprivation on cerebral responses to cognitive performance.Neuropsychopharmacology, 25, S68-S73.

3. Ferman, T.J., Smith, G.E., Dickson, D.W., Graff-Radford, N.R, Lin, S-C., Wszolek, Z., … & Boeve, B.F. (2014). Abnormal daytime sleepiness in dementia with Lewy bodies compared to Alzheimer’s disease using the Multiple Sleep Latency Test. Alzheimer’s Research & Therapy, 6, 76.

  1. Iranzo, A., Molinuevo, J. L., Santamaría, J., Serradell, M., Martí, M. J., Valldeoriola, F., & Tolosa, E. (2006). Rapid-eye-movement sleep behaviour disorder as an early marker for a neurodegenerative disorder: a descriptive study.The Lancet Neurology,5(7), 572-577.
  2. Hall, M. H., Smagula, S. F., Boudreau, R. M., Ayonayon, H. N., Goldman, S. E., Harris, T. B., … & Stone, K. L. (2015). Association between sleep duration and mortality is mediated by markers of inflammation and health in older adults: the health, aging and body composition study.Sleep,38(2), 189-195.
  3. Livingston, G., Blizard, B., & Mann, A. (1993). Does sleep disturbance predict depression in elderly people? A study in inner London.Br J Gen Pract,43(376), 445-448.
  4. Hill, E. L., Cumming, R. G., Lewis, R., Carrington, S., & Couteur, D. G. L. (2007). Sleep disturbances and falls in older people.The Journals of Gerontology Series A: Biological Sciences and Medical Sciences,62(1), 62-66.
  5. Hill, E. L., Cumming, R. G., Lewis, R., Carrington, S., & Couteur, D. G. L. (2007). Sleep disturbances and falls in older people.The Journals of Gerontology Series A: Biological Sciences and Medical Sciences,62(1), 62-66.
  6. Garfinkel, D., Laudon, M., Nof, D., & Zisapel, N. (1995). Improvement of sleep quality in elderly people by controlled-release melatonin.The Lancet,346(8974), 541-544.