Sleep & Psychiatric Disorders
Sleep and psychiatric disorders often occur at the same time, and untreated sleep disorders can increase the risk of developing psychiatric conditions, such as depression, later in life. Recent reports found that as many as two-thirds of patients referred to sleep disorders centers have a psychiatric disorder. The most common psychiatric disorders associated with sleep complaints include depression, anxiety, and substance (illicit drugs and alcohol) abuse. Treating sleep disorders has been shown to improve the co-existing psychiatric condition and overall quality of life.
Depression is a mood disorder identified by low mood and/or lack of interest in activities previously found to be enjoyable. Depression affects one’s appetite, concentration, energy level, and motivation. People with depression report feelings of helplessness, hopelessness, worthlessness, and have suicidal thoughts. The majority experience symptoms of insomnia, consisting of difficulty in falling asleep, staying asleep, early morning awakening, or non-refreshing sleep.
Studies of depressed patients demonstrate prolonged sleep latency (time to fall asleep), lack of slow wave sleep (also known as deep sleep), reduced REM sleep latency (time to REM sleep from sleep onset), and increased amount of REM sleep. REM stands for rapid eye movement, a sleep cycle characterized by the following physiological changes:
- Accelerated respiration
- Increased brain activity
- Eye movement
- Muscle relaxation
There is much evidence linking depression with sleep disorders. It has been shown that insomnia increases the risk of depression and that depression can cause insomnia. In a 34-year follow-up study of medical students at Johns Hopkins Medical Center, the risk of developing depression among students with insomnia was twice that of those without insomnia. Of all the symptoms of depression, insomnia is often the last to respond to medications. Failure to treat insomnia increases the risk of a depression relapse.
Rarely, people with depression report excessive daytime sleepiness. This is more common in patients with seasonal affective disorder, also known as "winter depression."
People with anxiety disorders feel nervous, tense, have difficulty controlling worrying, and find it hard to relax. Sleep disorders are found in over 50 percent of patients with generalized anxiety disorder. Difficulty in falling and staying asleep is the most common sleep disturbance. People with anxiety disorders report a high level of psychological distress and are unable to relax enough to sleep at night. Insomnia in turn can raise anxiety levels. Nocturnal panic attacks are also common; these are sudden awakenings from sleep accompanied by intense anxiety, shortness of breath, heart palpitations, and usually lead to difficulty falling back asleep.
Sleep and substance abuse
People who abuse alcohol and other illicit drugs frequently experience sleep problems. Many people say they use alcohol and illicit drugs in order to fall asleep. However, these substances are not effective in the long run and can lead to a variety of serious health and performance problems, including psychiatric and medical disorders, and psychosocial problems such as impaired performance at school or work. Though many believe in its sleep-promoting benefits, alcohol actually disrupts sleep, causing recurrent awakenings and a reduced amount of REM sleep. The use of alcohol and other illicit drugs to treat insomnia is strongly discouraged.
Treatment of co-existing psychiatric and sleep disorders requires a thorough evaluation by experts with knowledge in both sleep medicine and psychiatry. Medications to treat depression and anxiety must be chosen carefully, as some promote wakefulness while others cause drowsiness.
Cognitive Behavioral Therapy (CBT) is a structured and focused treatment for insomnia, typically provided by an experienced psychologist. CBT refers to a variety of behavioral strategies used to correct harmful or negative thought patterns and behaviors that can cause or worsen insomnia. This type of therapy is not only effective, but its benefits outlast those of medications. Examples of CBT include relaxation therapy and biofeedback (a type of therapy that uses medical monitoring equipment to help patients learn to relax by controlling their vital signs -- heart rate, breathing, etc).
People with insomnia should also adopt healthy habits and rituals that promote a good night's sleep. These include:
- Thinking positively
- Establishing fixed bed and wake times
- Relaxing before going to bed
- Maintaining a comfortable sleeping environment
- Avoiding clock watching
- Following a 20 minute "Toss and Turn" rule (giving yourself only 20 minutes to continue tossing and turning, before leaving the bed for some restful activity)
- Using the bedroom for sleep and sex only
- Avoiding daytime naps
- Avoiding caffeine, alcohol, and nicotine within 6 hours of sleep
- Exercising regularly but not within 3 hours of sleep