Sleep problems are a common feature of many psychiatric disorders 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 disorder 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 and life.
Sleep and Depression
Depression is a mood disorder characterized 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 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.
There is a substantial body of evidence linking depression with sleep disorders. The relationship between insomnia and depression is bi-directional; Insomnia increases the risk of depression and 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".
View the Sleep and Psychiatric Disorders Fact Sheet
Sleep and Anxiety Disorders
People with anxiety disorders feel nervous, tense, have difficulty controlling worrying, and find it hard to relax. Sleep disorders are found in over 50% 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 sufficiently to sleep at night. Insomnia in turn can elevate anxiety levels. Nocturnal panic attacks are also common; these are characterized by sudden awakening from sleep with intense anxiety, shortness of breath, and 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. In addition, many people abuse alcohol and illicit drugs to promote sleep. However, they are not effective in the long run and can lead to a variety of serious adverse consequences, 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. Other substances cause similar problems. The use of alcohol and other illicit drugs to treat insomnia is strongly discouraged.
The 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 aiming to correct maladaptive 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. People with insomnia should also adopt healthy habits and rituals that promote a good night's sleep. These include:
- Think positive
- Establish fixed bed and wake times
- Relax before going to bed
- Maintain a comfortable sleeping environment
- Avoid clock watching
- Follow a 20 min "Toss and Turn" rule
- Use the bedroom for sleep and sex only
- Avoid daytime naps
- Avoid caffeine, alcohol, nicotine within 6 hr of sleep
- Exercise regularly but not within 3 hours of sleep
National Sleep Foundation
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National Alliance on Mental Illness
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