Sleep and Depression: Understanding Connection & How it Affects

What is the Connection Between Sleep and Depression?

A common experience of individuals with depression is that many of them have a hard time getting out of bed. Even after 8 hours of sleep or more, they may wake up feeling tired, and void of any energy or will to get through the day, go back to sleep. This is just one manifestation of the deep connection between depression and sleep. While a depressed state increases the need for sleep in some cases, no amount of sleep seems to provide adequate rest and restoration. 

Understanding The Importance Of Sleep 

Sleep is one of the pillars of wellbeing, and plays several important roles for our physical and mental health. While the primary function of sleep is rest and repair, good quality sleep is also essential for various other physical and psychological functions. The physical benefits of sleep include regulation of hormones, metabolism, and protection against chronic illnesses like cardiovascular issues, stroke and diabetes. Sleep is also important for memory consolidation and improves focus, learning and decision-making. 

To reap the benefits of sleep, it is important that we get 6 to 9 hours of uninterrupted sleep. This is because sleep occurs in four stages, and it is during stage 3 and 4 of the sleep cycle that some of the magic happens. Stage 1, 2 and 3 are Non-REM (Non - Rapid Eye Movement) stages of sleep, while stage 4 is REM-stage. In Stage 1 Non-REM sleep, one’s body and mind slowly begin to relax.

In Stage 2, one enters a deeper state of relaxation and sleep wherein brain waves and muscle activity slow down. Stage 3 is also a Non-REM stage, but this stage is crucial for the restorative and cognitive functions of sleep. During the REM stage, brain activity picks up again, but the body enters a state of immobility. This is when also when we have dreams. Uninterrupted sleep is important for good health because it is only when we complete the full sleep cycle that all the benefits of sleep are reaped. 

Defining Depression

Depression is a mood disorder in which one experiences persistent low mood, feelings of hopelessness and worthlessness and changes in appetite and sleep. While some amount of sadness or low mood is a part of life, in depression, these feelings and behaviours don’t change much in response to positive or uplifting events. Some common symptoms of depression include: 

• Persistent low mood that lasts for most days 
• Feeling hopeless or helpless about the future 
• Changes in appetite 
• Irritability or anger outbursts 
• Loss of interest in activities one enjoyed previously 
• Changes in sleep 

The last symptom of depression - changes in sleep - is fairly common. Up to 80% of individuals with depression experience insomnia at some point. Hypersomnia, or sleeping too much, is also commonly associated with depression. Other sleep disturbances seen in cases of depression include difficulty falling asleep, and early waking. 

What’s The Relationship Between Sleep and Depression?

How Does Depression Affect Sleep and its Impact?

Does depression cause sleepiness or lack of sleep? Or do sleep disturbances cause depression? 

Perhaps these are not the right questions to ask. The reason is that depression and sleep have a bidirectional relationship, which is best understood as co-occuring conditions rather than one causing the other. Sleep disturbances seen in depression can broadly be divided into two categories - insomnia and hypersomnia. In simple words, a depressed individual might either have trouble falling or staying asleep, or may be oversleeping. Let’s look at these in a further detail: 

Insomnia and Depression

Insomnia is the inability to fall or stay asleep. Not getting enough sleep can not only be draining, but also have detrimental effects on one’s physical and mental health. Lack of adequate good quality sleep can lead to increased daytime fatigue, trouble concentrating, irritability, mood swings, decreased performance at tasks, and anxiety and depression. 

Depression and insomnia have a bi-directional relationship. While chronic insomnia may contribute to the precipitation of depressive symptoms, it is also a symptom of depression. It’s a bit of a chicken-and-egg situation and is best understood as comorbidity rather than trying to figure out what comes first. 

If one struggles with insomnia, here are a few things to keep in mind: 

1. Practice good sleep hygiene: Good sleep hygiene includes lifestyle habits and a bedroom environment that is conducive to sleep. Lifestyle habits that support good sleep include not eating heavy meals at night, not using screens for at least an hour before bedtime, avoiding caffeine after 2 pm, not consuming alcohol. The right bedroom environment includes a comfortable room temperature, no light or noise, and comfortable pillow and mattress. 
2. Exercise regularly: While the mechanics of how regular exercise improves sleep are not well understood yet, research does show that it is beneficial. As little as 30 minutes of aerobic exercise daily can lead to improvements in sleep.  
3. Have a soothing bedtime routine:  What you do for the last hour of your day before you go to sleep matters. Think about establishing a sustainable soothing bedtime routine. You may consider taking a hot shower before bed, journaling, meditating or doing some relaxation exercises. 

Hypersomnia: Why Do People with Depression Sleep So Much?

Hypersomnia is the tendency to oversleep. Common signs of hypersomnia include constantly feeling sleepy, sleeping for at least 10 hours a day and having difficulty waking up. But, is sleeping too much a sign of depression? About 30% of individuals diagnosed with idiopathic hypersomnia also have depression. Just like insomnia and depression have a bidirectional relationship where we can’t always be certain which leads to which, so do hypersomnia and depression. Excessive sleeping or hypersomnia can impact one’s daily life and relationships. If one regularly feels groggy, they may have difficulty in engaging with tasks at home or work. They may have low energy and motivation to engage in activities, leading to social isolation. 

Overview of Factors Contributing to Sleep Problems

What Causes Sleep Problems in Depression?

Sleep can often be a window to our physical and psychological well-being. Sleep problems are often an indication of unmanaged stress, poor schedule, lifestyle habits, or in some cases, underlying medical or mental health conditions like chronic pain, anxiety or depression. 

Sleep problems in depression are fairly common, and often one of the first giveaways of depression. Certain hormones, neurotransmitters and biomarkers play an important role in both sleep and depression. 

For example, serotonin plays an important role in both, mood regulation and regulation of sleep. In many cases of depression, one also experiences chronic inflammation. Chronic inflammation is associated with the physical symptoms of depression such as changes in appetite, fatigue and changes in sleep. 

It’s safe to say that there are several biological changes that are seen in both, depression and sleep disturbances which may explain why there is a close relationship between the two. 

The Vicious Cycle of Sleep Problems and Worsening Depression

Because of the bidirectional relationship between sleep and depression, sometimes one may end up in a vicious cycle where poor sleep worsens symptoms of depression, or vice versa. Sleeping too little can deprive one of the reparative and restorative benefits of sleep discussed above. This can lead to lowered immunity, poor concentration, irritability, brain fog, low productivity and mood swings. On the other hand, those who struggle with hypersomnia often feel listless throughout the day, making the cloud of depressiveness heavier. 

Sometimes, working on improving sleep may be easier than tackling other aspects of depression. It can also subsequently make it easier to tackle other aspects. Maintaining sleep hygiene, making necessary lifestyle changes and taking medication for sleep, if necessary can help one manage other aspects of depression too. 

What Are the Treatment Approaches and Lifestyle Changes?

Sleep disturbances can be managed with medication, psychotherapy, and lifestyle modifications. 

Medication for Sleep and Depression

A psychiatrist can prescribe medications for both, sleep and depression. What medication you should have, and in what dosage, is assessed based on the severity of symptoms and how you respond to the medication. Sedating antidepressants include tricyclics, trazodone, and some new agents such as nefazodone and mirtazapine. Some common side effects of sleeping pills include daytime drowsiness, headaches and nausea. 

It’s crucial to consult with a healthcare provider when consuming sleeping pills or antidepressants. It’s also important to not stop or change the dosage of the medication without consulting.

Cognitive Behavioral Therapy for Insomnia (CBT-I)

CBT is one of the most commonly researched evidence-based treatments for insomnia. CBT-i, or cognitive behavioural therapy for insomnia is seen to be as effective as sleep medication, and with no side effects. CBT-i has five key components - sleep consolidation, stimulus control, cognitive restructuring, sleep hygiene and relaxation techniques. 

Lifestyle Changes to Improve Sleep and Manage Depression

Lifestyle changes are important for both, improving sleep and managing depression. Some useful lifestyle changes include: 

1. Reducing screen time, especially for the last hour before bedtime 
2. Eating a light and early dinner - ideally two hours before sleeping 
3. Reducing caffeine and alcohol consumption 
4. Regular exercise and daily movement 
5. Relaxation practices such as guided visualization, progressive muscle relaxation and breathwork 

Are There Any Special Considerations?

Sleep Apnea and Depression

Sleep apnea is a sleep disorder in which one’s breathing starts and stops during sleep. Medical conditions such as high blood pressure and heart disease are common factors contributing to sleep apnea. Along with this, those with depression have a higher risk of developing sleep apnea. Since sleep apnea causes disruption in the full sleep cycle, it can lead to excessive daytime sleepiness, headaches, difficulty concentrating, irritability and mood swings. For those with depression, this essentially means that sleep apnea can lead to worsening of symptoms. 

Sleep Deprivation and Depression

Adequate sleep for good health falls between 6 to 9 hours of uninterrupted sleep. Many young professionals and students experience sleep deprivation due to lifestyle habits like long working hours or night shifts. In some sub-cultures, sleep deprivation is even glorified. 

An example of this is tech CEOs or entrepreneurs boasting about not needing more than 4 to 5 hours of sleep. While one may be able to function for some time despite not getting enough sleep, long-term sleep deprivation will lower one’s performance and wellbeing. As we have seen throughout this article, adequate sleep has an important function, including protecting us from depression. Chronic sleep deprivation can leave us feeling fatigued, irritable and lower our functioning, contributing to depressive symptoms. 

Sleep and Depression in Adolescents

Many adolescents are nightmongers. For some, nighttime can be an exploratory time where they sit with their thoughts, read or listen to music, or explore creative activities. However, since most adolescents have to wake up early to make it to school, chronically staying awake at night may impact mental well-being and academic performance. Prolonged periods of staying awake at night can lead to the development of depression and can be signs of depression, too. While most adolescents struggle with insomnia, hypersomnia is also seen among a smaller number. This, too, may impact one’s ability to wake up on time and engage in important activities and academics. 

Since adolescents need space and time to explore who they are becoming, it’s important for parents to not nitpick. However, if one sees that their adolescent child’s sleep habits are impacting their involvement in school activities, it’s worth bringing up. Psychoeducation and a rational, calm conversation with an adolescent is always more productive than telling them what to do. 

Sleep and Depression in Older Adults

Some changes in sleep patterns are a normal and expected part of ageing. Older adults tend to wake up 3 to 4 times a night and spend less time in deep sleep. They may need more daytime naps and overall, may be sleeping lighter, waking up at the slightest movement or noise. If an older adult has chronic health issues, this may also contribute to changing sleep patterns. 

As with adolescents, with older adults, too, it’s important to keep an eye on their overall functioning and mood. If, when awake, they exhibit mood changes or changes in energy or activity level, it may be worth consulting with the appropriate professional. 

Importance of seeking professional help

Since many changes in sleep and mood seem subtle, especially when they are not severe, the need to seek professional health is often missed. However, sleep disturbances and depression are difficult to overcome without professional help, and even when this is possible, it takes unnecessarily longer and may be confusing. If one is having trouble with sleep or mood, it’s advisable to see a mental health professional like a psychiatrist or psychologist who can direct you to the right course of treatment, or a different professional if needed. 

Conclusion and Call to Action

Sleep and depression are closely linked to each other, and have a bidirectional relationship. While sleep disturbances are common in individuals with depression, they also contribute to symptoms of depression. It’s important to seek professional help and adopt a holistic approach that may include medication, psychotherapy and lifestyle changes 

If you or someone you know has struggled with sleep disturbances and depression, we’d love to hear your story! We also have a team of qualified mental health professionals who will be happy to answer any questions you may have about the same. You can review their profiles here. 

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