Depressed? Can’t Sleep?

The stress and strain of depression is exhausting both physically and mentally. Yet, the majority of people suffering from depression are insomniacs as well. While it has long been understood that sleep disturbances are a primary symptom of mood disorders, researchers are now beginning to recognize insomnia and depression as two distinct disorders interacting with one another. And when the two co-exist, addressing the insomnia may be a big help in accelerating the treatment of depression.

“For years we’ve known that that sleep problems are part and parcel of depression,” explains Dr. Kumar Budur, who specializes in sleep disorders and psychiatry at Cleveland Clinic in Cleveland, Ohio. “In fact, one of the criteria for diagnosing depression is sleep disturbance. But more recently we have seen that patients who have insomnia go on to develop depression. Moreover, we’ve seen that when patients are treated for depression and insomnia simultaneously, the patient tends to get better faster—and they tend to stay better for a longer time.”

Dr. Budur cites the findings of a June 2006 study at Massachusetts General Hospital that explored dual treatment with antidepressants and hypnotics, or sleep aids. The subjects, who all suffered from insomnia and depression, were divided into two groups: One group was given antidepressants only, while the other received both antidepressants and hypnotics. The group receiving both drugs showed significantly more improvement to both conditions, and at a much faster rate.

The interplay of these disorders is just beginning to be understood. One unproven theory revolves around the role of serotonin, one of the brain’s messenger chemicals, which seems to have an influence on mood disorders and sleep alike. Psychologists have long suggested that we work out problems in our dreams; without the opportunity to imagine and hope in our sleep, perhaps it’s more difficult to resolve troubles in the waking world.

What we do know is that depression can lead to insomnia and vice versa. A careful analysis of symptoms has revealed the effectiveness of treating the two simultaneously. Dr. Burdur explains, “When we treat patients for depression, the least resistant symptoms, most of the time, are loss of energy, loss of concentration and mood. These symptoms respond to antidepressants. But fatigue and insomnia are the symptoms which are least responsive to treatment [with antidepressants]. So now there is the thinking that it is a subset of patients with depression in whom insomnia is a separate disorder. If we don’t treat insomnia, the risk of getting depressed again is probably much higher.”

Accurate diagnoses are key in resolving these disorders. Dr. Douglas Jacobs is CEO and president of the non-profit group Screening for Mental Health and founder of National Depression Screening Day (see details below). Dr. Jacobs supports the idea that anyone with persistent insomnia—that is, sleeplessness lasting more than 10 days—should consult a physician and be screened for depression.

“There’s a need for people to determine if they’re dealing with a primary sleep disorder or with depression,” he says. “Part of what’s happening today is that the entire medical community is much more sensitive to the notion that sleep disorders need to be diagnosed and treated.”

Dr. Jacobs emphasizes the need to assess and treat depression as early as possible. “Hypnotics have a place in the treatment of depression, under controlled usage,” he affirms. “Patients should understand that it’s a short-term use in the early phases of depression treatment, while a person is also being treated with antidepressants and other interventions such as psychotherapy.”

Like every drug, hypnotics come with a set of risks and should only be used under a doctor’s close supervision. The restriction to short-term usage, for example, addresses addiction concerns. Instances of an adverse effect—that is, when hypnotics actually worsen depression—have been reported, though in very small numbers.

Of course, the more we can call on our body’s internal pharmacy of healing hormones, the fewer drugs we need to take. A 2003 Australian study concurs that insomnia and depression should be treated simultaneously but favors a self-help program that combines relaxation techniques and cognitive therapy over sleep aides.