Do you think you could benefit from better sleep?

How does depression affect your sleep?

How does depression affect your sleep?

There’s been an increasing focus on mental health during the past few years and not without good reason:

  • In the UK, one in four people is likely to experience a mental health problem each year in England alone
  • One in six people will be unfortunate enough for that problem to be depression, anxiety or a combination of the two1.

The impact of these disorders can be crippling, with the adverse effects impacting upon every aspect of daily life.

Therefore, if you’re reading this and think you may be suffering from depression or anxiety, we urge you to seek help as soon as possible here

Sleep is just one of the aspects of your life affected by depression.

As we know from the literature, the extensive number of articles on the subject and relevant websites, a good night’s sleep benefits health, mental ability and mood. This means that:

Depression can affect sleep and sleep can affect depression.

While we can’t give a full review of how the many aspects of depression and sleep interact with another in a single article, we can break down the key science to date to show how people living with depression and poor sleep can use it to improve their mood and achieve better sleep.

Chicken and the egg - Depression can affect sleep and sleep can affect depression

Does depression cause an unusual sleep pattern or does an unusual sleep pattern cause depression?

Many people with depression experience poor sleep, either in the form of sleeping too little or too much.

In fact, when people seek treatment for poor sleep, many of them also exhibit symptoms consistent with depression2. Conversely, people seeking treatment for depression will often complain of poor sleep3.

‘Poor sleep’ can entail:

  • Taking a long time to fall alseep
  • Waking up frequently during the night
  • Lying awake for a large period of the time spent in bed
  • Not feeling refreshed after time asleep.

All of this can culminate in the low mood, difficulty concentrating, lethargy and daytime tiredness that people living with depression are all too familiar with2.

Depressed woman from lack of sleep

Even though the sleep that those with depression experience is poor, that’s not to say that depression causes a lack of sleep. In fact, many people living with depression experience hypersomnia, the condition of sleeping too much.

Nevertheless, if that sleep is poor quality sleep then it won’t help daytime functioning.

It’s also a sad fact that a link has been observed between extremes of sleep time and suicide risk but this may not be attributable directly to depression4.

At this point, it’s worth asking ‘why does depression affect sleep?’

The REM theory of sleep — and why it’s not quite right

Sleep consists of a number of stages, one of which is termed REM (rapid eye movement) sleep. The REM stage of sleep is linked to dreaming. Strangely enough, when in REM sleep, our brain activity levels are similar to what they would be when we’re awake.

There are a few non-REM stages as well and the most important is slow-wave sleep. That’s the type of sleep we need to feel refreshed in the morning.

When we sleep, we alternate between REM and non-REM stages. But it’s been found that people living with depression spend a greater amount of their sleep time in the REM stages of sleep 5 6. This altered sleep behaviour persists in people who have a history of depression but are not currently suffering an episode7.

This has led to the idea that increased REM sleep leads to depression. This is something you’ll often see written on other sleep websites and in earlier scientific literature but it isn’t strictly true.

A more helpful way to understand the sleep disturbances those with depression experience is to think of their sleep cycle being somewhat ‘shifted’. This disruption leads to mood disturbances like depression.

Depression and sleep cycles

As a result of this ‘shift’ it would seem that depressed populations experience less restorative slow-wave sleep during their time in bed, which may lead to a mood disturbance.

It also means that people living with depression experience REM sleep earlier in their night. That may have led earlier researchers to the conclusion that increased REM sleep leads to depressive illness.

With this in mind, let’s consider what options there are for someone living with depression to improve their sleep.

Sleepy eyes

Antidepressant treatment

One of the first lines of treatment for depression is the use of antidepressants. There are many types but the most commonly prescribed today are in the SSRI class. Although the mode of action of most antidepressants isn’t completely clear, one thing that most of them seem to do is to reduce REM sleep8.

A notable exception is the antidepressant Agomelatine. It doesn’t do anything to the amount of time spent in REM sleep but does appear to increase the amount of slow-wave sleep a patient gets — along with re-aligning the ‘shifted’ sleep cycle observed in depressed patients9.

What this tells us, is that suppression of REM sleep isn’t necessary for an antidepressant to work. It’s just that a lot of antidepressants on the market happen to suppress REM sleep.

At the start of treatment, this may lead to a feeling of even worse sleep. But after a few weeks you might experience improvements in your mood and sleep. This, coupled with the primary function of antidepressants (i.e. to reduce the severity of depressive symptoms), should lead to an increase in your overall quality of life.

Cognitive behavioural therapy for insomnia (CBTi)

In populations with depression, CBTi delivered in person delivers mood and sleep improvements 10.

As mentioned earlier, if sleep is improved then mood should improve and this appears to be the case10. The same is observed for remote CBTi but the evidence base isn’t quite as strong right now. This may be because:

  • The closer interaction between therapist and client leads to greater investment on the part of the client — they want to see the treatment through and have real support in doing so.
  • The varied way in which remote CBTi is currently delivered (e.g. in automated, semi-guided or guided forms) introduces differences in efficacy. Being treated by a robot following a script will never have the same level of tailoring that might be needed for the best treatment outcomes.

Our own survey data collected here at Sleepstation demonstrates that CBTi can help with depression.

We note that a large percentage of people (around half) we treat for poor sleep also report an improvement in their depressive symptoms if they’re living with depression as well as poor sleep.

We believe that’s because of the unique way in which we deliver remote CBTi. Components of a well designed course of CBTi will include, but aren’t limited to:

What’s interesting about sleep restriction, in particular, is that the mild sleep deprivation it induces can lead to an increase in slow-wave sleep. It may also be linked to the mood improvements that have been observed in some people with depression when sleep deprived11 12.

Of course, prolonged sleep deprivation to lift mood is unsustainable but it does suggest that sleep restriction can be an effective, short-term, non pharmacological antidepressant that complements any dedicated antidepressant medication a patient may be taking.

Room with a cat on a table

In summary

  • Depressive symptoms are commonly observed in people with insomnia and insomnia symptoms are commonly observed in those with depression.
  • These can include — but aren’t limited to — antidepressant therapy and some components of CBTi.
  • A well designed CBTi course may improve symptoms of both insomnia and depression.

In all cases, it’s critical to reach out. At Sleepstation we’re not specialists in depression but we can, alongside a dedicated mental health caregiver, give you the best chance possible to get your insomnia and mood under control.

References


  • Mind. Mental Health Facts and Statistics. Mind London; 2017. mind.org.uk/information-support/types-of-mental-health-problems/statistics-and-facts-about-mental-health/how-common-are-mental-health-problems/.

  • Ohayon MM, Caulet M, Lemoine P. Comorbidity of Mental and Insomnia Disorders in the General Population. Comprehensive Psychiatry. 1998 Jul;39(4):185–197.

  • Nowell PD, Buysse DJ. Treatment of Insomnia in Patients with Mood Disorders. Depression and Anxiety. 2001;14(1):7–18.

  • Gunnell D, Chang SS, Tsai MK, Tsao CK, Wen CP. Sleep and Suicide: An Analysis of a Cohort of 394,000 Taiwanese Adults. Social Psychiatry and Psychiatric Epidemiology. 2013 Sep;48(9):1457–1465.

  • Riemann D, Berger M, Voderholzer U. Sleep and Depression — Results from Psychobiological Studies: An Overview. Biological Psychology. 2001 Aug;57(1-3):67–103.

  • Hoofdakker RH, Beersma DGM. On the Contribution of Sleep Wake Physiology to the Explanation and the Treatment of Depression. Acta Psychiatrica Scandinavica. 1988 Jul;77(S341):53–71.

  • Moretto U, Palagini L. Sleep in Major Depression. In: Handbook of Behavioral Neuroscience. vol. 30. Elsevier; 2019. p. 693–706.

  • Wilson S, Argyropoulos S. Antidepressants and Sleep: A Qualitative Review of the Literature. Drugs. 2005;65(7):927–947.

  • Eser D. Agomelatine: The evidence for its place in the treatment of depression. Core Evidence. 2009 Aug;171.

  • Cunningham JEA, Shapiro CM. Cognitive Behavioural Therapy for Insomnia (CBT-I) to Treat Depression: A Systematic Review. Journal of Psychosomatic Research. 2018 Mar;106:1–12.

  • Berger M, van Calker D, Riemann D. Sleep and Manipulations of the Sleep-Wake Rhythm in Depression. Acta Psychiatrica Scandinavica. 2003 Oct;108(s418):83–91.

  • Wirz-Justice A, Van den Hoofdakker RH. Sleep Deprivation in Depression: What Do We Know, Where Do We Go? Biological Psychiatry. 1999 Aug;46(4):445–453.

Further information