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Mental Health and Sleep

June 24, 2019

 

The more we learn about sleep, the more we realize how central it is to our overall wellness.

 

While we all know that sleep plays a big role in our health, the specifics sometimes get lost in the shuffle. As researchers have investigated particular elements of sleep and health, the link with mental health has become increasingly apparent.

 

Studies have demonstrated a clear connection between mental health and sleep. According to Harvard Health, chronic sleep problems plague between 50% to 80% of mental health patients but only 10% to 18% of adults without mental illnesses.

 

Sleep issues can include reduced total time spent asleep, fragmented sleep, and sleeping too much, and these problems can be associated with a range of psychiatric conditions.  While the connection between sleep and mental health is undeniable, the exact relationship is complex and still not fully understood. Traditionally, sleep problems were understood as symptoms of mental health conditions, but it appears to not be so simple.  In fact, lack of sleep may be contributing or even causing psychiatric problems. For this reason, a growing number of psychiatrists and therapists are including a focus on improving sleep as a component of their patient care.

 

In this guide, we’ll explain the background behind this trend including an exploration of the ways that sleep and mental health are related and a discussion of concrete ways to try promoting better sleep.

 

Why Do Therapists Promote the Importance of Sleep?

 

Psychiatrists and psychologists work with patients with a diverse set of mental health problems, but a common theme that runs through many of these cases is abnormal sleep.  One way of viewing this connection is by seeing sleep problems as simply a consequence of a psychiatric condition. A more nuanced view of the evidence shows that sleep has a more significant role. For example, in people with depression, unresolved insomnia can increase the likelihood of a major depressive episode.

 

Enhanced understanding of the brain through neurochemistry and neuroimaging shows that sleep helps build the cognitive power that we need in numerous aspects of life. Limited or fragmented sleep hurts our executive function and emotional resilience.  Understanding the connection between sleep and mental illness as a two-way street opens new avenues for helping patients who struggle with these issues. A patient who is well-rested is generally less likely to suffer from more severe mental health episodes and is more emotionally equipped to take on the challenges that they face.  This doesn’t mean that getting more sleep is a cure for mental illness, but it does explain why a growing number of therapists are integrating sleep considerations into treatments for their patients.

 

What is the Relationship Between Sleep Problems and Mental Illness?

 

A significant number of people with mental illness report having problems with sleep. Insomnia, -- difficulty falling asleep, staying asleep, or waking up too early -- is a common complaint of patients with a broad range of mental health conditions. It is often reported even during periods when mental illness is in remission.  Hypersomnia, which involves chronic daytime sleepiness and often excessive amounts of sleep, can be an issue for many people with psychiatric conditions. Some patients experience both insomnia and hypersomnia, which poses even greater barriers to any type of consistency with regard to sleep.  The correlations between mental illness and disturbed sleep are extensive and can be found with conditions such as depression, anxiety disorders, post-traumatic stress disorder (PTSD), bipolar disorder, attention-deficit hyperactivity disorder (ADHD), and others.

 

The impact on sleep may be felt more strongly during intense periods of mental illness. One study found that 92% of patients in a major depressive episode reported suffering from insomnia, hypersomnia, or both.

At the same time, the relationship is bidirectional and can be negatively reinforcing.  Poor sleep can impact the inner workings of the brain including the function of hormones and neurotransmitters, the means of communication between cells in the brain. Without quality sleep, it is harder for the brain to manage all types of tasks, including those relating to emotional regulation.  This dynamic can worsen the severity and consequences of mental illness. Evidence is mounting that sleep disruptions are a risk factor for suicidal behaviors, and this risk may be amplified for patients who experience both insomnia and hypersomnia.

 

What Mental Illnesses Are Known To Be Related to Sleeping Problems?

 

Every individual’s situation is unique, so it is important to remember that having a mental illness does not guarantee that a person will have sleeping problems. That said, mental illnesses of different types have established connections to sleeping problems.

 

Depression has one of the most well-known relationships with sleeping problems. The majority of patients with depression complain of insomnia, obstructive sleep apnea, or other sleeping issues. Evidence points to insomnia as a risk factor for developing depression or for worsening symptoms of this condition.

In bipolar disorder, most patients experience insomnia during the manic phases of the disorder. During depressive phases, hypersomnia is more common. Sleeping problems may be an indication of the impending onset of a manic or depressive period.  Anxiety disorders are frequently accompanied by sleep problems. Sleep problems can be associated with general anxiety disorder (GAD), social anxiety disorder, phobias, panic disorder, separation anxiety, and obsessive-compulsive disorder. There is less clear evidence that sleep issues can cause anxiety disorders, but it is believed that lack of sleep may worsen symptoms.

Post-traumatic stress disorder (PTSD) is a type of anxiety disorder tied directly to a traumatic event. People with PTSD have considerable sleep problems: 90% to 100% of U.S. veterans with PTSD have reported having insomnia. Hyperarousal, or feeling permanently on alert, can foster profound sleep problems for people with PTSD. These sleep issues can then further anxiety and negative thinking about sleep.

Many children and adolescents with ADHD suffer from insomnia or have abnormal sleep schedules. In some cases, medications for ADHD can cause or intensify sleeping problems. For children with and without ADHD, reduced sleep commonly leads to hyperactivity, reduced attention span, and greater propensity for emotional challenges.

 

Does Mental Illness Cause Sleep Problems or Do Sleep Problems Cause Mental Illness?

 

In some ways, the relationship between sleeping problems and mental illness poses a chicken-egg quandary. Because they so often occur together, it can be challenging to parse out the exact “cause,” especially when taking into account the complexity of the brain and its multitude of functions.  Even the world’s most renowned neuroscientists acknowledge that there are many mysteries that remain about how the brain works. New investigative tools and studies help shed light on these mysteries, but definitive answers about complicated issues like mental illness are hard to come by.

 

Not everyone with a mental illness has sleep problems, and not everyone with sleep problems has a mental illness. As a result, the cause for any person may depend on their specific situation including their condition, sleep troubles, genetics, environment, and other factors.  What can be clearly stated is that these health issues can complicate each other. Abnormal or disturbed sleep can intensify symptoms or hinder efforts to address mental illness and vice versa.  As a result, an important conclusion is that health care providers must recognize these interrelationships and work with their patients to treat them accordingly.

 

Can Improving Sleep Help Treat Mental Illness?

 

Improving a patient’s sleep can have beneficial effects on the severity and frequency of symptoms of mental illness. Sleep doesn’t cure mental illness, but studies have shown that it can improve cognitive function, reduce the worst mental health episodes, and can increase overall well-being.  For example, treating insomnia has been shown to reduce the time that it takes to effectively treat depression. In older people, improved sleep through behavioral therapy has shown signs of reducing symptoms of depression.

 

Sleep-focused care has shown some positive results in helping patients with other mental health conditions as well including those with PTSD, anxiety, and bipolar disorder.

 

In addition, because sleep disturbances may portend worsening episodes of mental illness, there is some indication that insomnia-directed treatment may be a viable preventive mental health strategy.  The benefits of quality sleep extend far beyond just mental health. Sleep is critical for repair of the body and internal organs. Sleep is linked to virtually all aspects of wellness, and lack of sleep can sow the seeds of a huge range of afflictions.  Because the body operates with many complex and interrelated systems, these wellness benefits should not be overlooked in recognizing how sleep-focused care can meaningfully improve quality of life for people with mental health problems.

 

What Are the Best Methods to Improve Sleep?

There is no one-size-fits-all strategy for improving sleep. What helps one person may not offer much relief to someone else, and reversing ingrained patterns of bad sleep can take time and effort.  Treating sleep problems can be especially difficult in people who have co-occurring health conditions including things ranging from physical pain to psychiatric illnesses.  Given these challenges, a tailored strategy for addressing sleep problems offers the highest chances of success. This strategy can employ a range of different approaches, and in this section, we’ll explore some of those methods that have had the most promising results in research studies to date.

 

Cognitive Behavioral Therapy for Insomnia

 

Cognitive Behavioral Therapy for Insomnia (CBT-I) is a type of talk therapy that specializes in addressing the thoughts and habits that contribute to insomnia.  CBT-I is typically structured around one-hour sessions with a counselor trained in this technique. These sessions usually occur once per week for a period of 6-8 weeks. During the sessions, the therapist helps identify negative thoughts about sleep and works with the patient to implement changes that can reduce the effects of those thoughts.  Overall, CBT-I provides a framework for improving sleep hygiene with guided help, and in the general population, it has been shown to have high levels of effectiveness. Its success holds up when compared to treatment with medications that are often used for insomnia and when compared to a combination of CBT-I and medications. Results of CBT-I have been beneficial not just in adults but also in adolescents.  Because CBT-I requires working with a provider that has specialized training, some patients may have a hard time finding a therapist in their area. Thankfully, CBT-I has been shown to be effective in online programs, including for people with depression, providing greater access to people searching for non-pharmacological treatment for insomnia.

 

Does CBT-I Help People With Co-Existing Mental Illness?

 

As CBT-I has gained momentum, studies have expanded to investigate and evaluate how well it can work for people who have mental health problems.  Because of the high prevalence of insomnia in people with depression, CBT-I has been of considerable interest for these patients. In a randomized, controlled clinical trial with 107 patients, CBT-I produced improvements in sleep and reductions in depression both on its own and when used in combination with antidepressants.  In a study of post-menopausal women with depression, CBT-I showed solid results in improving sleep and reducing depressive symptoms. CBT-I, with its guided and multi-faceted approach, performed better than more limited sleep hygiene education programs. Another study in older adults found CBT-I to decrease reported symptoms of depression.

Positive results have been found for CBT-I focusing on bipolar disorder. This therapy, with the acronym CBTI-BP, found that patients undergoing this therapy had better sleep and decreased risk of relapse to mood changes associated with bipolar disorder.

 

Because CBT-I can be tailored to an individual, it has shown promise with conditions like PTSD, especially when CBT-I was combined with imagery therapy. For many patients, CBT-I can decrease symptoms of the condition and improve sleep. Given the significant prevalence of insomnia in patients with PTSD, these improvements can offer meaningful benefits in overall wellness.  In patients with other types of anxiety disorders, there is less research from controlled clinical trials evaluating the effectiveness of CBT-I. However, given the ability of CBT-I to reorient negative thoughts about sleep, there is reason to believe it may improve both sleep and anxiety symptoms. One study has found that CBT-I can improve overall quality of life for people with anxiety disorders.

 

In adult patients receiving medication as treatment for ADHD, CBT-I reduced symptoms of the condition.  Further research is planned to continue developing an understanding of how patients with ADHD can best benefit from CBT-I.  Another notable benefit of CBT-I for people with mental health issues is that it does not require the use of medications. Some sleep medications have uncomfortable side effects or may have unpredictable or negative interactions with medications that are prescribed for mental illness.

 

Sleep Hygiene Improvements

Sleep hygiene is a broad term that encompasses a person’s routines and habits around sleep as well as their sleep environment. Sleep hygiene plays a vital role in determining how easily a person can fall asleep and stay asleep through the night.  Improvements to sleep hygiene are a common element of CBT-I as a therapist generally works with a patient to make tailored suggestions about how to modify their sleep setting and routines. Modifications to sleep hygiene can occur independently and without specific direction from a therapist as well.

 

In this section, we’ll review various components of sleep hygiene and methods for improving it.

 

Sleep Restriction

 

Sleep restriction focuses on the fact that many people spend significantly more time in bed than they do actually sleeping. For example, they may lie awake in bed while hoping to fall asleep or when they are awoken in the middle of the night.  Sleep restriction therapy tries to change this by setting a strict amount of time spent in bed. That time is generally set to be equal to the amount of time a person reports actually sleeping.  At first, sleep restriction may sound counterproductive, but in most patients, it produces more efficient and durable sleep. This tactic decreases time spent with the mind wandering or worrying while struggling to fall asleep.  As a person starts to spend a greater and greater portion of their time in bed actually sleeping, the restriction can be gradually scaled back to permit a person to get additional sleep each night.

 

Stimulus Control

 

Stimulus control is another element of sleep hygiene and one that is commonly incorporated into CBT-I programs. The focus of stimulus control is on fostering an association between your bed and sleep so that your bed itself becomes a cue for sleep.

 

Some examples of how stimulus control can be implemented include:

  • limiting activities in bed to only sleep and sex;

  • getting out of bed if you don’t fall asleep within 15-20 minutes;

  • only getting into bed when you are actually sleepy;

  • having a consistent wake-up time every day.

These steps help to bring a degree of normalcy to your sleep routine and firmly plant in your mind the idea that getting into bed means going to sleep. As this association gets stronger over time, it provides a more robust cue to your body and brain that it’s time to be asleep.

 

Improving Your Sleep Environment

 

Stimulus control helps to associate your bed with sleep, and this process is easier if your bed and bedroom actually permit and invite sleep. Many elements combine to form your sleep environment.  For your bed itself, the mattress is a good starting point. Your mattress should be comfortable and should provide support to keep your spine aligned through the night. If you don’t like your mattress but can’t afford to replace it, a mattress topper may be a good bet. A good quality pillow can cushion your neck and promote spinal alignment in conjunction with your mattress.  Your bedding should fit your personal preferences in terms of softness, warmth, and breathability. For example, if you tend to sleep hot, avoid heavy blankets and use cooling sheets. If you sleep cold, invest in a cozy down comforter or a heated mattress pad.

Another consideration for your bedding is a weighted blanket. These blankets have extra material in them that may boost production of hormones helpful for sleep and mental health. Many patients with anxiety and depression report benefits from using a weighted blanket.

 

Once you’ve optimized the bed itself, think about the bedroom. You are most likely to fall asleep in a room that is dark, so use low-wattage, softer lights if you need some illumination. If your bedroom suffers from significant light pollution, invest in thick blackout curtains or a comfortable eye mask.

 

Sound is another critical component of your sleep environment. If sounds permeate into your bedroom, a white noise machine or white noise app may be able to help prevent those sounds from disturbing your sleep.

 

A pleasant smell can help make your bedroom a more permissive place for falling asleep. Some smells can even enhance relaxation. Essential oils are one way to help bring those beneficial aromas into your bedroom.

 

Lastly, don’t forget the temperature of your bedroom. Most studies indicate that a temperature of 60-65 degrees Fahrenheit is the best bet for sleep, but you can make modifications to find what works best for you.

 

Improving Sleep-Related Habits

 

A broad range of routines and habits can affect how easily we can fall asleep and stay asleep. Strong sleep hygiene coordinates these habits to work in our favor.  Getting regular exposure to sunlight during the day is one example. Sunlight exposure plays a vital role in aligning our biological clock with the day-night cycle in our local area. This helps standardize our sleep-wake cycle and promotes healthy sleep.

 

Solid physical activity or exercise during the day can help make the body more primed for sleep when bedtime rolls around. Hard exercise too close to bedtime, though, may have a stimulating effect that makes it harder to fall asleep.

 

While caffeine is a central part of the morning routine for many people, it can have a negative effect on sleep when it is consumed later in the day. Try to avoid caffeine after noon and especially at any time close to bedtime.  Alcohol can have profound effects on your sleep. While a drink before bed may make you feel sleepy, it detracts from your sleep quality and can make it more likely that you’ll wake up during the night. Limiting alcohol, especially in the time before bed, is a healthy habit of sleep hygiene.

As with alcohol and caffeine, nicotine can have negative consequences for sleep, so avoiding tobacco products can improve your rest. Quitting tobacco can contribute to your health in myriad other ways as well.

 

Limiting your exposure to blue light in the hour before bed helps your body fall asleep naturally. Blue light is produced at high levels by electronic devices like mobile phones, tablets, and laptops. LED lights produce it at higher levels than incandescent light.  Blue light suppresses melatonin, which is a hormone that promotes sleepiness, so do your best to stop using these devices before bed or in bed. A blue light filtering app is another option that lets you use electronic devices in a “night mode” that has a reduced effect on melatonin production.

 

If you enjoy a hot beverage before bed, you can consider a bedtime tea. In addition to the comforting ritual of enjoying a cup of tea, many of these products include natural ingredients that may promote relaxation or calmness. Read the label carefully to know what’s in any tea -- and to be sure that it doesn’t have caffeine -- and talk with your doctor if you have any questions or concerns about what is best for you.

 

Practice Relaxation

 

Relaxation techniques are a powerful tool for addressing sleep problems. Methods can include guided meditation, mindfulness meditation, deep breathing, muscle relaxation exercises, stretching, light yoga, and numerous other approaches.  The goal of these techniques is to reduce the stress or anxiety that may come about from struggling to fall asleep. Meditation and deep breathing can help calm the body and the mind to facilitate a more natural process of falling asleep.

 

These strategies are valuable at bedtime and can confer benefits in many other situations that may bring stress or concern.  A therapist, including a therapist familiar with CBT-I, can provide details about particular methods of relaxation. Smartphone apps provide useful resources for physical and mental relaxation and offer programs to promote regular periods of relaxation and calm.

 

Medications for Sleep

 

Most people who have dealt with sleep problems know that there are a tremendous number of medications and supplements that are promoted as helping with sleep.  Some medications for sleep are available only with a prescription. A benefit of these prescription drugs is that they have more extensive data from clinical trials documenting their effects, but they may carry a more serious risk of side effects.

 

Other products are sold as sleep supplements and are frequently marketed as natural sleep aids. While some people swear by these products, they generally have not been investigated in robust research studies. These products are not regulated by the U.S. Food and Drug Administration (FDA) in the same way as prescription drugs, which can make it harder for consumers to separate out fact from fiction in terms of their health claims.

For many patients with mental illnesses, a regimen of daily medications may be used to help control that illness. Adding other medications can pose risks of additional side effects or unforeseen drug interactions. Some prescription sleep medications are known to provoke mental health problems in certain patients.

Relying on drugs to fall asleep can create dependence. While this might help someone fall asleep in the short term, it may create longer-term problems because it may not be feasible or advisable to take the sleep aid indefinitely.

 

For these reasons, many health care professional prefer to try to treat sleep problems first with non-pharmacological approaches. CBT-I, for example, helps many patients without the need for medications. In some situations, treatment like CBT-I may be administered in combination with a tailored plan for using sleep aids.

 

Overall, it is critical that anyone who is suffering from sleeping problems talk with a doctor before taking any medication or natural sleep aid. Make sure that all members of your health care team know about your sleep issues and your mental health condition.  Working with your doctor and therapist is of particular importance for people who have a history of mental illness and who should use extra caution when considering potential side effects of medications to improve sleep.

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