Mental Illness and Sleep Disorders

The relationship between mental illness and sleep

Poor sleep js both a symptom and a cause of mental illness. Sleep problems may contribute to the development or prolongation of mental illness by making it more difficult to cope with mental problems.

Sleep disorders are comorbid with many other illnesses; the most common comorbidities with insomnia are mental illnesses. It’s estimated that 40% of insomnia patients and over 45% of hypersomnia patients have a psychiatric condition. On the other hand, people without mental illness have substantially lower rates of insomnia.  It’s a striking enough difference that nobody doubts the tie between sleep disorders and mental illness any more.

When it comes to the sleep they do get, people with mental illness often report that it’s not restorative. They wake up still feeling tired, whether from waking frequently during the night, falling asleep too late, or waking too early. In fact, as we’ll go into in the sections below, many studies show that patients with mental health disorders experiences demonstrable changes to their sleep architecture. Often, the individual spends more time in the lighter, less restorative stages of sleep, and less time in the critically important deep and REM stages of sleep.

Insomniacs on the whole tend to suffer from this problem – getting less sleep overall and spending insufficient time in the deeper parts of sleep. This is what makes the disorder so particularly frustrating: they feel like there is no relief from their discomfort.

This lack of sleep in turn makes it more challenging to cope with the symptoms of their mental illness. The REM stage of sleep provides us with the emotional and cognitive benefits of sleep. With sufficient REM sleep, we feel emotionally balanced, and able to regulate our emotions and make good judgments. Our brain works and processes information as it should. Without it, we’re moodier, prone to irrationality and poor decision-making, and have difficulty remembering things. It’s easy to see how this mindset makes it tough to cope with mental health.

Together, mental illness and insomnia exacerbate the effects of each other, creating a classic negative feedback loop, and once they get started, push the patient in a downward spiral. This makes treatment of both conditions difficult.

Left untreated, the sleep problems associated with mental health disorders can be particularly dangerous. A University of Michigan study found a strong correlation between insomnia and suicide.

In the following sections, we’ll review the sleep disorders commonly associated with different mental health conditions.

Anxiety disorders

Nearly one in five Americans suffers from some sort of anxiety disorder, such as generalized anxiety disorder, social anxiety disorder, obsessive-compulsive disorder (OCD), phobia, post-traumatic stress disorder (PTSD), or panic disorder.

Sleep problems associated with anxiety disorders

Anxiety results from a reaction to stress. Big or small, stress of all kinds affect the nervous system. Individuals with an anxiety disorder, however, experience stress at a more acute level. It may stem from obsessive anxious thoughts, or they may be coping with PTSD from a trauma. Regardless of the cause of their stress, their nervous system does not “reset” back to normal as it does for those without an anxiety disorder.

This heightened state of anxiety keeps their nervous system constantly alert, in direct opposition to the sort of relaxation necessary for falling asleep. This experience occurs even at the hormonal level. Cortisol, the body’s stress hormone, operates in inverse to melatonin, the hormone responsible for inducing sleep. With more stress in our system, the tougher it is for our brain to produce adequate amounts of melatonin.

People with anxiety disorders may be prone to the following sleep problems:

• Insomnia, which describes difficulty falling or staying asleep. Many individuals with anxiety disorder suffer from all-consuming anxious thoughts, anticipatory anxiety toward potential phobia triggers, or sense of feeling generally overwhelmed. This level of anxiety makes it difficult to relax the mind before sleep.
• Hypersomnia, defined as oversleeping. Individuals may find themselves oversleeping as a response to the stress or exhaustion from insomnia. Insomnia and hypersomnia frequently occur together in many cases of anxiety disorders:

• Nightmares are a common symptom of PTSD, where the individual relives the trauma during an intensely vivid dream.
• Nocturnal panic attacks are experienced by 44 to 71% of patients with panic disorder. These share symptoms with daytime panic attacks, except that they occur during non-REM sleep. The individual wakes up feeling extreme panic or fear, perhaps accompanied by sweats, pains in the chest, and increased heart rate.

Treatment

Psychotherapy, particular cognitive behavioral therapy (CBT), is one of the most effective treatments for individuals experiencing sleep problems related to their anxiety disorder.

CBT is often recommended for anxiety disorders. CBT-I, the specialization devoted to insomnia, applies the same principles the patient is already familiar with from regular CBT, such as reframing their negative thoughts, to sleep. Therapists work with patients to educate them about healthy sleep habits, help them recognize the thoughts and behaviors interfering with their sleep, and learn how to replace them with healthier reactions.

Additional resources:

• Guide to Anxiety and Sleep
• How Does Trauma Affect Sleep?
• National Institute of Mental Health: Anxiety Disorders Overview
• The Anxiety and Depression Association of America

Depression

About 16 million Adults have major depression. The negative affect, loss of interest in formerly enjoyable activities, suicidal ideation, and other symptoms severely impact their quality of life.

Sleep problems associated with depression

Insomnia affects 75% of individuals with depression, and it’s a major risk factor for suicide among this population. One study found that individuals with insomnia are 6 times more likely to develop major depression, and those with depression and comorbid insomnia are more likely to stay depressed.

Depressed individuals are more likely to spend a longer time falling asleep, spend less time asleep overall, experience disturbed sleep, and spend less time in REM sleep (as evidenced in the chart below):

Even when the mood change isn’t enough to merit depression, insomnia is associated with sadness. Researchers have followed groups of insomnias in longitudinal studies that stretch over years. They consistently find having insomnia increases the risk of later development of mental illness.

Women with depression are more likely to experience sleep problems. Individuals with seasonal affective disorder (SAD), a seasonal form of depression, will experience different sleep problems to varying extents during different seasons of the year.

In addition to insomnia, individuals with depression may be prone to the following sleep problems:

• Hypersomnia, or oversleeping, affects 40% of young adults and 10% of older adults with depression.
• Obstructive sleep apnea (OSA) is also highly correlated with depression. Individuals with sleep apnea are over 5 times more likely to have major depression. OSA is a sleep-related breathing disorder where the individual stops breathing momentarily during sleep, lowering their blood oxygen levels and disrupting their sleep.

Treatment

Unfortunately, many of the antidepressants prescribed to treat depression can cause or worsen insomnia. That increased insomnia can make them more depressed.

Antidepressant medications are often used to treat insomnia. Amitriptyline, trazodone, or mirtazapine are known as sedating antidepressants, and the more common SSRI drugs in use today are employed for patients with sleep disorders, too. Some patients react to antidepressant medication by becoming more active and energetic, making it more difficult to initially fall asleep, even as the relief of the depression alleviates other aspects of their insomnia, such as their ability to stay asleep.

Often treating the depression makes the insomnia go away. This is particularly true in cases of mild depression (dysthymia) which is very common, and often results in troubled sleep. Many people find their insomnia disappears quickly when they start taking antidepressant medication.

Similar to anxiety disorders, CBT is effective for treating both depression and insomnia. The principles of CBT can be applied to reframing negative thoughts that contribute to depression and poor sleep.

Light therapy is another therapy that can help individuals with depression, especially those with seasonal affective disorder or hypersomnia. The therapy involves sitting in front of a specialized light device for a set period of time each day, in an effort to reset the individual’s circadian clock. Practicing light therapy in the morning helps wake up the individual for the day, while an early afternoon practice helps them stay awake and avoid falling asleep too early.

Additional resources:

• Tuck Guide to Depression and Sleep
• Tuck Guide to Seasonal Affective Disorder and Sleep
• The Anxiety and Depression Association of America
• National Institute of Mental Health: Depression Overview

Attention-deficit/hyperactivity disorder

Attention-deficit/hyperactivity disorder (ADHD) is a neurobiological disorder commonly diagnosed in childhood. It affects 5% of children and can persist into adulthood for many. The disorder is characterized by behavioral symptoms that predominantly fall into categories of inattentiveness, impulsivity, and hyperactivity.

Sleep problems associated with ADHD

The symptoms of ADHD, along with the medication used to treat it, result in fragmented sleep and potential sleep disorders.

People with ADHD are prone to the following sleep problems:

• Insomnia affects up to 75% of people with ADHD. Some researchers believe this may be due to a delayed circadian rhythm (the individual naturally tires later in the day). In addition to difficulty falling asleep, individuals with ADHD may also wake frequently during the night.
• Excessive daytime sleepiness is a common symptom of many sleep disorders. The individual is excessively tired during the day, to the extent that it interferes with their quality of life. Due to their sleep problems, individuals with ADHD are significantly more likely to be tired during the day, even if they get the same amount of sleep as their peers without ADHD.
• Sleep apnea is also more common among people with ADHD. They can be twice as likely to display sleep-disordered breathing.
• Periodic limb movement disorder (PLMD) and restless leg syndrome (RLS) are both more prevalent among children with ADHD.
  • PLMD describes a tendency to repeatedly kick or move the legs during non-REM sleep. Such movements prevent the body from fully resting and restoring itself during sleep.
  • RLS is a condition where the individual feels an uncomfortable tingling sensation, often when in a supine position. In order to find relief, they have to keep moving their legs. Understandably, this movement prevents them from falling asleep.

Treatment

The medications used to treat ADHD symptoms often result in sleep problems. Longer-acting ADHD medication tends to have stronger effects on sleep. It is important that individuals with ADHD inform their doctor about any sleep issues they’re experiencing, so those can be considered when developing a treatment plan.

CBT-I is a behavioral method recommended for treating the sleep problems experienced by those with ADHD. To calm the mind and body and counteract the hyperactivity symptoms of ADHD, therapists may particularly focus on progressive muscle relaxation and stimulus control techniques.

Other effective sleep therapies for individuals with ADHD include sleep restriction therapy, where therapists set a sleep schedule for their patient. Patients strictly follow this schedule, only spending time in bed during those hours, and not allowing for any naps or sleep time outside of it. Additionally, light therapy can help those with delayed circadian rhythms.

Sleeping with a weighted blanket can provide relief for those suffering from RLS symptoms. The general rule is to find a blanket that weighs 10% of your body weight, plus 1 pound.

Additional resources:

• Tuck Guide to ADHD and Sleep
• National Institute of Mental Health ADHD OVerview
• CHADD: The National Resource on ADHD
• Attention Deficit Disorder Association

Schizophrenia

Schizophrenia affects 1% of Americans. This severe mental illness interferes with their ability to process reality, manage their emotions, and communicate with others. It’s accompanied by debilitating symptoms, such as hallucinations and psychosis.

Sleep problems associated with schizophrenia

Between 30 to 80% of people with schizophrenia experience disturbed sleep.

Sleep problems common to schizophrenia include:

• Abnormal or irregular sleep patterns. Individuals with schizophrenia don’t tend to sleep for one extended period overnight; instead, they are more prone to sleep at any point during the day or night. Based on their research of mice with defects in the SNAP25 gene (which is known to be linked to schizophrenia), scientists hypothesize the irregular sleep patterns are caused by a delayed melatonin release and shifted circadian rhythm. For individuals with schizophrenia, the delayed melatonin release continues pushing their sleep onset back later and later into the night, until eventually there is no clear circadian rhythm at all.
• Inconsistent sleep volume. In addition to sleeping at irregular hours, people with schizophrenia generally tend to not get a regular amount of sleep on a day to day basis. At times they are prone to insomnia, and at others prone to hypersomnia. The side effects of their medication, or the symptoms of the disorder such as hallucinations, can cause either extreme. Because their sleep is so irregular, both in onset and in volume, their sleep quality also tends to be low. As a result, they’re less well-rested and prepared to cope with the symptoms of their disorder.

Treatment

The first generation of antipsychotics used to treat schizophrenia had no universal effect on sleep architecture, but the later generation of so-called atypical antipsychotics, including clozapine, olanzapine, and quetiapine, have observable positive effects on sleep. Schizophrenic patients who take them sleep longer. Some drugs increase the length of their slow-wave sleep, while some increase REM latency, similar to the effect of SSRI drugs on people with depression.

Treating the sleep issues does tend to alleviate the intensity of the psychotic symptoms of schizophrenia. However, clinicians advise adjusting the CBT-I strategies to account for the potentiality of triggering psychosis:

Additional resources:

• Tuck Guide to Antipsychotics for Insomnia
• National Institute of Mental Health: Schizophrenia Overview
• National Alliance on Mental Illness: Schizophrenia Overview
• Schizophrenia and Related Disorders Alliance of America

Bipolar disorder

Bipolar disorder affects nearly 3% of American adults. Its most visible symptoms are wide swings in mood, behavior, and energy, accompanied by resulting swings in sleep and waking.

Sleep problems associated with bipolar disorder

The sleep issues a person with bipolar disorder experiences will change depending on whether they are in a state of mania or depression.

The most common sleep problems affecting individuals with bipolar disorder include:

• Insomnia, or difficulty falling or stay asleep. Insomnia can occur during both mania or depression.
• Sleeplessness is more common with episodes of mania. Distinct from insomnia, this describes the ability to go for long periods without sleeping, and without feeling a subjective need for sleep.
• Hypersomnia, or oversleeping, is more common during episodes of depression.
• Irregular sleep patterns are common, especially during episodes.
• Delayed sleep phase syndrome (DSPS) describes a condition where the individual’s circadian rhythm is delayed. The person naturally tires at a later time than “normal,” so they fall asleep and wake up later, causing disruptions and tiredness during their daily routine as they adhere to the “normal” schedule of daily life. DSPS is like living in a constant state of jet lag.
• Sleep apnea is significantly more common among individuals with bipolar disorder. The sleep-disordered breathing caused by sleep apnea disrupts their sleep, which can spark another manic episode or make it more difficult to cope during periods of depression.

Whether caused by or independent of bipolar disorder, the sleep problems these individuals experience make it more difficult to cope with the symptoms of the disorder. The highs and sleeplessness associated with mania catch up with the individual during the resulting depression stage, during they worsen the overall hopelessness they feel.

Meanwhile, lack of sleep prior to an episode of mania is one of the biggest warning signs that mania is about to occur. Even sleep deprivation from something as benign as jet lag can trigger an episode.

Even in between episodes, individuals with bipolar disorder also experience lower quality sleep. They have more difficulties falling asleep and experience more interruptions to their sleep.

Treatment

As with most cases of insomnia, research indicates CBT-I is an effective behavioral treatment for insomnia among individuals with bipolar disorder. Sleep restriction and stimulus control techniques in particular proved effective.

Additional resources:

• Tuck Guide to Bipolar Disorder and Sleep
• National Institute of Mental Health: Bipolar Disorder Overview
• Depression and Bipolar Support Alliance
• Mental Health America: Bipolar Disorder Overview