Treating Sleep Disturbances and Depression Concurrently

“When it comes to trying to work out this issue of sleep problems and depression, it is a classic chicken and the egg problem,” says Charles Raison, MD, University of Wisconsin at Madison, and Psych Congress Network Depression Section Editor.

In this video, Dr Raison walks viewers through his strategy for treating sleep disturbances as a result of depression onset, as well as the best approach to treating insomnia without depression. Tools at mental health clinicians’ disposal include antidepressants, cognitive behavioral therapy, and telehealth.

For more expert insights for your clinical practice, visit our Sleep Excellence Forum.

Read the Transcript

Charles Raison, MD: Hey everybody, I'm Dr Charles Raison. My friends call me Chuck, but when I'm at work, I guess I'm “Charles!”

I am a psychiatrist and a professor of human ecology and psychiatry at the University of Wisconsin-Madison. I also serve as the director of clinical and translational research for Usona Institute here in the Madison area, as well as as the director of the Vale Health Behavioral Health Innovation Center and the director of research on spiritual health at Emory University in Atlanta, Georgia.

Neurology Learning Network: What are the most common challenges when addressing both sleep issues and depression concurrently, and what evidence-based interventions have you found to be particularly promising in addressing those challenges?

Dr Raison: When it comes to trying to work out this issue of sleep problems and depression, it is a classic chicken and the egg problem, meaning that when people become depressed, one of the cardinal symptoms of depression is changes in how you're sleeping. We also know that people that have struggles with sleep are much more likely than other people to become depressed.

The question is, when we look at what's causing what, that's not just an idle sort of thing to think about. It has direct treatment and these sorts of implications, right? One of the interesting things that the DSM-5 has done, when compared to earlier iterations, is that it's recognized that insomnia is not just a symptom of other disorders—although it certainly is a symptom of many disorders—but that insomnia can exist by itself.

That’s a really important point because, in fact, insomnia is very common. Some studies suggest that perhaps 50% of Americans will struggle with insomnia at some point during any given year. That's much higher than the rate of depression, which is probably more like 7 to 8% a year. Insomnia is its own thing and it's its own problem. So, let's start there.

Folks that struggle with insomnia are really at increased risk of suffering and subsequently developing depression. There have been a number of studies over the years that have looked at that, and the risk has varied between studies anywhere from 2 to 3 times more likely to develop depression over [about] a year's period. There was one study from years ago suggesting they were like 50 times increased risk. But it's very clear that if you are struggling with sleep, you are at increased risk of becoming depressed.

Now, of course, it turns out that if you become depressed, your sleep is almost always going to be affected. Interestingly, if you look at the criteria for depression, there's 2 different ways that your sleep can be depressed. One way is that you can sleep more, and the other way is that you can sleep less. Both of these are very problematic, and interestingly, they're not random.

The type of depression that's associated with sleeping more is much more common in younger people. It’s very common for young people when they get depressed to become hypersomnic—they can sleep for, 16, 17 hours a day. That's also a risk factor for bipolar disorder, meaning that folks that have bipolar depression are more likely to have these sorts of patterns.

Meanwhile, older folks are much more likely when they become depressed to struggle with sleep and not be able to sleep. Over the years, I've done a lot of geriatric psychiatry off and on. I don't think I've ever seen somebody over the age of 50 that was struggling with hypersomnia. When you get older, it's always the insomnia, and melancholia, the type of depression where you're super anxious and your mood is just down all the time tends to be associated with insomnia problems.

Of course, the insomnia of depression has a certain signature to it—depressed people are more likely to be able to fall asleep, but then they have terminal or middle of the night insomnia. The insomnia of depression tends to be: fall asleep, but then I wake up at 2am and can't go back to sleep.

 This all has a lot of treatment implications because, if you're sleeping just fine and you develop a depressive episode, treating the depression is very likely to return you to much-improved sleep. Under that circumstance, the core thing to do is to make sure that the depression gets fully treated. The treatments for depression, per se, are not sleeping pills. They're antidepressants or psychotherapy.

Many people, however, will have chronic insomnia and we want to treat the insomnia now because we know it's a risk factor for developing other conditions, and we know that biologically, insomnia shares a lot in common with depression. So, how do you treat insomnia?

Now here, this is where medications can be useful but they can also really fail us. The first (and best-documented) thing to try with insomnia is not putting people on a chronic sleeping pills—it’s engaging them with something called cognitive behavioral therapy for insomnia. We really want to make this happen for people if we can.

The challenge, of course, with psychotherapy in general is that you've got to have a psychotherapist. It's not so easy to access. One of the interesting things that's developed in psychotherapy this regard with telepsychiatry is that there are now several studies, well done studies, suggesting that people can benefit from a telehealth approach to this cognitive behavioral therapy for insomnia (CBTI).

I often now encourage people to really look into these possibilities because what you really want to do with insomnia is trying to treat it behaviorally first rather than just immediately treat it with a medication because over time, the medications that treat insomnia have side effects. So, if we can get ahold of the insomnia using behavioral means first, that's going to be people's best chance at an optimal outcome.

Charles Raison, MD, is the Mary Sue and Mike Shannon Distinguished Chair for Healthy Minds, Children & Families and Professor at the University of Wisconsin-Madison. Dr Raison also serves as Director of Clinical and Translational Research for Usona Institute and as Director of Research on Spiritual Health for Emory Healthcare in Atlanta, GA. Dr. Raison is internationally recognized for his studies examining novel mechanisms involved in the development and treatment of major depression and other stress-related emotional and physical conditions, as well as for his work examining the physical and behavioral effects of compassion training. More recently, Dr. Raison has taken a leadership role in the development of psychedelic medicines as potential treatments for major depression.