talking with doctorThink back, if you suffer from both depression and insomnia. Which came first?

For years, the thinking on the subject was that depression gave rise to sleep problems. Being depressed causes changes in REM sleep (when we dream), and decreases in deep sleep (associated with feelings of rest and restoration). Insomnia was but a symptom of depression, so the story went. Treat the depression, and the sleep problems would go away.

A New Perspective

The story is different now. It looks more and more like chronic insomnia is a way station to depression (and perhaps to other mental disorders as well). Insomnia often precedes the first episode of depression, researchers note today. And even when depression is successfully treated, the insomnia may persist.

Consider these interesting facts, taken from an article by Chiara Baglioni and Dieter Riemann summarizing some very large studies:

  1. People with insomnia are twice as likely to develop depression as people without insomnia.
  2. While the incidence of depression in the general population is 9.9 percent, the incidence is 13.1 percent in people with insomnia and 4 percent in people without sleep problems. Not only are insomniacs more vulnerable to depression, but the absence of sleep problems is very protective in this regard.

Why Is This Important?

Chronic insomnia is now understood to be a causal factor in major depression and a risk factor for suicide. It also increases our vulnerability to heart disease, hypertension, obesity, diabetes, and a host of other medical problems.

Even so, it is still regarded by many—including some primary care physicians—as a trivial matter without serious consequences. Over the years I was interviewing insomniacs for my book, time and time again, I heard comments like these:

  • “Insomnia just wasn’t something my primary care doctor seemed to really have any concept of. He just said something to the effect of, ‘Well, maybe you just don’t need that much sleep.’ But I kept trying to tell him I felt much better when I got a little bit more sleep. So I really just got nowhere.”
  • “You mention it to doctors and they just kind of shrug their shoulders. I haven’t gotten a very in-depth response at all.”
  • “Year after year of going to the doctor, I would tell him my biggest problem is that I’m unable to fall asleep at night. And he’d say, ‘Well, you know, that’s how it is. A lot of women tell me that and I just don’t know what to say. Have you tried warm milk?’”

The research documenting persistent insomnia’s effects on long-term health is out there for the taking. Yet somehow it’s not trickling down to the places where we need it to be.

Have you discussed your sleep problem with your doctor? If so, what was his or her response?

Posted by Lois Maharg, The Savvy Insomniac

Lois Maharg is an author and journalist.She began her career as a teacher, capped off when she authored a pair of ESL textbooks with her husband. She then became a journalist, working both freelance and as a staff reporter and features writer. She has written about Latino affairs, education, government, health, social issues, exercise, and food. While reporting in Pennsylvania, she won a Keystone Press Award and awards from the Pennsylvania Women’s Press Association. Her stories have been picked up by the Associated Press.

4 Comments

  1. I think part of the problem with people willing to discuss sleep problems with their doctor is the almost inevitable result of an Rx for a hypnotic. Despite clear evidence of the effectiveness of CBT for insomnia, it is rarely recommended. This is probably due to the few clinicians knowledgeable in CBT techniques, as well as identification and treatment of sleep disorders (especially chronic insomnia) still not well covered in medical schools.

    Michael

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  2. I agree with you that the treatment of sleep disorders, and especially insomnia, is given short shrift in medical schools. And I think you’re right about not many clinicians knowing about CBT for insomnia. (People affiliated with the Society of Behavioral Sleep Medicine are making a push, though, to train more.)

    I’m not sure about the rest. Are you saying that when patients complain of insomnia, doctors feel obligated to prescribe sleeping pills, and one way to get around that is simply to opt out of treating patients at all?

    If you can get back to this, I’d really be interested in hearing your point of view.

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  3. I guess I was confirming what the insomniacs you interviewed for your book said about their doctor’s reaction to the sleep problem. A sort of indifference, or yet another hypnotic to try. CBT is just not on the radar in the primary physician groups I’ve spoken with, and for willing patients, the effectiveness is indisputable. Unfortunately, insomnia is just rarely considered anything but secondary…treat the _________ and sleep should improve. And if the _________ does improve but the sleep does not, then indifference from the doctor is common. Or a pill Rx.

    I’m not anti-hypnotic therapy for insomnia, just for chronic insomnia. Behavioral therapy can lead to lasting sleep improvement, and anecdotally, other non-specific improvements (e.g., “I’m more patient with my family members.”)

    Michael

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  4. It is true that primary care physicians who aren’t familiar with drug-free treatment options and who are averse to prescribing hypnotics for chronic insomnia may feel their hands are tied.

    But information about CBT and other drug-free therapies for insomnia has been out there a long time. I think what you call indifference also stems from a belief that while persistent insomnia may be a frustration, it has no long-term health consequences. And more and more research is showing this to be untrue.

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