Get Help for Sadness and Poor Quality Sleep

About 44% of people with insomnia also have a mental illness such as depression or generalized anxiety. So it’s no surprise that in healthy female college students there’s a relationship between sleep and mood, or affect.

But just what that relationship is—and how normal variations in sleep and affect might morph into insomnia and/or a mood disorder—hasn’t been established. Here’s what researchers at Kent State University and Henry Ford Hospital have found out.

Chronic insomnia and depression are linked and presaged by poor quality sleep and sadnessAbout 44% of people with insomnia also have a mental illness such as depression or generalized anxiety. So it’s no surprise that in healthy female college students there’s a relationship between sleep and mood, or affect.

But just what that relationship is—and how normal variations in sleep and affect might morph into insomnia and/or a mood disorder—hasn’t been established. Here’s what researchers at Kent State University and Henry Ford Hospital have found out.

Insomnia or Mood Disorder: Which Comes First?

Earlier studies have shown that just as depression and anxiety can precede development of insomnia, so sleep problems can precede development of a mood disorder. It’s a two-way street: sometimes depression and anxiety give rise to sleep problems and sometimes insomnia gives rise to depression or generalized anxiety.

But not much is known about how normal, specific emotional states that fluctuate with day-to-day experience affect sleep. Nor is it clear how different aspects of sleep affect people’s mood the next day. Knowing these things might shed light on the vulnerabilities that presage insomnia and mood disorders, making it possible to nip them in the bud. So the Kent State and Henry Ford researchers designed a study to find out more about the relationship between daily affect and sleep.

A Two-Week Study of Female College Students

The study was conducted on 171 healthy young female students at a Midwestern university. The protocol was simple. Every morning for 2 weeks, the women, immediately upon waking up, had to log onto their computers and evaluate feelings they’d had in the past 24 hours and how well they’d slept. To evaluate their affect, they assessed levels of 3 positive and 3 negative emotional states:

  • joviality (happy, cheerful, optimistic)
  • self-assurance (proud, strong, confident)
  • serenity (calm, relaxed)
  • fear (afraid, nervous, scared, jittery)
  • sadness (sad, alone, lonely, downhearted)
  • hostility (angry, hostile, irritable)

They also assessed nightly levels of 3 aspects of their sleep:

  • total sleep time
  • sleep onset latency (how long it took to fall asleep at the beginning of the night)
  • sleep quality (their own global, subjective assessment of their sleep. A panel of sleep experts convened by the National Sleep Foundation has just determined more precisely what sleep quality means. Read on to find out.)

Predictions and Results

The researchers expected to find a cyclical relationship between affect and sleep. High negative affect and low positive affect would predict greater sleep disturbance. Greater sleep disturbance, in turn, would predict higher negative affect and lower positive affect.

On the whole, data from the study confirmed these predictions. But the findings were also nuanced. Interestingly, affect had a more consistent impact on sleep than vice versa.

How Emotional States Affected Sleep

Positive feelings (joviality, self-assurance, serenity) generally predicted better quality sleep, greater total sleep time, and shorter sleep onset latency. In other words, the more upbeat participants felt during the daytime, the better they slept.

As for the influence of negative affect on sleep, while fear made it harder to fall asleep at the beginning of the night, sadness had the most damaging impact on sleep. Sadness, alone or in combination with low serenity, decreased both sleep quality and total sleep time. Combined with fear, sadness increased sleep onset latency as well. The results suggest that chronic distress—especially sadness—disturbs sleep and could, over time, trigger insomnia and possibly lead to chronic insomnia.

How Sleep Affected Mood

Neither total sleep time nor sleep onset latency affected study participants’ mood the next day. But sleep quality did. After a night of quality sleep, the women reported feeling happier and more confident. And a night of poor quality sleep predicted feelings of malaise and self-doubt. Over time poor quality sleep may lead to decreased positive affect, “which may partially explain how insomnia leads to depression,” the authors conclude.

The take-away here is clear. Don’t allow feelings of sadness or poor quality sleep to persist too long before you look for help. And here’s the National Sleep Foundation’s consensus on the determinants of quality sleep:

  • Sleeping at least 85% of the time you’re in bed
  • Falling asleep in 30 minutes or less
  • Waking up no more than once per night
  • Being awake for 20 minutes or less after initially falling asleep

If you have both insomnia and a mood disorder, which came first?

Anxiety? Cranial Electrotherapy Stimulation May Help

If you have chronic insomnia, you may have developed anxiety about sleep. I had lots of sleep-related anxiety until I went through sleep restriction. Once my sleep stabilized, the anxiety disappeared.

Studies have shown that cranial electrotherapy stimulation (CES) is modestly effective at controlling anxiety. It’s FDA approved and widely used in the armed forces for anxiety, PTSD, insomnia, and depression.

Anxiety, PTSD, insomnia, & depression respond to treatment with CESIf you have chronic insomnia, you may have developed anxiety about sleep. I had lots of sleep-related anxiety until I went through sleep restriction. Once my sleep stabilized, the anxiety disappeared.

If you go through cognitive behavioral therapy for insomnia (CBT-I), your therapist may address sleep-related anxiety by challenging some of your ideas and beliefs about sleep. This approach works for some insomniacs, research shows. But others remain anxious at the approach of bedtime and look for alternative treatments.

Studies have shown that cranial electrotherapy stimulation (CES) is modestly effective at controlling anxiety. It’s not endorsed as an insomnia treatment by the American Academy of Sleep Medicine. But it’s FDA approved and widely used in the armed forces for anxiety, PTSD, insomnia, and depression. Here’s more about it.

What CES Is and Does

CES is a treatment you administer on your own with a device that sends mild, pulsed, alternating electrical current to the brain via electrodes placed on the earlobes. When the device is turned on, most people feel nothing at all (a few report feeling a slight pulsing at contact points on the earlobes).

The electrical pulses trigger changes in the brain. When UCLA researchers used a functional MRI scanner to look inside the brains of people undergoing CES, they found evidence of two things:

  1. Decreased neural activity in three areas of the brain: the frontal, parietal, and posterior midline regions.
  2. Altered connectivity in the default mode network (DMN). The DMN is a network comprising several areas of the brain that are active during restful alertness, daydreaming, thinking about self or others, remembering the past, and planning for the future. It’s activated by default, when your attention is not focused on performing a task or on some aspect of the outside world.

Why CES Might Help

A device that decreases neural activity might be useful for people with insomnia, which is associated with hyperarousal. Or, by introducing high- or low-frequency cortical “noise,” CES may change activity in the cerebral cortex in helpful ways. It might produce an increase in alpha activity (associated with relaxation), as other studies have shown.

CES may also achieve its effects by altering communication between the nodes of the DMN. Studies of people with depression and anxiety have detected abnormalities in these connectivity networks—abnormalities whose effects may be lessened with CES. Changes in the DMN may help people disengage from worry and rumination and/or focus on things outside themselves.

Safety and Effectiveness of CES

Studies of CES suggest that devices such as Alpha-Stim, the Fisher Wallace Stimulator, and CES Ultra are quite safe. The FDA reclassified the devices two years ago. Now they’re in the same risk category as acupuncture needles and power wheelchairs. Adverse effects from CES—such as headaches and skin irritation under the electrodes—are rare.

As for effectiveness, while several controlled trials of CES have been conducted, the only consistent result obtained is that compared with sham treatment, CES was effective in reducing anxiety.

In a recent survey of veterans and service members using CES devices, 67% of the 145 who answered all the questions reported improvement in anxiety; 63%, improvement in PTSD; 65%, improvement in insomnia; and 54%, improvement in depression. But many of the respondents were also using medication for symptom mitigation, so it’s hard to know how much of the benefit was due to the CES device and how much, to medication.

If you try using a CES device (or if you tried one in the past), please comment on whether it helps.

The Stuff Insomniac Dreams Are Made Of

Back when my insomnia was chronic, I had a lot of scary dreams. They left me with a pounding heart and fear that could keep me awake for a couple of hours.

Surprisingly little is known about the dreams of people with insomnia. So when a new article about insomnia sufferers’ dreams came out in Sleep Medicine, I snapped it up.

Insomniac dreams can be scaryI remember dreams much less now than when my insomnia was chronic. Then, just as I felt myself about to slide over the brink of consciousness, I sometimes got a horrifying send-off: a plane exploded in a fireball overhead! I was on the road and a Mack truck was coming at me full on! I was on a roller coaster that ran off the track and was plunging to the ground! Scary dreams left me with a pounding heart and fear that could keep me awake for a couple of hours.

Surprisingly little is known about the dreams of people with insomnia. So when a new article about insomnia sufferers’ dreams came out in Sleep Medicine, I snapped it up.

Negativity in Dreams

Among humans overall, a majority of dreams with emotional content are disturbing. One hypothesis about dream content holds that dreams are mainly reflections of experiences we’ve had during our waking hours, and research suggests that one function of dreaming is to replay disturbing events in order to attenuate their emotional charge. The event gets filed away in long-term memory but some of the negative emotion accompanying the experience is lost. The result is that the person dreaming wakes up feeling less bad about it as time goes on.

Results of a few previous studies done on dreams and insomnia are mixed but, overall, they suggest that the dreams of insomniacs may be more unpleasant than the dreams of good sleepers. Insomniacs have reported more nightmares and more negative elements in sleep-onset dreams. They tend to characterize themselves more negatively in their dreams (as in feeling low self-esteem or lacking in something).

This might be because insomniacs are prone to worry and rumination at night. Worries like these—“Taxes are due in 3 days!” “I’ll never get back to sleep!” “Tomorrow I’m going to feel wasted!”—may spill over into sleep. And because insomniacs are more inclined to awakenings during the night (and to arousal overall), dream content might move more easily from short- to long-term memory, enhancing dream recall.

REM Dream Activity of Insomnia Sufferers

The new study was small (12 insomniacs and 12 matched good sleepers) but well designed. On 5 nights, participants underwent polysomnogram tests to record their brain waves and assess their sleep. On 2 of those nights, during several REM sleep episodes (when dreams were more likely to occur) they were awakened by an 80-decibel tone. Then they had to narrate their dream over an intercom, recall all memorable elements of the dream, and describe the mood associated with it.

The investigators found that the dreams of all participants contained more negative elements than positive elements, which confirms findings in past research. But when they examined the two groups separately, here’s what they found:

  • Only the insomniacs’ dreams contained significantly more negative elements (aggression, misfortunes, failures, and negative emotions) than positive elements (friendliness, good fortune, success, and positive emotions). Subjectively, too, the insomniacs appraised their dreams as being more negative than good sleepers did.
  • Good sleepers reported significantly more joy and happiness in their dreams, and a higher degree of vividness.
  • Insomniacs’ sleep was more broken than the sleep of the good sleepers. In other words, the sleep of insomniacs was less efficient. And the lower the sleep efficiency, the higher the number of negative elements in insomniacs’ dreams.

The one prediction these researchers made that didn’t hold up concerns dream and nightmare recall, which they expected would be higher among insomnia sufferers than good sleepers. In contrast to the results of previous studies, participants’ responses on a questionnaire showed that dream and nightmare recall was similar between the 2 groups.

As in Waking Life, So in Sleep

The waking hours of people with chronic insomnia are skewed toward the negative, with moodiness, low energy, and mental dross our daily fare. So it’s probably no surprise that the struggle and negativity carry over into our sleep by way of dreams.

If you have a recurring dream, please share it here.

Insomnia: Still Don’t Ask, Don’t Tell

I went to my family physician for a routine physical last week. I hadn’t had one in a while, so I decided to get the exam and requisitions for the usual blood work.

This doctor is one whose opinions I respect. But I never hesitate to speak up when information I have leads me to question those opinions. One topic we’ve had discussions about is insomnia and sleeping pills.

Insomnia may be something that doctors avoid bringing upI went to my family physician for a routine physical last week. I hadn’t had one in a while, so I decided to get the exam and requisitions for the usual blood work.

This doctor is one whose opinions I respect. But I never hesitate to speak up when information I have leads me to question those opinions. One topic we’ve had discussions about is insomnia and sleeping pills.

I use Ambien rarely now—sometimes only half a pill—and I’ve still got plenty left from the prescription she wrote last year. So I didn’t plan to mention sleeping pills or insomnia because I didn’t need to.

 

In the Consulting Room

The nurse sat down at the computer to update my medical record, asking about medications and supplements.

Yes, I was still using Ambien. No, I didn’t need a refill.

The nurse then walked out and the doctor walked in.

So what could she do for me today?

I explained the routine nature of my visit and that I wanted the usual blood tests.

She listened to my heart and lungs, placed her fingers under my jaw to feel for lumps, checked my ears and throat. She verified that my weight was stable and that I was getting regular exercise. She typed the lab requisitions into the computer and said I could pick them up on my way out. Then she left.

After the Consultation

Putting on my coat and boots, I happened to glance at the computer, where my medical record was still open. Three words jumped out, the only ones in bold red letters at the top right side of the screen: CHRONIC INSOMNIA. ANXIETY.

The sight was jarring. These words—diagnoses my doctor and I had talked about—felt like accusations. Why, at that moment, did everything I’d learned in my years of studying insomnia—its association with hyperarousal, the stigma attached to it and other disorders involving the brain, the work I’d done to learn to manage my sleep—fly out the window and leave me feeling bad about myself?

I scanned the record for other diagnoses and found one. It appeared in regular black type on the left.

A comment made by a friend of mine suddenly came to mind:

“Usually doctors are hesitant to prescribe sleeping pills for regular use,” she said, “and I’m hesitant to ask. Having worked in a medical office, I think that when you ask for pain pills a lot, or sleeping pills or muscle relaxants or anti-anxiety things, that’s a red flag for being a drug abuser.”

A red flag for being a drug abuser—was that why chronic insomnia and anxiety were at the top of my record in boldface and red? Because several medications used to treat sleep problems and anxiety are controlled substances and I use one? After decades of responsible use of sleeping pills—never using more than a few at a time, never developing tolerance or dependency—am I still seen as a potential drug abuser by my doctor?

The Question Not Asked

Later another thought came to mind. Chronic insomnia is the first thing anyone would see in my medical record, so why had the doctor not asked about my sleep?

I can’t exactly fault her for the omission. She may have assumed, since I didn’t raise the issue myself and didn’t need a sleeping pill prescription, that my sleep must be fine. She may have remembered other conversations we’ve had about my sleep problem—conversations involving some emotion—and decided to leave well enough alone.

All the same, it would have been nice if she’d asked about my sleep. In my imagination, that conversation would go something like this:

Dr: So how’s your sleep these days?

Me: Never better.

Dr: Really?

Me: Yes. With all the study and experimentation I’ve done, I think I’m managing my sleep about as well as a person prone to stress-related sleep disturbance can. There’s not much backsliding these days.

Dr: That’s wonderful. That’s an achievement.

Me: Yes. It is.

Does your doctor routinely ask about your sleep?

Insomniacs: Are We Dreaming About Sleeplessness?

Rapid eye movement sleep (REM sleep) is when most dreams occur. Episodes of REM sleep also help defuse negative emotions and improve the learning of motor skills.

Until recently, insomnia wasn’t thought to be a problem of REM sleep. Insomnia, the thinking went, was caused mainly by phenomena occurring—or failing to occur—during quiet, or non-REM, sleep: insufficient deep sleep, for example, or wake-like activity occurring in other stages of non-REM sleep, resulting in insufficient or poor sleep.

In the past few years, though, REM sleep has become a suspect in the quest to identify what causes people to wake up frequently in the middle of the night and too early in the morning. (This type of insomnia is called sleep maintenance insomnia). Here’s more about this intriguing proposition.

Insomnia sufferers may be remembering dreams of sleeplessness rather than lying awake for hoursRapid eye movement sleep (REM sleep) is when most dreams occur. Episodes of REM sleep also help defuse negative emotions and improve the learning of motor skills.

Until recently, insomnia wasn’t thought to be a problem of REM sleep. Insomnia, the thinking went, was caused mainly by phenomena occurring—or failing to occur—during quiet, or non-REM, sleep: insufficient deep sleep, for example, or wake-like activity occurring in other stages of non-REM sleep, resulting in insufficient or poor sleep.

But in the past few years, REM sleep has become a suspect in the quest to identify what causes people to wake up frequently in the middle of the night and too early in the morning. (This type of insomnia is called sleep maintenance insomnia). Here’s more about this intriguing proposition.

Do Insomniacs Really Underestimate Sleep Time?

It’s said that insomniacs tend to underestimate the amount of sleep they get. Polysomnography (PSG), the test conducted in the sleep lab, often shows that insomnia sufferers are sleeping more than they think.

Investigators now agree that PSG, as conducted and scored in standard fashion, is too crude a measure to capture what’s going on in disturbed sleep. Finer measures are needed. One such measure involves counting the number of arousals and micro-arousals—brief awakenings—during sleep.

In a seminal study published in 2008, a team of German scientists used PSG, sleep time estimates of study participants, and micro-arousal analysis to ascertain what the differences were between insomniacs and good sleepers. The results showed that compared with good sleepers, insomniacs

  • Got less non-REM and REM sleep overall
  • Experienced more micro-arousals during both non-REM and REM sleep, but the number of micro-arousals during REM sleep was more pronounced: about 2 to 3 times larger than the number experienced by good sleepers. Further, the more REM sleep insomniacs got, the greater was the mismatch between their sleep time as recorded by PSG and the sleep time reported by the insomniacs themselves.

These results suggest that (1) it may be disturbances that occur during REM sleep, more so than during non-REM sleep, that account for the discrepancy between PSG-measured sleep and insomniacs’ perception of their sleep, and (2) disturbed REM sleep may be the main problem for people with sleep maintenance insomnia.

How Disturbed REM Sleep Might Develop

Not much brain activity occurs during non-REM sleep. But REM sleep is marked by a mix of arousal in some parts of the brain and quiescence in other parts. The same group of scientists in a 2012 paper describe REM sleep as “a highly aroused ‘paradoxical’ sleep state requiring a delicate balance of arousing and de-arousing brain activity.” This brain activity involves many different groups of neurons. The over- or underexpression of any of these groups might disturb that “delicate balance,” causing fragmented REM sleep.

This idea fits in with the dominant explanation for chronic insomnia: it’s a manifestation of hyperarousal, which may come about in part due to stress. Stressful life experiences often cause sleep loss. If the poor sleep continues, then sleeplessness and worry about the daytime consequences themselves become stressors and insomnia becomes a chronic affair. The chronic stress accompanying chronic insomnia also leads to changes in the brain. These changes could cause REM sleep fragmentation and disrupted or poor sleep.

Remembering Dreams of Sleeplessness

The idea of REM sleep fragmentation as a driver of sleep maintenance insomnia also fits with the continuity hypothesis of dreaming, which posits that the content of dreams comes from everyday concerns. Not much research exists on the content of insomniacs’ dreams. What is known is summarized in a paper published in Sleep Medicine Reviews:

  • Compared with normal sleepers, insomniacs tended to experience themselves more negatively in their dreams
  • Problems that occurred in dreams were related to current real-life concerns
  • Health problems also appeared more frequently in insomniacs’ dreams.

People with chronic insomnia are prone to worry about sleep loss and its consequences, and these concerns might well dominate the content of our dreams. And if we’re experiencing lots of micro-arousals as we’re dreaming, the content of those dreams would be more accessible to conscious recall. Instead of actually lying awake for hours at night, sleep maintenance insomniacs might be awakening briefly but often to dreams of sleeplessness, making it feel like we’re sleeping less than we are.

Precisely how REM sleep becomes fragmented remains to be seen. But the finding that REM sleep is significantly unstable in sleep maintenance insomniacs is a step in the right direction.

Does the idea of REM sleep instability as a driver of sleep maintenance insomnia seem plausible to you?

Insomnia and Napping: No One-Size-Fits-All Prescription

If you have insomnia, you’ve probably heard it’s best to avoid naps. Maybe you heard it from your doctor in a conversation about the rules of “good sleep hygiene,” or maybe you read it in a magazine. Is the advice to refrain from napping really sound advice and, if so, do you have to swear off napping completely to get a better night’s rest?

There are no one-size-fits-all answers to these questions, say researchers who recently reviewed the evidence behind the recommendation to avoid napping and other sleep-related do’s and don’ts. It depends on your age and situation.

Chronic insomniacs should avoid naps, but people whose sleep problems are less severe need not abstainIf you have insomnia, you’ve probably heard it’s best to avoid naps. Maybe you heard it from your doctor in a conversation about the rules of “good sleep hygiene,” or maybe you read it in a magazine. Is the advice to refrain from napping really sound advice and, if so, do you have to swear off napping completely to get a better night’s rest?

There are no one-size-fits-all answers to these questions, say researchers who recently reviewed the evidence behind the recommendation to avoid napping and other sleep-related do’s and don’ts. It depends on your age and situation.

Chronic Insomnia

If you’ve got chronic insomnia (trouble sleeping at least 3 times a week for at least 3 months accompanied by daytime impairments), then forgoing naps may improve your sleep. Research has shown that the pressure to sleep builds higher and higher during the daytime and is released at night during deep sleep. Napping during the daytime may result in the early discharge of some of the sleep pressure. This can make it harder for people with persistent insomnia to fall asleep and stay asleep at night.

Accordingly, if you go through cognitive-behavioral therapy (CBT) for insomnia, you’ll be asked to refrain from napping during treatment. The fact that CBT works as well as it does supports the idea that cutting out naps is a useful strategy for insomniacs who want to improve their sleep at night.

What should you do if you can’t survive without a nap? Sleep therapists may recommend the following:

  1. Keep the nap short—30 minutes or less—to avoid descending into deep sleep
  2. Refrain from naps in the evening, when the pressure to sleep is high.

Mild or Occasional Sleep Problems

If you’re basically healthy and your sleep problems are occasional or less severe, then it’s not so clear that cutting out naps will help. Nor is it evident, in insomnia associated with aging, that the benefits of napping don’t compare favorably next to the difficulties created when the nap is cut out.

Napping occurs more frequently as people age, so the subjects in most studies of napping in naturalistic settings have been older adults. The results have not been consistent from one study to the next. However, the majority have not identified a significant association between daytime napping and nighttime sleep in older adults. Nor did researchers who conducted a study involving healthy young and middle-aged nappers find such an association.

Adding a Nap

Researchers have also looked at how adding a nap into people’s daily schedules affects their sleep at night—mostly in middle-aged and older adults. Here, too, the results are mixed. In some studies, naps resulted in shorter, less efficient sleep at night; in other studies, the naps had absolutely no effect on nocturnal sleep.

Of note is the fact that no researchers have ever conducted a study to determine whether depriving habitual nappers of their naps actually improves their sleep at night.

So the recommendation not to nap that appears on the list of habits consistent with good sleep hygiene? Unless you have chronic insomnia, for now, take this recommendation with a grain of salt. There may be other more effective paths to reliably sounder sleep.

If you take naps, what effect do they have on your sleep at night?

Insomnia Advice Can Miss the Mark

People sometimes offer advice when they hear about my insomnia. Their suggestions are not always helpful.

In fact, I used to feel impatient with–and occasionally hurt by—comments that to my ears sounded judgmental or attitudes toward insomnia that I felt were just plain wrong. The comments were well meaning, but that didn’t make them easier to tolerate. Here are a few that put me off and what I think about them now.

Advice about insomnia can hurt rather than helpPeople sometimes offer advice when they hear about my insomnia. Their suggestions are not always helpful.

In fact, I used to feel impatient with–and occasionally hurt by—comments that to my ears sounded judgmental or attitudes toward insomnia that I felt were just plain wrong. The comments were well meaning, but that didn’t make them easier to tolerate. Here are a few that put me off and what I think about them now.

There must be a part of you that doesn’t want to sleep.

No doubt this suggestion was meant to be insightful, but I found it exasperating. The idea that there might be a twin self lurking inside me that wanted to stay awake (to do what? force myself to read when my eyes could barely focus? play another round of Internet solitaire?)—just how crazy did that make me sound?

Normal sleepers may assume that people who have insomnia actually want to remain awake because of a belief that sleep can be regulated voluntarily. This belief is fairly common, and some people do seem to have quite a bit of control over their sleep. I once knew a woman who could will herself to take a 10-minute cat nap whenever and wherever she pleased. And what about the lucky ones that drop right off in their seats even before the plane is finished boarding?

Sleep is more complicated for people with insomnia. Yes, there are habits and attitudes we can adopt to avoid sleep problems and we should do this. Yet wanting sleep is not always enough to make it happen–any more than a person with asthma can breathe easily on command.

Something has to be causing your sleep problem. Maybe it’s time you went to a therapist to figure it out.

The suggestion that insomnia was a symptom of a larger psychological problem was dismaying. I doubted very much that an unresolved internal conflict was driving my insomnia–that, despite my years of psychotherapy, a dark secret buried in my unconscious was keeping me awake. Or that I was actually deriving some benefit from insomnia (the sympathy of friends, for example) and this was keeping it alive.

A general practitioner actually made the above suggestion to me not 10 years ago. Obviously he hadn’t read Harvard sleep scientist Gregg D. Jacobs’ book, Say Goodnight to Insomnia, in which Jacobs writes, “There is not one scientific study demonstrating that psychotherapy is effective in treating chronic insomnia.”

Theories about the psychological origins of insomnia were predominant for most of the twentieth century, though, so it’s not so surprising that people—even some doctors—put stock in them still. These days, people who study chronic insomnia say the disorder develops due to many factors: biological, situational, behavioral, and attitudinal. As for the suggestion that a therapist could help me “figure it out,” well, all the world’s sleep scientists haven’t been able definitively to do that yet. So a lone psychologist would surely come up short.

Have you tried melatonin/valerian/yoga/warm milk?

It still surprises me when people offer suggestions like these as though they were novel ideas. I know people are only trying to be helpful and that it’s curmudgeonly of me to complain. But anyone who hasn’t heard of these insomnia remedies has never been on the Internet or read a magazine!

These sleep aids remain popular because sometimes they work: Night owls, for example, can use melatonin successfully to shift their sleep to an earlier hour. Valerian taken nightly has been shown in some studies to improve sleep. The daily practice of yoga reduces arousal and builds resilience to stress, which will have a positive effect on sleep. Milk contains the sleep-friendly amino acid tryptophan. Combined with a complex carbohydrate, it makes a good bedtime snack.

But a person with chronic insomnia has probably been there and done that, not to mention experimenting with a raft of other sleep aids. Sometimes I think we could do with a few more expressions of sympathy and a little less “helpful” advice.

What suggestions have people made about your sleep problem that annoyed you?

A New Look at Insomnia and Depression

Think 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, but the story is different today. It looks more and more like chronic insomnia is a way station to depression.

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?