The Insomnia-Depression Connection Writ Large

Insomnia doesn’t often get front-page coverage, but it did on Tuesday. Benedict Carey of The New York Times reported on a study of people under treatment for depression. The results showed that nearly twice as many subjects were cured of depression when—in addition to taking an antidepressant or a pill placebo—they received cognitive-behavioral therapy (CBT) for insomnia.

It’s time to reassess the relationship between insomnia and depression.

Depression responds to treatment with cognitive behavioral therapy for insomniaInsomnia doesn’t often get front-page coverage, but it did on Tuesday. Benedict Carey of The New York Times reported on a study of people under treatment for depression. The results showed that nearly twice as many subjects were cured of depression when—in addition to taking an antidepressant or a pill placebo—they received cognitive-behavioral therapy (CBT) for insomnia.

It’s time to reassess the relationship between insomnia and depression. Sleep researchers in recent years have noted that the two disorders share biological turf. Compared with people who are healthy, those with insomnia and those with depression tend to get less deep sleep—the type of sleep associated with feelings of restoration. Elevated levels of cortisol, a stress hormone, and interleukin-6, a protein that stimulates the immune response, are also common to people in both groups.

Conventional Thinking About Depression and Sleep

Yet for hundreds of years, insomnia has been viewed as merely a symptom of depression. Just as in the fifteenth and sixteenth centuries sleeplessness was seen as a symptom of melancholia, so insomnia is still regarded by many psychotherapists as a symptom of depression. Treat the depression, the thinking goes, and the insomnia will disappear.

But this strategy does not always work, the authors of the current study concluded in an earlier study published in 2007, which I blogged about in September. Antidepressants may clear up depression, but insomnia often persists.

People I interviewed for The Savvy Insomniac (where I explore insomnia-related disorders and CBT at length) told stories of frustration as they looked for solutions to depression and insomnia. Laura, for example, had trouble sleeping long before she developed depression. Yet when she took her complaints to the doctor, all the doctor did was prescribe an antidepressant. The depression cleared up but the insomnia continued, and her doctor had nothing to suggest.

“Over the years,” Laura said, “they always assumed my insomnia was a symptom of depression rather than seeing it as separate. They don’t even consider the possibility that they’re exclusive with respect to each other.”

A New Perspective

New research is suggesting that insomnia may be a kind of way station to depression, and if results of the current study are confirmed by others soon to follow, they’ll really upset the apple cart. Not only may it be the case that CBT for insomnia helps clear up depression-related sleep problems. It may also true that supplementing traditional depression therapy with CBT for insomnia doubles the chance of recovery from depression.

Now put that in your pipe and smoke it.

If you’ve struggled with depression and insomnia, what treatments have you tried, and have they worked?

Laying Fear of Sleeplessness to Rest

Once fear of sleeplessness moves into your bedroom, it can feel like a permanent feature of the night, making insomnia worse. But does it have to be this way?

Therapy with a sleep specialist, or measures you can take on your own with instruction from a book or the web, can help set fears to rest.

night-demonOnce fear of sleeplessness moves into your bedroom, it can feel like a permanent feature of the night, making insomnia worse. But does it have to be this way? Therapy with a sleep specialist, or measures you can take on your own with instruction from a book or the web, can help set fears to rest.

Cognitive Restructuring

Many insomnia sufferers have sleep-related attitudes that interfere with sleep. Beliefs like these—“My ability to sleep is out of my control,” or “When I sleep badly I can’t function the next day.”—can contribute to the development of anxiety about sleep.

“Cognitive restructuring” may help. It’s a part of cognitive-behavioral therapy (CBT) for insomnia. As part of this program, a therapist tries to convince you that your catastrophic thinking is distorted, and persuade you to adopt a more realistic mindset. The claim is that changes in attitude—“I can control my sleep by adopting a better sleep schedule,” and “If I sleep badly one night, I’ll sleep better the next.”—can help to decrease sleep-related fears and improve sleep.

Sleep Restriction Therapy

Cognitive restructuring may be useful for some insomniacs, but I had better luck with sleep restriction, a therapy I blogged about on June 27 and July 1. The main goal of sleep restriction, another part of CBT, is to help insomniacs fall asleep more quickly and sleep through the night.

Sleep restriction helped me do just that. But it had another benefit as well: it helped me get rid of my fear of sleeplessness to a large extent. How? By functioning as an exposure therapy.

What Is Exposure Therapy?

Say you have a spider phobia. During exposure therapy, you might start by looking at a picture of a spider and eventually progress to sitting near a real spider outdoors. The goal would be to reduce your physiological response to spiders—the pounding heart, the urge to flee—and get more comfortable in places where spiders are likely to be.

Sleep restriction, which brought me face to face with my fear of sleeplessness, accomplished a similar thing. The first few nights were scary. It took every bit of resolve I had to stick to the program when my anxiety level was sky high.

But gradually things changed. As the nights went by, I found myself sleepier and sleepier at bedtime and began falling asleep within minutes of lying down. With improved sleep, I was less fatigued and my thoughts were clearer during the day. As bedtime approached, I began to expect that I would sleep. Within a few weeks, my fear of sleeplessness had all but faded away: an incredible boon for someone who lived with this fear off and on for years.

Occasionally my fear of sleeplessness will return in times of stress. When it does, it feels much more manageable. It’s not the demon it used to be.

My advice? If fear of sleeplessness is part of your problem, cognitive and behavioral therapies are worth checking out.

Do these therapies sound like they might help you?

Sleep Restriction in a Nutshell

In last week’s blog I explained the rationale behind sleep restriction as a treatment for insomnia. (Here’s a link to that blog post.) Now I’ll offer a quick and dirty description of how it works.

sleep-restrictionIn last week’s blog I explained the rationale behind sleep restriction as a treatment for insomnia. (Here’s a link to that blog post.) Today I’ll offer a quick and dirty description of how it works.

The first order of business is to keep a sleep diary, recording every morning how many hours you slept the night before. After one week, calculate the average number of hours you’re sleeping. This becomes the number of hours you’re allowed to be in bed during the first week of sleep restriction. (Many sleep therapists suggest starting with no fewer than 5 hours in bed.)

Start Restricting Your Time in Bed

Decide on a wake-up time, and count backward to determine your bedtime. Stay up until then every night, doing whatever it takes to stay awake. Get up at the same time every morning.

At the end of the first week of sleep restriction, calculate your “sleep efficiency” (percent of time in bed actually spent sleeping). Divide the total number of hours you slept during the week by the total number of hours you were in bed, and multiply by 100. If your sleep efficiency is above 85 percent (some therapists recommend that your sleep efficiency be at least 90 percent), then add 15 minutes to your time in bed during the second week.

For example, if during the first week you restrict yourself to 5 ½ hours in bed and your sleep efficiency is 90 percent, during the second week of sleep restriction, you increase your time in bed to 5 ¾ hours. If at the end of the second week your sleep efficiency is still above 85 percent, add 15 more minutes for a total of 6 hours in bed. And so on from week to week, until you find the maximum time you can spend in bed without your sleep efficiency falling below 85 (or 90) percent. This is your ideal sleep time, and, once you’ve found it, you stick with it.

The Hard Part

It’s not easy complying with such a rigid schedule, especially during the first week. I found it increasingly hard to keep myself awake until midnight, the bedtime I’d set. Passive activities like reading and watching movies led to nodding off early. So I switched to activities like folding clothes, rearranging cupboards, and walking around the house.

Also, it was harder and harder to pull myself out of bed when the alarm rang at 5 a.m. For three days I walked around like a zombie, forgetting appointments and misplacing glasses and keys.

But by the end of the first week, I was falling asleep the minute my head hit the pillow and sleeping right through the night—a major coup for me.

Sleep restriction is just one among a handful of treatments you may undergo as part of cognitive-behavioral therapy (CBT) for insomnia. Three online programs offering CBT are CBT for Insomnia, Sleepio, and SHUTi. Check into one of these if you’re leery of trying sleep restriction on your own.

Does sleep restriction sound like something you would try? Why or why not?

A Long Slog to Better Sleep

Persistent insomnia can be exhausting, and not just because you can’t sleep. The search for relief can sap your energy, and the remedies available often come with caveats.

For insomnia, I tried every remedy in the bookPersistent insomnia can be exhausting, and not just because you can’t sleep. The search for relief can sap your energy, and the remedies available often come with caveats.

Insomnia became a serious problem when I was in college, where the main point was to exercise my brain. Playing the piano could sometimes put a stop to the mental calisthenics that kept me from nodding off at night. When that failed, a couple glasses of my piano teacher’s home brew would usually do the trick. Trouble was, I woke up to hangover in the morning. No fun.

Sleep came no more easily when I started earning a paycheck. A friend suggested I take a muscle relaxant at night. The pill didn’t make getting to sleep any easier, but it sure packed a punch in the morning. I was lucky when I could hoist myself to a standing position—never mind trying to think.

On the advice of a doctor, I tried diaphragmatic breathing. “In, two, three, four, out, two, three, four,” and so on. It worked the first few times I tried it, and I was thrilled! But then there were nights when no matter how long I counted or how deeply I breathed, I could not manage to slide over the hump. Grrrrrr! My body had a mind of its own, or so it seemed.

The Big Guns

Then there were the little blue sleeping pills I carried around the year I taught in Mexico. They were fabulous. I kept them in a square pillbox, and one day I left it open on the bathroom sink. When I turned on the faucet (the water gushed like a geyser at the slightest touch of the handle) the pills got soaked. They swelled up like mushrooms and probably took in some iffy bacteria, but no matter. I let them dry out and eventually used every single one. But there was not a prayer of renewing my prescription. The 1980s were lean, mean years for users of sleeping pills. You might as well ask a doctor for crack cocaine.

The Alternative Route

Next came my years in California, when I tried every New Age insomnia cure under the sun. I talked about my insomnia with a therapist (to little avail). I listened to a relaxation CD, but the guy on the CD had an obnoxious voice. I took a meditation class. Traveling in Japan, I stank up rooms of sweet-smelling tatami mats with liquid valerian. The sole take-away was bad breath.

Back in the U.S., I discovered the soporific effect of nature programs I could play at low volume at night. In the late 1990s, the monotonous voice of Marty Stauffer and his leaping gazelles and lumbering polar bears could coax me into slumber. But the show lasted only half an hour—not long enough to put me into a deep sleep. The French horns trumpeting the end of the program were infuriating because they could jolt me awake again.

Better Options

My quest to beat insomnia eventually bore fruit. Knowledge of the sleep/wake system, cognitive-behavioral therapy (CBT) and well-timed exercise have led to better sleep for me. But what exhausting lengths I went to—and many insomniacs I interviewed for my book report going to the same lengths—before finding strategies that worked.

If you’re fed up with half-measures and can’t get help from your doctor, I suggest going beyond the insomnia remedies listed on the first page of a Google search. Consider trying CBT, and other strategies that are research-based.