Insomnia Is Not a Trivial Concern

If you’ve struggled with chronic insomnia for years, even if you have some reliable management strategies, you may occasionally find yourself talking about insomnia with people whose looks and responses suggest it can’t be such a big deal.

“Aren’t there pills for that?” “My doctor says that’s self-inflicted. You just THINK you can’t sleep.” Here’s some new research that shows why persistent insomnia is a serious problem deserving of concern and treatment.

Talking about insomnia with friends.If you’ve struggled with chronic insomnia for years, even if you have some reliable management strategies, you may occasionally find yourself talking about insomnia with people whose looks and responses suggest it can’t be such a big deal.

“Aren’t there pills for that?”

“My doctor says that’s self-inflicted. You just THINK you can’t sleep.”

Here’s some new research that shows why persistent insomnia is a serious problem deserving of concern and treatment.

Benefits of Sleep

First, though, let’s review the central role sleep plays in maintaining well-being. In the past, people thought that nothing much happened during sleep and that the human brain essentially shut down at night. How wrong that notion was!

Many critical functions occur during sleep. Sleep enables the shoring up of the immune system and the repair of injuries. During sleep, memories are consolidated and brain waste is pruned. Negative emotion is processed during REM sleep. After a full night’s sleep you awaken in a more positive mood. During sleep energy is conserved. In the morning you awaken feeling rested and restored, and your brain is primed to learn and retain new information.

When sleep is disrupted, whatever the reason, the critical functions that take place during sleep may be compromised. In the case of chronic insomnia, common symptoms during the daytime—tiredness and lack of stamina; moodiness; and impaired attention, concentration, and memory—are suggestive of compromise. They cut down on the quality of our day-to-day lives.

Effects of Persistent Insomnia Over Time

Chronic insomnia also has several more insidious effects.

It increases the odds of our developing depression and anxiety. A new meta-analysis of studies on insomnia as predictor of mental illness has found that chronic insomnia makes us nearly 3 times as likely to develop major depressive disorder and over 3 times as likely to develop an anxiety disorder as people without insomnia.

Insomnia and Chronic Pain

Insomnia intensifies and increases susceptibility to pain. Past research has suggested that the relationship between insomnia and pain is bidirectional, with painful conditions interfering with sleep and sleep disturbances worsening painful conditions. But recent longitudinal studies (studies involving repeated observations over time) suggest that more often it’s insomnia symptoms that predispose us to chronic pain or to the worsening of painful conditions.

Insomnia and Heart Disease

Insomnia, especially when accompanied by objectively measured short sleep duration (less than 6 hours), makes us more susceptible to heart, or cardiovascular, disease (CVD). Meta-analyses have found that people with insomnia are between 33% and 45% more likely to develop and/or die of CVD than people without insomnia.

A new study of sleep duration and atherosclerosis (plaque formation in arteries) has found that short sleepers are 27% more susceptible to atherosclerosis than people who sleep 7 to 8 hours a night, and those whose sleep is highly fragmented are at even greater risk (34%) for plaque build-up.

A disorder that has so many negative effects on quality of life and long-term health cannot be dismissed as a minor annoyance. It’s important to get treatment for insomnia as soon as possible, with cognitive behavioral therapy or, in cases that don’t respond to CBT, medication.

Talking About Things We Know

Despite what you might infer from the fact that I blog about insomnia, I don’t go around seeking opportunities to talk about the problem in my everyday life. Sleep disorders now get quite a bit of attention in popular media, but most of us know the topic has the appeal of moldy leftovers for the good sleepers of the world — and they are in the majority.

Occasionally, though, conversations turn to talk about sleep, at a party or a meeting or anywhere in casual conversation. And who better than us to raise people’s awareness about the problem of insomnia since we’re the ones with all the experience?

If you’ve talked about insomnia with your family, friends, or acquaintances, what has been their reaction?

Transitioning to Menopause? Don’t Give Up on Sound Sleep

I often hear sleep complaints from women approaching menopause. Hot flashes and mood swings are other common complaints. What can be done to improve sleep and reduce perimenopausal symptoms?

The key, say authors of a review paper published this year, is to use a variety of approaches based on individual women’s symptoms, history and needs.

Insomnia and hot flashes can be relieved with multi-pronged treatmentI often hear sleep complaints from women approaching menopause. Hot flashes and mood swings are other common complaints. What can be done to improve sleep and reduce perimenopausal symptoms?

The key, say authors of a review paper published this year, is to use a variety of approaches based on individual women’s symptoms, history and needs.

Sleep Problems in the Menopausal Transition

The transition to menopause begins 4 to 6 years before menstruation stops (the median age for menopause is 51 years). It’s a time of fluctuating reproductive hormone levels. Not all women suffer ill effects during this period but many do.

Sleep problems are one of the most common complaints, reported by up to 56% of women approaching menopause, say authors of the review, published in the journal Nature and Science of Sleep. In turn, trouble sleeping often compromises midlife women’s quality of life, mood and productivity.

There’s an uptick in sleep-disordered breathing (sleep apnea) among women transitioning to menopause. There’s also an uptick in insomnia. A study involving 982 perimenopausal women interviewed by phone found that 26% had symptoms qualifying them for a diagnosis of insomnia disorder as medically defined.

Not Just in Our Heads

Fluctuating levels of hormones—follicle-stimulating hormone, estradiol (an estrogen) and progesterone—likely play a role in insomnia that occurs during the menopausal transition. Hot flashes, too, which typically emerge as estrogen levels decline, are associated with poorer reported sleep quality and chronic insomnia.

As for objective evidence of menopausal sleep problems, results of population studies of midlife women involving polysomnography (PSG) are inconsistent. But in a recent study published in Psychoneuroendocrinology, investigators found “stark differences in PSG measures in women with, relative to women without, insomnia disorder developed in the menopausal transition.”

Women who developed insomnia during the menopausal transition

  • had poorer sleep efficiency
  • experienced more wakefulness after sleep onset
  • had shorter total sleep time, with 50% sleeping less than 6 hours
  • were more likely to have hot flashes, which predicted their number of awakenings per hour of sleep.

A Role for Depression and Stress

Symptoms of depression typically increase during the menopausal transition. Depression and insomnia are closely linked, with depression sometimes preceding insomnia and insomnia sometimes leading to depression. The results of one interesting study suggest that trouble falling asleep at the beginning of the night is associated with anxiety while nonrestorative sleep is linked to depression.

Chronic exposure to stress could be another factor in midlife women’s greater susceptibility to insomnia. And during the transition to menopause, traits associated with insomnia—increased tendency toward rumination, anxiety, generalized hyperarousal, stress reactivity, and neuroticism—are similar to tendencies predictive of hot flashes and other perimenopausal symptoms.

Treatments for Insomnia in the Menopausal Transition

Since insomnia in the menopausal transition is likely due to many factors, it’s challenging to treat. The reviewers recommend “flexible and individualized” treatments for insomnia depending on each woman’s current symptoms and history.

Hormone Therapy

Hormone therapy generally improves sleep quality in women who experience hot flashes during the transition. It may be a good option if, based on a woman’s history and health concerns, the overall potential benefits outweigh the risks. The reviewers note that abrupt discontinuation of hormone therapy is associated with hot flash relapse, which could in turn lead to insomnia.

Non-Hormonal Pharmacological Therapies

Sleeping pills, which are generally prescribed for short-term or intermittent use, are not a front-line treatment for insomnia in perimenopausal women. Taken nightly over time, many sleeping pills degrade sleep quality and have other negative effects. Following are the medications the reviewers suggest considering for perimenopausal women with insomnia and hot flashes:

  • Low-dose selective serotonin reuptake inhibitors—such as citalopram (Celexa) and escitalopram (Lexapro)—and low-dose serotonin norepinephrine reuptake inhibitors—such as duloxetine (Cymbalta) and venlafaxine (Effexor XR). Note that discontinuation of SSRIs is associated with hot flash relapse, which could lead to insomnia.
  • Gabapentin, shown to improve sleep quality in perimenopausal women with hot flashes and insomnia.
Non-Pharmacological Therapies
  • Cognitive behavioral therapy for insomnia (CBT-I) is the overall gold standard in drug-free treatments for insomnia. In a randomized clinical trial recently conducted on peri- and postmenopausal women experiencing at least 2 hot flashes daily, women who underwent CBT-I “had significantly greater reduction in insomnia symptoms and greater improvements in self-reported sleep quality” compared with controls. The improvements were maintained at 6 months after treatment.
  • Soy isoflavones—phytoestrogens found mainly in legumes and beans—have been shown in randomized controlled trials to reduce menopausal symptoms, including self-reported sleep disturbance. They’re available as dietary supplements.
  • High-intensity exercise and yoga are reported by the reviewers to be modestly beneficial in reducing menopausal symptoms and improving sleep.

Because many factors can combine to disrupt sleep in the period leading up to menopause—sleep disorders, mood disorders, medical conditions, and life stressors—no one-size-fits-all treatment will improve sleep and minimize menopausal symptoms. Instead, the reviewers recommend a multi-pronged approach to treatment based on individual women’s needs.

A Different Pathway to Chronic Insomnia

Let’s say you grow up in a family of champion sleepers, yourself included. At college, you sail through rowdy dormitory life sleeping like a log. Job interviews, stressful to some, don’t faze you. By 27, you’ve landed a good job and in a few years earned enough for a down payment on a house. Sleep is still dependable and stays that way for a decade.

Then, coinciding with a move and the birth of a second child, you find yourself wide awake at your normal bedtime, staring at walls. Soon this becomes the rule rather than the exception. Before you know it you’ve developed chronic insomnia. How can sleep go from good to bad so quickly?

Stress and poor sleep can lead to chronic insomnniaLet’s say you grow up in a family of champion sleepers, yourself included. At college, you sail through rowdy dormitory life sleeping like a log. Job interviews, stressful to some, don’t faze you. By 27, you’ve landed a good job and in a few years earned enough for a down payment on a house. Sleep is still dependable and stays that way for a decade.

Then, coinciding with a move and the birth of a second child, you find yourself wide awake at your normal bedtime, staring at walls. Soon this becomes the rule rather than the exception. Before you know it you’ve developed chronic insomnia. How can sleep go from good to bad so quickly?

How Insomnia Develops

For decades sleep scientists have been trying to work out how chronic insomnia develops. The main model they’ve proposed looks something like this:

  1. Predisposing factors are presumed to exist in everyone who develops chronic insomnia. They include such observable factors as (a) parental history of insomnia, (b) high sleep reactivity (a tendency to sleep poorly before and after stressful events such as giving a speech or having an argument; and to be highly reactive to caffeine, jet lag, and interpersonal stressors), and (c) poor health—all associated with biological challenges to sleep.
  2. Precipitating factors come next: major life stressors that often trigger an episode of insomnia such as a job loss, marriage, or relocation to a different town.
  3. Perpetuating factors are the habits some people then adopt for insomnia relief—taking naps, going to bed early, sleeping in on weekends—that actually make their sleep worse.
  4. Conditioned arousal of the cerebral cortex is the final step in in the process. Lying awake for long stretches of the night opens the door to worry and rumination. This brain activity can spill over into sleep and keep insomnia going indefinitely.

This may be how chronic insomnia develops in some people. There may also be alternative pathways to insomnia. A large community-based study (Evolution of Pathways to Insomnia Cohort) was recently conducted to figure out what those alternative pathways might be. Working with data from that study, Michigan researchers have concluded that even people who have no evident predisposition to insomnia may develop chronic insomnia through a process involving sleep system sensitization. Here’s more on what they found.

From Normal Sleep to Insomnia in Just One Year

In this prospective study, thousands of participants filled out a series of questionnaires at the start of the study and one and two years later. The Michigan researchers looked at the 262 participants who did not have insomnia at the start of the study but who, by year 1, had developed it.

These participants might be expected to have characteristics predisposing poor sleep from the start (a mother with insomnia, for example, or high sleep reactivity). But not all of them did. A total of 60 participants tested low for sleep reactivity at the start of the study (on the Ford Insomnia Response to Stress Test, or FIRST). But by year 1, these 60 people had jumped an average of 4 points on the FIRST, indicating a significant increase in sleep reactivity. Over two-thirds went from low sleep reactivity to very high sleep reactivity following major life stress and the onset of insomnia in the space of just one year. At year 2, the high sleep reactivity persisted regardless of whether their insomnia was chronic or not.

A Different Path to Chronic Insomnia

In a nutshell, here’s the take-away:

  • People with apparently low vulnerability to insomnia (like the person described at the beginning of this blog post) can develop high sleep reactivity in conjunction with major life stress and an episode of insomnia.
  • Stress exposure leading up to insomnia appears to sensitize the sleep system. This lends support to the idea that insomnia itself may be a perpetuating factor in chronic insomnia. Every episode may trigger neurobiological changes that increase the risk of subsequent bouts of insomnia, just as every experience of depression increases the risk of future depression.
  • High sleep reactivity, once it develops, is persistent.

No matter how or why your insomnia develops, don’t wait to look for help. Take action right away.

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?

What Makes You Vulnerable to Insomnia?

The causes of insomnia are still unknown, but many factors can make people more and less vulnerable to it.

A prospective study of Norwegian nurses offers new evidence of several factors, some well known and others that have gotten less attention in the past.

vulnerability to insomnia depends on several thingsWhen I set out to write my book about insomnia, I asked dozens of insomniacs what they thought had caused their insomnia. Several mentioned constitutional factors.

There are certainly grounds for thinking that a genetic component is involved. People who have a first-degree relative with insomnia are 7 times as likely to suffer insomnia as people without insomnia in the immediate family.

Other people I interviewed attributed their insomnia to stress at work or to family problems. Still others blamed their insomnia on an inability to quiet their mind at night.

The causes of insomnia are still unknown, but many factors can make people more and less vulnerable to it. A prospective study of Norwegian nurses offers new evidence of several factors, some well known and others that have gotten less attention in the past.

Anxiety and Depression

There’s plenty of evidence pointing to a relationship between insomnia and mood disorders. In the nurses’ study, where investigators reviewed data on 799 nurses collected at 2 time points 2 years apart, nurses higher on anxiety and depression measures in 2009 were significantly more likely to report insomnia symptoms in 2011.

The reverse relationship also held for insomnia and anxiety: nurses reporting insomnia in 2009 were more likely to have developed anxiety 2 years later. Surprisingly, although insomnia is widely understood to be a causal factor in depression, the nurses’ study found no evidence of this.

Morningness and Eveningness

The nurses in this study were all shift workers. Other research has suggested that people who dislike getting up early in the morning have an easier time adapting to shift work, where work at night is required.

In the current study, though, the nurses who disliked getting up early in the morning were actually more inclined to develop insomnia than the early risers. Other research has shown that people who like to get up early tend to have better lifestyle regularity and more regular sleep habits. Both these things tend to protect people from developing insomnia.

Personality Traits

Some people function quite well despite sleep loss while others feel drowsy and lethargic. (This is largely determined by genetic factors and is thus a stable trait.) Languidity—the tendency to experience drowsiness and lethargy after losing sleep—was found in the nurses’ study to predict an increase in insomnia symptoms over the 2-year period. No surprises here. Impairments in daytime functioning are classic symptoms of insomnia.

Another personality trait—flexibility, or the ability to sleep or stay awake at odd hours—has generally been known to protect against the development of insomnia. Among shift workers, this would be an especially useful trait. But in this study, a high score on flexibility had no positive or negative relationship with insomnia.

Smoking, Drinking, and Caffeine

The overall harmful effects of tobacco, alcohol, and caffeine on sleep are now well known. For many years insomnia was attributed to people drinking too much scotch or too much coffee.

More recently, studies have shown that people with insomnia do not typically drink more alcohol or caffeinated drinks than people who sleep well, and the nurses’ study supports this finding. None of these lifestyle factors predicted an increase in insomnia over time. In fact, nurses reporting insomnia symptoms in 2009 actually reported drinking less caffeine in 2011.

Bullying at Work

Several work-related stressors are known to increase the risk of poor quality sleep, and bullying—persistent exposure to negative actions from others—is one. Day-to-day contact with tyrannical bosses and manipulative supervisors often leads to psychological distress.

Nurses subjected to bullying at work reported more insomnia symptoms over time than the nurses working under better conditions. No surprises here: the worry and stress that result from bullying are two of the leading causes of sleep problems among workers.

Spillover Between Work and Family

Stress in one domain can affect another. In the nurses’ study, negative spillover from work to family and from family to work predicted an increase in insomnia symptoms over time. Conversely, insomnia led to reports of more work-to-family conflicts over time.

Shift Work

Finally, shift work, involving night work and rotating shifts, is known to precipitate insomnia. But in this group of nurses, the association did not hold. This unexpected result might be due to the young age of the nurses (average age 33) and their overall good health compared with shift-working nurses overall, many of whom likely self-selected out of the study.

What factors do you think led to your insomnia?

Q&A: Can Insomnia in Bipolar Disorder Be Treated with CBT?

Last week Dan wrote to Ask The Savvy Insomniac with questions about cognitive-behavioral therapy for insomnia (CBT-I). Dan has bipolar disorder, and because of this diagnosis, his sleep doctor had reservations about him undergoing CBT-I.

So Dan tried a modified version for 2 weeks. His sleep did not improve. He was wondering if he would have to use sleeping pills and if he should continue with CBT-I on his own.

Can CBT for insomnia be used if you have bipolar disorder?Last week Dan wrote to Ask The Savvy Insomniac with questions about cognitive-behavioral therapy for insomnia (CBT-I). Dan has bipolar disorder, and because of this diagnosis, his sleep doctor had reservations about him undergoing CBT-I.

So Dan tried a modified version for 2 weeks. His sleep did not improve. The doctor decided that “the only way CBT would be effective is if medication [sleeping pills] were the mainstay of my treatment,” Dan wrote. “So my question is, have you heard anything of the sort?” Dan also wondered about continuing with CBT-I on his own.

Bipolar Disorder and Sleep

Bipolar disorder is a diagnosis given to people who routinely experience extreme emotional states. Manic episodes are characterized by overexcitement and hyperactivity; depressive episodes, by sadness and hopelessness. The mood swings are disruptive to work and family life. The main goal of treatment is mood stabilization, which can be achieved with medication.

People with bipolar disorder often experience insomnia. Even when they’re successfully treated for the mood swings, the sleep problem doesn’t necessarily go away. In fact, say researchers in a September 2013 article in Sleep Medicine Clinics, “During the inter-episode period, clinically significant sleep disturbance persists in up to 70% of BD [bipolar disorder] patients.”

Insomnia associated with bipolar disorder is often treated with non-benzodiazepine sleeping pills and gabapentin (Neurontin). The efficacy of medications targeting the circadian system—melatonin and ramelteon (Rozerem)—is under study now.

But CBT-I, a drug-free treatment for insomnia, may also be effective for people with bipolar disorder—in a modified form.

CBT-I for Bipolar Disorder: Why Not?

Sleep restriction therapy, a key component of CBT-I, involves short-term sleep deprivation. This sleep deprivation helps build up pressure to sleep at night and reset the body clock.

Yet in some people with bipolar disorder, sleep deprivation triggers manic symptoms the following day. So sleep restriction should not be used for everyone with bipolar disorder.

Another component of CBT-I is stimulus control therapy. Guidelines specify that

  • you wait to go to bed until you feel sleepy
  • if after 15 to 20 minutes you can’t sleep, you leave the bedroom and do something quiet until you feel sleepy.

These instructions may be counterproductive for people with bipolar disorder, who often have trouble pulling away from arousing activities. Waiting to go to bed until they feel sleepy and getting out of bed in the middle of the night may arouse rather than calm them down.

Despite these caveats, UC Berkeley researchers Katherine A. Kaplan and Allison G. Harvey administered a modified version of CBT-I to 15 bipolar patients. The 8-week treatment was successful, with the majority of patients experiencing sleep improvement by the second week.

CBT-I Modified for Bipolar Disorder

While some insomnia sufferers can follow instructions and treat themselves, if you’re bipolar and want to try CBT-I, it’s better to work with a therapist who can tailor the treatment to your individual needs. Here’s what will likely be involved, say Kaplan and Harvey:

  1. You’ll keep a sleep diary throughout treatment.
  2. You should look out for symptoms of depression or mania. If you feel a mood swing coming on, your therapy may need to be modified or temporarily stopped.
  3. Rather than plunging headlong into sleep restriction, you’ll start by simply regularizing your hours in bed. Pick an average bedtime and a wake up time and observe them every day, including on weekends. This will involve setting an alarm clock to wake you up in the morning, and possibly setting it again in the evening to remind you of when to start winding down. Start your wind-down routine—take your shower, put on your pajamas, do relaxation exercises—an hour before bedtime.
  4. After 1 or 2 weeks, you’ll calculate your sleep efficiency.* If it’s 85%–90%, all you need to do to keep your sleep on track is continue with the same sleep schedule.
  5. If your sleep efficiency falls below 85%, your therapist may recommend sleep restriction. However, because mild sleep deprivation could trigger a manic episode, the authors of the Sleep Medicine Clinics paper have written that “Minimum time in bed during sleep restriction should likely be no lower than 6.5 hours.”
  6. Your therapist may also ask that you refrain from going to bed until you’re sleepy and observe the 15- to 20-minute rule (see above). But if doing these things is overstimulating or arouses intense anxiety, these aspects of therapy may need to be revised or simply dropped.

A clinical trial is under way in Norway to see if CBT-I improves the sleep quality and helps stabilize the mood of participants with bipolar disorder and insomnia. The results will help clarify for whom and in what situations it’s likely to work. For now, the answer to whether insomnia in bipolar disorder can be successfully treated with CBT-I is “maybe.”

* Calculate your sleep efficiency (SE) at the end of each week. SE = total sleep time ÷ planned sleep time X 100.

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Short Sleep: A Dose of Perspective on the Risks

A woman attending a talk I gave on insomnia was worried about developing Alzheimer’s because she wasn’t getting enough sleep.

“Sometimes I sleep only 4 hours a night,” she said, “and I’m really lucky when I get 5.”

There’s a lot of talk these days about the health risks that accumulate if we sleep less than 7 or 8 hours a night. But reports that appear in the popular media can make the risks sound greater than they actually are.

short sleep may increase the risk of health problems but not that muchA woman attending a talk I gave on insomnia was worried about developing Alzheimer’s disease because she wasn’t getting enough sleep.

“Sometimes I sleep only 4 hours a night,” she said, “and I’m really lucky when I get 5.”

After the talk I asked for details. Did she have trouble falling asleep? No. Did she wake up frequently at night? No again.

“When I fall asleep,” she said, “I’m out cold.”

What about her energy and alertness during the daytime? I asked. Did she feel tired, out of sorts, or foggy in the brain? No, no, and no. Then what was the problem?

“I read online that you’re supposed to get 7 or 8 hours of sleep,” she said, “but I can’t, no matter what. I read that people who don’t sleep enough get Alzheimer’s, and I don’t want to. I want more sleep.”

The Elusive 7 or 8 Hours

There’s a lot of talk these days about the health risks that accumulate if you sleep less than 7 or 8 hours a night.

  • Cardiovascular Disease. Short sleep (sometimes defined as less than 6 hours of sleep a night, and other times defined as less than 5 hours of sleep a night) is linked to increased blood pressure and hypertension, and a greater risk of heart attack and stroke.
  • Cancer. Short sleep duration makes you more vulnerable to breast cancer, colorectal cancer, and prostate cancer.
  • Dementia and Alzheimer’s. A study of healthy older adults found that short sleep was associated with greater age-related brain atrophy and cognitive decline. Another study found that short sleep and poor sleep quality were associated more beta-amyloid in the brain (the main component of the amyloid plaques found in Alzheimer patients).

No wonder short sleepers are worried these days. Who wants a sentence of any of these illnesses hanging over their head?

Interpreting the Numbers

If you read reports of studies that appear in the popular media, it’s easy to misinterpret the results. Let’s say you learn that people with insomnia (who may be short sleepers and who also experience daytime impairments) are twice as likely to develop depression as people who sleep well (research has shown this to be true). “Twice as likely” might make it sound as though if you have insomnia, your risk for developing depression is pretty high.

But often missing from these reports is mention of the actual number of people who do develop depression at some time in their lives—information that could help you put the study results in perspective. Let’s say the lifetime risk of developing major depression in the US is about 17 percent (as shown in a study by Blazer et al in 1994). This figure, which would include both people with and without insomnia, indicates that most people—83 in 100—will never experience major depression in their lifetime.

Now let’s imagine (because I haven’t been able to lay my hands on actual figures) that among people who sleep well, the lifetime risk of developing major depression is 12 percent. If people with insomnia are “twice as likely” to develop depression, then 24 percent of insomnia sufferers will go on to develop major depression at some time in their lives, and 76 in 100 will not. In other words, your odds of dodging the bullet are 3 to 1 in your favor. “Twice as likely” does not sound so bad after all.

Minimizing Risk

I don’t mean to downplay the significance of research exposing links between short sleep or insomnia and increased vulnerability to Alzheimer’s or any other illness. If sleeping less than 5 or 6 hours compromises health, we need to know it, and to understand why and how to minimize the risk.

I am suggesting that the results of these studies may not be as alarming as they seem at first glance. Beyond that, if they cause you to worry about your sleep, they do more harm than good. How long you sleep is determined in large part by genetic factors resistant to change. And—let’s face it—the last thing you need is one more worry to shorten your nights still further.

So what’s the secret to healthy aging if you clock 5 or 6 hours of sleep at best? You’ve heard it time and time again: get as much sleep as you can, eat healthful meals, and exercise daily.

If you’re a naturally short sleeper, what concerns do you have about your health?

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?