Depression and Sleep
Sleep and depression are closely interwoven. Lack of sleep and sleeping too much are both known to co-occur regularly with depression. It is natural to wonder if these sleeping problems are a cause or a symptom of depression.
The intricate relationship between sleep disturbances and depression can make it hard to say exactly which comes first. Research points to sleep problems and depression as being mutually reinforcing; sleep issues can be a risk factor for depression and a symptom of the condition.
In this guide, you’ll find an in-depth discussion of the connection between depression and sleep. We’ll review the key background, including the different types of depression, and review how mood disorders may be treated. We’ll also delve into how sleep and depression are linked and how improving sleep can play a role as part of a strategy for preventing and managing depression.
What is Depression?
Depression is a feeling of sadness or melancholy. People commonly describe depression as “the blues” or a feeling of being “down in the dumps.” It’s natural for everyone to have these feelings at various times in life. However, the feeling of depression is different from the mood disorder known as depression.
In depression as a mood disorder, feelings of sadness are severe and/or persistent. They can have dramatic impacts on a person’s well-being and harmful effects at work and in private life. Depression can also lead to suicidal thoughts and behavior.
Depression is estimated to affect over 264 million people worldwide with wide-ranging consequences for both individual and public health. It is more common in older adults and in women, but it can and does affect people of any gender or age.
The symptoms of depression can be wide-ranging. Feelings of sadness, irritability, hopelessness, worthlessness, and guilt are frequently experienced by people with depression. Things that previously brought happiness or interest may no longer be appealing. These feelings may be accompanied by emotional numbness characterized by experiencing neither joy nor sadness.
Other symptoms include inability to sleep (insomnia), sleeping too much (hypersomnia), fatigue, appetite changes, weight gain or loss, difficulty thinking, aches and pains, and neglecting responsibilities related to personal care, family, or work. Social withdrawal and thoughts of death or suicide can be symptoms as well.
The health impacts of depression extend beyond these overwhelming negative emotions. Depression may have harm the immune system, raising the risk for illnesses and infections. Depression has also been associated with cardiovascular problems including coronary heart disease (CHD), heart attacks, and stroke.
Not everyone with depression experiences all of these symptoms, and not everyone who has these symptoms has depression. In many cases, the symptoms gradually worsen with time or persist long after their initial cause. Variance in how individuals are affected by depression forms part of the differential diagnosis of the specific types of the condition that are described below.
What Are the Types of Depression?
The term depression describes what is actually a diverse set of related conditions. While the types of depression share many symptoms, the individual experience of each type can be dramatically different. This section provides an introduction to these distinct types of depression.
Major Depressive Disorder, also known as MDD, major depression, or clinical depression, is the most common type and affects an estimated 16.1 million Americans each year. In this type, a person is depressed on most days for a period of 2 weeks or more. Diagnosis requires the presence of multiple symptoms including significant melancholy and/or lack of interest in usual activities.
Major depressive episodes can be tied to a situation or event, but they can also happen spontaneously and without any clear connection to a recent experience. Some people may have just one or two major depressive episodes during their life while other people find that they occur frequently.
Persistent Depressive Disorder
Another type of depression is called Persistent Depressive Disorder (PDD), which was previously known as dysthymia. PDD is identified by a depressed condition that continues over a period of two years or more. PDD affects around 3.3 million people in the U.S. each year.
As with major depression, PDD affects a person on most days and involves the presence of multiple symptoms. People with PDD may find that the severity of their symptoms varies over time. For example, they may have major depressive episodes followed by periods of reduced symptoms. However, symptom-free periods do not last for more than two months at a time.
Postpartum depression is an extreme sadness that begins shortly after a woman has given birth and affects 10-15% of new mothers. This type of depression is distinct from the mild sadness -- “baby blues” -- that are common in the first two weeks after childbirth. Postpartum depression is more severe and lasts longer, frequently persisting for weeks or months.
Women who have been diagnosed with depression prior to or during pregnancy are at a higher risk of postpartum depression. This condition can have significant impacts on daily life and can affect a woman’s ability to effectively bond with her child. In some cases, postpartum depression can become postpartum psychosis in which a person has violent thoughts, suicidal ideation, hallucinations, and/or other abnormal behaviors.
Premenstrual Dysphoric Disorder
Premenstrual dysphoric disorder (PMDD) is a type of depression that arises in the days before a woman begins menstruating. The symptoms of PMDD, including sadness and irritability, are similar to premenstrual syndrome (PMS) but are considerably more intense. PMDD is believed to affect 2% to 6% of menstruating women. As with other types of depression, PMDD can have profound implications for well-being and the ability to successfully carry out normal activities.
Seasonal Affective Disorder
Seasonal affective disorder (SAD) is a condition related to reduced daylight exposure during certain months. It is effectively a type of major depression that is directly connected to the seasons of the year. It is most common in the late fall and winter months, but some people do experience a reverse-SAD during the summer.
Major Depression With Psychotic Features
This variant of depression involves losing touch with reality along with major depression. Examples of psychotic features include delusions and hallucinations, and these may have connections to the underlying depression.
Previously known as manic depression, bipolar disorder is a mood disorder in which a person experiences dramatic mood swings ranging from extreme happiness and energy -- mania -- to severe sadness and depression. It is estimated to affect around 4% of people in the U.S.
Bipolar disorder is not actually a type of depression, but it is included in this section because the condition involves depressed episodes. The symptoms of bipolar disorder depend significantly upon whether a person is in a manic or depressed phase. In the manic phase, a person has lots of energy, limited judgment and self-control, limited need for sleep, irritability, and racing thoughts and ideas. During the depression phase, symptoms are similar to those of major depression.
In some people with bipolar disorder, they may have episodes of mania and depression in succession, which is known as rapid cycling. In other cases, patients have a mixed state in which the symptoms of the two phases occur at the same time. Bipolar disorder can create enormous challenges for everyday functioning and mental health, and people with bipolar disorder are at an elevated risk for suicide.
What Are the Causes of Depression?
Researchers have worked to detect causes of depression by analyzing patterns of how the condition occurs and by studying brain chemistry. These investigations have not yielded clear answers or consensus about a specific cause of the condition. However, they have helped identify factors that can increase a person’s chance of suffering from depression.
Though the genetic underpinnings of depression are not fully understood, there does appear to be a pattern of cases in some families. For this reason, a family history of depression is believed to increase a person’s risk.
Women have a higher risk of depression than men, and while it affects people of virtually all ages, it is more common in older adults. Difficult situations or events, such as the death of a family member or the end of a long-term relationship, can induce depression. Certain medical issues, including thyroid problems, can raise the risk. Use of alcohol, drugs, and some prescription medications have also been found to make people more prone to depression. In some cases, depression co-occurs with other mental health conditions including anxiety disorders and schizophrenia.
It is critical to remember that not everyone who has one or more of these risk factors will develop depression. For example, many people experience stressful situations and have temporary sadness but do not develop a mood disorder. As a result, risk factors are not a prediction or a guarantee that someone will have depression; they are only an indication that someone has a higher likelihood than another person who does not have that risk factor.
How is Depression Treated?
There is no universal treatment for depression. Treatment is tailored to each individual, their symptoms, and the type of depression that they have been diagnosed with. Treatment may be adapted based on the presence of a co-occurring physical or mental illness.
While the course of treatment depends on a patient’s specific circumstances, it usually involves one or more of the following approaches.
One challenge in treating depression is that patients can feel disempowered and hopeless, posing a serious challenge to engaging in attempts to improve their mood. Support, which can take the form of frequent phone calls from a doctor or counselor, reinforces that depression is a disorder and not a personal failing. It normalizes the struggles of coping with depression and the fits-and-starts that patients may experience through therapy. Support of this type may be available from family, friends, and formal support groups as well.
Cognitive Behavioral Therapy
One common element of treatment is psychotherapy, specifically cognitive behavioral therapy (CBT). CBT is a form of talk therapy that attempts to identify and correct negative patterns of thinking and acting. CBT employes specific techniques coordinated by a trained professional and has proven in research studies to often be successful in empowering patients to address maladaptive thoughts and behaviors. CBT can be customized for specific conditions including bipolar disorder.
Medications, also referred to as pharmacotherapy, may be used alone or in combination with other treatments for depression, including CBT. Antidepressants are a class of prescription medications that act on brain chemistry to improve mood. There are a range of antidepressants approved by the U.S. Food and Drug Administration (FDA), and many patients try different medications over time to determine which offers them the greatest benefit.
Antidepressant medications are not effective for everyone and can cause side effects. They may not be safe or appropriate for use in younger people or women who are pregnant or plan to become pregnant.
It is important for anyone considering pharmacotherapy to talk honestly and in-detail with their doctor about their potential benefits and risks.
Electroconvulsive therapy (ECT) delivers an electric current to the brain through small devices, known as electrodes, that are placed on the head. This current causes a seizure in the brain that can reduce symptoms of depression. ECT is typically conducted every other day for a total of five to seven sessions that are done under anesthesia.
In the past, EC was commonly known as shock therapy or electroshock therapy. It is not clear why ECT works, but studies have demonstrated that it can benefit patients by decreasing their symptoms.
ECT is not usually the first line of treatment for depression. It may be used when a person has not improved after other treatments. It can be employed in severe cases including when someone is suicidal or psychotic. Its utility in these cases is higher because it generally has a much quicker effect that antidepressants or psychotherapy.
There are potential side effects from ECT including confusion and memory loss. In most cases, these effects are temporary, but in some cases, they may be longer-lasting or permanent.
In addition to ECT, there are other therapies that rely on brain stimulation. One type of brain stimulation is repetitive transcranial magnetic stimulation. This therapy places an electric coil on the forehead to create pulses in a specific part of the brain.
Another type of brain stimulation is vagus nerve stimulation. This technique puts a small device and wire under the collarbone and through these an electric signal is applied to the vagus nerve.
Both of these therapies function by trying to release neurotransmitters from specific regions of the brain that can enhance mood. Brain stimulation therapy is normally used only when other treatments have been unsuccessful.
Light therapy, also known as phototherapy, uses a high-intensity light box placed at a specific distance for 30-60 minutes. This treatment can help reorient a person’s circadian rhythm. Phototherapy is most commonly used to treat seasonal affective disorder but may have applications to other types of depression.
How Depression Affects Sleep
Sleeping problems and depression frequently go hand-in-hand. Initially, sleep disturbances were viewed as secondary to depression, meaning that they occurred as a symptom. Over time, though, epidemiological studies have revealed that the relationship is bidirectional and that sleeping problems can contribute to the onset, recurrence, and severity of depression.
Sleep Disturbances as a Symptom of Depression
Sleeping problems have long been recognized as a “core symptom” of depression. The association is so strong that some researchers have even indicated that health professionals should be cautious to diagnose a patient with depression if they do not complain of sleep disturbances.
Estimates of sleeping problems in depression vary, but virtually all research studies find a high rate of too much sleep, too little sleep, or a combination of both. One study found that during a major depressive episode 92% of patients described having sleep disturbances. In other studies, it has been found that around two-thirds of people in a major depressive episode have insomnia and around 15% have hypersomnia. Insomnia can remain a problem even when depression is in a period of remission.
As this data indicates, lack of sleep and depression are a significant problem. Insomnia can be related to sleep onset (falling asleep), sleep maintenance (staying asleep), or both. These problems can become more severe as depression symptoms worsen. The same is true with sleeping too much; hypersomnia can become intense during major depressive episodes.
Sleep disturbances can create significant challenges for the wellness of depressed patients. They can contribute to excessive daytime sleepiness and impair day-to-day functioning, and this may worsen feelings of helplessness. In clinical depression, these sleeping problems also heighten the risk of suicidal behavior.
The health challenges can become extremely complex. Mood and anxiety disorders can co-occur, exacerbating sleep problems and functional impairment. Some patients experience both insomnia and hypersomnia. For example, patients with bipolar disorder may sleep too much in the depressed phase and not enough in the manic phase. Other patients may have coexisting medical conditions, such as chronic pain, that can further complicate problems of sleep and depression.
Sleep Problems as a Risk Factor For Depression
Sleep disturbances are more than just a symptom of depression. They can also be a risk factor or predictor of the start of depression, its recurrence in patients who have had depression previously, and for the worsening of symptoms in depressed patients.
Epidemiological studies have consistently identified that people with insomnia are at a higher risk of developing depression. Even though precise causality is challenging to determine, these relationships hold true even after controlling for other variables. The risk appears to be higher in people who struggle with both sleep onset and sleep maintenance (combined insomnia). Hypersomnia or excessive daytime sleepiness has also been found to contribute to the risk of depression.
The exact biological or neurological explanation for this relationship is difficult to determine. It is possible that the same underlying factors make a person susceptible to both sleeping problems and depression. At the same time, anyone who has struggled with sleep deprivation knows that it can have a direct effect on mood. Studies of the brain support this observation by finding that lack of deep sleep can “wreak havoc” on cognitive function and emotional regulation.
Sleep deprivation and depression may also be linked through conditions like obstructive sleep apnea (OSA) and restless leg syndrome (RLS). OSA is a sleep disorder marked by pauses (apneas) in breathing at night, and recent study results showed a strong link between sleep apnea and depression. RLS is a problem of the nervous system that makes a person feel the urge to move their legs, and it frequently disturbs sleep. This condition has also been found to have a correlation with depression.
While there is still much to be learned about the multidimensional relationship between sleep and depression, it is clear that there is a bidirectional link. Sleeping problems can be both a symptom and a predictor of depression.
Sleep Tips for Managing Depression
While there’s no simple solution for depression, the direct link between sleep and depression offers one avenue for addressing this condition. Getting more sleep and higher-quality sleep may even be a preventive mental health strategy that can decrease the chances of the onset, recurrence, and worsening of symptoms of depression.
This section reviews some of the ways that people who have depression or who are concerned about depression can improve their sleep and overall wellness.
Remember That It’s Not Just You
People with depression often see it as a personal failing and blame themselves for their condition. This can heighten feelings of worthlessness or helplessness. Sleeping problems can become part of this equation and one more thing for which someone may find themselves at fault.
As this article has demonstrated, these problems are widespread and are not your fault. Depression is a mental health condition; it is not a sign of weakness or insufficiency. It is normal to have ups-and-downs when trying to cope with or treat depression, and sleeping problems may go through peaks and valleys as well.
No matter how severe depression may be at any moment, you have value and worth. The road is bumpy, but you’re not alone.
Get Professional Help
Depression is a complex and challenging condition, and professional help plays a vital role in managing it.
If you have feelings of suicide or harming yourself, there is immediate help available: call 1-800-273-8255 to reach a trained counselor at the National Suicide Prevention Lifeline. All calls are free and completely confidential, and the service is available 24/7/365. Similar services are available through the organization’s Lifeline Chat program.
Depression is treatable, and working with a doctor or mental health professional can identify the treatment that will work best for you. Even if the first treatment doesn’t work, other approaches may resolve or reduce your symptoms.
Focusing specifically on sleep, many patients benefit from cognitive behavioral therapy for insomnia (CBT-I). This is talk therapy that helps implement specific steps to make it easier to fall asleep and stay asleep. Research supports its ability to improve sleep and reduce symptoms of depression, and it may be combined with other treatments. Many psychiatrists are trained specifically in CBT-I, and there is evidence that it can be beneficial when conducted through online self-help programs as well.
In addition to professional help, many people with depression find it helpful to connect with others who have depression or who have dealt with it in the past. Online and in-person support groups are available to bring people together to help confront the symptoms of depression.
Review and Improve Sleep Hygiene
In many cases, sleeping problems are caused or worsened by poor sleep hygiene. Environment and routines play a meaningful role in how easily we can get to sleep and stay asleep through the night.
An Environment For Healthy Sleep
Your sleep environment is composed of multiple elements. Optimizing these for your needs and preferences can go a long way to easing you into sleep.
Habits For Healthy Sleep
In addition to your sleep setting, your habits and routines are a key element of sleep hygiene. There are a handful of ways to develop healthy routines around sleep.
Employ Relaxation Techniques
It’s easy to get worked up and upset when you face sleep disturbances. Relaxation methods can help take the edge off, and this list introduces some techniques that may be useful.
Learn More About Depression and Sleep
National Suicide Prevention Lifeline (1-800-273-8255). This is a free and confidential service to help people who are considering suicide and who are suffering from severe depression. Trained professionals can be reached 24 hours a day, 7 days a week, and 365 days a year.
The Substance Abuse and Mental Health Services Administration (SAMHSA) National Helpline. This phone service offers free support and referrals to people with mental illnesses. The service can be reached 24/7/365
Mood Network. The Mood Network is a free national program to bring together people with mood disorders to offer support and gather information to advance research about treatment.
Postpartum Support International (PSI). This organization is dedicated to providing information and support to women with postpartum depression. A helpline is available in English and Spanish at 1-800-944-4773.
American College of Obstetricians and Gynecologists (ACOG): Postpartum Depression. ACOG is the leading national organization of women’s health professionals, and this page offers detailed information about postpartum depression and links for finding support.
Depression and Bipolar Support Alliance (DBSA). DBSA offers articles, guides, podcasts, and videos to help educate people about these conditions, and they also offer services to help patients find support both in-person and online.
Premenstrual Dysphoric Disorder (PMDD)
International Association For Premenstrual Disorders (IAPMD). IAPMD is a national nonprofit focusing on premenstrual disorders including PMDD and PMS. The organization offers educational resources for patients and health professionals as well as tips for patient support.
Anxiety and Depression Association of America (ADAA): Support Groups. ADAA’s support page contains links to a long list of support organizations and provides ideas for starting up your own support group.
National Alliance on Mental Illness (NAMI): Support. This page gives advice for getting the help that you need and includes tips for family and friends of people with mental illness. NAMI has a national helpline available at 800-950-NAMI.
Depression in Youth
Cleveland Clinic: Depression in Children. This resource from the internationally-known Cleveland Clinic describes how depression can affect children of different ages and offers useful information for parents.
Mental Health America: Depression in Teens. This site from a national nonprofit supporting people with mental illness describes the unique ways that teens can be affected by depression and how they can get the help that they need.
American Academy of Adolescent and Childhood Psychiatry: Resources for Family & Youth. This organization made up of counselors for youth describes how these patients and their family members can find a trained psychiatrist and access other useful resources.
National Institute of Mental Health (NIMH): Psychotherapies. This U.S. federal government agency provides information about how psychotherapy works and gives tips for finding a qualified psychotherapist that can meet your needs.
Depression: What You Need to Know About Medications. This webinar from ADAA goes in-depth about the elements of pharmacotherapy for depression including the potential side effects of different medications.
UpToDate: Patient education -- Electroconvulsive therapy (ECT). UpToDate offers detailed, evidence-based information for patients and doctors, and this article describes the logistics as well as the benefits and risks of ECT.
Psychology Today: Cognitive Behavioral Treatment for Insomnia (CBT-I) Defined. For a detailed introduction to CBT-I, check out this article written by Allison Siebern Ph.D., a board-certified sleep psychologist and Assistant Professor at Stanford University.
NIMH: Signs, Symptoms, and Treatment of Depression. This roughly 4-minute video provides an overview of depression and the most important information for people to know if they suspect that they may suffer from this condition.
TED-Ed: What Is Depression? This animated video covers essential information about depression for both patients and friends and family of people affected by this mental illness. The video accompanies a full TED-Ed course about depression from Helen Farrell, M.D., an instructor at Harvard Medical School.
Johns Hopkins Medicine: We Need to Talk About Depression. In this video, core concepts about depression are reviewed, and strategies for support are discussed. The video has a specific focus on assistance through faith communities.
Harvard University: Sleep Health and Education. This website from the Sleep Medicine program at Harvard contains evidence-based articles about a broad range of sleep-related topics.
The National Sleep Foundation (NSF). This organization offers an array of information about sleep-related topics including sleep disorders and optimizing your sleep environment.