Insomnia and Depression: Seriously Frustrating Bedfellows

Lousy sleep can fuel depression, and depression can ruin sleep. But there are remedies for both, including several that offer a positive one-two punch.

This article is part of a Wise & Well Special Report: The United States of Depression.

Let’s say two people — we’ll call them Chris and Kerry — have been successfully treated for depression. They’re no longer clinically depressed. Yet Chris has some residual sadness, and Kerry still deals with some insomnia. You might think Chris is the most likely to relapse back into depression.

“But in fact it’s the opposite,” said Matthew Reid, PhD, a fellow in psychiatry and behavioral sciences at the Johns Hopkins School of Medicine.

Someone with insomnia is up to 10 times more likely to experience clinical depression again, Reid said, based on research suggesting sleep can help prevent and treat depression.

“Sleep is a tremendously important part of the recovery process, and one that, unfortunately, is often overlooked,” Reid told me. “There has been too much focus on treating the ‘core’ symptoms of depression, and hoping sleep will improve as a result. However, our studies and others have shown that this is perhaps misguided, because we’ve observed that participants who have an improvement in mood, but not sleep, have substantially worse outcomes.”

Good sleep is among the best ways to bolster physical and mental health and emotional well-being overall, numerous studies conducted at many sleep centers and universities have demonstrated convincingly.

“Improving sleep generally leads to improved mood, even in non-depressed people,” Reid said, “and it’s certain that increased positive mood can be a powerful buffer to overcome those negative depressive thoughts.”

That’s not to suggest better sleep is a cure-all for depression, or that depression is ever easy to resolve. Sleep and mood have a tricky, bidirectional relationship amid a crowd of factors that can combine to lead anyone into, or out of, depression. Yet for most people, there are multiple effective ways to battle insomnia and depression simultaneously, offering a one-two punch against these frequently co-existing conditions.

A red flag for depression

Poor sleep — either lack of duration or quality — can be an early warning sign for depression, like dark clouds looming on the mental horizon.

“Difficulties falling asleep, staying asleep, and awakening too early, are key risk factors for developing clinical depression,” said Patricia Haynes, PhD, a professor of health promotion sciences at the University of Arizona. “Often these difficulties with sleep tend to appear before other symptoms of depression, which is really important from a prevention perspective. Insomnia symptoms are sort of like a red flag telling us we need to pay attention to our body and our mental health, as well as our sleep health.”

While the focus on “good sleep” often revolves around duration — and total sleep time is important — many experts say sleep quality is more important.

Quality involves sleeping deeply, entering a stage called slow-wave sleep, when the mind reaches a low ebb of activity. A garbage collection system made up of microvessels, called the glymphatic system, literally clears the brain of misfolded proteins and toxins that build up during the day.

Frequent tossing and turning, on the other hand, is a sign of fragmented sleep, which can prevent entry into the vital slow-wave stage. You might think you get plenty of sleep — the seven or so hours for adults, as suggested by most experts — but the quality may be very low, and you may not even know it. This can lead to physiological inflammation throughout the body, raising the risk of disease and infection — all of which can trigger or contribute to depressive symptoms.

The inability to experience pleasure

A tremendous amount of biological restoration happens during the brain-cleaning stage of quality, deep, slow-wave sleep, and also amid the dream stage of rapid-eye-movement (REM) sleep. The mysterious corners of our metaphysical mind are upgraded, too. While you’re totally out of it, your brain sorts and manages thoughts and emotions by shuttling important stuff into the hard drive of memory, and processing and even deleting negative emotions, all to help us deal with reality the next day. Muscles, organs and all the cells of the body are rejuvenated, too.

Insufficient or fragmented sleep thwarts these restoration efforts, leaving you the next day with low levels of physical and mental energy, poor decision-making ability and nagging irritability; you’ll be less likely to pursue positive experiences that give life purpose and meaning — setting up a vicious downward spiral. Example:

Lack of energy might make you shun going out with your friends, and stay inside watching TV or doomscrolling, which then reduces your overall emotional well-being and sleep quality, Reid said.

He and his colleagues have tested these effects by depriving volunteers of sleep in a lab, waking them up eight times during the night.

“Sleep disruption reduced the participants' ability to experience positive, pleasurable emotions, but didn’t actually alter the amount of negative emotions they experienced,” he explained. “Other studies have since suggested that this may be due to sleep deprivation inhibiting the areas of the brain responsible for reward and pleasure. This is quite important, because we know that one of the most prominent and disabling symptoms of depression is anhedonia, an inability to experience pleasure.”

A separate study published this summer confirms yet again the restorative power of quality sleep, specifically in helping people cope with the stress of the pandemic. Those who slept better during the early months of the pandemic had fewer symptoms of anxiety and depression, scientists reported in the journal Cortex. I asked the lead researcher, Emma Sullivan, to explain how sleep quality has such a strong effect on the risk of developing depression.

Poor sleep leaves us more likely to ruminate and develop anxiety and stress, she explained, because we’re less able to employ common emotion-regulation strategies — thought processes we otherwise apply to an emotional event. Example:

“Say that we just came out of a bad work meeting where several colleagues dismissed our ideas,” suggested Sullivan, a PhD student in psychology at the University of York. “If we’re suffering from poor sleep, we’re more likely to use strategies that focus on dwelling and obsessing over the situation, thus maintaining our negative thoughts and increasing the symptoms of depression.”

Conversely, imagine we just came out of that bad work meeting, but we’ve been sleeping well. “We’re more likely to use strategies that focus on reframing the situation in a positive light,” she explained, “thus reducing our negative thoughts and reducing the symptoms of depression.”

The flip side: Depression ruins sleep

Other research has found that carrying the stress of the day into the evening can make it hard to fall asleep and stay asleep. That’s true for anyone, and more so for someone sliding into depression or already mired in it.

The relationship between sleep and mood is so complex and tightly woven that it can be difficult to sort out cause and effect. Poor sleep can lead to depression. Depression can make sleep difficult.

But it’s crystal clear that the last thing you want if you’re in a bad mood, generally sad or dealing with actual, diagnosable depression, is a bad night of sleep. Yet that’s often exactly what you’ll get.

“When people are depressed, they sometimes lay in bed awake, often with a very active mind and sad emotions related to the past or worrying about the future,” Haynes, the University of Arizona sleep expert, said in an email. “The bed can also become a place to avoid stress or life demands. It can be really hard to get up in the morning. All of these behaviors contribute to sleep problems and also problems with the timing of circadian rhythms.”

The circadian rhythms are a set of internal mechanisms that tune our body clock, a 24-hour timer that governs the release of hormones to let the body and mind know when to be awake and alert, and when to nod off for the night. A toxic soup of genetics, life situations and behavioral choices can conspire to mess with that clock: things like a natural tendency to be a night owl mixed with poor diet, lack of exercise, stress, anxiety, chronic pain or depression.

There are many steps that most people can take to improve sleep duration and quality, which can improve mood literally overnight and ultimately help prevent or resolve depression and other mental and physical maladies.

How to sleep better: The basics

In my book, Make Sleep Your Superpower, I discuss at length 20 science-backed tactics for improving sleep as part of an overall strategy to boost physical and mental health. Here are the most effective tactics, any one of which might bring a ray of sunshine in your tomorrow:

• Get plenty of daylight, actually outdoors, and especially in the morning, to help keep your body clock well timed. At least two hours daily is a good minimum, experts say.
• Aim for at least 22 minutes per day (150 minutes a week) of moderate physical activity. Doesn’t matter what you do: walk, run, bike, hike, swim, hit the gym, curl some soup cans or just run around the house like an idiot. Best to get your blood pumping and your breathing rate up, but seriously — anything that qualifies as movement versus sitting, and in any increments, will add up positively.
• Learn how to manage stress and anxiety before stressful events come your way. I know that sounds kinda “no duh.” But stress is not something that happens to us. Stress is how we react to something. And there are proven ways to control how we react.
• Avoid work email, social media, horror movies or other anxiety-inducing activities in the evening. The body and brain need to wind down, just as they might have ages ago in a cool, dark cave after a stressful day of hunting and gathering. Dim the lights (to help your body clock realize it’s nighttime) and read something light or engage in a mellow hobby or activity.
• Eliminate or greatly reduce alcohol consumption. For many people, booze is their №1 sleep kryptonite. It totally f**ks with sleep, keeping you in the light stages and robbing you of the restorative powers you so desperately need.
• Keep a consistent bedtime and wake time. This tactic could arguably be first on the list, but I put it here because if you do all the other things, its easier to do this one.

Better sleep amid depression: Individual solutions required

The above approaches can work really well for most people, and serve as preventive measures against depression for anyone.

But when a person is already struggling with depression, the battle against insomnia or other sleep problems often requires additional tools and tactics, starting with a clinical diagnosis, then therapies that typically are most successful when directed by a trained professional.

Clinical depression, the experts say, is not something a person can usually climb out of on their own.

“We have great, relatively inexpensive interventions for insomnia that work well,” said Haynes, who researches the link between depression and sleep and is a licensed clinical psychologist certified in behavioral sleep medicine. “If we can intervene with insomnia symptoms early, then we may prevent depression down the line.”

Daily routines, including a regular sleep schedule, are important for creating resiliency against depression and other conditions, she said.

Step one for anyone who is deeply depressed, then, should be to discuss all this with a doctor or other health expert. The causes of depression — underlying physical and mental conditions, genetics, family, work and social situations — are unique for each person, and so treatment must be individualized. If your primary doctor can’t help, ask for a referral to a specialist who can.

“I highly recommend finding a behavioral sleep medicine specialist, who can work with you directly on your sleep,” Haynes said. “While there are a number of apps and self-help programs that work, it can be hard to engage in behavior change when you are depressed and also exhausted. A behavioral sleep specialist will have training in depression and help the person take feasible steps to improve sleep, and also with an understanding for some of the biological factors associated with depression and depression medications as well.”

No matter who you seek help from, ask a lot of questions. Some remedies are particularly powerful because they address multiple issues. But your ideal solutions will be unique to your health profile and life situation.

The gold standard is cognitive behavioral therapy for insomnia (CBTi), which teaches how to reprogram your sleep cycle and deal with insomnia when it’s happening, said Reid, the Johns Hopkins researcher. It’s typically led by a trained expert over six weekly sessions, “but can also be done via apps and via telemedicine, which is often just as effective,” he said.

New research by Reid and colleagues — as yet unpublished — suggests CBTi can, in as little as five weeks, be as effective at reducing depressive symptoms as antidepressants, he told me.

Another option: Mindfulness meditation has been found effective at reducing stress, improving sleep and managing depression. Mindfulness can be learned and practiced in a group setting or on your own, via books, apps and online videos (learn more).

Medication: Necessary for some, really bad for others

A given person struggling with insomnia and depression might benefit from other complementary treatments, too. Options include bright-light therapy to mimic the body-clock regulation effects of sunlight, and, when necessary, prescription medication.

However, psychiatrists and other mental health experts advise against relying on any medication to battle insomnia or depression without close supervision from a trusted and experienced medical professional who first evaluates your entire health profile. In America particularly, medications are too often the primary prescription for dealing with anything that ails us, even though lifestyle remedies like better nutrition, more physical activity and improved sleep have a solid scientific track record of success.

Consider this glaring irony: Antidepressants prescribed for depression can cause insomnia in some people, Reid said.

Prescription sleep meds can also be dangerous. Side effects for Lunesta, a sedative containing the drug eszopiclone, include “worsening of depression or suicidal thinking,” as well as impaired alertness, sleep-walking, sleep-driving, and “bizarre behavior.” Ambien, another sleep aid, lists worsening depression, breathing problems, confusion and aggressive behavior among its side effects.

Over-the-counter sleeping pills should be avoided unless advised by a physician. They rarely work as promised, can leave you drowsy the next day (what the heck, right?) and have other side effects that include depression (and death).

Finally, among the more innocuous chemicals often taken for sleep problems are supplements of melatonin, a hormone the body releases naturally in the evening to induce sleepiness — if your body clock is in sync. The supplement can help some people improve their sleep timing patterns, especially as part of a one-time fix, but it is not recommended for insomnia (and pediatricians caution against giving it to children without doctor supervision). Also, some of the melatonin products on the market don’t contain what they claim, since supplements are not formally regulated by the FDA (learn more).

If you struggle with depression, or worry that you might, the take-home message is a powerful and enabling one: Sleep’s ability to treat stress, anxiety and depression is woefully under-recognized, and there are many proven ways to sleep more soundly.

“Treating sleep alone can be enough to shift somebody’s depression into remission,” Reid said.

This article is part of a Wise & Well Special Report: The United States of Depression. If you or a loved one is depressed, it’s vital to talk about it. Because depression increases the risk of suicide, consider calling the confidential National Suicide Prevention Lifeline at 1–800–273-TALK (8255) for English, 1–888–628–9454 for Spanish, or call or text 988. Global support in 44 languages is available from Befrienders Worldwide.