Written by Dr Hamish McAllister-Williams, MRC clinical scientist, senior lecturer and honorary consultant psychiatrist
Sleep problems are common. They can be caused by:
- physical illnesses that cause pain or frequent urination
- having noisy neighbours
- a partner who snores
- having young children
- an uncomfortable bed
- working shifts
- jet lag.
Some medicines, heavy or spicy food and drinks (eg alcohol and those containing caffeine, such as coffee and tea) can also make it harder to sleep or disrupt the normal pattern of sleep. In addition to all of these causes of sleep disturbance, depressive illnesses also commonly cause sleep problems.
Disturbed sleep can cause a great deal of distress for people, whether it is caused by depression or not.
What sort of sleep problems can affect people with depression?
People with depression can have many types of sleep problems. Generally, these involve getting less sleep than usual and include:
- difficulty getting off to sleep – often because of lying in bed with thoughts going round in your head.
- frequently waking up during the night.
- waking early in the morning and not being able to get back to sleep.
Even if people with depression do get a reasonable number of hours’ sleep, they often wake in the morning feeling ‘un-refreshed’ and feel tired through the day.
Occasionally, people with depression sleep too much, finding it hard to get out of bed and spending much of the day there. Again, this does not tend to lead to these people feeling any less tired.
How common are sleep problems in depression?
Probably more than 80 per cent of people suffering from depression have problems with their sleep, usually not getting enough.
Is it a problem not getting enough sleep?
We are all aware that if we don’t get a good night’s sleep, we are less effective the next day. Important body processes occur during sleep that help to ‘recharge our batteries’. If we get less sleep than we need, we are more at risk of having accidents in the home, at work or when driving.
In people with depression, not being able to sleep (especially when this involves spending hours lying in bed awake) can cause other problems as well. During this time, people tend to dwell on their problems.
If you are depressed, everything seems black and dismal. Such bleak thoughts going round and round your head can cause your mood to get even lower. A lower mood makes the thoughts even bleaker and a vicious circle can occur.
Severe sleep problems in depressed people are associated with an increased risk of suicide. On the other side of the coin, an improvement in sleep often indicates an improvement in mood.
How much sleep is enough?
Everybody’s needs are different. The range of time people sleep normally is as wide as 3 to 10 hours. As a general rule of thumb, five to six hours sleep is probably a minimum below which your performance at work, when driving, etc will be affected. Most people need between seven and eight hours sleep a night to feel refreshed. Generally, people require less sleep the older they get.
Sleep can be assessed by measuring the electrical activity that occurs in the brain. By doing this, sleep can be divided into a number of different stages: we tend to go through stages 1 to 4 when we fall asleep and the reverse when we wake up.
However, through the night we also make transitions between the different stages. Stages 1 and 2 are regarded as light sleep. Stages 3 and 4 are deep sleep.
During deep sleep various restorative processes go on throughout the body. If we do not get enough deep sleep we feel tired and ‘washed out’.
A fifth stage of sleep is called rapid eye movement sleep (REM) because although our eyes remain shut, they move around a lot during this stage. REM sleep is the time that we dream when we are asleep. Dreaming has important psychological effects, helping us to put ‘things in order’.
The content of dreams often includes things that have recently happened to us or that we have recently been thinking about. Dreams may be a way of making sense of all of this.
The various stages of sleep can be plotted on a graph called a sleep hypnogram. We normally undergo several cycles during the night moving through the various stages of sleep. We have most of our deep sleep in the first half of the night and REM sleep (when we dream) occurs later on. This explains why if you doze back to sleep in the morning, you will often wake and be aware of dreaming.
It is not uncommon to wake during the night. Normally, these wakenings are so brief that we are unaware of them.
The pattern of sleep in depression
The sleep pattern of somebody with depression is very different:
- it takes much longer to get off to sleep.
- the total sleep time is reduced.
- there is little or no deep sleep.
- REM sleep occurs earlier in the night.
- there are more frequent wakenings during the night, which may last long enough for the person to be aware of them. the person wakes up earlier in the morning.
What can I do about my sleep problem?
It can be extremely distressing not being able to sleep. Fortunately, there are a number of things that you can do to try and improve your sleep. These suggestions are not miracle cures and they do require some effort. This is good advice for anybody who has a sleep problem.
- Get into a routine with your sleep times. Get up at the same time each morning, even if you have not had a good night’s sleep. Don’t sleep during the day, and don’t go to bed early to try and get more sleep – you are likely just to lie in bed thinking over problems. Go to bed in the evening when you are tired.
- Take some physical exercise during the day. This helps to make your body more tired in the evening and makes it easier to get to sleep. Exercise is good for you physically, and there is also research that suggests that exercise can itself be antidepressant.
- Avoid exercise two hours before bedtime. This is because exercise ‘activates’ the body, which can make it difficult to get off to sleep.
- Avoid watching disturbing or violent films prior to bedtime.
- Avoid drinking caffeine (tea, coffee, cola) in the evening after 6pm. Caffeine is a stimulant and can prevent sleep.
- Drink herbal teas or milky drinks such as Horlicks in the evening. Herbal teas don’t contain caffeine and milky drinks have been shown to be as good as sleeping tablets for many people. However, be aware that chocolate or cocoa milk drinks often contain caffeine.
- Avoid heavy meals two hours before bedtime. It can be extremely difficult to get off to sleep with a full stomach.
- Avoid alcohol in the evening. While alcohol is sedative, it is not a good idea to try to use it to sort out a sleep problem. This is because alcohol does not lead to normal restful sleep. In addition, alcohol causes you to pass increasing amounts of urine, which further disrupts sleep. Unfortunately, a significant number of people with depression develop an alcohol problem from using alcohol to help them sleep.
- You should associate your room with sleep: avoid having a TV or radio in your bedroom.
- Your bedroom should be warm and familiar with a comfortable bed and quilt, etc. Ideally, the room should be decorated in a relaxing way. This all helps in associating the room in your mind with restful sleep.
- Use aromatic oils in the bath or on your pillow, such as lavender, which can help relaxation.
- Use relaxation techniques, which you can learn from books or audiotapes. Reading in bed helps some people, but it can prevent others from getting off to sleep. If you do read in bed, only read lighthearted books or magazines.
If you are kept awake, or wake up worrying during the night, try the following:
- at least two hours before bedtime, write down the problems that keep you awake. Also write down the next step you need to take towards resolving each problem.
- if you find yourself thinking over the problems in bed, tell yourself you have the matter in hand and that going over it now will not help.
- if a new worry occurs during the night, write it down or commit it to memory and deal with it the next day.
- if you still do not manage to get to sleep, or you wake during the night and can’t get back to sleep, get up. Do not lie in bed tossing and turning. Go and do something else like listening to relaxing music, having a warm bath or making yourself a milky drink. Go back to bed when you feel tired again.
Many people become preoccupied by sleep itself. In this case:
- do not try to fall asleep.
- tell yourself that sleep will come and that relaxing in bed is nearly as good.
- try to keep your eyes open. As they naturally try to close, tell yourself to resist for just another few seconds. This should tempt sleep to take over.
- if unhelpful thoughts pop into your mind, try and visualise a relaxing or pleasant scene.
Are there any medicines that can help?
It is always better to try to sort out a sleep problem using the techniques above, rather than relying on medicines. However, if, despite following all of these suggestions, a person still has problems with their sleep, a doctor may recommend some medicines. There are a number of different possibilities and many different medicines – far more than can be mentioned here.
For example temazepam, diazepam. These medicines help you get off to sleep. They are effective and they have few side effects. However, your body becomes ‘used’ to them very quickly (in two to three weeks), so their effect starts to wear off for many people. This can lead to you needing a higher dose.
In addition, they are addictive: it can be difficult to stop taking them after more than a few weeks, because you may get withdrawal symptoms. These include not being able to sleep. As a result, while they can be useful for short-term sleep problems (such as jet lag), they are not a solution for sleep problems generally.
This is particularly the case in depression, since it may take several weeks for the illness itself to respond to treatment (with an improvement in all symptoms including sleep problems). You may need to take the benzodiazepines throughout this period of time, which is long enough for your body to become dependent on them.
Some newer sleeping tablets have been introduced recently that are related to the benzodiazepines. These include zolpidem and zopiclone. It has been suggested that these are less likely to cause dependence than benzodiazepines, but this is far from certain and so they are also best avoided.
Some of the older antidepressants like amitriptyline and dosulepin are themselves sedative. As a result, they were used a great deal to help depressed patients who had marked sleep problems. However, the sleep they promote is not ‘normal’ sleep. They do not increase the amount of deep sleep a person has and so while they can help getting off to sleep, they tend not to prevent people still waking in the morning feeling tired.
Most of the newer antidepressants are not sedative, though they do ultimately lead to an improvement in sleep by effectively treating the underlying depressive illness. Indeed, sleep problems are often one of the first symptoms that start getting better when a person responds to antidepressants.
A few of the newer antidepressants are sedative. These include mirtazapine and trazodone. Mirtazepine is an effective antidepressant and the sleep it promotes is more normal that with drugs like amitriptyline. Trazodone is an antidepressant, but many doctors feel that it is not as effective as other antidepressants. However, it has relatively few side effects and promotes a good quality sleep. Because, like all antidepressants, it does not cause people to become dependent on it, trazodone is sometimes used in low doses instead of a benzodiazepine to help sleep problems, in addition to another non-sedative antidepressant.
Occasionally other sedative medicines are used along with an antidepressant. These may be a sedative neuroleptic (also known as an antipsychotic). This does not necessarily mean that your doctor thinks you are ‘psychotic’, since these medications can help anxiety, agitation, sleep and, under certain situations, may help somebody to respond to an antidepressant when they did not previously. Examples include thioridazine, sulpiride and olanzapine. (This is an unlicensed use of these medicines.)
But due to recent concern regarding the rare, but serious, heart side effects of thioridazine, it is no longer recommended for use in this way. If you are taking thioridazine you should not stop it, but you should consult your doctor to discuss an alternative treatment.
Last updated 06.01.200