Which Came First, the Depression or the Insomnia?

December 5, 2013 11:53 AM

Insomnia causes depression as much as depression causes insomnia: Three surprising points from a fascinating episode of KQED Forum [audio, no transcript] with guest Dr. Michelle Primeau of the Stanford School of Medicine.

• Insomnia has long been taught to be a symptom of depression, but in many cases is a cause of depression.
• CBT (Cognitive Behavioral Therapy) is an effective treatment for both insomnia and depression.
• CBT can be more effective and longer lasting than sleeping pills

For those averse to audio (like me, normally), the NYT also covered the research in print:

First story: Treating Insomnia to Heal Depression,

Follow up a couple of days later: Double Effectiveness of Depression Treatment by Treating Insomnia,

Two readers (both psychiatrists) respond, and

A NYT editorial.

The report on a pilot study at Stanford with 30 participants was published in 2008 by the journal Sleep: NIH Version, Original Abstract and PDF. That project continues through this year with 150 participants at Stanford, Duke, University of Pittsburgh, and UPenn. As the first NYT story above puts it, "If the figures continue to hold up, the advance will be the most significant in the treatment of depression since the introduction of Prozac in 1987." Another 66 person study done at Ryerson University in Toronto is just being published.

Related: Another recent post about the hidden drowsiness epidemic, possibly inspired by the fatal NY train crash, points out the extent to which many of us are sleep deprived.

posted by Hello Dad, I'm in Jail (22 comments total)

I sleep like it is my job when I am depressed. As a Viking, I feel better, and I usually feel better when I wake up, too, at least for a while.

I have always had great sympathy for depressed people with insomnia: that truly sounds hellish.
posted by thelonius at 12:13 PM on December 5, 2013 [7 favorites]

RELEVANT TO MY INTERESTS.
posted by insufficient data at 12:34 PM on December 5, 2013 [2 favorites]

Several years ago, my husband went to see a psychiatrist for depression and anxiety. The psychiatrist asked how he was sleeping and my husband explained that he's always had trouble sleeping because his legs hurt and wake him up for no reason. The psychiatrist said, "I don't think you have depression. I think that you're really sleep-deprived." He saw a sleep doctor, was diagnosed with restless leg syndrome, and it has really helped.

I completely understand how insomnia can cause depression. I had an undiagnosed sleep disorder that made me feel tired all the time and it made me sad - too tired to go to the gym, volunteer, see friends, have any fun. I wasn't suicidal but I definitely started thinking, what is the point of my stupid life if I can't do anything because I'm tired all the time?
posted by kat518 at 12:51 PM on December 5, 2013 [1 favorite]

Anecdata that agrees with the post: the telltale sign that my sleep disorder is acting up is that I slide into a state that bears a decent resemblance to clinical depression. This state lasts until I can finally get a decent night's sleep. During those periods, I have to remind my barely coping self that the darkness is a physical condition and it will pass in a few days. My goal during those periods is to avoid fucking things up too badly due to my "oh who gives a shit it's all pointless and hope is an illusion and all there is for us is to wade through fields of icy mud and hope the birds don't peck out our eyes until after death claims us" mindset.

Even those brief sample tastes of the outer fringes of clinical depression scare the shit out of me.

I hope these findings help some people. A fucking horrible state to live in.
posted by Harvey Jerkwater at 1:03 PM on December 5, 2013 [6 favorites]

I have noticed how much my sleep schedule has an impact on my mental health, but I think there is a marked difference between the insomnia and the depression I do still sometimes get. Which I just say to point out that I think it should be considered its own thing, not just "a thing that causes depression". There are actually some times where I feel markedly better for not sleeping, too, which suggests that there's a quality issue, not just a quantity issue. But it's definitely a thing, and... well, is there anything CBT doesn't make better? I'm on the verge of adding it to my 'things that should be included with public schooling' list.
posted by Sequence at 1:10 PM on December 5, 2013

I've spoken before about how I've just come out of a solid 4-5 years of recurring suck, where every six months some major shit went down, and just when I was starting to come back from it I got hit with something else. (It's kind of still going on.)

At some point late last year, I noticed that I was feeling kind of meh and apathetic about a lot of things, and actually got concerned enough to consider calling my doctor and asking if we should discuss whether I was depressed. But then I did the math on all the stuff that had happened to me within the past five years, including the solid year of insomnia on top of it and the longer-than-usual hours I was currently working - and I realized "wait, no, I'm not depressed. I'm just tired."

I tell ya, getting laid off from the longer-than-usual hours job actually didn't freak me out as much as I thought it would - because it was the first chance in years that I had of actually getting a good night's sleep, and so after a couple days of shock I was actually pretty okay, simply because I was rested, and no longer had to get up at five-fucking-thirty just to make it to work by quarter to eight. Right now, I'm in a temp job that is 9-5:30, making less money than I made at my financial work, and I can't even begin to tell you how much better I feel simply because I'm able to sleep.
posted by EmpressCallipygos at 1:17 PM on December 5, 2013 [5 favorites]

As someone who has gone through temporary bouts of relatively minor (but still sucky) depression, I've often wondered if "depression" is a set of symptoms common to many different possible causes.
posted by Foosnark at 1:23 PM on December 5, 2013

I've been struggling with insomnia for years and amidst the rest of the psychotic behavior there is surely a little bit of depression. My old lady got me a fitbit a couple months ago, one of the ones that also tracks your sleep, and its been nothing short of amazing. For me, for some reason, seeing plots of my hourly sleep and trends has somehow realigned my whole approach to bedtime and sleep and dammit I want a better looking chart and the outcome has been nothing short of amazing. I've gone from an average of 4 hours/night to 8, and my daily outlook and sense of well being has followed what this study is suggesting.
posted by H. Roark at 1:23 PM on December 5, 2013 [2 favorites]

(Temporary as in a couple of months, minor as in not actually suicidal but almost constantly sad/irritable/tired/unmotivated.)
posted by Foosnark at 1:25 PM on December 5, 2013

Trying to figure out this particular chicken-and-egg cycle with various medical professionals for years now.
posted by The Underpants Monster at 1:25 PM on December 5, 2013

At last - research to support common sense. Perhaps now the medical establishment will pay attention to their patients?

Me: "And the medical X is keeping me up nights and i haven't been getting more than about 2 hours a night for the past week -"
Doctor: "I think you need to consider seeing a psychologist. Your color is off and you're not concentrating, and your eyes are sort of staring -"
Me: "Well, as I said, with the pain of X keeping me up, I'm not sleeping at night, and yes, that's not making me feel very good, but I think if we-"
Doctor: "Not sleeping is a symptom of DEPRESSION."
Me: "Can we please talk about X?"
Doctor: "You don't need to be scared about thinking about your mental health. There's no stigma. You're not sleeping? I'm writing you a referral for a very nice psychologist who will make you feel all better about yourself."
True story.
Of COURSE it's depressing when you can't sleep. There's nothing like two hours a night for a week to turn your brain into sad, helpless porridge. Not to mention the feeling of infuriated helplessness as you watch your body do exactly what you desperately wish it wouldn't. And trying to process that desperation with a brain that's got all the processing power of the aforementioned sad and helpless porridge?
Sorry, I haven't slept in about a week right now myself. It's DEPRESSING.
posted by tabubilgirl at 1:33 PM on December 5, 2013 [3 favorites]

Did any of these studies mention psychodynamics' efficacy in treating insomnia?
posted by Apocryphon at 2:29 PM on December 5, 2013

This is interesting to me. I definitely have some insomnia, and it definitely gets worse when I'm depressed (or perhaps the other way around, hmm?) but I normally see it as more "sleep disruption" than insomnia specifically. It's not always that I'm sleep deprived – quite often I'm sleeping a lot when I'm depressed, like 14-16 hours a day when it's really bad, and even when it's pretty well controlled (like now) one of the most difficult parts of my depression is difficulty in getting up in the morning, even if I've been asleep for eight hours or more.

All that probably just falls under the heading of "depression is complicated, idiosyncratic, and poorly understood," I suppose. I know when I'm sleeping better my depression is better, and I think that's been pretty well established for a long time now. This new research might be highlighting the importance of appropriate amounts of consistently-scheduled, high-quality sleep in mitigating depression and it might well be showing a previously-unseen causal relationship, but I've always been told that one of the best things you can do for yourself when you're depressed is to practice good sleep discipline. It's up there with eating healthy and exercising in terms of Things That Are Good For You.
posted by Scientist at 2:44 PM on December 5, 2013 [1 favorite]

Good stuff; this has large implications and been confirmed by research into post-natal depression, for example; something that is slowly getting greater recognition (yet still needs more). When babies aren't sleeping, you can get really fucked up, really fast.

Australian researcher Kerry Thomas carried out a review of more than 100 international studies and found strong links between sleep deprivation and depressive symptoms in new mums during the first few months after giving birth..

This was certainly true in our case, and once the sleep issues were targetted, the turn-around was astonishing; I really wonder how much of the recovery we could put down to the medication, and how much was just restoring sleep.
posted by smoke at 3:39 PM on December 5, 2013 [2 favorites]

Isn't it also true though that sleep deprivation is an antidepressant? Wondering how to reconcile these...
posted by en forme de poire at 3:48 PM on December 5, 2013

Isn't it also true though that sleep deprivation is an antidepressant?

My recollection of that research is that you have to stay up all night. Also, not sure it's persistent beyond that first morning.
posted by i_am_joe's_spleen at 5:09 PM on December 5, 2013

This is a large part of why the first 6-12 months of having a new baby are such 100% pure unfettered joy.
posted by gottabefunky at 6:20 PM on December 5, 2013 [2 favorites]

I've been undergoing Dialectical Behavioral Therapy (a subset of CBT) to help with my anxiety and depression- I also take Trazodone as-needed for those nights when sleep simply won't come.

I find that the mindfulness exercises and other emotional skills learned through DBT have been extremely useful in day-to-day life as a way to let go of a certain resistance to negative emotional states and existential angst. It cuts the anxiety loop nicely, and on those nights when my brain itself seems to be keeping me from sleeping, gets me to take my sleep meds without succumbing to apathy.

All in all, I'm excited to see CBT picking up popularity- it's been extremely helpful to me in ways that other therapies haven't.
posted by maus at 10:12 PM on December 5, 2013 [1 favorite]

Insomnia and Depression? Let's throw Chronic Pain in there for the godawful feedback loop trifecta from Hell.
posted by Cookiebastard at 9:00 AM on December 6, 2013 [2 favorites]

en forme de poire: "Isn't it also true though that sleep deprivation is an antidepressant? Wondering how to reconcile these..."

i_am_joe's_spleen: " My recollection of that research is that you have to stay up all night. Also, not sure it's persistent beyond that first morning."

This Scientific American article says it only lasts until the next time the patient sleeps.
posted by Lexica at 3:04 PM on December 6, 2013 [1 favorite]

Thanks, joe's_spleen and Lexica. Explains a lot about the variance of my mood in college...
posted by en forme de poire at 4:58 PM on December 6, 2013

I have always had great sympathy for depressed people with insomnia: that truly sounds hellish.

Yes, a living hell would be an accurate description, in my own circumstances anyway. I have work-stress related depression, mostly because of my boss, that was diagnosed a bit over 4 years ago now. It's definitely co-morbid with insomnia. Treating the depression to get it managed (meds, and two rounds of CBT) has helped with the insomnia, but when my stress spikes, I end up stuck in an anxiety loop which means I can't sleep; which makes me late to work and exhausted all the time, which then gets me grief, and I end up under even more stress, more depressed, stressed about both, and I end up avoiding going to bed as long as possible trying to lift my mood because I dread trying to get to sleep. I end up looking like an extra from the Walking Dead.

Certainly it's intuitive that lack of sleep is making me feel a lot worse, and thus worsening the depression. I'm aware of the cycles I get stuck in, thanks to CBT, and can try and tackle it. I hadn't thought of tackling the insomnia directly though - and my doctors have certainly been of the approach that tackling the depression is the way to go, and that will solve the insomnia.

On the plus side, having survived for years on 5-6 hours sleep - and short periods of less - having a new-born (should we be lucky and succeed) holds no fear for me on that front!
posted by ArkhanJG at 1:47 AM on December 7, 2013 [2 favorites]