Sleep and Depression

My wife has been diagnosed with depression, and she also suffers from insomnia. Is there a connection between the two?

There is definitely a connection between sleep problems—particularly insomnia—and depression. We frequently find insomnia in patients diagnosed with clinical depression; in fact, sleep disturbance is one of the core symptoms of clinical depression. However, people with insomnia are more likely to develop depressive and anxiety disorders.

People with depression often have severe sleep disturbance, and they respond more slowly to treatment than other patients with sleep disorders. They also have an increased risk of recurrence of depression, and there is some evidence that people with depression also experience suicidal thoughts.

Don't some people with depression sleep too much?

Oversleeping is less common in cases of depression—it occurs in about 15% of patients with depression, mostly among younger adults, particularly those with bipolar affective disorder (manic depression). Excessive sleepiness can be a symptom of depression, but most patients with depression have insomnia.

Why is that?

Depression is often associated with disturbances in vegetative functions—the things the body does to keep itself alive, such as eating and sleeping. Depression is usually associated with loss of appetite and weight loss, but it can also result in increased appetite and weight gain.

Can medication help with depression as well as with insomnia?

There aren't many well-controlled studies on the effectiveness of different treatments for concurrent depression and insomnia. In general, medication treatments take four different approaches:

• The common anti-depressants (called selective seratonin reuptake inhibitors, or SSRIs) such as Prozac, Zoloft, and Celexa are usually well tolerated and effective. Many people report improvement in sleep as well as a general improvement in overall mood. However, in some patients, the SSRIs can inhibit sleep.
• The older anti-depressants (called tricyclics) such as Pamelor, Elavil, and Doxepin may be somewhat sedating, but they have more serious side effects then the SSRIs, such as increases in blood pressure. They can be lethal in overdose.
• Some physicians use an SSRI in combination with a low dose of a sedating antidepressant (such as Trazodone) or a short acting hypnotic (such as Ambien, Sonata, or Temazepam). The advantage of this approach as that the combination of medications used to treat the depression can also address the sleep problem, and the physician has the option of discontinuing the sleep drug while continuing to treat the depression.
• A fourth approach is to use either an SSRI or psychotherapy for depression with behavioral treatment for insomnia. There are studies that also show behavioral treatments for insomnia can be helpful in treating depression and minor sleep complaints.

The approach varies with the type of depression and the nature of the sleep disturbance.

How do you know if you have a condition that requires medical attention?

The general rule is that if you have a sleep disturbance at night and daytime drowsiness, or if you have a mood disturbance that is severe enough to interfere with your daily activities or your ability to function, than you should seek treatment. For depression, the key symptoms are a persistently low mood and a loss of ability to feel pleasure in things. If this lasts several weeks or more, then you should seek help. If you have thoughts of suicide, you should seek counseling immediately. Start with your primary care provider.

-- Dr. Buysse is Associate Professor of Psychiatry at the University of Pittsburgh, Western Psychiatric Institute and Clinic in Pittsburgh, PA. He has been on the faculty for 14 years.

This article originally appeared in the Fall 2001 issue of sleepmatters.

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