Mental Health Spotlight: Treating Insomnia and Depression

The depression and insomnia connection

Early morning wakefulness can sometimes be a sign of depression. And poor sleep has been shown to significantly worsen symptoms of many mental health issues.

A large 2016 meta-analysis found that insomnia is significantly associated with an increased risk of depression. Some theories for this are:

• Sleep loss may cause cognitive and mood changes.
• Sleep disturbance may impair emotional regulation and stability and alter neural processes.
• Lack of sleep may induce a stress response and increase levels of inflammatory markers.

According to a systematic review from 2013, evidence suggests that insomnia and depression are a two-way street: Having one condition increases the risk of having the other. The researchers also noted that insomnia predicts depression more consistently than depression predicts insomnia.

Other research suggests that about 90 percent of people with depression have a sleep complaint, such as:

• insomnia
• narcolepsy
• disordered breathing
• restless legs syndrome (RLS)

Dr. David A. Merrill, an adult and geriatric psychiatrist and director of the Pacific Neuroscience Institute’s Pacific Brain Health Center at Providence Saint John’s Health Center in Santa Monica, California, told Healthline that he sees a lot of patients with both insomnia and depression.

“It’s certainly one of those bi-directional relationships. Disrupted sleep is a core feature of depression. A classic symptom of depression is early morning awakening,” said Merrill.

“And disrupted sleep can lead to an anxious, depressed mood. Insomnia can present as part of a major depressive episode that’s clinically severe enough to need treatment.”

Should you treat insomnia or depression first?

The approach to treatment depends on the individual. According to Merrill, doctors usually first treat what a patient identifies as the primary problem.

“If you’re depressed and your doctor prescribes an antidepressant, your mood might get better. And sleep follows,” said Merrill.

“Or you can’t sleep, so you might get a sleeping pill. This can be more challenging. There’s not good evidence for long-term use of sleeping pills. They tend not to work for chronic insomnia.”

Sometimes treating depression can resolve your troubles with sleep, he added.

Non-medication and natural treatment options

You may be able to improve sleep and address depression with the following treatments:

• Cognitive behavioral therapy (CBT). CBT is led by a mental health professional who helps you learn how to identify and change thoughts and behaviors linked to insomnia or depression. It may be combined with other techniques to help you sleep better, including sleep hygiene and relaxation techniques. There are also CBT techniques designed specifically for insomnia, known as CBT-I.
• Relaxation techniques. Practices such as deep breathing, visualization, progressive muscle relaxation, and biofeedback are often recommended to address insomnia. A 2020 meta-analysis found that relaxation techniques are safe and may reduce depression symptoms if practiced regularly.
• Exercise. A 2021 meta-analysis found that regular exercise improved self-reported sleep quality, insomnia severity, and daytime sleepiness. And a 2016 review of 22 studies found that exercise was effective at treating depression, especially in combination with medication.
• Mind-body practices. A 2019 systematic review suggests that practices such as yoga, tai chi, qigong, and meditation can improve symptoms of insomnia and, therefore, overall health. A 2017 review concluded that yoga may be helpful in reducing depression, although most studies on the topic were small and short in duration.

Some natural supplements may enhance both mood and sleep, Nicole Siegfried, PhD, a licensed clinical psychologist and chief clinical officer of Lightfully Behavioral Health in Thousand Oaks, California, told Healthline.

“All supplements should be approved by a physician, especially when adding to an existing medication regimen,” she added.

Siegfried lists the following interventions that target both conditions:

• Valerian root, magnesium, and passionflower. These are thought to increase gamma amnio butyric acid (GABA), which may improve mood and sleep.
• Lavender. Lavender has antioxidant effects, which reduce inflammation and create better overall health and well-being. Lavender acts on on the cholinergic system, a part of the central nervous system that regulates high-level cognitive processing. This may be why it’s been shown to have a positive impact on mood and sleep.
• Tryptophan. This is a precursor to serotonin, a hormone that promotes sleep and alleviates depression.

Dr. Kimberly Shapiro, a psychiatrist and medical director of outpatient behavioral health services at Providence Mission Hospital in Orange County, California, told Healthline that although some natural supplements have been found to be useful for mild depression or insomnia, none are Food and Drug Administration (FDA)-approved for these uses.

Sleep hygiene can also help address insomnia specifically. This involves keeping a regular sleep schedule, avoiding stimulating activities and foods before bedtime, and creating a calm place to sleep.

Medication used to treat both insomnia and depression

A 2019 review article suggests that people with insomnia and depression tend to have more severe depressive symptoms than people with depression alone. The researchers found that antidepressants are generally prescribed for depression, but some types can interfere with sleep quality.

“Some antidepressants are used at bedtime because they happen to be sedating. You can take advantage of that side effect to help with sleep,” said Merrill. “But some older antidepressants can also cause memory impairment or other problems. So, we have to be careful.”

Medication for insomnia

If you have depression, check with your doctor before trying over-the-counter (OTC) sleep aids. Prescription sleep medications fall under several categories, including:

• benzodiazepine receptor agonists: triazolam, temazepam, estazolam, lorazepam
• non-benzodiazepine receptor agonists: eszopiclone (Lunesta), zaleplon (Sonata), zolpidem (Ambien)
• melatonin receptor agonists: ramelteon (Rozerem)
• histamine receptor agonists: doxepin (Silenor)
• orexin receptor agonists: suvorexant (Belsomra), lemborexant (Dayvigo)

“These medicines are really intended for short-term use. Classic sleeping pills can be problematic with long-term use. Quite often the body gets used to it, and you still have trouble getting to sleep,” said Merrill.

It’s important to always work with your doctor before starting any new medication. Merrill cautions that using multiple drugs can lead to interactions and add to symptoms of depression.

“I recommend not using combinations of medicines for sleep. Any sedative medicine added to another can cause daytime fatigue, confusion, and slowed reaction time. It’s better to work on the root causes of sleep dysfunction,” he continued.

“Psychotherapy or medication during the day may help you sleep better at night, by treating the depression,” said Merrill.

Medications approved for depression

There are many types of drugs used to treat depression. Among them are:

• selective serotonin reuptake inhibitors (SSRIs)
• serotonin and norepinephrine reuptake inhibitors (SNRI)
• atypical antidepressants
• tricyclic and tetracyclic antidepressants
• monoamine oxidase inhibitors (MAOIs)

“SSRIs and SNRIs can often be used to treat insomnia that is associated with depression, as it treats mood, it secondarily resolves the symptoms that come along with the syndrome of depression,” said Shapiro.

She noted that some types of antidepressants, due to their sedating effects, are commonly used to treat insomnia, even apart from depression:

• tricyclics doxepin and amitriptyline
• trazodone, a serotonin modulator
• mirtazapine, an atypical antidepressant

According to a 2017 review article, all antidepressants can improve sleep secondary to mood in the long term. But in the short term, some may impair sleep, particularly SNRIs, MAOIs, SSRIs, and tricyclics. That’s why it’s important to work closely with your doctor and report new or worsening symptoms.

How to find a mental health professional

Chronic insomnia is trouble falling or staying asleep at least three times per week that lasts more than 3 weeks. If you experience chronic insomnia, you should be evaluated by a physician.

If you’re not already in treatment for depression, start by visiting your primary care provider. From there, you can get a referral to a specialist, which may include a:

• therapist
• psychiatrist
• psychologist
• sleep specialist
• neurologist

Your individual circumstances will guide your treatment. You may need to work with more than one doctor.

If you have depression and don’t know where to turn, contact the Substance Abuse and Mental Health Services Administration (SAMHSA) National Helpline at 800-662-4357 or TTY: 800-487-4889. This free service can refer you to treatment and support services in your area. It’s confidential and available in English and Spanish 24/7.

Outlook

Even the most severe cases of depression can be treated. The earlier you start, the more effective it’s likely to be. Antidepressants can take 2 to 4 weeks to work. Symptoms such as sleep problems tend to get better before mood.

Insomnia can be successfully treated. It may take a combination of sleep habit adjustments and CBT. Sometimes, short-term use of sleep aids can help. Some research suggests that insomnia can become a persistent problem for some people, especially for those with more severe insomnia.

Trying to manage insomnia and depression on your own can be dangerous. Everyone is different. A doctor can help identify your specific needs and determine which treatments are likely to help.

Read this article in Spanish.