Depression and Its Impact on Sleep Architecture: NREM, REM, and Insomnia
If you have depression, you may notice you're having difficulties with getting to and staying asleep. This is because there is a link between depression and sleep. Below are some ways depression can impact sleep architecture.
Prolonged Sleep Latency (Time to Fall Asleep)
Depression may cause prolonged sleep onset latency which carries some clinical relevance. Studies show it's extremely important to subjective sleep quality. Prolonged sleep latency can lead to a subjective reduction in quality of sleep, with increased sleep preoccupation and hyperarousal, which can cause dysfunctional sleep patterns.
Lack of Slow Wave Sleep (Deep Sleep)
Different authors have reported a lack of slow-wave sleep in depression, although not all research shows this decrease. When it comes to NREM sleep and depression, decreased slow-wave sleep appears more pronounced in the NREM (non-rapid eye movement) sleep period, altering its distribution during the nighttime. Also observed is delta power reduction in quantitative electroencephalography research conducted during sleep.
AAST CCSH Designated Education Program Recorded Module
Reduced REM Sleep Latency and Increased REM Sleep Density
There's a link between REM sleep and depression as well. Patients who are struggling with depression often have a reduced REM sleep latency as well as increased REM sleep periods in the early night which leads to an increase in REM sleep quantity. Additionally, depressed patients' REM sleep is marked by a greater frequency of rapid eye movements than in control patients' REM sleep.
This increase in rapid eye movements does become normal when the individuals go into remission, whereas the reduced REM sleep latency continues. Also, reduced REM sleep latency has been found in first-degree relatives not impacted, which suggests a potential genetic link between major depressive disorder and REM sleep latency.
This extra REM sleep appears to come at the expense of slow-wave sleep or stage N3 sleep. There is not only a decrease in time spent in slow-wave sleep in individuals with depression compared with control patients, but the slow-wave activity (SWA) distribution, an SWS intensity marker, is irregular.
Insomnia Increases the Risk of Depression
Depression and insomnia go hand-in-hand. Approximately 80% to 85% of individuals with depression experience insomnia. One review suggested there is a bidirectional link between depression and anxiety and insomnia. Individuals with insomnia have:
Substantially greater depression levels than those not experiencing insomnia
Increased numbers of awakenings
Increased insomnia frequency
These are all related to increased anxiety and depression.
Depression Can Cause or Worsen Insomnia
It is common to see sleep disturbances in psychiatric disorders. The relationship between depression and poor sleep is well-known. Epidemiologic data shows individuals with psychiatric disorders account for up to 40% of people in the community who report insomnia symptoms, and that the most common psychiatric reason for insomnia is depression.
Depression Treatment Options
Treatment options that may help depression include:
A. Lifestyle Modification
To treat depression effectively, more needs to be done than simply going to therapy and taking medicine. Lifestyle changes can help ensure a healthy body and mind and should assist individuals to cope with depression's challenges.
Healthy eating is not just great for the body, but it also improves mood. The simplest way to improve diet is to eliminate junk food and avoid foods loaded with saturated fats and those high in refined sugar. Add healthy foods, such as:
Develop a soothing and calming bedtime routine to help with winding down in the evening. Stick to a consistent sleeping schedule to enhance the quality and amount of sleep achieved.
Exercise increases the body's natural antidepressant production. Exercising 30 minutes each day, three to five days each week, may ease depression without the use of medications.
B. Psychotherapy / CBT
CBT or cognitive behavioral therapy is a form of psychotherapy. This type of therapy works by modifying thought patterns to change behavior and mood. It's based on the concept that adverse feelings or actions are due to current distorted thoughts or beliefs, not unconscious past forces.
CBT blends together behavioral therapy and cognitive therapy. Behavioral therapy targets behavior and actions, whereas cognitive therapy focuses on thoughts and moods. Working with a therapist in a structured setting to practice a combined approach to CBT therapy is ideal. Typically certain negative behavioral responses and thought patterns to stressful or challenging situations are addressed using these therapies.
Treatment involves developing more constructive and balanced ways of responding to stressors. These new responses ideally eliminate or at least minimize the troubling disorder or behavior.
CBT principles can be practiced at home. One option is online cognitive behavioral therapy which uses the CBT principles to track and manage symptoms of depression online.
C. Psychopharmacological Intervention
Psychopharmacology is the study of medication used to treat mental disorders like depression. Some psychopharmacological intervention medications are:
MAO-Inhibitors: These work with brain chemicals, known as neurotransmitters, that are responsible for brain cell communication between each other. It's thought depression is due to low levels of certain neurotransmitters that include serotonin, dopamine, and norepinephrine. These are known as monoamines. A natural body chemical, monoamine oxidase, eliminates these neurotransmitters. MAOIs inhibit monoamine oxidase, allowing more of the neurotransmitters to stay in your brain, thereby elevating your mood through enhanced communication between your brain cells.
TCAs (Tri-Cyclic Antidepressants): These are also referred to as cyclic antidepressants. They were among the first types of antidepressants and continue to treat depression effectively. They're an ideal choice for some individuals whose depression is resistant to other medications.
SSRI: Selective serotonin reuptake inhibitors (SSRIs) increase the brain's serotonin levels which helps to treat depression. Serotonin is one of the brain's neurotransmitters (chemical messengers) that carry signals between neurons (brain nerve cells).
SNRI: These are referred to as serotonin and norepinephrine reuptake inhibitors. They are a class of medicines that also treat depression effectively. SNRIs alleviate depression by impacting neurotransmitters used for brain cell communication. SNRIs work like most antidepressants in that they affect brain communication and chemistry in the brain nerve cell circuitry for regulating mood and helping relieve depression. https://www.mayoclinic.org/diseases-conditions/depression/in-depth/antidepressants/art-20044970
Atypical antidepressants: Atypical antidepressants are often used in individuals struggling with major depression who have intolerable side effects or insufficient responses during SSRI first-line treatment.
Augmenting agents: Augmentation is used for treating treatment-resistant depression. The physician adds a medication with a different action mechanism into the therapeutic regimen.
Herbal preparations: Over the years, herbal psychopharmacology exploration has gained a lot of attention. Different literature shows various herbal preparations used for treating anxiety, depression, and insomnia involving hypothalamic-pituitary adrenal axis (HPA) or modulating neuronal communication, affecting channel transporter activity and neuroreceptor binding and reuptake of monoamines.
D. Vagal Nerve Stimulators
Vagal nerve stimulators are implanted devices that modulate depression's neural circuitry by stimulating vagal afferent fibers in the neck that carry impulses to the brain, targeting the dorsal raphe nucleus and locus coeruleus.
E. Transcranial Magnetic Stimulation
Transcranial magnetic stimulation (TMS) is a noninvasive procedure that uses magnetic fields for stimulating brain nerve cells to improve depression symptoms. TMS is generally used when other treatments for depression are not effective.
Electroconvulsive therapy (ECT) may be used for treating severe refractory depression. Formerly referred to as "shock therapy", ECT works by inducing a seizure similar to an epileptic "grand mal" seizure.
G. Light Therapy
Also called phototherapy, light therapy compensates for the lack of sunlight exposure that is thought to be associated with seasonal pattern major depressive disorder. Therapy involves sitting next to a lightbox that shines a strong light. This light typically mimics sunlight and has been shown to improve mood in many with seasonal affective disorder.
AAST CCSH Designated Education Program
The CCSH Workshop: Designated Education Program has been developed for health professionals working directly with patients as well as their families in sleep medicine education. They also work with other healthcare professionals for coordinating and managing the care of patients and improving outcomes. After completing the online program with a passing score on the post-test, RPSGT credential holders with at least one recertification who meet all BRPT requirements qualify to take the examination for the CCSH credential.
About Kevin Asp, CRT, RPSGT
Because of the implementation of his best practices of Implementing Inbound Marketing in its Medical Practice, he turned the once stagnant online presence of Alaska Sleep Clinic to that of "The Most Trafficked Sleep Center Website in the World" in just 18 months time. He is the President and CEO of inboundMed and enjoys helping sleep centers across the globe grow their business through his unique vision and experience of over 27 years in sleep medicine.