Sleep and mental health

Insomnia is a common sleep disorder which makes it difficult for you to fall asleep, stay asleep, and/or go back to sleep once you’ve woken up whether it’s in the middle of the night or early in the morning around dawn. Insomnia patients have chronic sleep deprivation issues, which is why they not only face all the symptoms and effects of sleep deprivation but are also likely to be diagnosed with a serious mental health disorder.

Anxiety disorder, depression, bipolar disorder, schizophrenia and attention-deficit hyperactivity disorder (ADHD) are some of the chief mental health disorders associated with insomnia. If you or someone you know suffers from even short-term insomnia, it’s best to consult a doctor, a psychiatrist or a psychologist before it progresses to a mental health issue.

A combination of lifestyle changes, sleep therapy and cognitive behavioural therapy may help remedy insomnia as well as the mental health issues associated with it.

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Sleep deprivation can be sporadic (occur once in a while) or chronic (continual), depending on your lifestyle habits. Binge-watching your favourite show, late-night studying or being stressed about an exam the next day can deprive you of sleep just as much as consecutive deadlines or issues in your personal and professional life.

Whatever the cause of sleep deprivation, the loss of sleep affects two parts of your brain—the amygdala and the prefrontal cortex.

Studies have shown that when you are sleep-deprived, the amygdala (involved in the fear response) goes into overdrive and becomes 60% more emotionally reactive. This causes you to be irritable, overly sensitive, angry, sad or impulsive the next morning (and that's where the expression “woke up on the wrong side of the bed” comes from).

On the other hand, sleep loss slows down the functioning of the prefrontal cortex, the part of the brain which regulates behavior, speech and logical reasoning. Functional impairment of the prefrontal cortex due to lack of sleep can therefore lead to mood swings, erratic behaviour, lapses in judgement and inability to make decisions.

Sleep deprivation also leads to imbalances in the hormones regulated by the brain's hypothalamus region. This leads to increased levels of histamine and cortisol, which may, in turn, cause an increase in stress and inflammation, and decreased levels of serotonin which regulates mood and sexual desire. Therefore, sleep deprivation—whether sporadic or chronic—can affect different aspects of your mental health.

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Weighted blankets are sometimes used for the treatment of sleep disorders as well as psychiatric disorders. These blankets are designed to provide a light, evenly distributed pressure on your body. This type of pressure stimulation provides a sense of security and comfort that is similar to being held or hugged, which is suggested to help you sleep better.

Studies have shown that weighted blankets improve sleep quality in people with psychiatric disorders, including those who have anxiety disorders, autism spectrum disorder, major depressive disorder, generalized anxiety disorder, bipolar disorder and ADHD. Research also indicates that weighted blankets are effective against sleep disorders like insomnia and restless legs syndrome.

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Cognitive behavioural therapy (CBT), also known as talk therapy or sleep therapy, is an effective and non-pharmacological (no medicines) treatment for both sleep disorders and mental health disorders.

CBT basically focuses on patterns of negative thoughts and methods to reformulate them in new ways to improve your quality of life. There are many types of CBT tailored to focus on the key diagnosis, whether it is depression or insomnia.

Clinicians may also use combined CBTs, CBT in combination with medications, etc., if you face multiple issues at the same time.

Poor sleep hygiene not only exacerbates sleep problems but also worsens the symptoms of mental health disorders. It is, therefore, important that you maintain proper sleep hygiene.

Set a bedtime and waking time, and stick to it. To wind down and get to sleep faster:

• Avoid caffeine, digital devices and other distractions well before bedtime
• Use relaxation techniques like taking a warm bath, deep breathing exercises, humming and sound meditation
• Prepare your bedroom. If possible, keep the room comfortably cool
• Dim the lights

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A person with bipolar disorder has episodes of extreme moods—they can either be very high or manic, or very low or depressive. A bipolar person’s feelings and symptoms oscillate and may be quite different depending on their current state of mind. This inevitably leaves a mark on their sleep patterns, too. During their manic phase, a bipolar person may not feel the need to sleep and may therefore be sleep deprived. During the depressive phase, on the other hand, they might sleep too much. 

Studies suggest that these sleep disruptions may continue even when a bipolar person is in-between phases. Some studies also indicate that a bipolar person may experience sleep problems before the onset of an episode, while evidence also suggests that sleep deprivation can worsen the symptoms of both high and low episodes. This bidirectional relationship between sleep and bipolar disorder may be managed better if the patient gets sleep therapy.

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Antidepressants, antipsychotics, benzodiazepines and other stimulants are widely used to treat a number of psychiatric disorders. Most of these medications work by modulating monoamines (neurotransmitters like dopamine which have one amino acid group) and receptors for serotonin and histamine, etc. With these interactions, these drugs can have a significant impact on sleep. This impact could be beneficial or adverse, depending on the dosage, patient response and other factors. While taking these medicines may improve sleep for some, in others it may induce insomnia, disturbed sleep or oversleeping. There is also the consideration that stopping the use of or petering out these medications slowly can also trigger sleep problems.

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Schizophrenia is a severe mental health disorder that involves the inability to differentiate between what is real and what is not. Delusional disorders like paranoia and hallucinations, and disorganized speech, abnormal motor function and severe psychosis are all symptoms of schizophrenia.

People with schizophrenia tend to have circadian rhythm disorders, which in turn increases their risk of having insomnia and other sleep disorders.

Schizophrenia and sleep problems are mutually reinforcing, which is why getting appropriate help from a mental healthcare professional and a sleep therapist for both conditions is vital.

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Broadly speaking, post-traumatic stress disorder (PTSD) is a severe anxiety disorder that is brought on by an inability to overcome a severely traumatic experience such as war, riots, sexual violence or a natural disaster. Research has found a very strong connection between PTSD and sleeping problems.

People with PTSD tend to have frequent flashbacks of the negative events that they lived through. This generates severe anxiety, which in turn leads to hyperarousal and hypervigilance. It is natural for a person with PTSD to not only suffer from insomnia but also from nightmares.

Sleep therapy, cognitive behavioural therapy, appropriate care and prolonged support are required to overcome these issues.

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Autism spectrum disorder (ASD) refers to a number of neurodevelopmental conditions that affect a person’s communication skills and social interactions. ASDs are usually diagnosed in childhood and often persist throughout adulthood.

Children and adults with ASDs report a higher prevalence of sleep problems, including insomnia and sleep-disordered breathing.

People with ASDs are at risk of having a lower quality of life and the presence of sleep issues doesn’t help their situation.

It is, therefore, very important for a person with ASDs, no matter what their age, to get appropriate therapy and sleeping aids.

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A reduced attention span and an increased level of impulsiveness are the characteristic features of ADHD, a neurodevelopmental disorder which is usually diagnosed in children but may continue well into adulthood.

Sleeping problems are very common in people with ADHD, as they may have difficulty falling asleep, frequent nighttime awakenings and excessive daytime sleepiness.  

People with ADHD also tend to report a higher incidence of obstructive sleep apnea (OSA) and restless legs syndrome. It must be noted here that more studies have been done regarding sleep problems in children with ADHD rather than adults with ADHD, and it is suggested that an increase in age and thereby stress levels may exacerbate ADHD and sleep problems in adults.

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Seasonal affective disorder (SAD) is a subtype of depression and usually affects people during autumn and winter. SAD is linked to the reduced number of daylight hours, which affects the circadian rhythm and thereby affects sleep. People with SAD either get too little sleep or sleep too much. SAD also affects other bodily processes. 

The effects of SAD on sleep can be handled by maintaining a proper routine and bringing about some lifestyle changes. Getting more outdoor exercise, eating a healthier diet with more energy-boosting foods, and increasing social activities or interactions can help minimise the effects of SAD and thereby lessen the risks of sleep problems.

Though rarer, SAD can happen in the summer months as exposure to too much sunlight may disrupt melanin production. Melanin is crucial to maintaining the circadian rhythm, so this can affect sleep.

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Depression is a type of mood disorder characterized by feelings of sadness and hopelessness. Studies suggest that around 75% of people diagnosed with depression also have insomnia. People with depression may also suffer from excessive daytime sleepiness and hypersomnia (sleeping too much)—both of which indicate disturbed circadian rhythm and, therefore, issues with brain and endocrine function.

While older research indicated that depression causes sleep problems, a growing corpus of evidence suggests that depression and sleep issues are mutually reinforcing. That is, having either of these conditions exacerbates the symptoms of the other.

This creates a negative feedback loop as the existence of one condition increases the risk of developing the other—if the patient already has both conditions, worsening sleep could increase the severity of depression and worsening depression could affect sleep negatively.

On the bright side, this link between depression and sleep problems shows that treating either might improve the symptoms of both.

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Anxiety, more specifically anxiety disorders, have the strongest possible association with sleep problems. Anxiety disorders include generalized anxiety disorder (GAD), social anxiety disorder, panic disorder, post-traumatic stress disorder (PTSD), obsessive-compulsive disorder (OCD) and specific phobias. These disorders create an excess of fear and worry, which can often be uncontrollable and debilitating. 

Fear and worry create a state of hyperarousal, which sets the mind racing and makes it almost impossible for a person with an anxiety disorder to fall asleep. Anxiety disorders usually cause insomnia, and this addition of a sleep disorder might even work as a further stressor, generate more anxiety and make getting even a nap difficult.

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