Sleep Disorders and Mental Illness: Connecting the Dots

When making a diagnosis, psychiatrists, more often than not, will inquire about sleep behavior as sleep quality is an indicator of mental health. More than 80 percent of patients dealing with mental health issues are also dealing with sleep problems. 

Of the patients seeking medical help for sleep issues, 40 percent have a psychiatric condition. The National Institute of Mental Health estimates that one in five Americans have a mental illness, with only a small percentage receiving medical treatment. Schizophrenia, bipolar disorder, depression, ADHD, anxiety, and panic disorders regularly coexist with sleep disorders which make managing the symptoms highly challenging.

The Link Between Sleep and Mental Illness

Mental illness can be both a cause and a symptom of poor sleep. Likewise, sleep issues can increase the difficulty of managing mental health problems, thereby aggravating and prolonging the issues. Mental illnesses are the most common comorbidities of insomnia, with 40 percent of insomnia patients and just over 46 percent of hypersomnia patients estimated to have a psychiatric condition. The rates of insomnia are so substantially lower in people without mental illness, that the link between mental illness and sleep disorders can no longer be disputed

Impact of Sleep on Mental Health

Studies show that mental health patients experience drastic changes to their sleep patterns, spending less time in REM and deep, restorative sleep stages, and more time in light sleep. The lack of restorative sleep has severe consequences, causing emotional unbalance, difficulty making thoughtful decisions, poor memory, and drastic mood swings. Insomniacs experience great frustration from this same issue as sleep deprivation does not allow them any relief or opportunity to restore homeostasis, thereby making it difficult to manage their mental health. It’s a never-ending, cyclical issue – one problem impeding your ability to manage the other.

Consequences of Untreated Sleep Issues

Without treatment, the consequences of poor sleep can be severe. A study by the University of Michigan found a strong correlation between insomnia and suicide. This underscores the importance of addressing sleep issues in mental health care.

Mental Health Conditions Associated with Sleep Disorders

Anxiety Disorders

Anxiety disorders, including phobias, panic disorder, OCD (obsessive-compulsive disorder), PTSD (post-traumatic stress disorder) social anxiety disorder, and generalized anxiety disorder, affect 40 million Americans, or 18.1 percent of the population each year. Whether it’s a side effect of PTSD or simply from continual anxious thoughts, people with anxiety disorder experience stress at a much higher intensity than the average person. 

Stress, of any kind, affects the nervous system, which results in anxiety. If you have an anxiety disorder, your nervous system does not ‘reset’ itself, causing a constant state of high stress, which is not conducive to sleep. Again, very cyclical in nature.

Anxiety Disorders and Sleep

Sleep is induced by the melatonin hormone and works inverse to the stress hormone Cortisol.

Simply put, increased stress means less production of melatonin, hence, poor or little sleep.

Those with anxiety disorders may experience the following sleep issues:

• Nightmares caused by PTSD where traumas are re-lived in dreams.

• Nocturnal panic attacks caused by panic disorder. This affects 44 to 71 percent of individuals with panic disorder. With similar symptoms as daytime panic attacks, nocturnal panic attacks occur during non-REM sleep and may cause increased heart rate, chest pains, and night sweats.

• Insomnia is caused by high anxiety levels, creating feelings of overwhelm or anxious thoughts over fears or phobias.

• Hypersomnia (oversleeping) caused by insomnia. Compensating for the lack of sleep due to insomnia, people often fall into hypersomnia

Treatment

One of the most effective and natural remedies for people dealing with sleep issues due to anxiety disorder is CBT (Cognitive Behavior Therapy). While CBT is used to treat anxiety disorder as a whole, CBT uses the same methods but is specifically used to treat insomnia caused by the disorder. Therapists focus on teaching their patients to replace current thoughts and behaviors with healthier ones, as well as educating them on good sleep habits.

Depression

Depression is a pervasive mental health condition characterized by persistent feelings of sadness, hopelessness, and a lack of interest or pleasure in activities once enjoyed. It affects the way an individual thinks, feels, and handles daily activities, often leading to various physical and emotional problems that can diminish a person's ability to function at work and home. Unlike normal mood fluctuations, depression involves severe and long-lasting symptoms that require professional treatment to manage effectively.

Sleep and Depression

Studies by Harvard suggest that 65 to 90 percent of adult patients with major depression, and approximately 90 percent of children with the disorder, experience some form of sleep disorder. The majority of patients who suffer from depression also have insomnia, but one in five also suffer from obstructive sleep apnea (OSA).

Women are more likely than men to develop insomnia, with the Office of Women’s Health reporting that more than one in four women suffers from insomnia, while less than one in five men are affected. Additionally, the gap becomes more substantial as women age and are affected by changes in hormones

Those who suffer from the spring and summer version of SADs, a seasonal form of mild to moderate depression, may develop hypersomnia (excessive daytime sleepiness, aka EDS). The Semantic Scholar wraps it up thus:

"...three-quarters of depressed patients have insomnia symptoms, and hypersomnia is present in about 40% of young depressed adults and 10% of older patients, with a preponderance in females. The symptoms cause huge distress, have a major impact on quality of life, and are a strong risk factor for suicide."

Treatment

Antidepressants are used to treat both depression and insomnia. However, reactions to antidepressants can vary greatly, and in some patients may cause an increase in energy, making it more difficult to fall asleep. The most common SSRI (selective serotonin reuptake inhibitors) drugs in use today are sedating antidepressants such as mirtazapine, trazodone, and Amitriptyline. 

Cognitive behavioral therapy and light therapy are other options used to treat depression and insomnia. A psychosocial intervention, CBT focuses on reframing negative thoughts while the light therapy consists of resetting the person’s circadian clock by exposing them to a special light device for daily-set time periods.

Oftentimes, treating depression treats insomnia, particularly in those who are experiencing dysthymia (mild depression), which is likely to cause troubled sleep. Many have found insomnia goes away if the depression is treated.

ADHD

Attention-deficit hyperactivity disorder (ADHD) is a neurobiological mental health disorder that affects 5 percent of children and can continue into adulthood. Behavioral symptoms include inattentiveness, hyperactivity, and impulsivity.

Sleep and ADHD

As with both anxiety and depression, both the symptoms and the treatments for ADHD cause disrupted sleep and possible sleep disorders. 

The following sleep disorders are likely to occur in individuals who have ADHD:

• As much as 75 percent of people with ADHD experience insomnia, which may possibly be due to a delayed circadian rhythm, meaning the person gets tired late in the day. They may also have difficulty falling asleep and wake frequently during the night.

• Excessive daytime sleepiness is a prevalent symptom of sleep disorders. The fatigue is extreme enough to degrade the quality of life. Even with e qual amounts of sleep, those who also have ADHD experience much more tiredness during the day.

• Those with ADHD are more likely to suffer from sleep apnea and are two-times as likely to experience sleep-disordered breathing.

• RLS (restless leg syndrome) and PLMD (periodic limb movement disorder) are more commonly seen in children with ADHD.

Treatment

ADHD symptoms are commonly treated with medications that, unfortunately, can cause sleep issues. It is important for individuals with ADHD to advise their doctor about their sleep problems to ensure they are taken into consideration when creating a treatment plan. 

Sleep issues caused by ADHD are also often treated using the CBT-I behavioral method using stimulus control and progressive muscle relaxation techniques to calm the mind and body. 

Other effective treatment options include: Sleep restriction therapy, where patients strictly adhere to a sleep schedule set by a therapist. Light therapy can also help individuals with delayed circadian rhythms.

Sufferers of RLS may find relief using a weighted blanket during sleep. A blanket weighing one pound plus 10 percent of your body weight is suggested.

Schizophrenia

Schizophrenia is a severe mental illness that affects 1 percent of Americans. It impairs the ability to think clearly, manage emotions, and relate to others. Symptoms are severe, including psychosis and hallucinations.

Sleep and Schizophrenia

Of those who suffer from schizophrenia, a vast majority also experience sleep disturbances that reach the level clinical significance.

Sleep issues prevalent to schizophrenia include:

• Inconsistent sleep patterns: Those who suffer from schizophrenia tend not to follow a consistent or regular sleep schedule, sleeping at any time during the day or night. Scientists hypothesize that this is caused by a delayed release of melatonin which continually shifts the circadian rhythm.

• Irregular hours of sleep: Individuals with schizophrenia are prone to inconstancy in the volume of sleep they get, often shifting between insomnia and hypersomnia caused by medication side effects or symptoms of schizophrenia such as hallucinations. 

Irregularity of both the quantity and pattern of sleep degrades the quality of sleep, making coping with the symptoms of the disorder difficult.

Treatment

Although the first generation of antipsychotics was shown to have no effect on sleep architecture, observable positive effects on sleep have been seen on the later generation of atypical antipsychotics such as olanzapine, quetiapine, and Clozapine. Similar to how SSRI medicines affect individuals with depression, some medicines increase REM latency and the length of slow-wave sleep.

You should note, the intensity of psychotic symptoms of schizophrenia is not relieved by treating sleep problems. Clinicians do, however, recommend using CBT-1 strategies, moving down the list as the psychotic experiences intensify:

• Assessment  

  • Psycho-education

• Normalization

  • Formulation 

• Sleep Environment

  • Sleep Hygiene

• Stimulus Control

  • Associate bed with sleep

• Daytime Activity

  • Developing routine

• Relaxation

  • Worry Strategies

• Imagery Rehearsal

  • Training (IRT)

Bipolar Disorder

According to the National Institute of Mental Health (NIH), over 4 percent of U.S. adults will experience bipolar disorder during their lifetime. Drastic changes in energy, behavior, and mood are some of its most obvious symptoms. 

Sleep and Bipolar Disorder

Whether the individual affected by bipolar disorder is in a state of depression or mania will determine the sleep problems they experience.

People with bipolar disorder are prone to the following sleep issues:

• The probability of experiencing hypersomnia increases during the depressive state.

• Insomnia is not specific to either state and can be experienced through both mania and depression.

• Sleeplessness differs from insomnia in that the individual is capable of going long periods of time with no sleep and without feeling the need to sleep. This is common through the mania state.

• Much like jet lag, DSPS (delayed sleep phase syndrome) is a condition where the delay of the circadian rhythm causes the person to tire later, falling asleep and waking up later, which, in turn, causes fatigue during the day.

• Individuals suffering from bipolar disorder are highly prone to sleep apnea. Sleep is disrupted by the sleep-disordered breathing, which may cause a manic episode, which, in turn, increases the difficulty of managing depression. 

The symptoms of bipolar disorder become even more challenging to deal with when the side effects of sleep problems lower the individual’s ability to cope with stress. The side effects of lack of sleep caused by the mania state put the person in a position of weakness when transitioning into a depressive state, deepening the depression and contributing greatly to feelings of hopelessness.

One of the precursors to a manic episode is lack of sleep, with jet lag being a possible trigger due to the resulting sleep deprivation. When in neither a mania or depressive state, people with bipolar disorder often continue to be symptomatic between episodes, having greater difficulty falling asleep and getting only fitful sleep. 

Treatment

Bipolar disorder can be treated with three classes of medication including mood stabilizers, antipsychotics, and antidepressants. While alternative non-drug treatments include CBT-I which has proven to be an effective behavioral treatment and electroconvulsive therapy which is administered to severely manic and depressed patients who are pregnant or do not respond to medications. 

Light therapy is also proven as an effective additional treatment when bipolar disorder is in connection with seasonal affective disorder. Stimulus control techniques and sleep restrictions have also proven to be effective in treating insomnia caused by bipolar disorder. Practicing relaxation, deep-breathing exercises and progressive muscle relaxation techniques can also help with insomnia.

Summary

To conclude, the close link between sleep disorders and mental illness highlights the crucial need for integrated care approaches addressing both issues simultaneously. Early recognition and professional guidance can greatly enhance one's quality of life. If you or someone you know struggles with sleep or mental health, take a step towards a healthier future now. Consult The Sleep RN at Vallarta Vitality for personalized care plans tackling the intertwining of sleep and mental health, guiding you to improved well-being. Reach out today to start your journey towards revitalization and peace of mind, leaving restless nights behind.