Sleep and depression

Federica Provini MD

Sleep Disorders

Updated 11.24.2023
Released 12.23.1994
Expires For CME 11.24.2026

Sleep and depression

Author: Federica Provini MD

See Contributor Disclosures

Editor: Antonio Culebras MD FAAN FAHA FAASM

Sleep and depression

In This Article

Quick Link

Introduction

Overview

There is increasing interest in the connection between sleep disturbances and psychiatric disorders. It has been established that 4.4% to 20% of the general population suffers from a major depressive disorder, which is frequently associated with insomnia and evening circadian preference (61). Disturbances of circadian rhythms are a cardinal feature of psychiatric dysfunctions, including major depressive disorder, suggesting that biological clocks may play a role in their pathophysiology. In addition, the habit of sleeping at a time that is out of phase with the body's other biological rhythms is a common finding in patients with depression (61; 55). Depression is associated with longer sleep latency, frequent and long awakenings, or early morning awakening associated with poor sleep satisfaction. Depression treatment studies indicate poorer outcomes for those with comorbid sleep disturbances because even if half of adults with major depression receive pharmacotherapy, at least a quarter of them do not experience remission. In addition, pharmacotherapy including the selective serotonin reuptake inhibitors and duloxetine, associated with unpleasant side effects, increased sleep disturbances. In this chapter the author describes the most common sleep disturbances observed in depression, focusing on the link between the presence of sleep disorders and greater depressive symptom severity, worse treatment outcomes, and greater risk of relapse.

Key points

	• Sleep disorders are common in depression.
	• Symptoms of insomnia exceed 80% in those who are concurrently depressed.
	• Insomnia predicts the onset, course, and reoccurrence of unipolar depression.
	• Insomnia can lead to depression, or common causalities underlie both disorders.
	• Prevention of sleep disturbance is best achieved by preventing the onset of depression.

Historical note and terminology

Sleep disturbance in depression has been described at least as far back as the ancient Greeks. Throughout history there have been great numbers of famous people who are known to have suffered from insomnia and depression. It is a well-known fact that for most of his life Winston Churchill suffered from insomnia and depression that persisted until old age. Churchill referred to this depressive state as his "black dog." The famous British mathematician, astronomer, and philosopher, Sir Isaac Newton, one of the leading pioneers of scientific discovery, was also known to have suffered from inability to sleep and depression.

Mood disorders, including depressive disorders and bipolar disorders, are commonly associated with sleep disturbances. Major depressive disorder or unipolar depression is diagnosed in people who have experienced one or more major depressive episodes. The essential feature of a major depressive episode is a period of at least 2 weeks during which there is depressed mood or a loss of interest in pleasure, together with at least four of the following symptoms: (1) weight gain or significant weight loss when not dieting; (2) insomnia or hypersomnia; (3) psychomotor agitation; (4) fatigue or loss of energy; (5) feelings of worthlessness or excessive or inappropriate guilt; (6) diminished ability to think or concentrate; (7) recurrent thoughts of death, suicidal ideation, or a specific plan to commit suicide. The Diagnostic and Statistical Manual of Mental Disorders (DSM-V) criteria for major depressive episode include insomnia or hypersomnia nearly every day.

Insomnia is seen in 80% to 85% of patients with depression and it is bidirectionally related to anxiety and depression. People with insomnia have significantly higher levels of depression than people not having insomnia; increased insomnia frequency and increased numbers of awakenings are related to increased depression and anxiety, which is also among adolescents and university students.

Less frequently, in about 15% to 20% of cases, patients with depression complain of hypersomnia, with prolonged sleep episodes at night or increased daytime sleepiness and fatigue. Co-occurring insomnia and hypersomnia appear to be a unique risk factor for greater functional impairment and use of treatment (89).

Depression may be also associated with other sleep disturbances, such as restless legs syndrome, obstructive sleep apnea syndrome (47; 72), narcolepsy (01), and REM sleep behavior disorder (85).

Clinical manifestations

Presentation and course

	• Patients with depression commonly complain of sleep disturbances.
	• Depressed patients with evening circadian preference experience more severe depressive symptoms.
	• Patients with depression showed sleep abnormalities, including prolonged sleep latency and increased wake time during sleep, resulting in reduced sleep efficiency.

Patients with depression commonly complain of sleep disturbances, including difficulty falling asleep, frequent nocturnal awakenings, early morning awakening, nightmares, nonrestorative nocturnal sleep, and daytime fatigue or loss of energy and diminished concentration (03; 02).

As they investigate the risk of incident major depressive disorder in the Danish population, Byrne and colleagues found an increased risk of incident depression for all sleep disorders analyzed (13). Highest incidence rate ratios (IRRs) were found for circadian rhythm disorders (IRR = 7.06 [2.78-17.91]) and insomnia of inorganic origin (IRR = 6.76 [4.37-10.46]). Those diagnosed with a sleep disorder in the last 6 months were at highest risk of developing depression compared to those with at least 1 year since diagnosis (3.10 vs. 2.36).

When studied polysomnographically, patients with depression showed sleep abnormalities, including prolonged sleep latency and increased wake time during sleep, resulting in reduced sleep efficiency. The time spent in slow-wave sleep during the night is reduced; REM sleep latency is reduced, and REM density and REM sleep percentage are increased. Some authors studied slow-wave activity (SWA) in hypersomnolent patients with mild/moderate major depressive disorder (66). SWA is the power density of low-frequency delta activity during sleep; it more accurately reflects slow oscillations than traditional sleep staging and is a marker of sleep homeostasis, which is also associated with sleep restoration. Hypersomnolent patients with major depressive disorder demonstrate significantly reduced parieto-occipital all-night SWA, suggesting that decrements in slow waves during sleep may be related to subjective report of hypersomnolence in mood disorders (66).

Insomnia and depression do not follow a typical cause-and-effect relationship. Insomnia may precede or follow depression; sometimes depression and insomnia are unrelated, but in many cases depression and insomnia are comorbid. Different studies examined the relationship between insomnia and depression, showing that insomnia is a risk factor for onset and worsening of depression.

Insomnia may predict depression in various populations, including younger and older adults (79; 17; 36). Sleep duration has a significant negative impact on a range of mood states in healthy adolescents across all geographical regions. Many studies documented reciprocal effects for major depression and sleep deprivation among adolescents, suggesting that reduced duration of sleep increases risk for major depression, which in turn increases risk for decreased sleep. In a survey investigating quality of life and depressive symptoms among 1814 medical students undergoing postgraduate neurology specialty training in China, one-third of respondents had depressive symptoms (90). In a study examining the association between morningness-eveningness preferences, sleep duration, weekend catch-up sleep duration, and depression among 8655 Korean high-school students, eveningness preference and insufficient weekday sleep duration were associated with an increased risk of depression (45). These results highlight that sleep is a universal and modifiable risk factor for preventing mood deficits and for reducing depressive symptoms in this at-risk population, including children (45; 75; 52; 55). Persistence and worsening of poor sleep or insomnia, but not their full remission, are significant predictors of incident depression (39). Greater depressive symptom levels are associated with more subjective reporting of poor sleep and objective evidence of sleep fragmentation and napping in older women.

There are different hypotheses to explain how insomnia may cause depression: insomnia is related to decreased quality of life, with a negative impact on social and interpersonal performances that could trigger, maintain, or worsen depression; lying awake may facilitate depressive ruminations; loss of control of sleep may trigger thoughts of impotence and vulnerability and may cause alterations in neurobehavioral functions that may result in depression. Persistent insomnia also increased the risk of suicide in adults, both directly and indirectly, by affecting the risk of depression (32).

The epidemic of a highly contagious coronavirus 2019 disease (COVID-19) that was identified in China at the end of 2019 is associated with anxiety, depression, distress, and sleep disturbances (57). In a systematic review and meta-analysis to estimate the pooled prevalence of depression, anxiety, insomnia, and psychological distress related to COVID-19 among affected populations, the prevalence of depression and insomnia was 15.97% and 23.87%, respectively. In an online assessment of 667 participants from the Netherlands, COVID-19 lockdown measures more often worsened sleep complaints in pre-pandemic good sleepers whereas a subset of people with pre-pandemic severe insomnia symptoms underwent a clinically meaningful alleviation of symptoms (44). The COVID-19 pandemic significantly affected the mental health of healthcare workers, who stand at the frontline of this crisis (14; 67). A systematic search of literature databases including 13 studies with a combined total of 33,062 participants suggested that a considerable proportion of healthcare workers experienced mood disturbances (23%) and insomnia (38.9%) during the outbreak (62). Reports of insomnia are significantly higher among adolescents, especially senior high school and college students, suggesting devotion of more attention to sleep disorders in this patient population while combating COVID-19 (92).

Even after COVID-19 recovery, patients are prone to a variety of mental health problems including a high rate of insomnia (86). Individuals reporting a previous mental health diagnosis had worse stress, anxiety, and depression than those without a previous mental health diagnosis (53).

In bipolar disorder, switches into mania may be preceded or precipitated by periods of reduced sleep. Sleep disturbances may frequently appear 1 year or more before the onset of bipolar disorder, often during childhood or adolescence. A decreased need for sleep may precede the onset of the illness, especially in a manic episode, whereas insomnia appears to anticipate either a manic or a depressive episode. Hypersomnia seems to precede bipolar depressive episodes (60).

Hypersomnia is considered to be one of the main symptoms of depressive disorder (07). Relationships between symptoms of hypersomnolence, psychiatric disorders, and hypersomnia disorders (ie, idiopathic hypersomnia) are complex and multidirectional (07). Hypersomnia increases the risk of incident depression, is a highly treatment-resistant symptom, increases the risk of depressive relapse, and increases the risk of suicide. Patients with depression often report daytime fatigue and daytime sleepiness, with extended nocturnal sleep periods, difficult morning awakening, and frequent daytime naps. Self-reported daytime sleepiness shows the highest utility as a marker for major depressive disorder among the youngest patients. These patients spend more time in bed and report “resting” more than “sleeping”; the multiple sleep latency test (MSLT) usually shows normal mean sleep latencies. Similarly, patients with a seasonal pattern of depression, who have depressive episodes recurrent in a particular time of year (depression occurs during the winter months and disappears in the spring), may also complain of increased daytime sleepiness. Most patients with bipolar disorders report symptoms of hypersomnia while depressed, but excessive daytime sleepiness as assessed by the MSLT is not usually present (41).

The prevalence of depressive symptoms is high in patients with excessive daytime somnolence and narcolepsy (81; 63; 49). In the CoLaus-PsyCoLaus population-based cohort (Lausanne, Switzerland), among the 2438 subjects without excessive daytime sleepiness (Epworth Sleepiness Scale ≤ 10) at baseline, the 5-year incidence of excessive daytime sleepiness was 5.1% (n = 124). Multivariate logistic regression revealed that male sex, depressive symptoms, reported poor sleep quality, and moderate to severe obstructive sleep apnea were independent predictors of incident excessive daytime sleepiness (08). A meta-analysis revealed that the overall pooled prevalence of depression or depressive symptoms in patients with narcolepsy was 32% (49). The scores of depression associated with the level of sleepiness are the main correlates of the subjectively perceived attention deficits of patients with narcolepsy (88).

Depression may be reactive to narcolepsy but, according to some authors, may be related to the pathophysiology of the disease. Moreover, stimulant drugs may worsen the depressive symptoms. A large observational French study of central hypersomnia showed that patients with cataplexy treated with antidepressant and stimulant drugs had a higher depression frequency than patients treated by stimulants alone.

Poor sleep quality was strongly associated with mood disturbance among extremely obese patients, and depression was often present in patients with obstructive sleep apnea syndrome, both in adults and adolescents (68). A literature search in Medline, PubMed, PsycInfo, Scopus, and Web of Science showed a pooled prevalence of depressive and anxious symptoms in patients with obstructive sleep apnea of 35% (95% CI, 28%-41%) and 32% (95% CI, 22%-42%), respectively (29). Severity of the disorder, obesity, and excessive daytime sleepiness are strong risk factors for prevalent and incident depression (10). Patients with obstructive sleep apnea showed more intense depressive and somatic symptoms than patients with only snoring. The association between obstructive sleep apnea, anxiety, and depression indicates the value of an early diagnosis and personalized treatment of obstructive sleep apnea to improve mental disorders conditioning compliance to therapy (29).

Although some studies do not support a causal link between obstructive sleep apnea and severe depression (43), the association between depression and obstructive sleep apnea syndrome may have different explanations. Depression may be coincidental but unrelated to obstructive sleep apnea (72); a depressed mood may be induced by the symptoms of the sleep disorder; obstructive sleep apnea syndrome and depression could be induced by the same biological mechanisms (ie, the serotoninergic systems play a central role in the regulation of upper airway muscle), and deficiency in serotoninergic activity is associated with depression.

Symptoms of depression are common in individuals with restless legs syndrome. The prevalence is variable among different studies (16% to 53%). Given the high prevalence of both depression and restless legs syndrome in the general population, it would not be surprising that some patients have both disorders. However, emerging data indicate that occurrence of depression symptoms with restless legs syndrome is not a simple coincidence and a common pathogenetic mechanism, such as dopaminergic abnormality, may underlie restless legs syndrome and depression (65).

Prognosis and complications

For a particular episode of depression, the prognosis is usually good, with response to treatment in about three fourths of patients. Although resolution of sleep disturbance associated with depression usually parallels that of other depressive symptoms, some patients may develop psychophysiological insomnia that persists for years after depression has remitted.

The most serious complication of depression is suicide, and sleep disturbance is predictive of a greater risk of suicidal behavior (27). In a large population of 297 patients with narcolepsy type 1 and 346 controls, depression, depressive symptoms, suicidal thoughts, and suicide risk were frequent in patients with narcolepsy type 1, especially those without treatment, and were associated with narcolepsy type 1 severity (06). Depressive symptoms and suicidal thoughts improved after narcolepsy type 1 management. The causal role of mechanism of sleep disturbances in suicidal behavior remains unclear. Sleep disturbances could exacerbate psychological distress, but future researches are necessary to examine the specific mechanism of vulnerability and whether there are specific sleep profiles (for example, nightmares, insomnia, early morning awakenings, morningness-eveningness chronotype) that may discriminate individuals who are at risk to suicide behaviors (55). According to the diathesis-stress model of insomnia, insomnia may develop in vulnerable individuals in response to stress. A low resilience, which is the psychobiological factor that determines an individual's capacity to adapt successfully to stressful events, increases vulnerability for development of mental disorders (59).

Sleep seems to also have a role in the association between depressive symptoms and cardiovascular mortality (05).

Prestroke short sleep duration may be an independent risk factor for poststroke depression. Comparing with participants reporting 7 to 8 hours of sleep prestroke, those with short sleep duration (less than 6 hours) had significantly increased risk for poststroke depression, after adjustments for covariates including prestroke depression and sleep apnea risk (23). Prestroke short sleep duration may be an independent risk factor for poststroke depression, which needs to be investigated; the simple rule of adding an antidepressant to all patients poststroke who declare less than 6 hours prestroke may improve rehabilitation outcomes (21).

Clinical vignette

A 36-year-old female executive assistant complained of weariness and excessive daytime sleepiness since the age of 28 years. She reported frequent daytime naps (several times a day) that were refreshing. The naptime sleepiness often occurred with little warning, but was not usually irresistible.

At 29 years of age, the patient reported depressed mood, poor concentration and memory, withdrawal from social situations and activities, and apathy. Antidepressants (venlafaxine and reboxetine) improved depressed mood and weariness but had no effect on excessive daytime sleepiness.

Neurologic examination and routine laboratory tests were within normal limits. But 48-hour polysomnographic recording disclosed a reduced nocturnal sleep efficiency (68%; normal values: greater than 85%) and sleep onset rapid eye movement periods both in nighttime (REM sleep latency: 4 minutes) and in two daytime naps. The Multiple Sleep Latency Test showed a reduced sleep latency (3 minutes as a mean) and two sleep onset rapid eye movement periods.

After initiation of modafinil, excessive daytime sleepiness markedly improved.

Comment. This vignette illustrates a case of major depressive disorder in a patient with narcolepsy without cataplexy.

Biological basis

Etiology and pathogenesis

Relatively little is known about the etiology of mood disorders. There have been a number of hypotheses for the cause of altered sleep in depression, and many of them suggest that the sleep changes are not epiphenomena but, indeed, may be central to the genesis of the overall illness (82; 20). At this point, no single hypothesis is generally accepted as the most likely, and many are not mutually exclusive.

Sleep changes in depression may be the consequence of:

	• a phase advance or delay of the central pacemaker and related circadian rhythms that regulate sleep, wake, temperature, cortisol, and melatonin (38).
	• an imbalance of the opponent interaction between the circadian and homeostatic processes such that a weaker circadian output signal leads to an overexpression of sleep-wake homeostasis influences (34).
	• a deficiency of a sleep/waking-dependent process (Process S) involved in sleep regulation (11).
	• a cholinergic-aminergic imbalance. Enhanced cholinergic neurotransmission or reduced aminergic neurotransmission may explain the short REM sleep latency and elevated REM density in depression.
	• a dysregulation in the hypothalamic-pituitary-adrenal axis, present in many patients with depression, which may contribute to sleep changes in depression related to excessive daily amounts of cortisol (which reduces REM sleep latency) and corticotropin-releasing hormone (which increases arousal and contributes to reduced REM sleep latency) (78).
	• an alteration of clock genes that might lead to desynchronized and abnormal circadian rhythms impairing in turn the synchronization between external and internal rhythms and, therefore, the adaptation of the individual to his/her internal and external environment with the development of psychiatric disorders (16; 51).

Humans, like other living organisms, show cyclical physiological changes across the 24-hour day. Sleep and wake are the most overt manifestations of the circadian rhythm, but mood also exhibits changes throughout the day. In one study, patients with depression showed early morning awakenings, early occurrence of REM sleep, and melatonin secretion shift; these features were central to the “phase shift” hypothesis, according to which mood disturbances result from a phase shift in the circadian pacemaker. An alternative model was based on the shortened REM latency and REM sleep suppression, but these features are not specific for depression. Lastly, the social rhythms hypothesis of depression postulates a role of disrupted social rhythms and associated changes in physiological rhythms in the pathogenesis of depression.

Diurnal variations of mood and sleep disturbances are the classical symptoms linking depression to the circadian system. A bidirectional association between evening circadian preference and depression emerges from studies on adolescents stratified into either low-risk for depression, high-risk for depression, or experiencing current major depressive disorder (MDD). The high-risk adolescents shared sleep and rhythm alterations (ie, higher social jetlag, lower relative amplitude of activity, and higher exposure to artificial light) with the major depressive disorder group (55).

Seasonal affective disorder shows how an alteration between the external light-dark cycle and circadian rhythms may trigger a depressive episode (70). An interaction between the Epworth Sleepiness Scale and the work schedule and the short-term Center for Epidemiologic Studies-Depression scale and the work schedule was stronger in shift workers than non-shift workers (48). The depressive symptoms of shift workers are associated with sleep problems, and the effects of sleepiness on depression were more prominent in shift workers than non-shift workers (48), suggesting the urgent need for the development of public health interventions that promote healthy lifestyles aimed at improving the mental health of shift workers (87).

Disruption of the circadian rhythms has been found among patients with depression. These changes may contribute to depression (as suggested by the dysphoria triggered by jet-lag), but they may also be a consequence of depression. Some studies reported that in patients with depression, mean core temperature is increased, cortisol and norepinephrine secretion are phase advanced, and there is an abnormal melatonin secretion.

REM alterations in depression have been attributed to an imbalance between monoaminergic and cholinergic neurotransmission; enhanced cholinergic neurotransmission or reduced aminergic neurotransmission may explain the short REM sleep latency and elevated REM density in depression (58).

In patients with depression, a lower sleep pressure (low Process S) could be related to sleep initiation disturbances rather than to hyperarousal (as in primary insomnia).

Sleep deprivation and selective REM sleep deprivation have been shown to have antidepressant effects through a mechanism that probably involves the activity of limbic structures (84). Sleep deprivation can acutely reverse depressive symptoms in some patients with major depression; the mood-elevating effects of sleep deprivation have been demonstrated by reports that sleep deprivation can trigger mood episode switches in patients with bipolar disorder. REM sleep deprivation also improves depressive symptoms, but it is not clear if REM sleep deprivation is more effective than non-REM sleep deprivation.

Finally, among older adults, insomnia symptoms appear partially related to personality, with persons higher in neuroticism experiencing greater insomnia symptom severity and those higher in conscientiousness experiencing lower insomnia symptom severity (69).

Prevention

	• Because of the relationship between depression and sleep disturbances, all patients with sleep complaints must be screened for depression.
	• Sleep problems can co-occur with, precede, or follow common psychiatric disorders (such as generalized anxiety disorder and depression), especially during childhood and adolescence.
	• Screening children for sleep problems could offer promising opportunities for reducing the burden of mental illness during the early life course.

Asking about total sleep time in a clinical setting may be more informative than only assessing for insomnia symptoms to more fully characterize the relationship of sleep to suicide (54; 89). Treating depression in patients who present with sleep difficulties may subsequently help mitigate suicide risk (22).

Treatment of insomnia with cognitive behavioral therapy for insomnia (CBT-I) has an overall benefit in the prevention of incident and recurrent major depression in older adults with insomnia disorder (37).

Untreated obstructive sleep apnea impacts affective disorders and often leads to decline of cognitive functions or even leads to permanent brain damage. Further studies are needed to analyze the connection between obstructive sleep apnea and affective disorders, anxiety disorders, and its effect on cognitive functions more thoroughly, especially in the context of CPAP treatment (80).

In a retrospective study on a total of 105,071 individuals diagnosed with cancer and 420,284 age- and sex-matched patients without a diagnosis of cancer, patients with both sleep disorders and depression are at a higher risk of cancer (35). Clinically, a meticulous cancer risk evaluation could be recommended for patients with both sleep disorders and depression.

Differential diagnosis

Confusing conditions

The diagnosis of depression in patients with sleep disturbances may be complicated by a failure of the patient to recognize the nature of the illness. Some patients with sleep disorder associated with depression may deny or minimize other depressive symptoms or attribute depression to the effects of poor sleep. In such cases, complaints of poor or nonrestorative sleep may suggest diagnoses of psychophysiological insomnia, inadequate sleep hygiene, or idiopathic insomnia. If anxiety is a prominent component of the depression, the sleep complaint and clinical presentation may suggest sleep disorders associated with anxiety disorder. If frequent awakenings are the major complaint, movement disorders, obstructive sleep apnea, or sleep disorders associated with medical disorders may be considered.

Sleep disorder associated with primary depression should be distinguished from that associated with secondary depression due to another disorder such as alcoholism or anorexia nervosa. In some cases, depressive symptomatology may be associated with a specific medical disease such as disorders that cause pain, breathing, or cardiovascular problems and limited motility. Depression in the elderly that is associated with symptoms of cognitive dysfunction may be difficult to differentiate from dementia.

Diagnostic considerations in persons with difficulty falling or staying asleep include sleep disorder associated with medical, neurologic, or other psychiatric illness; psychophysiological or idiopathic insomnia; an extrinsic sleep disorder such as inadequate sleep hygiene; and circadian rhythm disturbances. When early morning awakening is a prominent complaint, advanced sleep phase syndrome is a consideration.

Depression with complaints of hypersomnolence may suggest narcolepsy, idiopathic hypersomnia, or obstructive sleep apnea. The temporal association with other depressive symptoms, a multiple sleep latency test that is usually normal, and the absence of complaints of falling asleep in inappropriate circumstances (as opposed to a feeling of fatigue and a desire for sleep) help to distinguish hypersomnolent depression from these other disorders.

Management

	• Sleep disturbances are modifiable risk factors in the development and maintenance of depression and may be treated with medications, psychotherapy, or both.
	• Treating sleep disturbance may prevent the future depressive episodes.
	• Patients with moderate to severe depression are usually treated with antidepressants that may have significant effects on sleep.
	• Hypnotics can usually be combined with antidepressant drugs (or treatments).
	• Cognitive behavioral therapy was effective at reducing insomnia and depression severity.

Selective serotonin reuptake inhibitors (SSRIs) are the class of drug most commonly used for depression. The adverse effects of SSRIs include REM sleep suppression (reduction in the amount of REM sleep and delayed onset of REM sleep). These effects are dose-related and are probably due to an increased level of synaptic serotonin.

Although the use of tricyclic antidepressants has diminished because of the associated side effects, the sedative effects of these drugs may be helpful in depressed patients with insomnia. In clinical practice, low doses of amitriptyline have been commonly prescribed for insomnia although there are no controlled studies on the use of tricyclic antidepressants as hypnotics in nondepressed patients. Tricyclic antidepressants and SSRIs have a similar effect on REM sleep. REM sleep rebound after withdrawal has been described and may be due to a rebound increase in cholinergic function. Trimipramine is the only tricyclic antidepressant that does not affect REM sleep. Insomnia may, however, be exacerbated by antidepressants (both SSRIs and tricyclic antidepressants) and may directly or indirectly precipitate or exacerbate sleep disorders such as restless legs syndrome and periodic limb movements.

Mirtazapine has a robust and sustained effect in improving sleep continuity in patients with depression and has been polysomnographically shown to increase total sleep time, sleep efficiency, and slow-wave sleep both acutely and after 1 to 2 months of treatment when administered to depressed subjects. Mirtazapine has been reported to induce or exacerbate restless legs syndrome in some patients; venlafaxine can increase periodic limb movements.

Trazodone (50 to 200 mg) is particularly useful in the treatment of patients with depression and insomnia (42). Side effects of trazodone include priapism, orthostatic hypotension, and induction of cardiac arrhythmias in subjects with preexisting cardiac disease. Daytime sedation can be a side effect of the use of trazodone as a hypnotic, but tolerance of this adverse effect usually develops within several weeks.

Agomelatine is an antidepressant acting as an agonist at melatoninergic MT1 and MT2 receptors and as an antagonist at 5-HT2c serotoninergic receptors. This dual mechanism is the basis of the drug’s antidepressant efficacy as well as its capacity to improve sleep-wake rhythm disorders.

Modafinil is a wake-promoting agent that is indicated for the treatment of excessive sleepiness in patients with narcolepsy, obstructive sleep apnea (as an adjunct to standard treatment aimed at the underlying obstruction), and shift-work sleep disorder. In an open-label study, Schwartz and colleagues found that adding modafinil at a dose of 100 to 400 mg daily to the medication regimen of patients on stable treatment with selective serotonin reuptake inhibitors led to significant improvement in overall depressive symptoms, fatigue, and sleepiness (as measured by the Epworth Sleepiness Scale) (71). The authors concluded that adjunctive modafinil improves wakefulness and reduces fatigue in patients who experience sedation as a side effect of serotonergic antidepressant therapy. Modafinil induces cytochrome p450 3A4 activity and inhibits the activity of cytochrome p450 2C19. Through cytochrome p450 3A4 induction, modafinil can decrease the effectiveness of oral contraceptives.

Cognitive behavior therapy for insomnia (CBT-I) is an effective treatment for patients with insomnia and a comorbid mental disorder, especially depression, post-traumatic stress disorder, and alcohol dependency (04). CBT-I is also an effective add-on treatment for improving mental health in patients with depression (33). Treatment options in patients with depression and insomnia include:

	• Basic sleep hygiene education should include general guidelines about lifestyle (eg, diet, exercise, drug use) and environmental factors (eg, light, noise, temperature) that may promote or interfere with sleep (12).
	• Sleep restriction therapy consists of curtailing time in bed and creating mild sleep deprivation, although using a methodologically rigorous approach, a meta-analysis did not find evidence that the addition of sleep deprivation to treatment packages leads to favorable depressive outcomes (56).
	• Stimulus control therapy can help patients to reassociate the bed and bedroom with sleep (ie, go to bed only when sleepy, get out of bed when unable to sleep, use the bed for sleep only--no eating, reading, watching TV).
	• Relaxation training (eg, progressive muscle relaxation, autogenic training, biofeedback) is important, and clinical procedures to reduce somatic tension or intrusive thoughts can be helpful.
	• Cognitive therapy can teach patients coping skills to prevent excessive preoccupation with sleep and their daytime consequences, which often exacerbate insomnia and depression, and to control intrusive thoughts interfering with sleep. All chronotypes benefited from sleep improvement, but those with greater eveningness or less sleep improvement experienced less reduction in depressive symptom severity.
	• Light therapy is an effective treatment for seasonal affective disorders and delayed sleep phase disorders (28; 31). Morning and evening light exposure is associated with a 50% decrease in depression severity scores and reduced suicidal ideation. Adults with unipolar depression and evening preference who experienced a change in eveningness by week 5 of treatment with bright light therapy were twice as likely to experience remission of depression at follow-up than those who did not experience a change (15).
	• In a randomized, double-blind study involving 90 patients with major depression and insomnia, transcranial direct current stimulation of the dorsolateral prefrontal cortex improved symptoms of depression and anxiety and had a positive effect on sleep quality (91).

For patients with mood disorders and significant insomnia or hypersomnia that does not respond to appropriate pharmacotherapy or for those with known comorbidities such as restless legs syndrome or obstructive sleep apnea syndrome, it is necessary to treat the concomitant primary sleep disorders.

Repetitive transcranial magnetic stimulation (rTMS) seems to exert direct effects on both mood and sleep in patients with major depressive disorder, regardless of age, sex, sedative-hypnotic use, number of rTMS treatments, depression severity, and changes in depressive symptoms (18).

Outcomes

Stress and depression symptoms should be considered risk factors that play an important role in the long-term outcome of cognitive behavioral therapy (73). Patients with insomnia who had stress and depression symptoms maintained the highest percentage of clinical depression at the end of treatment and insomnia at follow-up in comparison with others classes.

A depressive mood disorder in patients with moderate/severe obstructive sleep apnea impairs the rate of initial acceptance of CPAP treatment (24) and many authors reported a decrease in symptoms of anxiety and depression from baseline to follow-up of CPAP treatment. The improvement in symptoms of depression was depending on CPAP adherence (50), with a trend toward greater reduction in those with high CPAP adherence (83).

Special considerations

Very few studies have examined the directionality of the sleep-depression link in children. In a large ongoing population-based longitudinal study, the Norwegian Mother, Father and Child Cohort Study, a total of 35,075 children were included. Short sleep duration (≤10 hr) and frequent (≥3) nightly awakenings at 1.5 years predicted the development of depressive symptoms at 8 years of age. Also, internalizing problems at 1.5 years predicted onset of later short sleep duration after accounting for early sleep problems (77).

Pregnancy

Insomnia during the perinatal period associated with depressive symptoms warrants screening pregnant mothers for insomnia and depression (25).

Poor sleep quality and depression are prevalent during pregnancy and may negatively impact maternal and fetal outcomes, including perinatal depression, gestational diabetes, preeclampsia, and preterm birth (30). In addition, in a study on 267 pregnant women, high rumination and insomnia were associated with depression and suicidal ideation (40). Different BMI status and gestational age impact sleep habits, depression, and anxiety/stress levels (64).

The use of antidepressant or mood-stabilizing medications during pregnancy depends on a careful risk-benefit analysis of treatment, addressing the potential risk to the fetus from teratogenic effects (including neurobehavioral teratogenesis) as well as untreated depression in the mother. Limited data suggest that appropriately timed bright light therapy may be an effective treatment of depression during pregnancy.

Depression can occur in the postpartum period, with symptomatology similar to non-postpartum depressive episodes. A systematic review found a strong relationship between postpartum sleep disturbance and postpartum depression, especially in educated, middle class females older than 30 years of age (09).

Preliminary evidences suggest that digital cognitive behavior therapy for insomnia use during pregnancy may prevent postpartum depression and anxiety (26).

References

01: Alasim H, AlQazlan S, Albanyan S, et al. Comorbid psychiatric disorders among patients with narcolepsy. Sleep Breath 2020;24(2):629-36. PMID 31280401
02: American Academy of Sleep Medicine. International classification of sleep disorders, 3rd ed. Darien, IL: American Academy of Sleep Medicine, 2023.**
03: American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 5th edition. Washington, DC: American Psychiatric Association, 2013.
04: Asarnow LD, Manber R. Cognitive behavioral therapy for insomnia in depression. Sleep Med Clin 2019;14(2):177-84. PMID 31029185
05: Azevedo Da Silva M, Singh-Manoux A, Shipley MJ, et al. Sleep duration and sleep disturbances partly explain the association between depressive symptoms and cardiovascular mortality: the Whitehall II cohort study. J Sleep Res 2014;23(1):94-7. PMID 23898807
06: Barateau L, Lopez R, Chenini S, et al. Depression and suicidal thoughts in untreated and treated narcolepsy: systematic analysis. Neurology 2020;95(20):e2755-68.** PMID 32963102
07: Barateau L, Lopez R, Franchi JA, Dauvilliers Y. Hypersomnolence, hypersomnia, and mood disorders. Curr Psychiatry Rep 2017;19(2):13. PMID 28243864
08: Berger M, Hirotsu C, Haba-Rubio J, et al. Risk factors of excessive daytime sleepiness in a prospective population-based cohort. J Sleep Res 2021;30(2):e13069. PMID 32412149
09: Bhati S, Richards K. A systematic review of the relationship between postpartum sleep disturbance and postpartum depression. J Obstet Gynecol Neonatal Nurs 2015;44(3):350-7.** PMID 25819463
10: Bixler EO, Gaines J, Vgontzas AN. Obstructive sleep apnoea and depression: is there an association? Eur Respir J 2017;49(6).** PMID 28572131
11: Borbély AA. The S-deficiency hypothesis of depression and the two-process model of sleep regulation. Pharmacopsychiatry 1987;20(1):23-9. PMID 3823126
12: Brupbacher G, Gerger H, Zander-Schellenberg T, et al. The effects of exercise on sleep in unipolar depression: a systematic review and network meta-analysis. Sleep Med Rev 2021;59:101452. PMID 33667885
13: Byrne EM, Timmerman A, Wray NR, Agerbo E. Sleep disorders and risk of incident depression: a population case-control study. Twin Res Hum Genet 2019;22(3):140-6. PMID 31203833
14: Cénat JM, Blais-Rochette C, Kokou-Kpolou CK, et al. Prevalence of symptoms of depression, anxiety, insomnia, posttraumatic stress disorder, and psychological distress among populations affected by the COVID-19 pandemic: a systematic review and meta-analysis. Psychiatry Res 2021;295:113599. PMID 33285346
15: Chan JWY, Chan NY, Li SX, et al. Change in circadian preference predicts sustained treatment outcomes in patients with unipolar depression and evening preference. J Clin Sleep Med 2022;18(2):523-31. PMID 34534071
16: Charrier A, Olliac B, Roubertoux P, Tordjman S. Clock genes and altered sleep-wake rhythms: their role in the development of psychiatric disorders. Int J Mol Sci 2017;18(5). PMID 28468274
17: Chen TY, Saito Y. Longitudinal effects of nocturnal insomnia symptom subtypes and nonrestorative sleep on the incidence of depression among community-dwelling older adults: results from the Health and Retirement Study. Sleep Med 2021;79:155-63. PMID 33540204
18: Collins AR, Cheung J, Croarkin PE, Kolla BP, Kung S. Effects of transcranial magnetic stimulation on sleep quality and mood in patients with major depressive disorder. J Clin Sleep Med 2022;18(5):1297-1305. PMID 34931606
19: Cross NE, Carrier J, Postuma RB, et al. Association between insomnia disorder and cognitive function in middle-aged and older adults: a cross-sectional analysis of the Canadian Longitudinal Study on Aging. Sleep 2019;42(8):zsz114. PMID 31089710
20: Crouse JJ, Carpenter JS, Song YJC, et al. Circadian rhythm sleep-wake disturbances and depression in young people: implications for prevention and early intervention. Lancet Psychiatry 2021;8(9):813-23. PMID 34419186
21: Culebras A. Sleep at the cross-roads of post-stroke depression. Sleep Med 2021;77:323-4. PMID 33067142
22: Don Richardson J, King L, St Cyr K, et al. Depression and the relationship between sleep disturbances, nightmares, and suicidal ideation in treatment-seeking Canadian Armed Forces members and veterans. BMC Psychiatry 2018;18(1):204. PMID 29921268
23: Dong L, Brown DL, Chervin RD, Case E, Morgenstern LB, Lisabeth LD. Pre-stroke sleep duration and post-stroke depression. Sleep Med 2021;77:325-29. PMID 32828696
24: Drakou T, Steiropoulos P, Saroglou M, et al. The presence of insomnia and depression contributes to the acceptance of an initial treatment trial of continuous positive airway pressure therapy in patients with obstructive sleep apnea. Sleep Breath 2021;25(4):1803-12. PMID 33411189
25: Emamian F, Khazaie H, Okun ML, Tahmasian M, Sepehry AA. Link between insomnia and perinatal depressive symptoms: A meta-analysis. J Sleep Res 2019:e12858. PMID 30983027
26: Felder JN, Epel ES, Neuhaus J, Krystal AD, Prather AA. Randomized controlled trial of digital cognitive behavior therapy for prenatal insomnia symptoms: effects on postpartum insomnia and mental health. Sleep 2022;45(2):zsab280. PMID 34850238
27: Ferentinos P, Porichi E, Christodoulou C, Dikeos D, Papageorgiou C, Douzenis A. Sleep disturbance as a proximal predictor of suicidal intent in recently hospitalized attempters. Sleep Med 2016;19:1-7. PMID 27198939
28: Figueiro MG. Delayed sleep phase disorder: clinical perspective with a focus on light therapy. Nat Sci Sleep 2016;8:91-106. PMID 27110143
29: Garbarino S, Bardwell WA, Guglielmi O, Chiorri C, Bonanni E, Magnavita N. Association of anxiety and depression in obstructive sleep apnea patients: a systematic review and meta-analysis. Behav Sleep Med 2020;18(1):35-57. PMID 30453780
30: Garbazza C, Hackethal S, Riccardi S, et al. Polysomnographic features of pregnancy: a systematic review. Sleep Med Rev 2020;50:101249. PMID 31896508
31: Geoffroy PA, Schroder CM, Bourgin P. Light treatment in depression: an antique treatment with new insights. Sleep Med Rev 2018;40:218-9. PMID 29678399
32: Hedström AK, Hössjer O, Bellocco R, Ye W, Trolle LY, Åkerstedt T. Insomnia in the context of short sleep increases suicide risk. Sleep 2021;44(4):zsaa245. PMID 33216134
33: Hertenstein E, Trinca E, Wunderlin M, et al. Cognitive behavioral therapy for insomnia in patients with mental disorders and comorbid insomnia: A systematic review and meta-analysis. Sleep Med Rev 2022;62:101597. PMID 35240417
34: Hickie IB, Naismith SL, Robillard R, Scott EM, Hermens DF. Manipulating the sleep-wake cycle and circadian rhythms to improve management of major depression. BMC Med 2013;11:79. PMID 23521808
35: Hsu FC, Hsu CH, Chung CH, et al. The combination of sleep disorders and depression significantly increases cancer risk: A nationwide large-scale population-based study. Int J Environ Res Public Health 2022;19(15):9266. PMID 35954622
36: Inkelis SM, Ancoli-Israel S, Thomas JD, Bhattacharjee R. Elevated risk of depression among adolescents presenting with sleep disorders. J Clin Sleep Med 2021;17(4):675-83. PMID 33196433
37: Irwin MR, Carrillo C, Sadeghi N, Bjurstrom MF, Breen EC, Olmstead R. Prevention of incident and recurrent major depression in older adults with insomnia: a randomized clinical trial. JAMA Psychiatry 2022;79(1):33-41. PMID 34817561
38: Jagannath A, Peirson SN, Foster RG. Sleep and circadian rhythm disruption in neuropsychiatric illness. Curr Opin Neurobiol 2013;23(5):888-94. PMID 23618559
39: Kalmbach DA, Arnedt JT, Song PX, Guille C, Sen S. Sleep disturbance and short sleep as risk factors for depression and perceived medical errors in first-year residents. Sleep 2017;40(3). PMID 28369654
40: Kalmbach DA, Cheng P, Ong JC, et al. Depression and suicidal ideation in pregnancy: exploring relationships with insomnia, short sleep, and nocturnal rumination. Sleep Med 2020;65:62-73. PMID 31710876
41: Kaplan KA, Harvey AG. Hypersomnia across mood disorders: a review and synthesis. Sleep Med Rev 2009;13(4):275-85. PMID 19269201
42: Kaynak H, Kaynak D, Gözükirmizi E, Guilleminault C. The effects of trazodone on sleep in patients treated with stimulant antidepressants. Sleep Med 2004;5(1):15-20. PMID 14725822
43: Kendzerska T, Gershon AS, Hawker GA, Tomlinson GA, Leung RS. Obstructive sleep apnoea is not a risk factor for incident hospitalised depression: a historical cohort study. Eur Respir J 2017;49(6). PMID 28572118
44: Kocevska D, Blanken TF, Van Someren EJW, Rösler L. Sleep quality during the COVID-19 pandemic: not one size fits all. Sleep Med 2020;76:86-8. PMID 33126035
45: Koo DL, Yang KI, Kim JH, et al. Association between morningness-eveningness, sleep duration, weekend catch-up sleep and depression among Korean high-school students. J Sleep Res 2020;e13063. PMID 32391631
46: Lacruz ME, Schmidt-Pokrzywniak A, Dragano N, et al. Depressive symptoms, life satisfaction and prevalence of sleep disturbances in the general population of Germany: results from the Heinz Nixdorf Recall study. BMJ Open 2016;6(1):e007919. PMID 26729376
47: LaGrotte C, Fernandez-Mendoza J, Calhoun SL, Liao D, Bixler EO, Vgontzas AN. The relative association of obstructive sleep apnea, obesity, and excessive daytime sleepiness with incident depression: A longitudinal, population-based study. Int J Obes (Lond) 2016;40(9):1397-404. PMID 27143032
48: Lee S, Lee J, Jeon S, Hwang Y, Kim J, Kim SJ. Sleep disturbances and depressive symptoms of shift workers: Effects of shift schedules. J Psychiatr Res 2023;161:371-6. PMID 37012196
49: Li X, Sanford LD, Zong Q, et al. Prevalence of depression or depressive symptoms in patients with narcolepsy: a systematic review and meta-analysis. Neuropsychol Rev 2021;31(1):89-102. PMID 32671534
50: Lundetræ RS, Saxvig IW, Lehmann S, Bjorvatn B. Effect of continuous positive airway pressure on symptoms of anxiety and depression in patients with obstructive sleep apnea. Sleep Breath 2021;25(3):1277-83. PMID 33098538
51: Lyall LM, Wyse CA, Graham N, et al. Association of disrupted circadian rhythmicity with mood disorders, subjective wellbeing, and cognitive function: a cross-sectional study of 91105 participants from the UK Biobank. Lancet Psychiatry 2018;5(6):507-14.** PMID 29776774
52: Marino C, Andrade B, Campisi SC, et al. Association between disturbed sleep and depression in children and youths: a systematic review and meta-analysis of cohort studies. JAMA Netw Open 2021;4(3):e212373. PMID 33749768
53: Meaklim H, Junge MF, Varma P, Finck WA, Jackson ML. Pre-existing and post-pandemic insomnia symptoms are associated with high levels of stress, anxiety and depression globally during the COVID-19 pandemic. J Clin Sleep Med 2021;17(10):2085-97. PMID 33985647
54: Michaels MS, Balthrop T, Nadorff MR, Joiner TE. Total sleep time as a predictor of suicidal behaviour. J Sleep Res 2017;26(6):732-8. PMID 28568246
55: Mirchandaney R, Asarnow LD, Kaplan KA. Recent advances in sleep and depression. Curr Opin Psychiatry 2023;36(1):34-40.** PMID 36449730
56: Mitter P, De Crescenzo F, Loo Yong Kee K, et al. Sleep deprivation as a treatment for major depressive episodes: A systematic review and meta-analysis. Sleep Med Rev 2022;64:101647.** PMID 35700677
57: Morin CM, Vézina-Im LA, Ivers H, et al. Prevalent, incident, and persistent insomnia in a population-based cohort tested before (2018) and during the first-wave of COVID-19 pandemic (2020). Sleep 2022;45(1):zsab258.** PMID 34698868
58: Palagini L, Baglioni C, Ciapparelli A, Gemignani A, Riemann D. REM sleep dysregulation in depression: state of the art. Sleep Med Rev 2013;17(5):377-90.** PMID 23391633
59: Palagini L, Moretto U, Novi M, et al. Lack of resilience is related to stress-related sleep reactivity, hyperarousal, and emotion dysregulation in insomnia disorder. J Clin Sleep Med 2018;14(5):759-66. PMID 29734989
60: Pancheri C, Verdolini N, Pacchiarotti I, et al. A systematic review on sleep alterations anticipating the onset of bipolar disorder. Eur Psychiatry 2019;58:45-53. PMID 30818134
61: Pandi-Perumal SR, Monti JM, Burman D, et al. Clarifying the role of sleep in depression: a narrative review. Psychiatry Res 2020;291:113239. PMID 32593854
62: Pappa S, Ntella V, Giannakas T, Giannakoulis VG, Papoutsi E, Katsaounou P. Prevalence of depression, anxiety, and insomnia among healthcare workers during the COVID-19 pandemic: a systematic review and meta-analysis. Brain Behav Immun 2020;88:901-7. PMID 32437915
63: Parmar A, Yeh EA, Korczak DJ, et al. Depressive symptoms, sleep patterns and physical activity in adolescents with narcolepsy. Sleep 2019;42(8):zsz111. PMID 31070768
64: Pauley AM, Moore GA, Mama SK, Molenaar P, Symons Downs D. Associations between prenatal sleep and psychological health: a systematic review. J Clin Sleep Med 2020;16(4):619-30. PMID 32003734
65: Picchietti D, Winkelman JW. Restless legs syndrome, periodic limb movement in sleep, and depression. Sleep 2005;28(7):891-98.** PMID 16124671
66: Plante DT, Landsness EC, Peterson MJ, et al. Altered slow wave activity in major depressive disorder with hypersomnia: A high density EEG pilot study. Psychiatry Res 2012;201(3):240-4. PMID 22512951
67: Proserpio P, Zambrelli E, Lanza A, et al. Sleep disorders and mental health in hospital workers during the COVID-19 pandemic: a cross-sectional multicenter study in Northern Italy. Neurol Sci 2022;43(4):2241-51. PMID 35022932
68: Robillard R, Chase T, Courtney D, Ward M, De Koninck J, Lee EK. Sleep-related breathing disturbances in adolescents with treatment resistant depression. Sleep Med 2019;56:47-51. PMID 30648538
69: Rojo-Wissar DM, Wanigatunga AA, Simonsick EM, et al. Personality and insomnia symptoms in older adults: the Baltimore Longitudinal Study of Aging. Sleep 2021;44(9):zsab082. PMID 33791794
70: Sandman N, Merikanto I, Määttänen H, et al. Winter is coming: nightmares and sleep problems during seasonal affective disorder. J Sleep Res 2016;25(5):612-9. PMID 27174375
71: Schwartz TL, Azhar N, Cole K, et al. An open-label study of adjunctive modafinil in patients with sedation related to serotonergic antidepressant therapy. J Clin Psychiatry 2004;65(9):1223-7. PMID 15367049
72: Sforza E, Saint Martin M, Barthélémy JC, Roche F. Mood disorders in healthy elderly with obstructive sleep apnea: a gender effect. Sleep Med 2016;19:57-62. PMID 27198948
73: Sforza M, Galbiati A, Zucconi M, et al. Depressive and stress symptoms in insomnia patients predict group cognitive-behavioral therapy for insomnia long-term effectiveness: a data-driven analysis. J Affect Disord 2021;289:117-24. PMID 33979721
74: Shochat T, Barker DH, Sharkey KM, Van Reen E, Roane BM, Carskadon MA. An approach to understanding sleep and depressed mood in adolescents: person-centred sleep classification. J Sleep Res 2017;26(6):709-17. PMID 28573658
75: Short MA, Booth SA, Omar O, Ostlundh L, Arora T. The relationship between sleep duration and mood in adolescents: A systematic review and meta-analysis. Sleep Med Rev 2020;52:101311. PMID 32240932
76: Sivertsen B, Harvey AG, Reichborn-Kjennerud T, Ystrom E, Hysing M. Sleep problems and depressive symptoms in toddlers and 8-year-old children: a longitudinal study. J Sleep Res 2021a;30(1):e13150. PMID 32743857
77: Sivertsen B, Hysing M, Harvey AG, Petrie KJ. The epidemiology of insomnia and sleep duration across mental and physical health: the SHoT study. Front Psychol 2021b;12:662572. PMID 34194368
78: Steiger A. Sleep and the hypothalamo-pituitary-adrenocortical system. Sleep Med Rev 2002;6:125-38. PMID 12531148
79: Sun Y, Shi L, Bao Y, Sun Y, Shi J, Lu L. The bidirectional relationship between sleep duration and depression in community-dwelling middle-aged and elderly individuals: evidence from a longitudinal study. Sleep Med 2018;52:221-9. PMID 29861378
80: Vanek J, Prasko J, Genzor S, et al. Obstructive sleep apnea, depression and cognitive impairment. Sleep Med 2020;72:50-8. PMID 32544796
81: Vignatelli L, Plazzi G, Peschechera F, Delaj L, D’Alessandro R. A 5-year prospective cohort study on health-related quality of life in patients with narcolepsy. Sleep Med 2011;12:19-23. PMID 20851047
82: Vitiello MV. The interrelationship of sleep and depression: new answers but many questions remain. Sleep Med 2018;52:230-1. PMID 29907415
83: Walker A, Naughton MT, Shaw L, Jeklin AT, Martin C, Dabscheck E. Depression scores improve with continuous positive airway pressure in specialized sleep clinics: real-world data. J Clin Sleep Med 2021;17(6):1201-9. PMID 33590822
84: Walker MP. The role of sleep in cognition and emotion. Ann N Y Acad Sci 2009;1156:168-97. PMID 19338508
85: Wang J, Chau SW, Lam SP, et al. Prevalence and correlates of REM sleep behaviour disorder in patients with major depressive disorder: a two-phase study. J Neurol Neurosurg Psychiatry 2022;93(9):1010-17. PMID 34764151
86: Xu F, Wang X, Yang Y, et al. Depression and insomnia in COVID-19 survivors: a cross-sectional survey from Chinese rehabilitation centers in Anhui province. Sleep Med 2021;S1389-9457(21)00093-9. PMID 33627300
87: Xu M, Yin X, Gong Y. Lifestyle factors in the association of shift work and depression and anxiety. JAMA Netw Open 2023;6(8):e2328798. PMID 37578795
88: Zamarian L, Högl B, Delazer M, et al. Subjective deficits of attention, cognition and depression in patients with narcolepsy. Sleep Med 2015;16(1):45-51. PMID 25434299
89: Zhao J, Liu H, Wu Z, et al. Clinical features of the patients with major depressive disorder co-occurring insomnia and hypersomnia symptoms: a report of NSSD study. Sleep Med 2021;81:375-81. PMID 33813234
90: Zhong X, Liu Y, Pu J, et al. Depressive symptoms and quality of life among Chinese medical postgraduates: a national cross-sectional study. Psychol Health Med 2019;24(8):1015-27. PMID 31179736
91: Zhou Q, Yu C, Yu H, et al. The effects of repeated transcranial direct current stimulation on sleep quality and depression symptoms in patients with major depression and insomnia. Sleep Med 2020a;70:17-26. PMID 32179428
92: Zhou SJ, Wang LL, Yang R, et al. Sleep problems among Chinese adolescents and young adults during the coronavirus-2019 pandemic. Sleep Med 2020b;74:39-47. PMID 32836185

Contributors

All contributors' financial relationships have been reviewed and mitigated to ensure that this and every other article is free from commercial bias.

Author

Federica Provini MD

Dr. Provini of the University of Bologna and IRCCS Institute of Neurological Sciences of Bologna received speakers' fees from Idorsia, Italfarmaco, and NeoPharmed Gentili Spa.
See Profile

Editor

Antonio Culebras MD FAAN FAHA FAASM

Dr. Culebras of SUNY Upstate Medical University at Syracuse has no relevant financial relationships to disclose.
See Profile

Former Authors

Wallace Mendelson MD (original author), Sinan Baran MD, Michael J Rack MD, and Maria Alessandria MD

Patient Profile

Age range of presentation: 2 to 65+ years
Sex preponderance: male=female
Heredity: heredity may be a factor
Population groups selectively affected: none selectively affected
Occupation groups selectively affected: none selectively affected

ICD & OMIM codes

ICD-9: Major depressive disorder: 296.2, 296.3
ICD-10: Severe depressive episode without psychotic symptoms: F32.2

Recurrent depressive disorder, unspecified: F33.9

Bipolar affective disorder: F31

Organic mood [affective] disorders: F06.3

This is an article preview.
Start a Free Account
to access the full version.

Nearly 3,000 illustrations, including video clips of neurologic disorders.
Every article is reviewed by our esteemed Editorial Board for accuracy and currency.
Full spectrum of neurology in 1,200 comprehensive articles.
Listen to MedLink on the go with Audio versions of each article.

Questions or Comment?

MedLink®, LLC

3525 Del Mar Heights Rd, Ste 304
San Diego, CA 92130-2122

Toll Free (U.S. + Canada): 800-452-2400

US Number: +1-619-640-4660

Support: service@medlink.com

Editor: editor@medlink.com

ISSN: 2831-9125

Sleep and depression

Associated Disorders

Hypersomnolent depression
Sleep disorders associated with bipolar disorders
Sleep disorders associated with major depression
Sleep disorders associated with mania
Sleep disorders associated with seasonal affective disorder

Differential Diagnosis

psychophysiological insomnia
inadequate sleep hygiene
idiopathic insomnia
sleep disorders associated with anxiety disorder
periodic limb movements
- obstructive sleep apnea
- sleep disorders associated with medical disorders (eg, carcinoma of the pancreas)
- sleep disorders associated with alcohol use and abuse
- sleep disorders associated with anorexia nervosa
- dementia
- sleep disorders associated with neurologic disorders
- sleep disorders associated with psychiatric illness

Also Relevant

Delayed sleep phase syndrome
Depression after stroke
Drug-induced parasomnias, sleep apnea, and restless legs syndrome
Inadequate sleep hygiene
Insufficient sleep syndrome
- Sleep and alcohol use and abuse
- Sleep and parkinsonism
- Sleep disorders
- Sleep and medical disorders
- Sleep and mental disorders
- Sleep, stroke, and vascular dementia

Clinical Categories

Sleep Disorders

	• Major depressive disorder is one of the most common mental disorders.
	• Women are 70% more likely than men to experience depression during their lifetime.
	• Self-reported insomnia symptoms are present in more than 50% of individuals with a major depressive episode (76).
	• Hypersomnia occurs in roughly 30% of patients with major depressive disorder (41).

Sleep and depression

Sleep and depression

Introduction

Overview

Key points

Historical note and terminology

Clinical manifestations

Presentation and course

Prognosis and complications

Clinical vignette

Biological basis

Etiology and pathogenesis

Epidemiology

Prevention

Differential diagnosis

Confusing conditions

Diagnostic workup

Management

Outcomes

Special considerations

Pregnancy

References

Contributors

Author

Editor

Former Authors

Patient Profile

ICD & OMIM codes

This is an article preview.
Start a Free Account
to access the full version.

Questions or Comment?

Also in This Category

Hypersomnolence

Fatal familial insomnia

Central sleep apnea

Sleep and mental disorders

Sleep paralysis

Sleep and epilepsy

Narcolepsy

Confusional arousal

	• Clinical history is mandatory to establish the diagnosis.
	• Polysomnography is neither specific nor sensitive enough to diagnose depression.
	• Actigraphy, a noninvasive method for monitoring motor activity, can be used to objectively assess circadian rest-activity rhythms and sleep patterns in patients with depression.

Sleep and depression

Introduction

Overview

Key points

Historical note and terminology

Clinical manifestations

Presentation and course

Prognosis and complications

Clinical vignette

Biological basis

Etiology and pathogenesis

Epidemiology

Prevention

Differential diagnosis

Confusing conditions

Diagnostic workup

Management

Outcomes

Special considerations

Pregnancy

References

Contributors

Author

Editor

Former Authors

Patient Profile

ICD & OMIM codes

This is an article preview. Start a Free Account to access the full version.

Questions or Comment?

Also in This Category

Hypersomnolence

Fatal familial insomnia

Central sleep apnea

Sleep and mental disorders

Sleep paralysis

Sleep and epilepsy

Narcolepsy

Confusional arousal

This is an article preview.
Start a Free Account
to access the full version.