Insomnia and Depression: Common Misconceptions and Evidence-Based Treatment

Having trouble sleeping? And feeling depressed? You are not alone. Insomnia and depression are closely connected and also, often misunderstood.

It is estimated that 10-15% of the population struggles with chronic insomnia (lasting more than 3 months) and 7-13% have had at least one major depressive episode. These estimates are based on pre-pandemic numbers and likely there are significant increases in depression and sleep problems since COVID-19 started. Further, about ¾ of depressed patients suffer from insomnia symptoms.

When it comes to insomnia and depression, there are some important misconceptions. And if we can better understand what we’re getting wrong, we can improve outcomes for both of these disorders.

Insomnia is a Symptom of Depression

Conventional wisdom tells us that insomnia is a symptom of depression. In the past, we believed that if you are depressed, you may have difficulty falling or staying asleep, or you might sleep too much. And while these two conditions often go hand-in-hand, the relationship may be different than we previously thought.

New research shows that insomnia is not just a symptom of depression and that insomnia and depression are separate but interrelated disorders. In fact, insomnia and other sleep problems tend to arise before a period of depression occurs and can often serve as a warning sign. A 2011 study showed that non-depressed people with insomnia were twice as likely to develop depression compared with normal sleepers. Chronic insomnia often exists for months or years, prior to the depression.

If we can see insomnia as a co-morbid condition, or even an indicator of depression, then we can treat insomnia first, resulting in better clinical outcomes for depression.

Treat the Depression and Insomnia will Improve

If a patient reports depressive symptoms, along with insomnia, it is common for doctors to prescribe antidepressants to treat both conditions. The hope is that insomnia will improve with anti-depressant medication, like SSRIs, for instance.

But research shows that treating depression only may not improve insomnia. A 2007 study found that sleep disturbance persisted, even after treatment for depression in over half of patients. And left-over insomnia can be predictive of depression relapse.

Sleep Deprivation Causes Depression

It is commonly thought that a good night’s sleep can help with depressive symptoms. Doctors often warn against sleep deprivation of any kind and may recommend 8 hours of sleep per night. For patients with depression, hearing advice like this may actually exacerbate insomnia.

The belief that sleep will aid in symptoms of depression is far from true. Sleep deprivation is in fact, a quick and efficient way to treat depressive symptoms. Either partial or total sleep deprivation for one night works 45-50% of the time on symptoms of depression, which is often better than medication. And for some depressed patients who don’t respond to medication, sleep deprivation can help. The caveat is that sleep deprivation is a short-term treatment for depression and many symptoms re-appear when normal sleep resumes. This is where CBT-i should be considered.

CBT-i for Insomnia and Depression

In 2016, the American College of Physicians recommended CBT-i as a first-line treatment for chronic insomnia. CBT-i is well-established as an effective insomnia treatment, but what about depression?

There is growing evidence that CBT-i not only treats insomnia but is an effective treatment for depression. A 2017 study showed that CBT-i significantly improved depressive symptoms, more than the group taking anti-depressants. Another 2008 study showed that antidepressant therapy along with CBT-i had a 62% remission rate, as compared with 33% in the only antidepressant group. Other studies have shown that just 4 sessions of CBT-i can help depression. And there is evidence that CBT-i provides a longer-lasting benefit to symptoms of depression.

Treat the Insomnia

There are clear implications for how we should treat both insomnia and depression. Therapists and physicians alike should consider directly treating insomnia in order to improve depression.

It can be difficult to have both insomnia and depression, but the good news is that there is a short-term treatment that works for both. At DC Metro Sleep and Psychotherapy, we are experienced in providing CBT-i. Contact us for a free consultation to learn if CBT-i is right for you.

Annie Miller is a licensed psychotherapist in private practice in the Washington DC area. Annie specializes in working with insomnia (CBT-i)trauma (EMDR)teen mental healthanxiety disorders, and chronic pain. Interested in learning more about Insomnia Treatment? Check out DC Metro Sleep and Psychotherapy’s Insomnia Treatment Page.

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