Sleep and its discontents

We have all heard the common refrain of, ‘I didn't get any sleep last night.’ In fact, I’d hazard a guess that we’ve all uttered something close to this at some point in our lives. Truth be told, it’s usually hyperbole because, of course, you got some sleep last night — it’s more the quality (or lack thereof) of sleep that we’re bemoaning.

Whatever the quality or quantity of one’s sleep, reality is, we need it, and many of us suffer from an absolute poverty of sleep. For me personally, a poverty of sleep does not accurately describe my relationship with sleep. To torture the metaphor, I am years behind on sleep payments and close to sleep insolvency. Research suggests I’m not alone.

A paper published in Journal of Clinical Sleep Medicine in 2019 reports that around one-third of adults identify at least one or more of the symptoms of insomnia.¹

Not to be outdone by their older counterparts, a 2021 survey found that more than 50 percent of 17 to 20 year olds reported sleep issues three or more of the last seven nights. Teens and preteens didn’t fare much better.²

It appears as though the sleep thief is an equal opportunities offender, indiscriminately besetting us at that most inopportune of times – bedtime.

Do all these sleepless nights matter? Do we even need to sleep so much? Didn’t Steve Jobs only sleep three hours a night? I’m not here to audit the sleep schedules of the uber-successful, except to say that, I too would sleep very little if it meant my bank balance were as healthy as Jobs’s.

The myth of the night-owl billionaire is not what I want to focus on. These are selective cases at best, suffering from all the endemic biases associated with any retrofitting of success to certain attributes. No, instead, I want to focus on why some of us can’t sleep and what effect this can have on our mental health.

The Complex Interplay Between Sleep and Mental Health

The CDC reports that being awake for 24 hours is the equivalent of having a blood alcohol level higher than what would fail you in the US.³ That is to say, you may not be drunk, but you sure as hell are driving as though you are.

Research in this area offers various accounts of the impact of sleep deprivation on people’s ability to function cognitively. In fact, daytime functional impairment forms part of the diagnostic criteria for insomnia.⁴ Sleep deprivation clearly creates somewhat of a cerebral tempest, and this is no more apparent than in its association with mental health.

It’s not difficult to comprehend the fact insomnia would have effects on one’s mental health. Anyone who has experienced even minimal sleep deprivation will know they’re not firing on all cylinders. The question then becomes, is this relationship borne out by the research?

The answer is yes, no, and we don’t know. The bidirectional nature of sleep and depression, for example, could mean one or more of many things: insomnia causes depression; depression causes insomnia; they both act on each other, or there is no causative relationship and they just happen to neatly track each other.⁵

A paper published in the journal Sleep reports that people with insomnia are roughly 10–17-fold more likely to experience depression and anxiety, respectively.⁶ This is an association (a very strong one) but offers very little in the way of a causative mechanism, or a direction of that mechanism, for that matter.

However, this research is buttressed by a large body of research; 21 longitudinal studies showed that insomniac participants were twice as likely to develop depression from baseline to follow-up.⁷ While this research does show a directional association – from insomnia to depression – it doesn’t rule out the potential of a bidirectional causative relationship.

There are various other comorbidities associated with sleep and we’re likely to be only scratching the surface in terms of causative mechanisms.^8,9

The COVID-19 pandemic certainly hasn’t helped the problem, with some populations reporting worse sleep outcomes and mental health. It will come as no surprise that healthcare workers predominately fell victim to sleep issues (and correlative mental health issues) during the pandemic.

A systematic review and meta-analysis illustrated a high prevalence of insomnia, depression, and anxiety in these populations.¹⁰ The people we most need to be fully alert – those treating these very issues – are the last ones we want to be plagued with these maladies.

It appears that the high prevalence of sleep problems and mental health concerns are here to stay for the foreseeable future. A very important question thus emerges, are there any effective solutions?

Is insomnia – and its attendant issues – treatable?

Sleep and its attendant issues have been around since time immemorial. The scientific methods are younger, to be sure, but there is – and continues to be – swathes of research dedicated to a better night’s sleep.

Cognitive behavioural therapy (CBT) is the de jure treatment for various mental health afflictions. Like much of the research in this field, it has met with varying degrees of success for insomnia and mental health.

As explained above, it is difficult to tease apart what is causing what. A recent meta-analysis of insomnia treatments on depression suggested that there were positive clinical effects (although they were relatively weak and did not reach statistical significance) in treating insomnia with CBT.¹¹

Koffel et al., in a 2014 meta-analysis on the effects of group cognitive behavioural therapy for insomnia (CBT-I), are more optimistic regarding CBT-I: “It is well-documented that CBT-I is an effective treatment for insomnia that results in durable improvements in sleep.” The authors add that the group nature of the therapy in this meta-analysis, “can increase the efficiency of delivery,” perhaps resulting in more people being treated.¹²

To deviate from the research momentarily, I’m not convinced that group therapy for people with insomnia is an unalloyed good. I participated in group therapy and my experience was one of anxiety and isolation. I did not find it to be a productive environment and, if anything, it may have added to my sleep problems (I cannot prove this).

There are also a number of pharmacological interventions, such as zopiclone actavis. It has been shown to have clinical effects but is recommended for transient use only.¹³ This is of little value for those – me included –  who are chronically suffering.¹⁴

My personal experience on zopiclone has been anything but transient. The guidance states that patients should be treated for a maximum of 2 to 4 weeks.¹³ I have been on zopiclone every night for the last 11 years (no exaggeration).

The positive effects have tapered downwards over time. It no longer puts me to sleep within 15 minutes and getting to sleep is now a drawn-out process that makes bedtime a battle of attrition every night.

The cruel irony for me is that while insomnia can cause episodic memory loss, a side effect of zopiclone is that it can also cause a loss of memory including retrograde amnesia and anterograde amnesia – I have noticed (as have those close to me) memory lapses on occasion.

This is my experience, the only experience I am qualified to speak to. As with any treatment, there are trade-offs that need to be considered.¹³

The complex nature of insomnia and depression (and other morbidities) means that the jury is still out on these treatments. There are several other treatments that I haven’t touched on here – such as melatonin, benzodiazepines, and sleep hygiene – but I’ll save those for another time.¹⁵

Insomnia and concomitant depression are likely to be evergreen issues. The takeaway, as always, is more research is needed, and we night-owls will continue to wait patiently for a solution.

Sweet dreams.

References

1. Roth T. Insomnia: definition, prevalence, etiology, and consequences. J Clin Sleep Med. 2007;3(5 Suppl):S7-S10.
2. Mental Health of Children and Young People in England, 2021 Wave 2 follow up to the 2017 survey. NSA Digital. Available at https://files.digital.nhs.uk/97/B09EF8/mhcyp_2021_rep.pdf. Accessed May 2023.
3. Risk from not getting enough sleep: Impaired Performance. Centers for Disease Control. Available at https://www.cdc.gov/ Accessed May 2023.
4. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM5). Arlington, VA: American Psychiatric Association, 2013.
5. Fang H, Tu S, Sheng J, Shao A. Depression in sleep disturbance: A review on a bidirectional relationship, mechanisms and treatment. J Cell Mol Med. 2019;23(4):2324-2332.
6. Chai, Y., Fang, Z., Yang, F.N. et al. Two nights of recovery sleep restores hippocampal connectivity but not episodic memory after total sleep deprivation. Sci Rep 10, 8774 (2020)
7. Baglioni C, Battagliese G, Feige B, et al. Insomnia as a predictor of depression: a meta-analytic evaluation of longitudinal epidemiological studies. J Affect Disord. 2011;135(1-3):10-19.
8. Harvey A.G., Jones C., Schmidt D.A. Sleep and posttraumatic stress disorder: a review. Clin Psychol Rev. 2003;23(3):377–407.
9. Lauer C.J., Krieg J.-C. Sleep in eating disorders. Sleep Med Rev.2004;8(2):109–118.
10. Pappa S, Ntella V, Giannakas T, et al. Prevalence of depression, anxiety, and insomnia among healthcare workers during the COVID-19 pandemic: A systematic review and meta-analysis [published correction appears in Brain Behav Immun. 2021 Feb;92:247]. Brain Behav Immun. 2020;88:901-907.
11. Gebara MA, Siripong N, DiNapoli EA, et al. Effect of insomnia treatments on depression: A systematic review and meta-analysis. Depress Anxiety. 2018;35(8):717-731.
12. Koffel EA, Koffel JB, Gehrman PR. A meta-analysis of group cognitive behavioral therapy for insomnia. Sleep Med Rev. 2015;19:6-16.
13. Zopiclone Actavis New Zealand Data Sheet. Available at https://www.medsafe.govt.nz/ Accessed May 2023.
14. Edinger JD, Arnedt JT, Bertisch SM, et al. Behavioral and psychological treatments for chronic insomnia disorder in adults: an American Academy of Sleep Medicine systematic review, meta-analysis, and GRADE assessment. J Clin Sleep Med. 2021;17(2):263-298.
15. De Crescenzo F, D'Alò GL, Ostinelli EG, et al. Comparative effects of pharmacological interventions for the acute and long-term management of insomnia disorder in adults: a systematic review and network meta-analysis. Lancet. 2022;400(10347):170-184.