How Insomnia and Depression are linked

A few months into the pandemic, Héctor González*, 57, visited the Álava Reyes Psychology Centre in Madrid. He had developed insomnia in response to the widespread fear and uncertainty of the virus.

According to the centre’s director,  psychologist María Jesús Álava Reyes, the corporate executive would fall asleep easily at bedtime but awaken two or three hours later with worrisome thoughts that kept him restless.

Eventually he’d nod off, then arise for the day two hours early, preoccupied with negative thoughts. Over time, the lack of sleep soured his mood and his ability to function. 

“Insomnia produced very high levels of anxiety, which led to frequent frustration, and a weariness that ended up leading to depression”, says Álava Reyes about González.

Thomas Müller-Rörich, who lives near Stuggart, Germany, fell into a depression while visiting Sardinia with his family back in 1992, when he was 38. Thomas found himself inexplicably unhappy, irritable, and tense. He yelled at his children for playing noisily and picked fights with his wife over nothing. 

After returning home, his mood didn’t lift; he lost his appetite and couldn’t concentrate at the electrical engineering firm that he ran. Two years later, he was formally diagnosed with depression. Shortly thereafter he began experiencing insomnia, awakening at 4am with anxious feelings that prevented him from falling back asleep, which was making it even harder for him to be productive during the day.

“The combination of depression and insomnia definitely made things worse”, says Müller-Rörich, who is now 67. He adds: “I felt empty and numb, that everything I had done in life was wrong.”

It’s becoming increasingly clear that insomnia and depression are linked. A widely cited 2011 meta-analysis from researchers in Freiburg, Germany, showed that insomnia doubles the risk of developing depression compared with those who have no sleep difficulties.

And in 2020, follow-up research found that the conditions have a bi-directional relationship, and that early treatment for insomnia may help to prevent depression, although more study is needed. 

Both insomnia and depression affect many across Europe. Between six and ten per cent of European adults have chronic insomnia, the most common sleeping disorder.

About four per cent of adults experience depression, the second most common mental health disorder in Europe. And some people, including Thomas Müller-Rörich and Héctor González, experience both simultaneously. 

“Sleep disorders and depression often occur together,” says psychotherapist and somnologist Dr Hans-Günter Weess, head of the Interdisciplinary Sleep Centre of Pfalzklinikum in Klingenmünster, Germany. “Up to 80 per cent of depressions are accompanied by sleep disorders. They’re like siblings.” 

And about half of people with insomnia report symptoms of depression. “Their risk of developing depression is up to three times higher, compared with people without sleep disorders", he adds.

Both conditions can negatively affect health: people with chronic insomnia are more likely to have weaker immune systems and get sick more often, and they’re at greater risk of high blood pressure, Type 2 diabetes, and heart disease. People with chronic depression are more likely to experience stress, chronic pain, or weight gain, and they may also be at the risk of misusing drugs or alcohol. 

People may not always know which came first, insomnia or depression, but it isn’t necessary to be sure. Research shows that treating one condition may improve symptoms of both. 

“It’s not so much a case of the chicken or the egg, what caused what,” says Dr Dan Chisholm, programme manager on mental health for the World Health Organisation’s European office in Copenhagen. Chisholm adds: “The things that might help are going to help both of those conditions.”  

Why insomnia may increase the risk of depression

People with insomnia may have trouble shutting down their minds when it's bedtime. 

“They have very frequent, brief wake-reactions all the time”, says Dieter Riemann, head of clinical psychophysiology at Freiburg University’s Medical Centre and founder of the European Insomnia Network. Reimann co-authored the 2011 and 2020 studies mentioned earlier.

“Usually, if you’re a good sleeper, your whole brain and all relevant brain centres go into a sleep state. We assume that in insomnia, some parts of the brain do not sleep as deeply.” 

Repeatedly losing sleep this way can affect your mood. “In your waking hours, you’re more likely to be irritable, a bit exhausted, a bit less likely to want to interact socially", says Dr Chisholm. 

If you find yourself staring at the clock all night, panicking that you’ll be a wreck tomorrow, you may feel powerless to help yourself.  “We want to have control over everything, but you can’t control your sleep; sleep is involuntary”, Riemann says. “Chronic insomnia means feeling helpless. And feeling helpless is a common feature of depression.” 

Why depression may increase the risk of insomnia

One classic symptom of depression is altered sleep habits. Many people with depression experience insomnia as a matter of course. 

“Often, depression is diagnosed through a checklist, and that includes sleeplessness as well as irritability, feelings of sadness and so on,” says Dr Chisholm. “There’s a clear relationship, in that sense, between depression and one of its underlying symptoms.” 

Sometimes, traumatic life circumstances elicit such strong responses that people may suffer from both depression and insomnia. “Someone may be in a state of psychological grief or stress that causes depression symptoms and insomnia symptoms, says Dr Alexander Sweetman, a research associate who studies insomnia at Flinders University in the Australian city of Adelaide.

“The pandemic has led to an increase of mental health problems covering depression and insomnia,” Riemann adds. “It’s fear-associated: Can I get infected? The lockdown. The social consequences. The economic consequences. And many people have worked from their home, so the structure of their lives was altered.” 

Treatments are available for both conditions

Coping with insomnia or depression by itself may seem draining; having both problems simultaneously may feel like a great challenge. But there are many resources to help you find relief. Whenever possible, it's important to seek treatment for both conditions. 

“If you have severe depression coupled with insomnia, you should not neglect the insomnia”, Riemann advises. “Many doctors will say, ‘OK, I’ll give you a sleeping pill for a week or so.’ But there’s no special attention paid to it. It’s good to have an eye on both.” 

Treatments for one condition may help to alleviate both, but this isn’t always the case. This is why doctors recommend treating both insomnia and depression, if you realise that you have both conditions. If you don’t realise that you have both, treating one disorder may still help. Experts recommend these following treatments:

Catch insomnia early.

The 2011 German study suggests insomnia may be an early sign of depression, and that people with chronic insomnia may inadvertently double their risk of developing depression. 

“There is some evidence that identifying and treating insomnia symptoms early can reduce depression symptoms and also prevent them from becoming worse in the future”, Dr Sweetman makes sure to confirm.
Make lifestyle changes. Modest changes may reduce depression risk and protect against insomnia.

“You don’t need to rush off to see a specialist; some people might end up there, but there are other things we can do to take care of ourselves,” says Dr Chisholm. “Physical exercise is very important for good sleep and protective against depression, as are healthy eating habits and staying off alcohol. Make sure you stay active and go back to the things that interest you and give you pleasure.” 

Opening up to a trusted friend about your struggles with insomnia or a depressed mood may help. “This can often be very therapeutic in its own way”, Dr Chisholm says. He adds: “If there are still issues, then you might need, and want, to seek help from a health professional.” 

Limit sleep medication.

Sleeping pills should be taken only for a short time, if at all, because you may develop a dependence. Plus, the medicine won’t address underlying causes of your insomnia. “A hypnotic works well in the short term,” says Riemann, but it doesn’t do anything to address sleep issues in a sustained way. He adds: "It only helps you when you take it.” 

Seek cognitive behavioural therapy for insomnia (CBT-I).

Learning techniques to help you sleep more effectively may help with both insomnia and depression. The European Sleep Research Society recommends CBT-I for adults with chronic insomnia. 

“Studies show that CBT-I for insomnia not only improves sleeplessness, it also helps those patients with depression as well,” says Dr Weess, a board member of the German Sleep Society. “Specific behavioural therapy techniques such as thought-stopping, and physical and mental relaxation techniques, have a positive effect on both disorders.” 

Therapists who administer CBT-I may suggest that you stop napping, create a calming bedtime routine, avoid looking at the clock while you’re in bed, use your bed only for sleep and sex, get out of bed to read or do something relaxing if you can’t fall asleep, and always get up at the same time each morning.

After Héctor González from Madrid sought help for his insomnia and depression, his therapist recommended that he shower and read in the evening, instead of watching television. He was advised that if he awoke in the middle of the night and didn’t fall asleep within 15 minutes, he should go into another room and read. He also began taking anti-anxiety medication. 

“As soon as he managed to have restful sleep, in parallel he started to decrease his anxiety levels, and in a few weeks he overcame his depressive crisis,” Álava Reyes says. “It was very clear to him that the key to his recovery was through eventually overcoming his insomnia.” 

Consider therapy and antidepressants. For depression coupled with insomnia, going for talk therapy and taking antidepressants may improve both conditions. “Sedative antidepressants taken in the evening have proven to be effective in the treatment of depression with insomnia", he says.

Not all antidepressants have the same impact on insomnia. The most common type of antidepressant, selective serotonin reuptake inhibitors (SSRIs), may cause sleep problems in some people.

“Some of them may induce insomnia, maybe in 20 to 30 per cent of subjects,” Riemann points out. “You shouldn’t take these drugs at night. Take them in the morning so that there’s not so much effect on sleep.” 

Thomas Müller-Rörich of Germany found relief from his depression and insomnia after getting psychoanalysis and taking antidepressants and sleeping pills.

He experienced insomnia and depression once more in the early 2000s but recovered again with the help of doctors and medication. He was so pleased by these interventions that he co-founded the German Depression League in 2009, so that more people would know that help is available.

“I was happy to see that depression—and insomnia—are treatable,” Müller-Rörich says. “I became myself again, was able to show my love for my family, and enjoyed work.” 

 If you’re experiencing insomnia and depression, struggling with sleep and with your emotions, it doesn’t matter which problem developed first; seek treatment from your doctor and know that the self-care tips listed above can also be of help in getting you towards a place of recovery and renewed health. 

And as Dr Chisholm says, “Things can and do get better.” 

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