‘Sleep and Mental Health’ first appeared in Mental Health Todayin April 2011. To subscribe to the magazine click here.
Sleep and mental health are interlinked, and treating problemswith one can help the other, but this link is stillunder-recognised.
Dr Dan Robotham, senior researcher at the Mental HealthFoundation
Sleep is essential to human life. On average, we spend a third ofour life asleep. Sleep regenerates our brains and bodies, andwithout it we cannot function effectively. During sleep the bodyundergoes several physiological and psychological processes;processing information, learning and consolidating memories. Notgetting enough sleep leads to the build-up of a sleep debt, onlyrepayable through sleeping.
Keeping a regular sleep pattern is important. This relates to theregularity and timing of our sleep. Sleeping at set times each dayenables the body to establish a routine, increasing the need forsleep at that time each day. This is based on a mechanism calledour internal circadian rhythm.
Furthermore, the type of sleep we get is important. Broadly, thesleep phases include light sleep, deep sleep and rapid eye movement(REM) sleep. Light sleep is the bridge between being asleep andbeing awake, and the sleeper is easily woken during this phase.Deep sleep is thought to be the most refreshing type of sleep, andit is here that the sleeper is most difficult to waken. REM sleepis a relatively shallow stage in which we experience dreams. REMsleep is thus named because the sleeper moves their eyes whilst inthis phase, as if following the images of a dream.
Mental health and sleep
Mental health and sleep are interlinked. Insomnia is the mostcommonly reported mental health complaint in the UK (Singleton etal, 2001). Mental health problems can affect the amount of sleep,the type, and the time spent in various sleep phases.
People who suffer from depression may experience sleep disturbanceswhich disrupt the process of falling and staying asleep. Thesleeper may wake intermittently throughout, or wake early in themorning and be unable to sleep again (Holsboer-Trachsler &Seifritz, 2000).
Roughly 15-40% of people with depression oversleep (Quitkin, 2002),which is possibly worsened by some antidepressants acting assedatives. Sleep-related disorders such as periodic limb movementdisorder and restless legs syndrome can arise as side effects ofantidepressants (Picchietti & Winkelman, 2005). People withdepression also spend more time in REM sleep and have more frequentrapid eye movements (Lauer et al, 1991). Many antidepressants aimto limit REM sleep (Dunleavy et al, 1972).
People who suffer from bipolar disorder may experience disruptedcircadian rhythms, which affects sleep patterns and may lead tosleeping at irregular times throughout the day. Furthermore,changes in circadian rhythms may trigger bipolar disorder (Kupferet al, 1988).
Insomnia can be a common complaint in people who suffer fromschizophrenia (American Psychological Association, 1994); peoplewith schizophrenia may reach deep sleep and REM sleep later (Monti& Monti, 2005), and some such medications affect the ability tomaintain sleep.
Anxiety is perhaps the most obvious example of how mental healthcan affect sleep. Many of us have experienced sleepless nights dueto worrying about upcoming events. People with anxiety experiencesuch feelings often, and to the extent where they can severelyaffect a person’s daily life. People who suffer from anxiety tendto spend less time in deep sleep (Monti & Monti 2000).
Anxiety is also an underlying cause of teeth grinding during thenight; roughly 70% of people who ground their teeth attributed itto stress and anxiety (Manfredini et al, 2005). Anxiety may alsocontribute to recurrent nightmares. For example, people who sufferfrom post-traumatic stress disorder, a type of anxiety, may havedisturbed REM sleep and can experience distressing dreams ornightmares as a consequence of past traumas (Habukawa et al,2007).
Sleep and mental health
Good sleep is fundamental to good mental health, just as goodmental health is fundamental to good sleep. Symptoms of poor sleepinclude fatigue, sleepiness during daytime, poor concentration,irritability and memory loss.
Poor sleep can make people less receptive to positive emotions(Woodson, 2006) in turn making them feel down during the day. Ahistory of insomnia has been shown to increase the risk ofdeveloping depression (Cole & Dendukuri, 2003; Riemann &Vodelholzer, 2003).
Mental state is paramount in allowing or preventing insomniadeveloping into a chronic problem. Anxiety about sleeplessness canmake sleeping more difficult. Anyone who has ‘watched the clock’throughout the night will recognise this. The clock is used as agauge to monitor sleep performance. The pressure to achieve sleepturns into a type of ‘performance anxiety’, which in turn makes itmore difficult to sleep. Such thoughts perpetuate a negative cycleover time.
This is why therapies that aim to challenge negative thoughts aboutsleeping and re-establish good sleep patterns are most effectivefor
treating chronic insomnia. There is comprehensive evidence tosuggest that cognitive behavioural therapy (CBT) is effective inthis context. Across 85 clinical trials (and 4,194 participants),it was associated with improvement in 70% of cases (Morin et al,2006; 1999).
A comprehensive CBT approach for insomnia includes a sleep hygieneregime, relaxation training, attention to sleep patterns, andattention to thoughts and behaviours that hinder sleeping (Perliset al, 2011). Full CBT courses delivered by trained sleeppractitioners can be intensive. Still, as few as four CBT sessionsmay be effective for less complex cases of insomnia (Edinger et al,2007). Simple CBT-based interventions such as information bookletsand internet courses may help if the insomnia has not become toosevere or long-lasting.
Sleep hygiene refers to lifestyle and environmental factors thatcan affect sleep. Substances like caffeine, nicotine and alcoholhave an effect. The environment of our bed and bedroom can help orhinder sleep; noise, light, temperature, ventilation. Positivesleep hygiene may help to improve sleep quality, but will not treatchronic insomnia.
Relaxation is also an important element of CBT. The art of relaxingmay require patience, discipline and practice. People with insomniaoften find it difficult to relax before and during bedtime.Relaxation training involves paying attention to breathing andmuscle tension. People who have trouble sleeping should aim to’wind down’ with relaxing activities at least an hour before goingto bed.
Someone who wishes to overcome insomnia must break the link betweentheir negative thoughts about bedtime, and how they feel aboutthese thoughts. CBT aims to question the assumptions behind ourthoughts, reconfiguring links between thoughts and emotions. Forexample, even people with insomnia get some sleep on most nights,but tend to underestimate the amount of sleep they have had.Thinking about sleep in a negative way increases anxiety about notsleeping, and subsequent emotional consequences feedback intothoughts, making sleep ever more difficult.
CBT approaches encourage not pressurising oneself to ‘achieve’sleep, instead taking practical steps to help adjust to theprocess. The absence of effort allows good sleepers to sleepeasily. They treat sleep as an automatic process that happens whenthey go to bed. In other words, they do not spend time thinkingabout sleep, or about the need to sleep.
On the other hand, people with insomnia often place undue pressureon themselves to sleep. To this end, CBT uses a technique calledparadoxical intention. Someone who is finding it difficult to sleepwould be advised to remain awake passively, reducing the effortspent forcing sleep yet maintaining the commitment to get tosleep.
In order to sleep, the bed and bedroom need to be psychologicallyassociated with sleeping, not with sleepless nights. Lying in bedawake, thinking or worrying, is never conducive to sleeping.
In these circumstances CBT recommends getting up, leaving the roomand engaging in a relaxing activity elsewhere, returning to bedwhen sleepy. Spending significant time in bed without fallingasleep strengthens the association between the bedroom andsleeplessness, making the act of getting to sleep more difficult.Getting out of bed may seem counterproductive, but in the long-termit allows reestablishment of the psychological connection betweensleeping and the bedroom environment.
Creating a healthy, regular sleep pattern is perhaps the mostchallenging aspect of CBT for insomnia. People with insomnia oftenhave inappropriate sleep patterns. Keeping a sleep diary will helpgauge the amount of time spent sleeping per night. Following this,a person needs to set a bedtime and waking time based on theaverage amount of time they spend asleep each night. For example,someone who gets an average of five and a half hours sleep pernight may want to set their alarm for time 7:00am and go to bed at1:00am. This leaves a six-hour period in the day in which theperson can sleep. This sleep window can be increased gradually ifthe person begins to sleep sufficiently into this pre-determinedtime.
Conclusion
Sleep is a complex process that is crucial to good mental andphysical health. It is important to recognise the link betweensleep and mental health; people who visit sleep disorder clinicscomplaining of insomnia may have underlying mental health problems.In such cases, the mental health problem needs to be treatedalongside the insomnia.
Sleeping poorly increases the risk of poor mental health. Theimportance and benefits of sleep for mental and physical healthshould be highlighted in national and local public healthcampaigns, including schools and workplaces. There is a dire needfor people to begin to take sleep seriously as a healthconcern.
References
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