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Harvard Commentaries
Harvard Commentaries
Reviewed by the Faculty of Harvard Medical School

Minding Your Mind Minding Your Mind

Sleep and Mental Health

July 23, 2010

By Michael Craig Miller M.D.

Harvard Medical School

Americans are notoriously sleep deprived. Whether it's stress, financial worries or the Internet keeping people up, 10% to 18% of adults have chronic sleep problems. A study published in the June issue of Neurology found that almost one in five adults suffers moderate to excessive daytime sleepiness. That's a lot of yawning and nodding off!

But people with mental health conditions are even more likely to have problems sleeping: 50% to 80% of patients in a typical psychiatric practice have chronic sleep problems. They are particularly common in patients with anxiety, depression, bipolar disorder and attention deficit hyperactivity disorder (ADHD).

Studies in both adults and children now suggest that while sleep problems may be a symptom of a mental disorder, they can increase the risk for developing some mental illnesses.

The good news is that treating a sleep disorder may help relieve mental symptoms and decrease the risk of getting them in the first place.

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Benefits of Sleep

Brain studies suggest that a good night's sleep helps foster both mental and emotional resilience. Chronic sleep disruptions, however, set the stage for negative thinking and emotional vulnerability.

Normal sleepers cycle between two major categories of sleep every 90 minutes — although the length of time spent in one or the other changes as sleep progresses.

  • "Quiet" sleep – We move through four stages of increasingly deep sleep. Body temperature drops, muscles relax, and heart rate and breathing slow. The deepest stage of quiet sleep produces physiological changes that help boost immune system functioning.


  • REM (rapid eye movement) sleep – This is the period when people dream. Body temperature, blood pressure, heart rate and breathing increase to levels measured when people are awake. Studies report that REM sleep enhances learning and memory, and contributes to emotional health.

Scientists have discovered that sleep disruption impairs thinking and the ability to regulate our emotional reactions. In this way, insomnia may add to the effects of psychiatric disorders, and vice versa.

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Sleep Disorders in Psychiatric Patients

Sleep problems are a common part of these mental health disorders:

Studies show that between 65% and 90% of adult patients with major depression have some kind of sleep problem. Ninety percent of depressed children have a sleep problem. Sleep problems make it more likely that people prone to depression will develop symptoms. They make depression less responsive to treatment (both medication and psychotherapy). And depression is more likely to return even in patients whose mood improves with therapy.

Bipolar disorder
Bipolar disorder leads to two different kinds of sleep issues. During a manic episode (the "up" pole), up to 99% of people have insomnia or want less sleep. In bipolar depression (the "down" pole), however, as many as 75% of patients sleep too much (hypersomnia), while others may experience insomnia or restless sleep. In many cases, when a sleep problem gets worse, it can be a clue that an episode of mania or bipolar depression is about to begin. Lack of sleep can trigger mania.

Worrying is not good for peaceful sleep. Sleep problems affect more than 50% of adults with generalized anxiety disorder. People with (PTSD), panic disorder, obsessive-compulsive disorder or phobias may also have trouble sleeping. People with anxiety take longer to fall asleep and tend to sleep less deeply than people without anxiety. The lack of sleep, in turn, can make anxiety symptoms worse.

Attention deficit hyperactivity disorder (ADHD)
Sleep problems affect one-quarter to one-half of children with ADHD. These children may have difficulty falling asleep, sleep fewer hours, or appear restless during sleep. Sleep disorders can lead to ADHD symptoms such as hyperactivity, inattentiveness and irritability.

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Ways To Improve Sleep

The treatment for insomnia — which is the most common sleep problem — is the same for people with and without a mental health disorder. The basics include a combination of lifestyle changes, behavioral strategies, psychotherapy and drugs, if necessary.

  • Lifestyle changes. Most people know that caffeine contributes to sleeplessness, but so can alcohol and nicotine. Alcohol initially depresses the nervous system, which helps some people fall asleep. But the effects wear off in a few hours and people wake up. Nicotine is a stimulant that speeds heart rate and thinking. Giving up these substances is best, but certainly avoid them before bedtime if you can.


  • Physical activity. Regular aerobic activity helps people fall asleep faster and stay asleep. It also increases time spent in deep sleep. Exercise in the evening makes it harder for some people to fall asleep, so avoid evening exercise if you fit into this category. And leave yourself time to wind down after exercising.


  • Sleep hygiene. Many experts believe that people learn insomnia and the way to overcome the problem is by learning good "sleep hygiene." This term is often used for tips like:
    • Keep a regular sleep-and-wake schedule
    • Use the bedroom only for sleeping or sex
    • Keep the bedroom dark and free of distractions (no computer or television)

    Some experts also recommend sleep retraining. This involves restricting most of the time you spend in bed to sleeping rather than worrying about not sleeping.


  • Cognitive behavioral therapy. People with insomnia tend to become preoccupied with not falling asleep. Cognitive behavioral techniques help them to change negative expectations and build more confidence that they can have a good night's sleep. These techniques can also help people stop the "blame game" of attributing every personal problem during the day to lack of sleep.


  • Relaxation techniques. Meditation, guided imagery, deep breathing exercises and progressive muscle relaxation (alternately tensing and releasing muscles) can quiet anxiety and a mind full of thoughts.

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Medication Options

If non-drug treatments are not enough, sleep medication is an option. In some cases, both a sleep disorder and a psychiatric problem can be treated with one drug.

People with depression and bipolar disorder often see improved sleep when they have their underlying illness treated. For depression, it is often useful to start with or add a sedating antidepressant (such as trazodone or one of the tricylic antidepressants).

A mood stabilizer may normalize sleep in bipolar disorder. Because antidepressants can trigger mania, it is often best to add sleep aids if sleep is not regulated by the mood stabilizer alone.

Many of the standard anti-anxiety medications — benzodiazepines like lorazepam (Ativan) or alprazolam (Xanax) — are also used as sleep medications. But, as with mood disorders, sleep often improves when the anxiety is treated. The opposite is true in ADHD: Stimulants tend to prevent sleep, so they should be taken early in the day.

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A Good Night's Sleep

It's best to take direct aim at sleep problems, rather than treating them as a minor symptom. This may help improve a person's mood, anxiety level and ability to focus. In other words, better sleep may be the route to a better quality of life.

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Michael Craig Miller, M.D. is editor-in-chief of the Harvard Mental Health Letter and an assistant professor of psychiatry at Harvard Medical School. Dr. Miller has an active clinical practice and has been on staff at Beth Israel Deaconess Medical Center for more than 25 years.

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