Depression and anxiety disorders: the relationship with sleep

Why sleep is where these two conditions show up first

In practice, insomnia is what finally brings most patients in, even when the larger problem is mood. That is understandable: not sleeping is a concrete symptom, it can be said out loud, and it carries no stigma. "I think I am depressed" is a far harder sentence, particularly for men and for older people.

So a good insomnia consultation always includes questions about mood and anxiety. Not in order to attach a label, but because treating one side while ignoring the other usually gives a half result followed by a relapse.

Signs of depression

A diagnosis of depression requires symptoms lasting at least two weeks, nearly every day, and affecting daily life. The two core symptoms are low mood and loss of interest, and at least one of the two usually has to be present.

• Persistent sadness, emptiness or hopelessness.
• Loss of interest or pleasure in things you used to enjoy, including very small things.
• Disturbed sleep: insomnia, or sleeping far too much.
• Changes in appetite and weight.
• Fatigue, very little energy left.
• Feeling worthless, or excessive guilt.
• Difficulty concentrating, difficulty deciding.
• Noticeably slowed down, or the opposite, restless and unable to settle.
• Thoughts of death or of harming yourself.

Signs of an anxiety disorder

• Excessive worry about many things, hard to control, lasting months.
• Restlessness, tension, difficulty relaxing.
• Tiring easily, irritable.
• Difficulty concentrating, mind going blank.
• Muscle tension, aching neck and shoulders.
• Disturbed sleep, usually trouble falling asleep because the mind will not stop.
• Panic attacks: racing heart, sweating, trembling, breathlessness, a sense of impending death, rising fast and peaking within minutes.

The anxiety and insomnia spiral

In people with chronic insomnia, the thing that causes the most worry is usually not work or family but sleep itself. Lying down, looking at the clock, counting how many hours are left, dreading how tomorrow will go. Each turn of that loop raises arousal, and high arousal is exactly what blocks sleep. The loop runs by itself and no longer needs any outside cause.

The cognitive part of CBT-I aims straight at this. It does not tell you "stop worrying", because that advice never works. It works on the specific beliefs feeding the spiral, for example the belief that you must get eight hours or tomorrow will be ruined.

Asking someone directly about suicidal thoughts does NOT increase the risk. This is a widespread misunderstanding and it keeps many people silent. That question is usually what opens the conversation that needed to happen.