Not getting enough sleep skews our ability to regulate our emotions. In the long run, this can increase our risk of developing a mental health condition. In turn, conditions such as anxiety and depression may cause further sleep disruption.
Fortunately, there are proven ways to improve sleep quality and break out of this vicious cycle. In this Special Feature, we discuss sleep and its deep relationship with mental health.
More than 400 years ago, William Shakespeare described the gift of sleep and the distress of insomnia:
O sleep! O gentle sleep!
Nature’s soft nurse, how have I frighted thee,
That thou no more wilt weigh my eyelids down
And steep my senses in forgetfulness?
– Henry IV, Part 2
Shakespeare’s description of sleep as “nature’s soft nurse” was closer to the truth than he could have known.
According to the Centers for Disease Control and Prevention (CDC), insufficient sleep increases the risk of type 2 diabetes, cardiovascular disease, and obesity.
Sleep is essential for the physical upkeep of the body, but it also helps maintain cognitive skills, such as attention, learning, memory, and emotional regulation.
Getting a good night’s rest even underpins our ability to perceive the world accurately. Research suggests that going completely without sleep for 3 or more nights in a row results in perceptual distortions, hallucinations, and delusions.
The latest discoveries about the importance of sleep for physical and mental well-being come at a time when technology is putting pressure on sleep time as never before. Social media, the internet, TV on demand, and video games are increasingly keeping us from our beds in the evenings.
The CDC advise that adults get between 7 and 9 hours of sleep a day, with the specific recommendation varying by age.
However, according to the 2012 National Health Interview Survey, almost one-third (29%) of adults in the United States sleep for less than 6 hours each night.
Two-way link to mental health
Poor sleep is a recognized risk factor for the development of a range of mental health issues.
A study that followed 979 young adults in Michigan, for example, found that insomnia was associated with a four-fold higher risk of depression 3 years later.
A review of research found evidence that insomnia preceded the development of not only depression but also bipolar disorder and anxiety disorders. The researchers also found a link between insomnia and an increased risk of suicide.
In 2020, a study published in JAMA Psychiatry identified an association between sleep problems in early childhood and the development of psychosis and borderline personality disorder in adolescence.
As well as increasing the risk of developing mental health problems, sleep disturbances are also a common feature of most mental illnesses, including anxiety, depression, bipolar disorder, and schizophrenia.
Prof. Daniel Freeman, a psychiatrist, and his colleagues at the University of Oxford in the United Kingdom believe that the two-way relationship between sleep problems and poor mental health can result in a downward spiral.
Writing in The Lancet Psychiatry, they say that doctors can be slow to address these issues in people with mental health problems:
“The traditional view is that disrupted sleep is a symptom, consequence, or nonspecific epiphenomenon of [mental ill health]; the clinical result is that the treatment of sleep problems is given a low priority. An alternative perspective is that disturbed sleep is a contributory causal factor in the occurrence of many mental health disorders. An escalating cycle then emerges between the distress of the mental health symptoms, effect on daytime functioning, and struggles in gaining restorative sleep.”
A form of cognitive behavioral therapy for treating insomnia (CBT-I) has proven its worth as a way to tackle this cycle of sleep problems and mental health conditions.
When Prof. Freeman and his colleagues randomly assigned 3,755 students with insomnia from 26 universities in the U.K. to receive either CBT-I or usual care, they found that the treatment was associated with significant improvements.
Students who received CBT-I not only slept better, but they also experienced less paranoia and had fewer hallucinations.
According to a 2015 meta-analysis, CBT-I may also be an effective treatment for anxiety and depression in people with insomnia.
How does CBT for insomnia work?
The treatment involves educating people about sleep and aims to change their sleep-related behaviors and thought processes.
People learn about good sleep hygiene, which involves practices such as limiting daytime naps, avoiding alcohol, nicotine, and caffeine in the evening, and refraining from using digital devices at bedtime.
The behavioral techniques include:
- Sleep restriction: Reducing the time the person spends in bed to match more closely the amount of sleep they need.
- Stimulus control: For example, using the bedroom only for sex and sleeping, going to bed only when sleepy, and getting out of bed after 15–20 minutes of wakefulness.
- Relaxation: For example, tensing and relaxing the muscles while in bed, or focusing on the breath.
The cognitive techniques include:
- putting the day to rest, which involves setting aside time before bed to reflect on the day
- paradoxical intention, or trying to stay awake
- belief restructuring, which means addressing unrealistic expectations about sleep
- mindfulness, in which the person acknowledges their thoughts and feelings before letting them go
- imagery, which requires a person to generate positive mental images
Medical reference: Medical News Today