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The Correlation Between Depression

and Insomnia

Written By :

TIARA RAHMAWATI

030.08.240

FACULTY OF MEDICINE

TRISAKTI UNIVERSITY

JAKARTA, JUNE 2011

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ABSTRACT

Depression classifications include major depressive disorder (MDD), depression with

melancholic or catatonic features, atypical depression, and seasonal affective disorder 

(SAD). In the primary care setting, where many of these patients first seek treatment,

the presenting complaints often can be somatic, such as fatigue, headache, abdominal

distress, or change in weight. (1)

The depressive syndrome is frequently accompanied by a group of vegetative

symptoms, such as decreased appetite or insomnia. Decreased appetite often leads to

some weight loss, although some depressed persons will force themselves to eat

despite decreased appetite, or they may be urged to eat by a parent or spouse so that

the weight loss is minimal. Less frequently, depression expresses itself as a desire to

eat excessively and is accompanied by weight gain. (2)

Insomnia may be initial, middle, or terminal. Initial insomnia means that the patient

has difficulty faliing asleep, often tossing or turning for several hours before dozing

off. Middle insomnia refers to awakening in the middle of the night, remaining awake

for an hour or two, and finally falling asleep again. Terminal insomnia refers to

awakening early in the morning and being unable to return to sleep.

Patients with insomnia will often worry and ruminate while they are lying awake.

Patients who have terminal insomnia may have more severe depressive syndromes.

Depressed patients also may complain of restless sleep, indicating that they have

awakened so frequently throughout the night that they scarcely got any sleep at all. (2)

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INTRODUCTION

A number of long-term demographic studies have indicated that there is a

longitudinal relationship between insomnia and depression.  For example, one study

showed that current insomnia carry a high likelihood of developing depression in the

future.  National Institute of Mental Health (NIMH) Epidemiological Catchment Area

Study results, noted that, over a 1-year period, individuals who had no evidence of 

 psychiatric conditions other than insomnia at study outset were much more likely to

develop new major depression after 1 year when the insomnia persisted compared

with those in whom it resolved. These and similar studies have supported theories of a

causal link between insomnia and major depression, a link in the direction of the

former to the latter. Such theories have been supported by the high comorbidity of the

2 conditions and shared neurophysiological findings, such as cerebral cortical

hyperarousal.

The existence of a causal link between insomnia and depression raises the

intriguing question of whether effective management of insomnia could offer an

opportunity to prevent the future emergence of depressive disorders. Indeed, the

available data suggest that alternative explanations can also be made regarding the

link between insomnia and depression. For example, one of the longitudinal studies

cited above also shows that current insomnia enhances the risk not only for future

depression, but also for substance abuse and anxiety disorders. Another also indicates

that hypersomnia is even a stronger predictor of future depression than insomnia. (3)

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Chapter 1

DEPRESSION

Major depressive disorder is a common disorder, with a lifetime prevalence of 

about 15 percent, perhaps as high as 25 percent for women. The incidence of major 

depressive disorder is 10 percent in primary care patients and 15 percent in medical

inpatients. (4)

Common Causes of Depression(5) 

If you're depressed, it might not be easy to figure out why. In most cases,

depression doesn't have a single cause. Instead, it results from a mix of things. Here

are a few of the things that can play a role in depression :

  Biology. Studies show that certain parts of the brain don't seem to be

working normally. Depression might also be affected by changes in the

levels of certain chemicals in the brain, called neurotransmitters.

  Genetics. Researchers know that if depression runs in your family, you have

a higher chance of becoming depressed.

  Gender. Studies show that women are about twice as likely as men to

 become depressed. The hormonal changes that women go through at

different times of their lives may be a factor.

  Age. People who are elderly are at higher risk of depression. That can be

compounded by other factors (example : living alone and having a lack of 

social support).

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  Health conditions. Conditions such as cancer, heart disease, thyroid

 problems, chronic pain, and many others increase your risk of becoming

depressed.

  Changes and stressful events. It's not surprising that people might become

depressed during stressful times (such as during a divorce or while caring for 

a sick relative) can sometimes trigger depression.

  Medications and substances. Many prescription drugs can cause symptoms

of depression. Alcohol or substance abuse is common in depressed people. It

often makes their condition worse.

Physical Examination(6)

 

 No physical findings are specific to major depressive disorder; instead, the

diagnosis is based on the history and the Mental Status Examination. Nevertheless, a

complete mental health evaluation should always include a medical evaluation to rule

out organic conditions that might imitate a depressive disorder.

Appearance and affect (6) 

Most patients with major depressive disorder present to their physician with a

normal appearance. In patients with more severe symptoms, a decline in grooming

and hygiene can be observed, as well as a change in weight. Patients may show

 psychomotor retardation, which manifests as a slowing or loss of spontaneous

movement and reactivity, as well as demonstrate a flattening or loss of reactivity in

the patient's affect. Psychomotor agitation or restlessness can also be observed in

some patients with major depressive disorder.

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Major Depressive Episode (6) 

Criteria for the diagnosis of major depressive episode are laid out in the Diagnostic

and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-

TR). A major depressive episode is defined as a syndrome in which at least 5 of the

following symptoms have been present during the same 2-week period :

  Depressed mood (For children and adolescents, this can also be an irritable

mood.)

  Diminished interest or loss of pleasure in almost all activities (anhedonia)

  Significant weight change or appetite disturbance (For children, this can be

failure to achieve expected weight gain.)

  Sleep disturbance (insomnia or hypersomnia)

  Psychomotor agitation or retardation

  Fatigue or loss of energy

  Feelings of worthlessness

  Diminished ability to think or concentrate; indecisiveness

  Recurrent thoughts of death, suicidal

  A pattern of long-standing interpersonal rejection ideation, suicide attempt,

or specific plan for suicide.

Depressive disorders can be rated as mild, moderate, or severe. The disorder 

can also occur with or without psychotic symptoms, which can be mood congruent or 

incongruent. Depressive disorders can be determined to be in full or partial remission.

When an episode lasts longer than 2 consecutive years, the depression should be

diagnosed as chronic.

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Chapter 2

INSOMNIA

Insomnia is a sleep disorder that is characterized by difficulty falling and/or 

staying asleep. People with insomnia have one or more of the following symptoms: (7)

  Difficulty falling asleep

  Waking up often during the night and having trouble going back to sleep

  Waking up too early in the morning

  Feeling tired upon waking

Causes of Insomnia(7) 

  Significant life stress (job loss or change, death of a loved one, divorce, 

moving).

  Illness.

  Emotional or physical discomfort.

  Environmental factors like noise, light, or extreme temperatures (hot or 

cold) that interfere with sleep.

  Some medications (for example those used to treat colds, allergies, 

depression,high blood pressure, and asthma) may interfere with sleep.

  Interferences in normal sleep schedule (jet lag or switching from a day to

night shift, for example).

Physical Examination(8)

The physical examination may be helpful because findings may offer clues to

underlying medical disorders that predispose the patient to insomnia.

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If the history suggests sleep apnea, perform a careful head and neck 

examination. Common anatomic features associated with obstructive sleep

apnea/hypopnea syndrome include the following:

  Large neck size (18 inches or greater in males)

  Enlarged tonsils

  Mallampati airway score of 3 or 4.

  Low-lying soft palate, particularly in patients with hypertension or cardiac

disease

Other features include enlarged tongue, retrognathia, micrognathia, or a steep

mandibular angle. An elevated body mass index (BMI) of 30 kg/m2 or higher is also

common.

If the patient reports symptoms of restless legs syndrome or any other 

neurologic disorder, perform a careful neurologic examination.

If the patient reports daytime symptoms consistent with any of the medical

causes of insomnia, a careful examination of the affected organ system (eg, lungs in

chronic obstructive pulmonary disease) may be helpful.

Diagnosing Insomnia(7)

If you think you have insomnia, talk to your health care provider. An

evaluation may include a physical exam, a medical history, and a sleep history. You

may be asked to keep a sleep diary for a week or two, keeping track of your sleep

 patterns and how you feel during the day. Your health care provider may want to

interview your bed partner about the quantity and quality of your sleep. In some

cases, you may be referred to a sleep center for special tests.

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Chapter 3

Depression and Insomnia

Most chronic psychiatric disorders are associated with sleep disturbances.

Depression is most commonly associated with early morning awakenings and an

inability to fall back asleep. Conversely, studies have also demonstrated that insomnia

can lead to depression: insomnia of more than 1-year duration is associated with an

increased risk of depression. (9) 

Insomnia and depression often go hand-in-hand. Although just 15% of people

with depression sleep too much, as many as 80% have trouble falling asleep or 

staying asleep. Patients with persistent insomnia are more than three times more likely

to develop depression.

The relationship between insomnia and depression is far from simple,

however. Until recently, insomnia was typically seen as a symptom of depression, but

new research shows that insomnia is not just a symptom of depression. Insomnia and

depression are two distinct but overlapping disorders. Research shows that by treating

 both simultaneously, doctors have a better shot at improving a patient’s sleep quality,

mood, and overall quality of life. (10)

It can be difficult to distinguish between the occurrence of primary insomnia

or insomnia as a symptom of an underlying psychiatric disorder. Insomnia has been

demonstrated to be a risk factor for major depressive disorder (MDD), dysthymic

disorder, and bipolar disorder. One sleep survey found that more than 40% of patients

reported symptoms of insomnia before the development of a mood disorder.  Another 

study found that unresolved insomnia increases the odds of developing a new

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 psychiatric disorder over the course of 1 year. Some evidence has demonstrated that

treating the underlying symptoms of insomnia may provide beneficial effects toward

reducing or preventing depression.  Thus, it is tempting to predict that aggressive

treatment of insomnia could, in some cases, help prevent the occurrence of depressive

disorders. However, this would require additional study because other data have

suggested that the use of hypnotics themselves may contribute to the incidence of 

insomnia. (11)

Can Insomnia Trigger Depression?(10)

It’s easy to understand how insomnia might be linked to depression. “Chronic

sleep loss can lead to a loss of pleasure in life, one of the hallmarks of depression,”

explains Stanford University research psychologist Tracy Kuo, PhD. “When people

can’t sleep, they often become anxious about not sleeping. Anxiety increases the

 potential for becoming depressed.” 

Indeed, recent findings show that insomnia often shows up before a bout of 

depression strikes, serving as a useful warning sign. A worsening of insomnia can

also signal depression.

But the relationship is far more than simply cause and effect. When depressed

 people suffer from insomnia, their risk of recurring depression is greater than that of 

 patients who don’t have insomnia. So, insomnia may serve as a trigger for depression,

 but it also appears to perpetuate depression.

How Insomnia Treatment Can Ease Depression(10)

The latest findings have helped improve treatment strategies. Evidence shows

that treating sleep problems can ease depressive symptoms and may even prevent

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relapses. In one study, 56 people who suffered both depression and insomnia received

 psychotherapy for their sleep problems alone. The symptoms of depression eased in

more than half of the people, even though their treatment had not targeted depression.

Another study, with 545 patients, found that depressed patients with insomnia

who were treated with both an antidepressant and a sleep medication fared better than

those treated only with antidepressants. The people treated for both insomnia and

depression slept better and their depression scores improved significantly more than

 patients on antidepressants alone.

“Both of these studies offer strong evidence for why it’s so important to treat

insomnia, whether it’s associated with depression, chronic pain, cancer, or other co-

existing disorders,” Perlis tells WebMD. 

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CONCLUSSION

A complex relationship exists between insomnia and depressive disorders.

Increased emphasis should be placed on treating insomnia in depression because it is

a risk factor for depression. Insomnia also plays an important role in the course and

severity of the depressive episode, and persistent insomnia is a risk factor for 

depressive relapse. Treatment strategies should address both depressive symptoms

and insomnia and should consider use of both pharmacologic and nonpharmacologic

strategies.

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BIBLIOGRAPHY

1. 

Halverson JL. Background of Depression. Available at

http://emedicine.medscape.com/article/286759-overview. Accessed on June 12th

2011.

2.  Andreasen NC, Black DW. Introductory Textbook of Psychiatry. 3rd edition.

London : American Psychiatric Publishing ; 2001. p 272-4.

3.  Doghramji K. Insomnia and Depression. Available at

http://www.medscape.org/viewarticle/501334. accessed on June 14th 2011.

4.  Sadock BJ, Sadock VA. Synopsos of Psychiatry. 9 th edition. USA : Lippincott

Williams and Wilkins ; 2002. p 534.

5.  Chang L. Common Causes of Depression.

http://www.webmd.com/depression/recognizing-depression-symptoms/common-

causes. accessed on June 12th 2011.

6.  Halverson JL. Depression Clinical Presentation. Available at

http://emedicine.medscape.com/article/286759-clinical#showall. Accessed on

June 12th 2011.

7.  Chanin LR. An Overview of Insomnia. Available at

http://www.webmd.com/sleep-disorders/guide/insomnia-symptoms-and-causes. 

accessed on 18th June 2011.

8.  Benbadis SR. Insomnia Clinical Presentation. Available at

http://emedicine.medscape.com/article/1187829-overview. accessed on 19th 2011. 

Accessed on June 20th 2011.

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9.  Benbadis SR. Insomnia Due to Mental Disorder. Available at

http://emedicine.medscape.com/article/1187829-overview#showall. Accessed on

June 20th 2011.

10. Jaret P. Depression and Insomnia. Available at

http://emedicine.medscape.com/article/1187829-overview. Accessed on June 20th

2011.

11. McCall WP. Exploring the Relationship Between Insomnia and Depression

Insomnia as a Precursor of Depression. Available at

http://www.medscape.org/viewarticle/581779_2. Accessed on June 2oth 2011.