Depressed, Then Sleepless? Or Vice-Versa?

The official code for psychiatric diagnosis indicates that insomnia is a symptom of depression. This implies that depression causes a disruption of the normal sleep process. However, sensitive clinicians have long noted that sleep changes often precede mood shifts, both toward depression, and, in the case of bipolar disorder, toward hypomania or mania. Surely we are looking here at a bidirectional process in which the two problems are linked, perhaps by way of an underlying cause.

The hot news this week is that a combination of talk therapy for insomnia and antidepressant drugs can relieve depression better than either one alone.

Specifically, the therapy concentrates on encouraging patients to regularize wake-up times, resist daytime napping, and avoid nighttime TV/computer time.

sleep guy

The researchers had their depressed patients keep records of when they got in bed to try to sleep, when they actually fell asleep, how often they became alert in the middle of the night, and when they finally woke up.

But what is actually happening before patients start following the new rules, and what changes as a result?

1.   Light exposure in the late evening, at the start of our desired sleep period, tells the brain’s inner clock to shift later, thereby delaying sleep onset – in other words, “causing insomnia.” Without artificial lighting that extends the day – laptop screens are major villains – our circadian rhythm issues its sleep-onset signal earlier in the evening.

2.   When we fall asleep later, we create a pressure to sleep later the next morning. Bedroom curtains that shut out the early morning light encourage sleeping in, but we need that light to keep our inner clock in sync with the outside world. During the workweek, the alarm clock helps us fight this pressure, but we pay for it with daytime fatigue – and yes, even depression if we’re in that vulnerable group. We might succumb to napping, especially early evening napping when we get home from work. We try to make up for it on weekends by sleeping in, going against the therapy principle of regular sleep schedules. This has the effect of further denying us early morning light exposure, and allowing our inner clock to shift more out of sync.

3.   Napping in the latter part of the day – which happens because we don’t get enough nighttime sleep – uses up a protein in the brain that is responsible for the restorative feel of a good night’s sleep. Two results: it’s harder to fall asleep, and what sleep we get is less restorative than we need, further fueling daytime fatigue and blue mood.  Cutting out these late-in-the-day naps has an obvious benefit.

INDIRECT VS. DIRECT THERAPY

The new research shows that you are less likely to lie in bed for hours wishing for sleep, and then suffer disturbed, unrefreshing sleep if you take these behavioral measures. They work by indirectly adjusting the brain’s circadian rhythm toward its normal state. However, taking direct measures to shift the inner clock into sync with optimum sleep time might considerably strengthen the therapeutic impact. We’re talking about light therapy (in the morning) and light reduction (in the evening). These are simple home treatments that can reduce reliance on both antidepressant meds and sleeping pills.

sleepy woman

How do we standardize morning wake-up time? Two methods: bedroom dawn simulation and post-awakening bright light therapyOur recent paperback explains how to set this up.  Better to use nature’s morning alerting signals than yield to the aversive alarm clock, which can interrupt your sleep just as you’ve fallen into your final dream period of the night.

A simple way to standardize sleep onset is to reduce specific kinds of light that have an activating effect just as you’re hoping to calm down. You don’t have to turn off all the lights or dim them to uncomfortable levels to allow the circadian sleep signal to do its work. Rather, you should adjust your lamps – and TV and computer screens – to cut down on the shortest wavelengths of white light (the violet, indigo and blue) that tell the inner clock to shift later, thereby delaying the sleep onset signal. In technical terms, we want to shop for bulbs rated at 2700 or 3000 Kelvin, rather than the higher levels that supposedly mimic daylight.

In combination, these morning and evening light regimens are energizing and antidepressant, so you feel less urge to nap. In case of an occasional afternoon slump, even a brief supplementary light therapy session – at work or at home – can quell the urge.

I am not disparaging the very hopeful news that the combination of antidepressant meds and talk therapy can speed relief from depression. However, I am suggesting that direct control of the inner clock accesses the underlying mechanism, is therapeutic in its own right, and can reduce reliance on drugs.

Michael Terman received his doctoral degree in physiological psychology from Brown University. After years of basic science studies in circadian rhythms and light, he moved to Columbia, where he established a novel outpatient clinic, the Center for Light Treatment and Biological Rhythms. In 1994 he founded the nonprofit Center for Environmental Therapeutics, which offers chronotherapy guidance to consumers, patients, and doctors. In 2013, he created the Clinical Chronotherapy Group, which offers patients coordinated chronotherapy, pharmacotherapy, and psychotherapy, according to individual needs. Michael is the coauthor of the 2013 Penguin paperback, Reset Your Inner Clock.

 

 

 

Don’t Let the Sun Go Down on Me: Seasonal Affective Disorder and Depression During the Winter

There is a distinctive pallor that comes over our world at this time of the year; grey parking lots seem a lot harsher, people wandering into Starbucks this morning a tad glummer. But nothing seems tougher to deal with than a dearth of sunshine.  It feels as though Mother Nature has pulled down the shades and they ain’t coming back up anytime soon.

As I scrape the shellacking of quarter-inch ice off my windshield at 6 a.m. that had built up overnight before I drive into work, I find myself pining for spring, for the sweet smell of the soil bursting back to life.  But most of all, I yearn for the return of more sunny days, to the end of the great ball of light’s hibernation.

“One must maintain a little bit of summer, even in the middle of winter” wrote Henry David Thoreau.  Well, that’s not always easy for those of us stuck in office buildings behind desks.

For some, the lack of sunshine actually causes a type of depression called Seasonal Affective Disorder (SAD); a syndrome of god-awful crummy symptoms that affects about 14 million Americans during the winter. Symptoms of SAD include decreased concentration, increased appetite, weight gain (whereas some other forms of depression can lead to weight loss), social withdrawal, moodiness, and fatigue.

Some people chalk these nagging symptoms up to just being down in the dumps when in reality, SAD is really a form of clinical depression.  SAD is highly dependent on a person’s hormonal state, seasonal characteristics like ambient temperature, and exposure to natural light (which can influence the body’s production of melatonin).  Research has linked the prevalence of SAD to higher latitudes, regions that tend to have more intense and longer winters.   Just great, I thought. I live in Buffalo, New York.

But the lack of sun just doesn’t cause depression in those who might not ordinarily have it.  One study found that a lack of sunshine actually may cloud memory and other thinking functions in some people who already have depression to begin with.   Depressed adults from the least sunny areas were more than twice as likely to have impairments in memory and cognitive functions as those with the greatest sun exposure.  The sunshine-cognition link was not seen in adults without depression, however.

Here are some ideas to start feeling better:

Shake it in the morning.  For those afflicted with SAD, the time of day you work out matters.  Studies show that morning exercisers report better sleep, burn up more calories throughout the day, and have lower blood pressure.  Even if you don’t make it to the gym, just walking outside in the morning can really help.

Avoid the Pit Stop at The Olive Garden.  When I read that white pastas, bagels and bread could lower my mood, I just switched off my computer in protest – I love pasta as much as my mom and there’s no way I can possibly give it up. But I started watching as my mood did dip after consuming a leviathan portion of rigatoni. That’s so because simple carbohydrates – think white flour stuff – give us short-lived every boost, so it’s only a matter of time before we reach for that second helping of cake spackled with butter-cream frosting.  Instead, choose foods rich in protein and complex carbohydrates which release sugar into the body slowly and have a low glycemic index.  Check out foods that will actually help lift your mood.

Fill Up Your Calendar.  I know, I know.  It’s six o’clock and you just pulled in the darkened driveway on a freeze-your-ass-off day and you just want to eat dinner and park yourself in front of the old T.V. Even on weekends.  Yet research shows that people who suffer from depression report higher levels of well-being and satisfaction after positive social interactions.  Feeling a sense of belonging makes us all feel better, but all the more so when you’re feeling down.

Sleepless in Seattle.  Getting less slumber during these darkened days sounds like a crazy prescription for lifting one’s mood.  When we feel down and the world is dark, it seems like more sleep is what’s called for to make us feel better.  Not so say scientists. Instead, it’s very important to maintain a steady rhythm of sleep per night by waking up and going to bed at the same times every day – including weekends.

Light the (Artificial) Light Shine In.  A light therapy regimen can significantly reduce SAD symptoms, regardless of the condition’s severity.  Light therapy boxes range in brightness and type of light, so consult a physician before buying one.

Read Up.  Pick up a copy of Winter Blues by Dr. Norman Rosenthal, the psychiatrist who came up with the SAD term and has studied it extensively.  Check out his very informative website.

They say time heals all things.  If we can hang on just long enough, the days start getting longer and the sunshine becomes more plentiful.  In meanwhile, try these tips to make things more bearable and remember what the French philosopher Albert Camus once wrote,

“In the depth of winter, I finally learned that within me there lay an invincible summer.”

 

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