This document discusses the bidirectional relationship between sleep disorders and psychiatric illnesses like depression. It notes that insomnia and sleep disturbances are both diagnostic symptoms of many psychiatric disorders and risk factors for developing psychiatric issues. Treatment of either sleep problems or psychiatric illnesses can provide benefits for the other condition. The document examines specific links between insomnia, depression, PTSD, RLS, and other disorders and how they may relate on a biological and genetic level. It also explores how different antidepressant medications may impact sleep architecture, motor activity during sleep, and risks of issues like RLS or REM sleep behavior disorder.
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MGH---Sleep and Depressive Illness for Psychiary Academy 2020_0.pptx
1. SLEEP DISORDERS AND DEPRESSIVE
ILLNESS
John W. Winkelman MD, PhD
Departments of Psychiatry and Neurology
Massachusetts General Hospital
Professor of Psychiatry
Harvard Medical School
2. Insomnia and Depression
“But at three o’clock in the morning, a forgotten
package has the same tragic importance of a death
sentence, and the cure doesn’t work – and in a real
dark night of the soul it is always three o’clock in the
morning, day after day.”
– F. Scott Fitzgerald, 1956
3. Sleep disorders and psychiatric illness
• Transdiagnostic
• Cuts across psychiatric disorders
• Sleep disorders (esp insomnia ) are diagnostic symptoms in multiple
psychiatric disorders
• Causally bidirectional
• Each is a risk factor for the other
• Treatment of one has benefit for the other
4. Transdiagnostic and causally bidirectional
Sleep Medicine
• Insomnia
• Hypersomnia
• RLS
• Obstructive
Sleep Apnea
• Nightmares
Psychiatry
• Major Depression
• Bipolar Disorder
• PTSD
• Suicide
• Substance Use Disorder
• Alzheimer’s Disease
6. Bidirectional relationship of psychiatric illness
and sleep disorders
• Prediction of risk for developing a new-onset psychiatric disorder
• Prediction of risk of relapse in stabilized remitted patients
• Prediction of response to pharmacologic treatment
• Biomarker of genetic vulnerability (endophenotype)
• Clues to underlying neurobiological mechanisms
• Effects of psychiatric illness on sleep: insomnia, hypersomnia,
nightmares
• Effects of psychiatric medications on sleep (acute and chronic)
7. Can we even distinguish insomnia from
depression?
8. Insomnia and depression are both
symptoms and disorders
Insomnia
Disorder **
Insomnia
symptoms
Major depressive
disorder
Mood
symptoms
**Requires daytime impairment related to sleep disturbance
9. Symptom overlap of primary insomnia and
depression
• Fatigue
• Loss of interest
• Sleep disturbance
• Depressed mood
• Impaired
concentration
• Worry
• Agitation
• Irritability
Insomnia
Disorder
Major Depressive
Disorder
10. Insomnia as a precursor (or even cause) of
depression and suicidality
11.
12. Insomnia predicts depression after 15 years in
Johns Hopkins undergraduates
RR 2.0, 95% CI 1.2-3.3 RR 1.8, 95% CI 1.2-2.7
Chang PP et al, Am J Epidem, 1997
Sleep
13.
14.
15.
16. Comorbidity of other psychiatric disorders
with MDD (all of which produce insomnia)
• Anxiety Disorders
• PTSD, OCD, panic disorder, GAD
• Bipolar disorder
• Substance abuse
• Psychotic disorders
17. •PTSD is a disorder with an essential difficulty maintaining states of
decreased vigilance
•PTSD will therefore nearly always interfere with sleep
•Specific questions as to the circumstances of traumatic episodes (eg
night, bedroom) may shed light on sleep disturbance
•Treatments:
- education as to relationship of PTSD to sleep disturbance
- safety of sleep environment
- judicious use of hypnotics
- prazosin or Image Rehearsal Therapy for nightmares
36. On the other hand, although sleep commonly improves with
treatment of MDD, sleep disturbance is the most common
persistent symptom in remitted MDD
Symptoms
Percentage
of
Subjects
0
10
20
30
40
50
Mood Interest Weight Sleep Psycho-
motor
Fatigue Guilt Concen-
tration
Suicidal
Ideation
Subthreshold
Threshold
MDD = Major depressive disorder.
Nierenberg AA et al. J Clin Psychiatry. 1999.
**25% had treatment-emergent onset of nocturnal awakenings (Nierenberg et al, 2012)**
37. Persistent insomnia in treated MDD:
sleep disorder or mood disorder?
• Fatigue
• Loss of interest
• Sleep disturbance
• Depressed mood
• Impaired
concentration
• Worry
• Agitation
• Irritability
• Suicidality
Insomnia
Major
Depressive
Disorder
•inadequately treated MDD
•treatment-induced insomnia
•pre-existing independent (or primary) insomnia
•combination of above
38. No evidence of any distinctions between SSRIs in
degree of benefit or worsening of sleep complaints in
patients treated for depression
Fava et al., 2002
39. Do SRIs worsen/produce RLS?
• SSRIs were a risk factor in RLS by automated phone
interview (N=18,980): OR=3.11, 1.66-5.79)
• Another study found no difference in RLS prevalence in
those taking SSRIs vs those not taking these medications
Fluoxetine, paroxetine, sertraline, citalopram, venlafaxine, escitalopram, duloxetine
40. Antidepressants produce PLMS
OR of PLMI >20 = 5.15 (2.09-12.68) for SSRIs compared
to controls (no antidepressant)
Yang C et al., Biol Psychiatry 2005
41. Antidepressants and REM sleep
• Immediate and persistent prolongation of REM latency
and decrease in REM time
• REM latency may increase to four to five hours
• Bupropion does not suppress REM
42. Effects of serotonergic antidepressants on motor
activity in sleep
• Increased phasic EMG in REM
• Fast eye movements in NREM sleep
• Periodic leg movements of sleep (PLMS)
