By: Raymond J. Kotwicki, MD, MPH, Charles B. West Chief Medical Officer
We all struggle through times when sleep is in short supply: when college exams, a new baby, or a financial worry prevent us from getting a peaceful night’s rest. But research continues to uncover the consequences of regularly missing out on healthy sleep and the potential perils of sleeping too much.
Sleep seems to be especially important for learning and may play a significant role in the regulation of some mental illnesses like depression, bipolar disorder, and anxiety disorders. As demands for our time and attention increase, what steps should we all take to protect our sleep? What special steps should we take if we have a psychiatric diagnosis?
The Biology of Sleep
Scientists are still working to understand why our bodies need sleep, and it’s a difficult topic to study. However, research is starting to coalesce around the theory that sleep is especially important for our brains and that activity in the brain then drives activity in many other biological systems.
Disruptions in sleep affect a part of your brain called the suprachiasmatic nucleus (SCN). The SCN controls circadian rhythms and your body’s sleep-wake cycle. When the SCN is activated, it affects many different biological functions including how hormones are released, body temperature, how sugars are metabolized, and more.
Sleep and Brain Plasticity
Generally, our brains need about eight hours of sleep every night. Beyond just how long you sleep, getting the sleep your brain needs also means ensuring you get appropriate amounts of different stages of sleep.
Getting the sleep your brain needs also means ensuring you get enough deep stage sleep.
Researchers in Italy have demonstrated that, when individuals experience deep stage sleep, their brains shrink about 20 percent. Though counterintuitive, shrinking is good.
Shrinking is an indication that, during deep stage sleep, relevant connections between brain cells become hardwired, while extraneous connections are pruned. The brain consolidates important neuropathways and gets rid of what it doesn’t need.
Researchers think this activity is important for neuroplasticity, meaning our brain’s ability to change. The activity in our brains during restorative sleep seems to allow us to create memories, learn, and adapt to our environment throughout our lifetimes.
Deep stage sleep comprises three of five stages of sleep. Each night, the body cycles through the five stages of sleep four to six times, spending approximately 90 to 120 minutes in each stage.
Initially, you enter lighter sleep stages, followed by deeper, slow-wave sleep. Later in the night, you should enter the extremely important stage of sleep, Rapid Eye Movement (REM) sleep. During REM, your brain is actually very active despite your body being physically at rest. REM is the stage of sleep when you dream. REM sleep alternates with slow-wave sleep for several hours.
“Sleep architecture” is a term used to describe how someone moves through the stages of sleep each night, the order of the cycles, the time spent in each cycle, and any periods of wakefulness in between. The best kind of sleep for restoring and promoting brain health is when you cycle through the stages of sleep in a predictable way, uninterrupted, every night.
People who don’t cycle through the stages of sleep in a predictable way because, for example, they have sleep apnea, may appear to get eight hours of sleep every night, but they are not getting the full benefits of restorative sleep.
Sleep and Mental Health
Sleep and Mood Disorders
Sleep is particularly important for people with mood disorders. Research indicates that a combination of medication therapy, evidence-based psychotherapy, and behavioral changes yield the best results in preventing mood episodes. While important behavioral changes also include a healthy diet, exercise, and social interactions, a regular schedule of eight hours of sleep each night is highly correlated with improved mood.
For example, for someone with bipolar disorder who is experiencing a manic episode, getting three nights of eight hours of sleep in a row greatly improves the likelihood that the manic episode will break, whereas prolonging a pattern of sleeplessness may lengthen the duration of the manic episode.
Individuals with atypical depression often get too much sleep; they may sleep 12 to 14 hours a night. For these individuals, taking steps to limit sleep to just eight hours a night can help improve mood and end a depressive episode.
Many antidepressant medications, such as SSRIs, actually change the amount of time you spend in certain stages of sleep so that you spend more time in the deeper stages of sleep and REM. Some in the medical community think this function of SSRIs is one of the reasons the medications work to alleviate symptoms of depression.
Sleep and Thought Disorders
Some researchers point to a potential correlation between lack of restorative sleep and thought disorders like schizophrenia. For individuals with a genetic predisposition for schizophrenia, sleep disruption may contribute to the development of symptoms like hallucinations and delusions.
Without regular deep stage sleep, the brain is unable to “prune” the connections between neurons that have associated a thought with an image or sound, for example. Over time, the association becomes hardwired and may manifest as a visual or auditory hallucination or a delusion, which are cardinal symptoms of schizophrenia.
Sleep and PTSD
People who have experienced trauma sometimes experience night terrors, which are especially frightening and vivid nightmares. During a night terror, a trauma survivor might re-experience the trauma or a more generalized terrifying scenario. In fact sleep disturbance is the most common medical complaint among veterans with PTSD.
Night terrors can drive an unhealthy pattern of behavior in which a trauma survivor is anxious about falling asleep because they don’t want to experience a night terror. After falling asleep, they have a night terror and wake up in a highly stimulated and emotional state. They often are unable to fall back asleep, and some individuals may use alcohol or other unhealthy strategies to cope with the resultant anxiety. Without deep sleep, the frightening memories and associations continue to become hardwired in the brain and start to affect thinking and behaviors, which can impact an individual’s ability to function.
Exposure with response prevention (ERP treatment) may be indicated to help alleviate PTSD symptoms, including night terrors. As the night terrors fade, individuals with PTSD can focus on developing healthy sleep habits and start benefiting from restorative sleep.
How to Get Good Sleep
Medications and Sleep
Sleep medications, thought helpful in some situations, tend to be overprescribed. Unsurprisingly, people often want a quick fix to a problem that really requires an intentional change in behaviors. Sleep medications have a host of problems associated with them, including the possibility of addiction and an increased risk of impulsive behaviors like binge eating or late-night online or TV shopping. Over time, repeated use of sleep medications can lead to cognitive slowing.
In most cases, the better option is to focus on sleep hygiene, a prescriptive set of environmental conditions and behaviors to promote regular, healthy sleep.
First we start with where you sleep: the bedroom.
Your bedroom should be:
- Completely dark. Use light-blocking curtains or shutters to protect your bedroom from street lights or other light sources. Turn off or cover any electronics that emit light. Consider a small piece of electrical tape for small indicator lights that stay on even when a device is powered off.
- Slightly cold. Set your thermostat to 68 to 70 degrees F.
- Unstimulating. The only activities taking place in your bedroom should be having sex and sleeping. Reading, eating, looking at your phone or tablet, watching TV, should all be done in another room. Only get in bed when it’s time to sleep.
Then, consider what you do to fall asleep.
If you are unable to fall asleep after 30 minutes, get out of bed. Go to a dimly lit room and do something unstimulating like reading something uninteresting, knitting, or drawing or doodling for 20 to 30 minutes. Then return to bed and try again. Repeat the cycle if needed.
Many studies demonstrate that light, particularly LED light from TVs and smart devices, interferes with the sleep-wake cycle.
What to Avoid Before Going to Bed
- Eating or drinking. Avoid eating or drinking two hours before going to bed. The old wives’ tale of drinking hot milk or tea when you can’t sleep is counterproductive to sleep unless you drink it two hours before bed.
- Exercising. Exercising to raise your core body temperature is actually very beneficial to good sleep. But schedule your workout for no less than two hours before bed.
- Watching TV or Looking at a Screen. Many studies demonstrate that light, particularly LED light from TVs and smart devices, interferes with the sleep-wake cycle. Some studies show it delays the release of the sleep-inducing hormone melatonin. In addition to delaying when you fall asleep, exposure to short-wave artificial blue light may delay the onset of REM sleep and reduce the total amount of time you spend in deep stage sleep. Further, recent studies link regularly falling asleep while watching a screen – a TV, tablet, or smart phone – to a 30 percent greater risk of developing obesity. Try to avoid screens one to two hours before going to bed. Consider setting a “digital curfew” for your household by setting a nightly “screens off” time.
- Taking a hot shower or bath. Taking a shower can be initially stimulating and raises your core body temperature. If bathing is part of your nightly routine, allow a period of two hours before you go to bed.
- Drinking alcohol. While alcohol may act as a sedative for some people and help you fall asleep, it can also affect your sleep architecture and interfere with restorative sleep. Alcohol can also exacerbate snoring and symptoms of sleep disorders like sleep apnea.
Mindfulness Meditation and Sleep
Mindfulness meditation can be a useful component of a good sleep routine. It can be especially helpful for people with anxiety. The past and the future can be unpleasant bedfellows. If worrying about tomorrow or ruminating over yesterday is keeping you awake, mindfulness meditation can help you focus on the present moment to feel calm and restful.
Techniques like focusing on your breathing or gently flexing and relaxing your muscles can bring your mind’s attention to the present and help you relax. A guided meditation app may be helpful, as long as it is audio only and the screen remains dark.
Teens and Sleep
Developmentally, teens and adolescents need more sleep that younger children or adults. Researchers generally agree that teens should get 9 to 9 1/2 hours of sleep each night. This helps support brain health during a time when significant cognitive development is taking place.
To Limit Sleep
For you are an adult diagnosed with depression and your mental health professional has recommended you limit sleep to eight hours a night, try setting five alarm clocks, and set them at increasing distances from your bed. By the time to get to the fifth alarm clock you hopefully are out of bed and the chances of going back to sleep are lower. Do something stimulating immediately when you wake up like taking a shower or exercising.
When to Seek Help
If someone is experiencing a physiologic illness related to sleep deprivation, for example high blood pressure or diabetes, and they feel tired during the day to the point that they need a nap, they should see a doctor about their concerns. The doctor may recommend a sleep study.
If someone with a mental health diagnosis, for example major depression or bipolar disorder, experiences sleep disturbance for two weeks or longer, they should consult their psychiatrist. Cognitive behavioral therapy for insomnia (CBT-I) is an evidence-based therapy that may be helpful, especially for people with anxiety disorders.
For children or adolescents, especially those who are experiencing behavioral problems or a notable change in academic performance, sleep disturbance – especially not sleeping without feeling tired – can be an early warning sign of the emergence of a mental illness like bipolar disorder or depression. Parents should consider scheduling an evaluation with a mental health professional for their child or adolescent.
Residential Mental Health Treatment and Sleep Hygiene
Residential mental health treatment may be helpful for individuals with mental illness who are struggling with sleep-wake habits and other activities of daily living (ADLs). Residential psychiatric treatment provides a structured schedule with established times for waking, purposeful activities, exercise, eating, and sleeping.
Residential treatment also ensures that individuals have support and coaching from mental health professionals as they make behavioral changes to ensure healthy sleep. And weekly sessions with staff psychiatrists can help patients resolve any concerns about the effects of medications on sleep.
To learn more about psychiatric residential treatment at Skyland Trail, please call 866-504-4966.