Sleep and Mental Health: Chicken, Egg, or Both?

Rude Awakenings

One of my first jobs out of college was at a “sports rehabilitation facility” for young men convicted of serious crimes.  Though the emphasis of the facility was on sports-based therapies—I was a “coach” and the young men were “athletes”—there was no getting around the fact that this place was essentially a prison.  My athletes ranged from career marijuana farmers to car thieves to violent criminals.  As such, they needed constant supervision.

As a new coach, one of my duties was to stay up all night and guard the barracks where the young men slept.  Every fifteen minutes I checked each bed with my flashlight to make sure none of my 30 athletes had escaped into the rattlesnake-infested Nevada Desert that surrounded us.  Then, at 6 AM sharp, I roused my athletes and supervised their showering, dressing, eating, morning workout, and military-style march to class.

From nine A.M. to four P.M., while my athletes were in school, I did my best to sleep on the floor of a hot, shutterless office.  At four I slammed a cup of coffee and groggily supervised the afternoon workout, dinner, and preparation for bed.  Then it was another six hours of nighttime bed checks.   Athletes and coaches alike were fueled by copious amounts of instant coffee to make up for (and, ironically, exacerbate) our mostly sleepless days and nights.

Depression and anxiety were rampant among the athletes and, I realize in retrospect, among the staff as well.  During my rounds at night, those athletes who were able to successfully nod off audibly ground their teeth, emitting loud, staccato chirps.  At first I thought my barrack was infested with crickets.  During the day these tough young men were prone to fits of rage…and fits of tears.

Losing It–One Sleepless Night at a Time

Though our strict daily regimen kept them externally under control, I could see that this setting did not have the rehabilitative effect it aspired to.  In fact, it was clear that both the athletes and my fellow coaches descended, week by week, into an increasingly fragile, low-functioning state.  Some shut down.  Others became mildly paranoid or aggressive.   I found myself spiraling into a depression I didn’t understand, dreading my shift a little more with every passing week and feeling, at times, a bit crazy.

Once I left that job and had a few weeks of normal sleep under my belt, I felt fine again.  Only years later did I come to understand what had triggered my depression.  It was simple sleep disruption.  The fact that nobody at the facility was getting adequate amounts of quality sleep meant that everybody was suffering the effects of sleep deprivation, which can include depression, anxiety, symptoms of ADHD, cognitive impairment, and emotional instability.  Six months after I left, the facility was investigated for serious lapses in safety caused, I now believe, by institutionalized sleep deprivation.

Ah-Ha!  Research on Sleep and Mental Illness.

When I was working at the facility in the late 90’s, most mental health clinicians—including those on staff at the facility—viewed insomnia and other sleep disturbances principally as symptoms, not causes, of mental illness.  As such, ensuring a good night’s sleep was at best a secondary concern rather than a primary treatment modality.  Only recently have researchers come to understand that sleep disturbance can actually cause mental illness.

Unlike the classic chicken and egg conundrum, this “which comes first” question has profound implications.  Specifically, it means that proper sleep is a prerequisite for good mental health.  It also means that in many cases preventing and treating psychiatric and psychological issues may be as simple (or complicated) as getting a good night’s sleep.

Following are some surprising statistics that reinforce the idea of a causal link between poor sleep and mental illness*:

  • 50% – 80% of psychiatric patients also have chronic sleep problems while only 10% – 18% of the general population have chronic sleep problems
  • Sleep disturbance (e.g. insomnia, difficulty falling asleep, poor quality sleep) is especially common in patients with anxiety, depression, bipolar disorder, and ADHD
  • High quality “quiet sleep” (the deepest part of the sleep cycle) causes physiological changes that are critical for immune system function
  • The quality of REM (the dream part of the sleep cycle) appears to have a direct impact on learning, memory, and emotional health
  • Sleep and psychiatric  researchers now believe not only that mental health problems exacerbate sleep problems, but that the reverse is true too—sleep issues can severely exacerbate existing mental health problems
  • 65% to 90% of adult patients with major depression also have sleep issues
  • Approximately 90% of children with major depression also have chronically disrupted sleep
  • Most patients with depression have insomnia and about 20% suffer from obstructive sleep apnea
  • Sleep problems affect more than 50% of adult patients with generalized anxiety disorder, are common in those with post-traumatic stress disorder (PTSD), and may occur in panic disorder, obsessive-compulsive disorder, and phobias.
  • Unresolved sleep issues can interfere with the treatment of anxiety and depression
  • 25% to 50% of children with ADHD also have problems with sleep
  • Children who have sleeping disorders may exhibit the symptoms of ADHD (hyperactivity, distractibility, emotional dysregulation)  even if they do not actually have ADHD

*Source: Harvard Medical School

What it Means

What all of this means to practitioners, patients, and parents, is—quite simply—that sleep is often the best medicine.  Understanding sleep disturbance as a cause of mental health concerns instead of just a symptom should compel us to put it at the top of the list of treatment priorities.

Ruling sleep disorders into or out of the causative equation can not only help us determine the most effective course of treatment, it can also help prevent the misdiagnosis or over-treatment of disorders that are caused or exacerbated by poor sleep patterns. Patients, parents, and practitioners should always evaluate sleep as a part of mental health diagnostics prior to prescribing treatments.

Schools, psychiatric practices, residential treatment facilities, and even correctional facilities like the one I worked at early in my career can maximize their outcomes only to the extent that they make sleep an institutional priority.  Looking back, it’s conceivable that even my ill-fated “sports rehabilitation” experience could have been a positive one had schedules, sleeping arrangements, cafeteria options, coffee selections (decaf, please), and treatments been focused on quality sleep for everyone involved.