Sleep and mental health: How to break the vicious cycle

Sleep and mental health are so closely related, it’s usually impossible to say which comes first; that’s because, as with the proverbial chicken and egg, sleep problems can have a negative impact on your mental health, while mental health problems can also affect how well you sleep. This bidirectional relationship has even made some doctors reluctant to diagnose one particular mental health issue – namely depression – when poor sleep isn’t a problem at the same time too (i).
 
There are lots of different ways you can experience problems with sleeping. Insomnia, for instance, is when you find it hard to fall asleep, stay asleep or when you wake up too early – there’s more information about this in our sleep and insomnia guide. 
 
You might, on the other hand, find it hard to wake up or get out of bed and sleep too much. Or you may have problems that stop you sleeping through the night without being disrupted – having nightmares, for instance, or a condition called obstructive sleep apnoea (this is when your breathing stops briefly while you’re asleep because of an airflow problem).
 
If you’re not getting the sleep you need, you can feel irritable and tired all the time, and you may struggle to cope with even the simplest aspects of everyday life. So it’s hardly any wonder that you’re also more likely to be affected by health problems – including mental health problems such as anxiety and depression. 
 
If you have a mental health problem, it can affect your sleep in different ways – here are just a few examples:
 

• Some medicines used to treat some mental health conditions can cause problems with sleeping as a side effect – these problems include insomnia, nightmares, and oversleeping. Coming off some types of medication can also cause problems with sleep.

• Anxiety can make you worry and struggle to quieten your thoughts, which can make it really hard to fall asleep

• Depression and seasonal affective disorder (SAD) can make you sleep more (depression can also make you struggle to get enough sleep – read on for more information about this).

What happens when you sleep?

 
The US-based Sleep Foundation offers an explanation for how mental health is related to sleep (ii):
 

• When you sleep you have fluctuating levels of brain activity during the different sleep stages – three non-rapid eye movement stages and one rapid eye movement stage – that make up the sleep cycle

• Activity in different parts of the brain in each of these sleep stages helps improve thinking, learning and memory

• Brain activity during sleep also has strong effects on emotional and mental health, with activity taking part in the rapid eye movement stage helping the brain to process emotional information

• When you’re affected by a lack of sleep it may harm your brain’s consolidation of positive emotions, which can influence mood and mental health disorders as well as their severity

 
Of course, there are many other things besides mental wellbeing that can affect your ability to get a good night’s sleep, plus numerous other factors that can increase your risk of developing mental ill health. Yet the close ties between sleep and mental health still strongly suggest improving one might have a beneficial effect on the other.
 

Depression and sleep problems

 
Depression is one of the most common types of mental health disorder, with the World Health Organization describing it as a leading cause of disability worldwide (iii). So it should be no surprise that it’s also one of the mental health disorders that’s most often associated with sleep problems.
 
Disturbed sleep is a very distressing symptom that has a huge impact on quality of life for people living with depression, researchers claim that (i):
 

• Three quarters of people with depression have difficulty falling asleep or maintaining sleep.

• Sleep problems among people with depression increases with age: 77 per cent of 16-24-year-olds experience at least one insomnia symptom compared with 90 per cent of those aged 55 – 64.

• Hypersomnia – which is sleeping too much and being unable to wake up or get out of bed – is less common, affecting about 40 per cent of people with depression aged 30 or younger and 10 per cent of those in their 50s (more women with depression experience hypersomnia than men across all age groups).

• Some people, however, can experience both insomnia and hypersomnia during the same depressive episode.

 
Meanwhile, the Sleep Foundation claims around 20 per cent of people with depression experience obstructive sleep apnoea (iv). It also suggests approximately 40 per cent of people with insomnia have clinical depression.
 

What are the signs of depression?

 
Besides poor sleep and the problems it causes, there are many symptoms of depression that can vary widely from one person to the next. Here are some of the main ones to look out for:
 

• Restlessness and agitation

• Poor appetite, which may lead to weight loss

• Lack of interest in sex

• Feeling sad and in low spirits all the time

• Not finding any pleasure in life

• Having difficulty making decisions

• Low self-confidence and self-esteem, withdrawing from family and friends

• Feeling generally helpless and hopeless

If you’ve been having one or more of these symptoms for a few weeks or more – whether you’re sleeping poorly or not – it’s a good idea to speak to your GP about it.
 
You may also want to get medical advice if you don’t have depressive symptoms, but you’ve been experiencing regular problems with sleeping, as University College London researchers have found consistently sleeping for less than five hours a night might raise your risk of developing depression (v). Indeed, researchers suggest sleep problems may be the reason many people with depression seek medical help in the first place (i).
 
However, not everyone with depression has a problem with sleep and vice versa.
 

Sleep and other mental health problems

 
Depression is a common cause of sleep problems, but other mental health conditions are linked with sleep difficulties too. Seasonal affective disorder (SAD), for instance, is a type of depression that usually affects people at times when there are fewer hours of daylight hours (autumn and winter if you live in a northern hemisphere country like the UK). People affected by SAD often experience hyposomnia and can struggle to get out of bed when it’s dark in the mornings, while some may also suffer a lack of sleep.
 
Meanwhile, other mental health conditions linked with sleep include:
 
Anxiety disorder   It’s normal to feel anxious every now and then, but when you feel generally anxious most or all of the time it could be a sign you have generalised anxiety disorder (GAD), a condition that currently affects more than one in five people in the UK (vi). Where sleep is concerned, anxiety can be a major problem because the constant worry can stop you getting to sleep. You may even start to become anxious at bedtime because you’re worried about not getting enough sleep. According to the mental health charity Mind, some people also have panic attacks – a form of anxiety – while they’re trying to sleep (vi).
 
Bipolar disorder   People experiencing mania – a symptom of bipolar disorder that makes you feel extremely elated and hyperactive – may not feel tired or want to sleep, plus they may also have racing thoughts that keep them awake. When they’re experiencing a depressive episode, however, they may sleep too much. Studies also suggest sleep disturbances may worsen the symptoms of bipolar disorder, and that sleep deprivation can trigger a manic episode (viii). Read more about bipolar disorder in our guide. 
 
Schizophrenia   People living with this condition have a high risk of experiencing insomnia, often because the medications used to treat schizophrenia can cause poor sleep as a side effect.
 
Paranoia and psychosis   Both of these mental health conditions can make sleeping difficult as they can make you hear voices or see things that seem scary or disturbing.
 

Can treatments help?

 
If you’ve been diagnosed with a mental health condition your doctor may have already prescribed medication to help relieve the symptoms, such as antidepressants for depression and anxiety medication for anxiety disorders, and perhaps talking therapies too. The good news is many people find treating their mental health condition has a knock-on effect on their sleep quality – though it may not be enough to improve sleep in all cases.
 
Treating both problems at the same time, however, may be even more effective – for instance, tackling insomnia while also having treatment for depression might help stop any recurrence of depressive symptoms at a later date. In this situation someone might benefit from taking antidepressants while at the same time having cognitive behavioural therapy (CBT) sessions to learn strategies for better sleep (indeed, there is a specific type of CBT designed to manage chronic insomnia called CBT-I).
 
However, it’s a good idea to speak to your doctor about any medication you’re taking, as according to the Sleep Health Foundation in Australia, some types of antidepressant medication can occasionally cause or even worsen insomnia – though simple changes such as changing the time you take your antidepressants may be all you need to fix this (ix).
 
Medications for treating insomnia such as sleeping tablets, however, aren’t usually a first-line option, since they are typically intended for short-term use thanks to the fact that they can be addictive and often cause side effects such as daytime drowsiness, confusion and slower reactions.
 

Is there anything else you can do?

 
Arguably the most important thing you should do if you have a mental health condition and sleep problems is to take your issues with sleep seriously and talk to your doctor about them. Understanding the relationship between mental health and sleep could also help you be more aware about the risks and get help earlier, which might get you back to your normal self more quickly.
 
Improving your lifestyle may also help you cope more easily with having a mental health condition as well as sleeping difficulties. Eating a healthy, nutritious diet is a goal we should all strive for – though admittedly eating well may not always be easy when you’re experiencing problems with your mental wellbeing. Try to make it a rule to have five portions of fruit and vegetables every day and aim to stick to regular mealtimes, even if you don’t feel particularly hungry (though avoid having big meals close to bedtime, as this can keep you awake).
 
The Mental Health Foundation also suggests certain foods may help increase your desire to sleep, such as rice, oats and dairy products – plus you may also want to avoid foods and drinks that contain lots of caffeine or sugar, as these will often stop you getting a good night’s sleep (x).
 
You may also want to try a nutritional supplement, such as one that helps with sleep and/or supports your mental wellbeing:
 
B vitamins   If you’re not getting enough of certain B vitamins, it may not do you any favours when it comes to bedtime. There is, for instance, some evidence that being deficient in vitamin B6 may cause sleep disturbance because it promotes psychological distress (xi). Another more recent study suggests taking B6 may help improve sleep quality and duration (xii), while researchers elsewhere have suggested taking B complex along with magnesium may also be beneficial (xiii).
 
Valerian   Long used as a treatment for insomnia, valerian is still often recommended as a treatment for occasional sleeplessness and also as a treatment for mild anxiety. However, study results on the effectiveness of valerian for insomnia are mixed – though one review of 16 studies concludes it might improve sleep quality without triggering side effects (xiv).
 
Ashwagandha   A herb that’s had an important place in the Indian natural healing system Ayurveda for centuries, ashwagandha is often used to help with stress. Studies also suggest it may help with insomnia, with one systematic review concluding that it may be effective for adults with insomnia and that it may help with anxiety too (xv). Another study published in the journal Sleep Medicine also claims ashwagandha improves sleep quality, including in people who experience frequent non-restorative sleep (xvi).
 
Theanine   A non-protein amino acid found almost exclusively in green, black, oolong and pekoe tea, theanine is also available in nutritional supplements. It’s thought to make you feel calmer by helping your brain produce alpha waves. But as well as helping you to feel relaxed – which is always a good thing when bedtime comes along – theanine could help you get a better night’s sleep, with studies suggesting it may be more effective than a placebo (dummy pill) at helping produce sleep satisfaction (xvii). Theanine is also found combined with lemon balm in some herbal supplements. This combination may be even more effective at helping you relax at night, especially if you’re affected by anxiety, as there’s some evidence that lemon balm may help reduce anxiety levels (xviii).
 
Magnesium   Found in a range of foods such as whole grains, nuts and green leafy vegetables, magnesium is an important mineral for human health. One of its properties is it may support sleep quality. One clinical trial, for instance, has found it improves a range of factors involved in sleep in older adults, including sleep efficiency, sleep time, sleep onset and early morning wakening (xix). Researchers elsewhere have found a daily magnesium supplement may help with sleep in people who are experiencing mental and physical stress (xx). If want to try a magnesium supplement, try choosing one with a good absorption rate, such as magnesium citrate.
 
PEA   Short for palmitoylethanolamide, PEA is a fatty acid produced naturally by the body that’s found in all cells, tissues and fluids, including the brain. You can also get it in foods such as soya beans, peanuts, eggs, flaxseed and milk. An endocannbinoid-like chemical that belongs to a family of fatty acid compounds called amides, PEA may help with sleep difficulties, with one study finding PEA supplements may help you fall asleep faster as well as feel more awake faster in the morning (xxi).
 
Sour cherry concentrate   Drinking sour (tart) cherry juice has often been recommended as a home cure for insomnia, since cherries contain melatonin – a chemical that has been widely linked to insomnia prevention and sleepiness (all cherries contain melatonin but sour cherries contain particularly high amounts). One small-scale study has indeed concluded that drinking sour cherry juice increases sleep time and efficiency after just two weeks (xxii).
 
5-HTP A substance called 5-Hydroxytryptophan (5-HTP) – sourced from the seeds of the Griffonia simplicifolia plant – may also be useful for sleep problems as it’s thought to help increase the production of serotonin (a sleep-inducing hormone) in the brain. Indeed according to an older study, taking 5-HTP supplements may help treat a range of conditions, including insomnia (xxiii). 5-HTP has also been studied as a natural remedy for low mood (xxiv).
 
Live bacteria   Some researchers believe the microbiome of the human digestive tract is closely linked to mental health and sleep. One study, for instance, investigated 156 adults who took supplements containing species of lactobacillus and bifidobacterium live bacteria (also sometimes called probiotics)  for eight weeks. It concluded that not only did the supplements support sleep quality, but they helped with the symptoms of anxiety too (xxv). Find out more about how probiotics may support your wellbeing in our article What are the benefits of live bacteria?
 
Vitamin D   Having low levels of vitamin D has been linked with a range of health issues, with researchers believing it may also play a part in sleep difficulties. However, a review of sleep studies suggests taking vitamin D supplements may have a positive effect on sleep disorders, including improving sleep duration and efficiency and reducing sleep latency (that is, the amount of time it takes you to fall asleep) (xxvi). Many of us are at risk of falling low in vitamin D, especially during the autumn and winter months – since our best source of this nutrient is exposure to sunlight. This is why the UK government advises we all take a daily vitamin D supplement when sunshine is in short supply – or indeed all year round for those who don’t get much sun during the spring and summer months too.
 

Can exercise help?

 
Physical activity can also have a strong impact on sleep, with moderate to vigorous exercise thought to help increase sleep quality by reducing the amount of time it takes you to fall asleep as well as reducing the amount of time you lie awake in bed at night (xxvii).
 
It may be a good idea, however, to avoid working out in the three or so hours before bedtime, as this can increase your heart rate, body temperature and adrenaline levels – all of which can keep you alert and stop you falling asleep quickly. Then again, some types of exercise – light activities such as gentle yoga and stretching moves – might actually help you sleep more soundly when you do them at night.
 
Meanwhile, some of the other things you could do to sleep better and therefore support your mental wellbeing include the following:
 

• Stick to a regular bedtime routine – try to go to bed and get up at the same time every day (your routine could also include avoiding using electronic devices for at least an hour before bed).

• Practice relaxation techniques such as deep breathing and progressive muscle relaxation in the run-up to bedtime (progressive muscle relaxation involves slowly contracting one muscle group at a time and then releasing it – try starting with the muscles in your toes and work up to the top of your head).

• Take a nap – but not for too long. Anything between 10 and 20 minutes is ideal – shorter naps aren’t long enough to offer any real benefits while napping for more than 20 minutes could make you feel too awake at your usual bedtime.

• You probably already know to avoid caffeine in the evening but steer clear of alcohol before bedtime too (it may feel like having a drink or two helps you relax and sleep better, but alcohol actually disrupts your sleep and shortens the all-important REM sleep).

• Go outside during the daytime, as exposure to sunlight reinforces your body’s internal clock and triggers chemicals in the brain that can help you sleep better.

 
There are lots more tips on getting a better night’s sleep in our guide to sleep and insomnia. You may also want to check out the many articles featured in the mental heath pages of our pharmacy health library. 

References:

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Olivia

Olivia Salter has always been an avid health nut. After graduating from the University of Bristol, she began working for a nutritional consultancy where she discovered her passion for all things wellness-related. There, she executed much of the company’s content marketing strategy and found her niche in health writing, publishing articles in Women’s Health, Mind Body Green, Thrive and Psychologies.

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