Sleep Disturbances in Mood Disorders

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Key points

  • Self-reported and objective sleep disturbances are common in people with depressive, bipolar, and other mood disorders.

  • Sleep disturbance alone is a risk factor for future onset of depressive disorders and dysregulated rest-activity patterns are a risk factor for onset of affective episodes in people with bipolar disorders.

  • Residual sleep disturbance is common in people with remitted mood disorders and can lead to higher risk of relapse.

  • Other sleep disorders are more prevalent in people with mood

Mood disorders overview

Mood disorders are among the most prevalent and debilitating psychiatric conditions affecting the population worldwide. They make up the second most common category of psychiatric illness following anxiety disorders, and estimates suggest that approximately 12% of individuals meet criteria for a mood disorder during their lifetimes.1 Mood disorders are associated with increased morbidity and mortality from other illnesses and, in 6% to 15% of those affected, can result in eventual suicide.2 The

Common sleep disturbances in mood disorders

Box 1 presents an overview of common sleep disturbances in mood disorders as measured by self-report, polysomnography, and actigraphy.

Sleep disturbance as a risk factor and interepisode persistence of sleep disturbance

Historically within psychiatry, sleep-wake disturbances, including insomnia, hypersomnia, and rest-activity dysregulation, have been considered secondary to the mood disorder. That is, as the mood disorder improved, sleep disturbances would improve and, if depression worsened, sleep disturbance would do so as well. However, there is a large body of epidemiologic data that instead supports the contention that sleep disturbance can be independent of, and have a bidirectional relationship with,

Mechanisms for sleep changes in mood disorders

Several potential mechanisms have been proposed to explain the association of sleep disturbances with mood disorders. Early theories primarily attempted to account for the REM sleep abnormalities that seemed to be most characteristic of depression.

One of the first theories was related to the neurotransmitter imbalance hypothesis for depression, initially proposed by Janowsky and colleagues56 in 1972. They suggested that depression was related to a relative increase in cholinergic activity and

Sleep disorders in patients with mood disorders

Patients with mood disorders may also have increased rates of other primary sleep disorders and vice versa, so it should not be assumed that all sleep complaints in psychiatric patients are related to psychiatric illness. Patients with depression have an increased prevalence of obstructive sleep apnea (OSA), and individuals with apnea have higher rates of depression.72 Moreover, OSA is a risk factor for developing depression, and in those with apnea, depression contributes to the severity of

Effects of psychiatric drugs on sleep

Most medications used in the treatment of depression can have effects on sleep (reviewed in Ref.81). Sedating antidepressants, including trazodone, mirtazapine, and tricyclic antidepressants (TCAs) such as amitriptyline are frequently used as sleep-promoting agents in doses that are subtherapeutic for depression. Only doxepin has been approved by the US Food and Drug Administration as a hypnotic, also in a dose that is considerably less than is needed for an antidepressant effect. Mood

Summary

Both self-reported and objective sleep disturbances, including insomnia, hypersomnia, changes in sleep architecture, and rest-activity dysregulation, are common in people with mood disorders. In addition, this population often is at greater risk for other primary sleep disorders, such as OSA, restless legs syndrome, and circadian rhythm disorders, and although some psychiatric medications may be beneficial for sleep, others may disrupt sleep. Attending to sleep disturbances in this population

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    Disclosures: Dr M.E. Rumble reports grant support from Merck; Dr K.H. White has no disclosures to report; Dr R.M. Benca has served as a consultant to Jazz and Merck, Inc, and receives grant support from Merck.

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