Up All Night, Down All Day

In a role switch worthy of Clark Kent, insomnia, long recognized as a symptom of depression, now appears to transmute itself into the mood disorder. Recent evidence indicates that persistent sleeplessness can actually instigate depression—suggesting that taking sleep routines seriously can be a powerful intervention against major mood disorders.

For 40 percent of adults in the United States, each month will bring at least one night of staring at the ceiling, tangling with the blanket, and counting sheep into the thousands as the alarm clock prepares its vengeful cry. Fortunately for most, a bout with sleeplessness—caused, say, by anxiety about a big project or presentation—will pass in a day or two. But for others, a few days of insomnia stretch into a week or more, causing further stress, exhaustion during the day, and even depression.

Almost any sleep disorder can mess with mood. But insomnia—nightly sleeplessness for three weeks or more—has the strongest link to major depression. According to one study, people with persistent insomnia are 40 times more likely to develop depression within a year than are those who sleep well.

In a 2006 study, epidemiologist Eric Johnson of Research Triangle Institute International in North Carolina, found that about half of adolescents who had ever had insomnia developed a psychiatric disorder. Among those with both insomnia and depression, the insomnia preceded the depression 69 percent of the time.

The deep causes of insomnia and depression are still unclear. The leading theory of why insomnia precedes depression focuses on neurotransmitters. Serotonin, in particular, helps regulate mood and sleep, along with body temperature, appetite, and various other functions. When serotonin levels rise, you tend to feel sleepy. When serotonin levels drop for too long, you'll begin to develop symptoms of insomnia, says Michael Thase, professor of psychiatry at the University of Pittsburgh. And low serotonin levels are a hallmark of depression.

The connections between sleep and mood are complex, emphasizes Michael Perlis, a leading sleep researcher at the University of Rochester. The appearance that insomnia causes depression may be only an illusion, he says. It may manifest earlier, but both may result from anxiety. "If stressful events precipitate both insomnia and depression, we can expect insomnia to precede the mood slump as it can be expressed over hours and days, whereas depression takes time to develop."

Alternatively, insomnia could also be the body's way of trying to correct itself, Perlis says. Waking early seems to enhance production of serotonin. In fact, researchers have long known that missing a night's sleep is a powerful antidepressant—during the hours you actually remain awake.

The problem is, insomnia does not have a strong enough effect on serotonin levels to counteract major depression long-term. Restricting sleep can actually be counterproductive over the long haul; according to a 2005 German study, sleep restriction desensitizes serotonin receptors, making them less responsive to the transmitter—another characteristic of mood disorders.

Despite the chicken-or-egg relationship between insomnia and depression, treating insomnia tends to be easier than treating depression itself. "Any early intervention for sleep problems may defer the need for a 'pound of cure'" for depression, Perlis says.

The key is taking the right corrective action before chronic sleeplessness evolves into full-blown blues. Thase recommends watching out for three key symptoms of depression: changes in mood, changes in interests, and, of course, changes in sleep. "If your insomnia has lasted for more than a few days, especially if it is affecting your normal routine, be sure to see someone who can help."