November 26, 2013

If We Cure the Accompanying Insomnia, Can We Cure the Depression?

This is the sixth in a continuing series about sleep.

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We’ve known for a long time that insomnia is a hallmark – among the most common – of depression. As recently as November 19, I wrote in this space about the two intertwined conditions, and quoted the Norwegian Institute of Public Health’s Børge Sivertsen, who lead a recent study of the connection:
We conclude that insomnia predicts cumulative incidence or several physical and mental conditions. These results may have important clinical implications, and whether or not treatment of insomnia would have a preventive value for both physical and mental conditions should be studied further.
It didn't take long to find out. And yes, there is now evidence, slim but growing, that treating insomnia also treats -- even cures -- depression. In many ways, these recent study results – and the possibilities they suggest – represent a major landmark in the long journey toward treating depression . . . a milestone not unlike the arrival several decades ago of wildly popular drugs like Prozac and Zoloft.

The latest report comes from Toronto’s Ryerson University, where a research team studied 66 people with both depression and insomnia. Amazingly, 87% of the study participants who successfully resolved their sleep problems also “cured” their depressions, after an eight-week period. Sufferers unable to resolve their insomnia were twice as likely to experience continuing depression. All subjects received regular antidepressant medication – or a placebo – through the study period.

Cognitive Behavior Therapy vs. Sleep Hygiene Therapy
Whether subjects received real pills and placebos didn’t seem to matter much. What made the difference is something researchers call “cognitive behavior therapy for insomnia" (CBT-I). in this particular technique, participants are taught, among other things, to:
  • Keep regular wake-up times,
  • Stay out of bed when awake,
  • Avoid eating, reading, watching TV (etc) in bed,
  • Eliminate daytime naps.
Dr. Colleen E. Carney, who lead the Ryerson study, said we needed to "curb this idea that sleeping requires effort, that it’s something you have to fix. That’s when people get in trouble, when they begin to think they have to do something to get to sleep."

This CBT-I is different from standard “sleep hygiene therapy,” which has traditionally advised patients, among other suggestions, to:
  • Exercise regularly, but not close to bedtime,
  • Avoid caffeine and alcohol, especially close to bedtime.
The Stanford Study
In 2008, Dr. Rachel Manber, a professor in the psychiatry and behavioral sciences department at Stanford, conducted a small study with 30 people suffering from both depression and insomnia. 33% of participants who received sleep hygiene therapy and antidepressant medication reported full recoveries from their depressions. Impressively, 60% of those who received CBT-I and the same medication reported full recoveries.

These small studies have shown how best to treat insomnia in depressed patients, and -- most important --that depression clearly abates when proper sleep is restored. We’ll see additional results from similar studies soon.

Stanford, Duke, and the University of Pittsburgh will soon release results from their own studies – each with about 70 participants – to measure the effectiveness of CBT-I to restore sleep and thus treat depression. In those studies, individuals will record data in their journals, including:
  • what time they went to bed every night, 
  • what time they tried to fall asleep, 
  • how long it took, 
  • how many awakenings they had, and 
  • what time they woke up.
Dr. Andrew Krystal heads the CBT-I study at Duke and called sleep “this huge, still unexplored frontier of psychiatry.” He continued:
The body has complex circadian cycles, and mostly in psychiatry we’ve ignored them. Our treatments are driven by convenience. We treat during the day and make little effort to find out what’s happening at night.
You might say he's urging his colleagues to think outside the box-spring.

New York Times editorial, 11/23/13: "Curing Insomnia to Treat Depression"
New York Times article, 11/18/13: "Sleep Therapy Seen as an Aid for Depression"

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