There is a growing public awareness of the importance of sleep to overall health and mental health. Reporting on health related issues continues to emphasis the importance of good sleep to so many aspects of our overall health. Research has demonstrated links to learning and memory, metabolism and weight, mood, and cardiovascular health. The goal of this article is to advocate for the inclusion of sleep assessment as a standard aspect of mental health treatment by highlighting the role sleep problems play in the several prominent mental health conditions.
It’s important to understand that simply because someone is having sleep problems, it doesn’t mean that they are experiencing a sleep disturbance that can be treated with behavioral intervention. The importance of appropriate sleep disturbance assessment is a critical component of the treatment process in order to understand the cause. Individuals can experience sleep disturbance from a variety of causes, including sleep-related breathing disorders, insomnia, nightmares, circadian rhythm disorders, etc. Understanding the cause of the sleep disturbance will guide the intervention.
This is highlighted in the DSM-5 criteria for insomnia, which includes: dissatisfaction with sleep quantity or quality, associated with one (or more) of the following symptoms: Difficulty initiating sleep, difficulty maintaining sleep with frequent awakenings with difficulty falling back to sleep, and early morning awakening with inability to return to sleep. As part of a comprehensive sleep assessment, screening for other possible sleep disturbances other than insomnia is critical, as outlined in the rule out criteria of the DSM-5: “The insomnia is not better explained by and does not occur exclusively during the course of another sleep-wake disorder (e.g., narcolepsy, a breathing-related sleep disorder, a circadian rhythm sleep-wake disorder, a parasomnia)”. CDPs training course on Cognitive Behavioral Therapy for Insomnia (CBT-i) are a fantastic resource to fully understand how Insomnia can be assessed to ensure the proper treatment course (https://deploymentpsych.org/treatments/cognitive-behavioral-therapy-insomnia-cbt-i).
Individuals with PTSD very frequently experience insomnia as part of the disorder and the day time fatigue associated with the condition can significantly increase the functional difficulty they experience. A study by Maher, Rego, and Asnis (2006) indicated that 70-91% of patients with post-traumatic stress disorder (PTSD) have difficulty falling or staying asleep.
Even when there is effective treatment of PTSD, insomnia is likely to remain. Often times the individual can experience conditioned arousal and general disruption of sleep patterns even after nightmares have significantly reduced. It is important to note that Insomnia is also a significant risk factor when examining suicide risk.
There is a growing body of research that indicates insomnia is an independent predictor of suicide risk. Multiple studies have demonstrated that individuals with insomnia are twice as likely to die by suicide that those without insomnia. In my own clinical practice, I will always monitor assess and monitor those with severe insomnia for suicide risk, regardless of the primary condition.
In addition to the risk related to suicide, Insomnia is also strongly related to the onset of depression. A meta-analysis conducted by Baglioni et al (2011) showed that people with insomnia have a two-fold risk to develop depression, compared to people with no sleep difficulties. Additionally, a study by Carney et al (2017) indicated that individuals with depression who only received CBT-I improved on depressive symptoms. The same study showed that depressed individuals treated with anti-depressant medication combined with sleep hygiene had worsening sleep problems
Anxiety has long been associated with insomnia and is often viewed as one of the causal factors in its development. But this relationship can be bi-directional. Difficulty with sleep may begin a pattern of worry about sleep related functional impairment for an individual that is more prone to experiencing anxiety.
This article was intended to briefly highlight the importance of sleep disturbance assessment as a stand part of all mental health evaluations. This has been a brief introduction to the role that sleep disturbance plays of in the onset, maintenance and exacerbation of other mental health disorders. I would encourage all mental health providers to learn more about insomnia and reach out to out experts with any questions you have!
The opinions in CDP Staff Perspective blogs are solely those of the author and do not necessarily reflect the opinion of the Uniformed Services University of the Health Science or the Department of Defense.
Jeffery Mann, Psy.D., is a Senior Military Internship Behavioral Health Psychologist at the Center for Deployment Psychology (CDP) with the Uniformed Services University of the Health Sciences and is located at Naval Medical Center San Diego.
Baglioni, C., Spiegelhalder, K., Nissen, C. et al. Clinical implications of the causal relationship between insomnia and depression: how individually tailored treatment of sleeping difficulties could prevent the onset of depression. EPMA Journal 2, 287–293 (2011). https://doi.org/10.1007/s13167-011-0079-9
Carney, C. E., Edinger, J. D., Kuchibhatla, M., Lachowski, A. M., Bogouslavsky, O., Krystal, A. D., & Shapiro, C. M. (2017). Cognitive Behavioral Insomnia Therapy for Those With Insomnia and Depression: A Randomized Controlled Clinical Trial. Sleep, 40(4), zsx019. https://doi.org/10.1093/sleep/zsx019
Maher MJ, Rego SA, Asnis GM: Sleep disturbances in patients with post-traumatic stress disorder: epidemiology, impact and approaches to management. CNS Drugs. 2006; 20(7):567-90