Insomnia and depression are two highly comorbid conditions, with evidence suggesting insomnia may precede and contribute to the onset and maintenance of depression (Charlotte & Lucy, 2022). This paper will examine the current theory and evidence on the bi-directional association between insomnia and major depressive disorder (MDD). It will then discuss the psychiatric-mental health nurse practitioner’s (PMHNP) role in providing psychotherapy and counseling for clients with both insomnia and depression. The specific focus will be on integrating cognitive, behavioral and mindfulness-based psychotherapies and tailoring them to address insomnia and depression together. The importance of ongoing assessment of symptoms and client feedback to determine treatment effectiveness will also be discussed.
Epidemiological evidence suggests up to 90% of individuals with depression report symptoms of insomnia, and early morning awakening is particularly characteristic (Charlotte & Lucy, 2022). Cognitive models of insomnia propose that arousal and distress create a cycle of overestimating the consequences of poor sleep and appraising their ability to cope negatively (Aernout et al., 2021). This leads to mental worry that paradoxically makes sleep more difficult, and provides a framework for understanding the pathway between insomnia and depression. Additionally, several neural changes found in depression, including abnormal REM sleep patterns and dysregulation of the sleep/wake homeostasis system, are consistent with symptoms of insomnia. A number of theories have been proposed to explain the relationships between insomnia and depression including a vulnerability model. The vulnerability theory suggests that a predisposition to hyperarousal and poor emotion regulation may precede and trigger both insomnia and depressive symptoms (Aernout et al., 2021).
The temporal sequence between insomnia and depression is understood as complex and bi-directional, with the likelihood that both vulnerabilities contribute to different clinical manifestations (Rusch et al., 2019). Longitudinal data indicate insomnia leads to two to three times greater risk for developing depression, while depression is a significant predictor for the onset of insomnia even in those without prior symptoms. Once present, insomnia and depression demonstrate a close relationship, with changes in sleep consistently linked to changes in mood and depressive symptoms from day to day (Zhang et al., 2023). For example, spending less time in REM sleep and experiencing longer periods awake during the night can precipitate stronger feelings of hopelessness, anhedonia and suicidal thinking the following day, providing a pathway through which the two outcomes reinforce each other over time. According to Charlotte and Lucy (2022), risk factors for chronicity have also been identified with early onset insomnia, hypersomnia across the whole day, and insomnia comorbid with anxiety or pain.
The psychiatric-mental health nurse practitioner (PMHNP) is uniquely positioned to address comorbid insomnia and depression through an integrated approach combining psychotherapy and medication management (Rusch et al., 2019). Prior to treatment, a thorough assessment of sleep habits through interview, sleep diaries, symptom checklists and screening tools is essential to identify chronology of onset, bidirectional influences, maintaining factors and motivation for change. Integrating questions on sleep into standard depression screenings and assessments facilitates identifying associated features that may otherwise be missed. The PMHNP must complete a differential diagnosis ruling out other medical and psychiatric explanations for reported sleep difficulties and tailor interventions to individual contexts and client preferences (Charlotte & Lucy, 2022).
When insomnia symptoms precede or trigger the onset of depression, directly treating sleep problems may provide initial relief of depression in parallel. According to Aernout et al. (2021), cognitive and behavioral sleep psychotherapies are recommended as first line treatment for insomnia and have demonstrated comparable or greater effectiveness to sleep medications alone. Formats guided by the PMHNP include stimulus control to strengthen associations between bed and sleep, sleep restriction to enhance drive for sleep, sleep hygiene education, relaxation strategies and cognitive restructuring of maladaptive beliefs about consequences of poor sleep (Charlotte & Lucy, 2022). Common cognitive distortions the PMHNP may explore and reframe include magnification of daytime impairment, unrealistic standards for sleep requirements, overestimation of side effects and conditional thinking predicting negative outcomes from insomnia such as emotional distress (Zhang et al., 2023).
The integration of mindfulness-based cognitive therapy (MBCT) into treatment protocols for comorbid insomnia and depression can help address contributing thought patterns for both. MBCT incorporates elements of cognitive-behavioral therapy (CBT) to target disorder-specific content, while teaching participants mindfulness skills to cultivate nonjudgmental observation of thoughts and feelings that may otherwise provide fuel for rumination and dysfunctional attitudes associated with sleep difficulties or low mood (Aernout et al., 2021). Preliminary findings suggest group MBCT adapted for insomnia helps reduce sleep onset latency, wake after sleep onset and dissatisfaction with sleep while simultaneously alleviating depressive symptoms (Zhang et al., 2023).
Throughout treatment PMHNPs utilize ongoing evaluation of therapeutic effectiveness and symptom tracking to calibrate type and dose of psychotherapy or indicated medications. Particularly when depression is in partial remission, residual sleep disturbance signals higher risk for relapse and need for prolonging or intensifying treatment protocols (Rusch et al., 2019). PMHNPs must carefully monitor sleep outcomes both objectively and subjectively to help clients determine reasonable treatment goals that may require compromise between expectations and achievable targets.
In summary, insomnia and major depressive disorder demonstrate clear bidirectional relationships, with evidence that the presence of insomnia may increase vulnerability to onset, maintenance and relapse of depression over time. Assessing for sleep difficulties and integrating treatment of insomnia into standard protocols for depression has potential to improve treatment responsiveness for both conditions. Psychiatric-mental health nurse practitioners utilize multifaceted skillsets combining psychotherapy and medication management to address mutually reinforcing symptoms of insomnia and depression. Cognitive-behavioral therapy for insomnia provides non-pharmacological options for sleep improvement that can positively impact mood, while mindfulness-based approaches target thought patterns contributing to both disturbances concurrently.
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Charlotte, B., & Lucy, E. (2022) The Impact of Cognitive-Behavioral Interventions on Sleep Disturbance in Depressed and Anxious Community-dwelling Older Adults: A Systematic Review. Behavioral Sleep Medicine, 20(4), 477-499, https://doi.org/10.1080/15402002.2021.1933488
Rusch, H. L., Rosario, M., Levison, L. M., Olivera, A., Livingston, W. S., Wu, T., & Gill, J. M. (2019). The effect of mindfulness meditation on sleep quality: a systematic review and meta-analysis of randomized controlled trials. Annals of the New York Academy of Sciences, 1445(1), 5–16. https://doi.org/10.1111/nyas.13996
Zhang, N., Ma, S., Wang, P., Yao, L., Kang, L., Wang, W., Nie, Z., Chen, M., Ma, C., & Liu, Z. (2023). Psychological factors of insomnia in depression: a network approach. BMC Psychiatry, 23, 949. https://doi.org/10.1186/s12888-023-05454-9