Why your sleep matters to your mental health —Dr Makanjuola

Dr Victor Makanjuola, Consultant Psychiatrist at the University College Hospital (UCH), Ibadan, in this interview by Sade Oguntola, explains the close and often overlooked relationship between sleep and mental health, explaining that sleep disturbance is a core symptom of most major mental disorders and is frequently one of the earliest warning signs that a mental health condition is developing.

How are sleep disorders and mental conditions like anxiety, depression, and bipolar disorder related?

Sleep symptoms are inherent parts of major mental disorders or most mental disorders. Virtually all the major mental disorders have sleep disruption as one of their symptoms. These symptoms may even be the symptoms that herald the mental disorder, such that one of the first few signs that an illness is coming is that sleep is lost. This is true for anxiety disorders, depression, psychosis, and many other mental health challenges.

Sleep is lost’ means that the person may even be unable to initiate sleep at all, as we may have in anxiety disorder or some depressive disorders. Also, it may be that the sleep is non-restorative; it is not sound or maintained. The person sleeps for one or two hours and then wakes up and become unable to sleep again. Early morning awakening—they wake up very early in the morning, and they are unable to go back to sleep for the rest of the day. Of course, in psychosis too, sleep may be lost completely, so that the individual is even unable to sleep for days.

Loss of sleep is a major part of many mental health conditions. However, I must say that an individual can have an isolated sleep disorder without any accompanying mental health disorder. In that situation, the individual’s main complaint is the inability to sleep, the inability to maintain sleep, or non-restorative sleep. That is what we describe as insomnia. Then, we say this is primary insomnia.

Does it mean, therefore, that a sleep disorder can be a symptom of an underlying mental health issue just as a mental health problem can be a reason why somebody has sleep problems?

Not in the exact same words. Sleep disorder is a condition on its own. But poor sleep can be present in many mental disorders. People with anxiety disorders usually have poor sleep. Depressed patients usually have poor sleep. Patients with psychosis may not be able to sleep for days.   Of course, you can also have isolated sleep disorders that do not come with any other mental health condition.

Moreover, virtually all physical health conditions also have poor sleep as part of their symptoms. Individuals with malaria or typhoid will have poor sleep. But when poor sleep exists alone, that is when it is called a sleep disorder.

What are the most common sleep disorders that you see in patients with these mental health conditions in your clinic?

Sleep problems can exist in these mental health conditions: anxiety, depression, mania, bipolar disorder, schizophrenia, drug dependence, and addiction. And the most common sleep disorders are insomnia and hypersomnia. With insomnia, you sleep less than is deemed necessary for you. You may sleep less than six hours every night. While hypersomnia means you sleep more than is necessary. You are sleeping more than 10 hours in a night.

Insomnia is the commonest sleep disorder seen in individuals with mental health challenges that come up quite frequently at the clinic; only few people complain of hypersomnia.

When that complaint comes up, you have to exclude the presence of mental disorders and a major physical health problem that could be responsible for the sleep problem. It is only when you have done that that you can say this person has a sleep disorder. And begin to focus on improving their sleep both pharmacologically and non-pharmacologically.

 What about hypersomnia?

Hypersomnia is not very common but does happen. You find patients coming in and complaining of sleeping more than usual. Take somebody sleeping for more than about nine hours to 10 hours in a day who wakes up not feeling refreshed and still feels like he needs more sleep. And if you let him go at it, he may be sleeping for 14 to 15 hours of the day. And there are a few other sleep disorders, such as narcolepsy, where the individual falls asleep suddenly. Even during activities, maybe talking, the individual suddenly falls asleep. Luckily it is rare, but it does happen to a few people.

People with hypersomnia try to keep the people awake and alert as much as possible. In addition to regular stimulants, such as coffee, we also have medications that are also stimulating to help such people to stay awake more than they are doing. Even with hypersomnia, mental disorders need to be excluded. Depression could give you either insomnia or hypersomnia. This is done before the clinician goes ahead to treat.

But there are also a few other sleep disorders like obstructive sleep apnea (OSA). In which case, for the individual, each time they are asleep, the airway becomes obstructed such that they wake up startled from the airway being blocked. And when this happens repeatedly, it increases the individual’s risk of developing other health conditions. Just as they may develop physical health problems like hypertension more easily, they are also more likely to develop other mental health conditions.

So, it’s important that people with obstructive sleep apnoea receive appropriate treatment as quickly as possible so that they do not develop the other consequences of this frequent interruption of sleep. That could also include mental health issues. They may need to see an ear, nose, and throat expert to look at the airway if there is redundant tissue there that needs to be removed. But in some cases, they can wear the continuous positive airway pressure (CPAP) mask over their face when sleeping to reduce the tendency of the airway collapsing when they are asleep. That has been known to improve the symptoms of OSA tremendously in those with that condition.

So how do you typically treat sleeping disorders in patients with co-occurring mental conditions?

When there’s a co-occurring mental condition, you have to have a holistic approach to the treatment. You do not just prescribe medications to improve sleep but also manage the underlying condition. You have to find a bouquet of treatments that will address both the mental health condition and the sleep problem. Sometimes we are able to achieve this even with just one medication because many of the mental health medications also have sleep as their side effect. That side effect of sedation will help to address the sleep part of the problem as well.

Are there other forms of non-pharmacological methods of treatment for these individuals?

Yes, we talk about sleep hygiene. We expect adherence to the tenets of sleep hygiene, which includes things like having a specific and regular sleep time. Whatever it is, it must be regular. Exercising actively late in the night is avoided to ensure that the body relaxes by nighttime. Stimulants like tobacco, kola nut, and coffee are avoided, especially in the evenings. You also avoid a room with very bright lights when you are trying to sleep. Avoid having bright lights from other sources, such as the laptop and television, before you retire to your bedroom to sleep. It also requires that you only go to bed when you are feeling sleepy or when the aim is to go and sleep, and you don’t go there to begin to do other activities, such as non-restive activities like using your phone or reading. So, your body associates the bed with rest rather than frustration.

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Cold beverages could help because of the tryptophan that is known to be in milk and in cocoa. But of course, you have to do this in moderation, especially if you are middle-aged. You don’t want to be taking so much sugar in the evening when there is little chance of burning it off because you are going to sleep right afterwards.

But for primary insomnia that has no mental health issue, there are medications that we call sedatives that we can use on a short-term basis to improve the individual’s sleep while they are also encouraged to adopt the sleep hygiene strategies.

Of course, major life events or challenges in life can precipitate the sleep problems. People have had difficult periods with sleep after the loss of a loved one, especially the loss of a spouse. You may want to help the individual to have an objective view of those life events so that they find them less threatening. And that may also help them to re-establish their sleep pattern afterwards. So you may need to address the issue of grieving and bereavement in that individual while you are also prescribing medications for them to sleep.

Are there other lifestyle changes required to improve quality of sleep and mental health at the same time?

Exercise is one of the things you prescribe earlier in the day to improve sleep quality; exercise itself will improve both physical and mental state. If you do the exercise in the morning and you are diabetic, it also means your sugar use and control in the course of the day will be better than if you are the non-exercising type. Essentially, exercise is good for overall well-being and health.

Are there any cognitive behavioural therapies to help with both sleep disorders and mental health?

Cognitive behavioural therapies can help the individual change their mindset or the way they view the situation they are in, how catastrophic it is, and all that. That’s where the issue of what precipitates the sleep disorder comes from. With CBT, you may be made to see those events as more objective and less threatening than you previously thought they were. If that is done, then your sleep will improve, and your mental health will also improve because you are seeing the events for what they truly are and not something that is meant to damage your psyche, your sleep, or your mental health, which is a wrong way of perceiving those events in the first place.

Relaxation therapy, where you focus on particular pleasant imagery and then you begin to experience your muscles relaxing and the rest of your body relaxing, could also help with sleep. Yoga could help with sleep because it helps you to meditate and put your mind at rest. They are applicable to everybody, whether you have mental health issues or not. Also, breathing exercises could also help. So, virtually all of the behavioural therapies could improve one’s sleep and also improve one’s mental health.

Any dos and don’ts for people with sleep disorders and mental health issues?

A: Avoid vigils, whether it’s prayer or reading or whatever, at any time. It will worsen the balance of the chemicals that are necessary to maintain sleep and also to maintain mental health in their brain. This can precipitate a relapse of the illness. We also do not advise fasting because fasting also puts some pressure on the brain. The brain uses glucose for its metabolism.   When you have a low level of glucose in the blood and the brain does not get its adequate supply of glucose, the tendency to have a relapse of a pre-existing illness is also very high.

Q: In non-conventional medical care, fasting and prayer as well as vigils are recommended for individuals with mental problems.

A: That’s a fallacy. That prescription could work for somebody without a mental health condition. It can help in terms of probably improving your spirituality and your sense of connection with God.   Essentially, prayer is a form of meditation. That’s the well-being or peace of mind that comes from meditation in yoga, Zen Buddhism, and all that. But that can help someone with only a sleep disorder to get better if there is no associated mental health condition. Fasting is not going to make a mentally ill patient better. He might get calm from exhaustion because he doesn’t have any glucose in his body. But the mental health has not improved in any way. It doesn’t help at all.

Q: Are there myths and misconceptions that you talk about every time regarding sleep problems?

A: The one that might seem like a myth is part of sleep disorders that we call parasomnias. Those are abnormalities or events that occur during sleep. A dream is one of those events that occur during sleep. And there could be an abnormality in the amount of dreams that one has in the course of sleep. So we can talk about nightmare disorder, where the person has more frequent nightmares than usual. Some medications are known to cause nightmares. And it may just be a neurological disorder that is presenting that way.

But the one that is common is the scenario where the individual feels as if some forces are pressing them down when they want to wake up from a sleep. They know that they are awake, but they can’t get up. That is called sleep paralysis or isolated sleep paralysis. Basically, what is happening is that the individual is waking up during a phase of sleep in which the body normally has a loss of muscle tone. That phase of sleep is called rapid eye movement (REM) sleep.

During REM sleep, it is difficult to arouse an individual because the body’s muscles are limp and just lifeless. Unfortunately, some people wake up in that state. And it takes the brain sometimes to send the message across that, okay, you’re awake now. The muscles should gain the tone, and then you get up. So this person is struggling to get up while the message has not been sent to the muscles to gain their tone. That typically lasts only a few seconds.

But to that individual, it feels as if he’s been battling it—a force or evil people trying to kill him during sleep.   It usually lasts for a few seconds in reality for the brain to get the message across to the muscles that, okay, this person is awake. Get up and go.  It’s a myth to think that there are some spiritual forces or undertones to the experience because it’s purely a physical phenomenon, which tends to increase when the individual is going through a lot of stress. So the individual tends to have more episodes of sleep paralysis.

Unfortunately, the health-seeking behaviour follows that pattern of going to look for spiritual healers or traditional healers who will help them deal with these spiritual forces. But it’s a natural phenomenon that does not require spiritual interventions. And once the explanation is given and their circumstances or the stressors are removed, the individual stops having sleep paralysis completely. So that is one myth that I think is worth busting.

Q: You said sleep disorder cut across a range of problems. What are examples of this condition?

A: This includes insomnia, hypersomnia, obstructive sleep apnoea, isolated sleep paralysis, sleep paralysis, and nightmare disorders. These are quite common. The other one that might be a bit common also is when people act out their dreams when they’re sleeping. In sleepwalking, people are still dreaming and walking. It’s also during REM sleep that most dreams take place. Some people, though sleeping, have toned muscles. So if in the dream they are fighting, you see them punching the air while they are unconscious. They may even stand up and be punching the air.   That is also because the loss of muscle tone that was supposed to be in the REM phase is not there.

But they all resolve with time; they are not issues that one should ascribe spiritual undertones to because once the doctors are approached and they give you the right explanation, the anxiety associated with the event first goes away, and that reduces the tendency of it reoccurring. Sometimes we give medications to ensure that you sleep through the night and experience normal muscle tone during sleep; that is essentially what we do.