Insomnia and depression

Rebecca is a 29 years old mother of a 4 year old daughter. She works part time as a dental assistant. She has no alcohol intake. She does not drink caffeinated beverages. At the time of assessment she was on mirtazapine (Avanza™) 30mg at bedtime and propanolol (Inderal™) for prophylaxis for migraine.

She described insomnia with difficulty initiating and maintaining sleep starting around the period of her pregnancy and retrospectively she had postnatal depressive illness, which was not recognized as such at the time. There was an element of anxiety with panic attacks.

About 12 months after the onset of her symptoms she was started on an antidepressant that brought about partial improvement in her symptoms during the day but insomnia persisted.

Rebecca is a local person who described her upbringing in negative terms, mostly in terms of traumatic experience with her father who was a heavy drinker and although he never physically abused the children, he was violent to her mother. Sarah eventually left home around age 19 to live with her current husband. However, after 5 years of living together they separated and she went overseas by herself. She came back 12 months later and they restarted their relationship, but then separated a second time when she went to live in Darwin for about 2 years. After coming back the couple got back together and they settled down in their own home. Soon after the birth of her daughter she felt depressed with increased headache. It was her view that most of the difficulty with sleep started at that time which would be in keeping with insomnia associated with postnatal depression that persisted intermittently up to this presentation.

On the DASS scale (depression, anxiety and stress score) she scored high both in anxiety and depression.

Reviewing her sleep diary, which she kept for a week, she was going to bed between 9-10pm and it would take at least 2 hours to fall asleep. After having fallen asleep she would wake-up up to 2-3 times per night up to 20 minutes each time. She would eventually get up between 8.30-9am and feel unrefreshed. She felt tired during the day but not sleepy as such.

We had a good discussion with Rebecca regarding the importance of depression in the origin of difficulty initiating and maintaining sleep. Over a period of 3 years of intermittent difficulty falling asleep and only partial benefit from the use of antidepressant and psychotherapy, an element of psycho physiological insomnia was also present with the sense of hopelessness in terms of being able to achieve a good night’s sleep.

Rebecca was encouraged to reassess some of the issues around her marriage and relationship with her husband, which, from the previous history, seems to have been somewhat difficult. The need for cognitive behavioral therapy for her depressive illness was considered useful. She was left initially on the Avanza™. It was explained that Inderal (used for prophylaxis of migraine) would also have a potential detrimental effect on Melatonin and an alternative for a prophylaxis for migraine was suggested.

Specifically as far as sleep is concerned she was requested to maintain restriction of time in bed between 11.30pm-6.30am irrespective of how much sleep she was getting. She was also started on Melatonin 3mg between 8.30- 9pm (approximately 2.-3 hours before intended bedtime). She was encouraged to see her symptoms within a 24-hour context and we stressed the importance of addressing some of the daytime issues.

She was reviewed about 6 weeks after the implementation of the above strategy and the sleep quality was much improved with only occasional awakening through the night. The level of daytime tiredness had improved but not completely lifted. She was encouraged to continue reviewing objectively some of the issues that have been relevant in the past. The Melatonin was stopped at the time of the second review but she was encouraged to maintain a very regular bedtime around 11-11.30pm and regular get up time between 6-6.30am.

In this case insomnia was certainly triggered by depression that initially went unrecognized as is sometimes the case. In fact symptoms of insomnia may occur even 12 months before depression becomes fully manifested. Even when the postnatal depression as such had lifted, however, insomnia persisted due to psycho physiological mechanism (the learned negative association between bedtime, the bedroom and sleep).

This is a good example how, although insomnia can be a symptom of depression eventually it can become an issue in its own right, which in medical terms is described as co-morbid insomnia. The practical relevance of this observation is that often insomnia does not lift once medication and/or psychotherapy or both improve the depressive symptoms. Therefore insomnia needs attention on its own right together with the other strategies that are helpful to improve either depression or anxiety.

It is also important to know that insomnia can occur weeks or months before other symptoms of depression are apparent. It can also be the first symptom of relapse in depression after improvement from it.