Quarterly scientific, online publication by Department of Nursing A, Technological Educational Institute of Athens

Insomnia and

depression in primary psychiatric care

ngeliki Statharou , !hristina Taka
"

-$E.IE/,ackground0 Insomnia is most often 1ust a )o2e(er, a gro2ing body of e(idence suggests that insomnia is not 1ust a symptom of depression, but that it may actually precede depression# Aim0 The aim of the present study 2as to e3plore relation bet2een insomnia and depression# %aterial and method0 $esearch 2as carried out 2ithin the 4reek and international bibliography# /e used
the /eb data base including 5 medline6pubmed, 2ikipedia, medscape7 2ith key72ords0 insomnia,

# $N, %Sc, A Department of &sychiatry clinic, 'ni(ersity of Athens, Aiginitio )ospital

"#$N, %S*c+, A Department of &sychiatry clinic, 'ni(ersity of Athens, Aiginitio )ospital

A,ST$A!T

symptom of depression#

relationship, depression, primary care#

$esults0 Insomnia is an e3tremely common condition 2ith ma1or social and economic conse8uences 2orld2ide# In spite of its pre(alence and significant negati(e impact on the 8uality of life, insomnia

recei(es inade8uate attention from health authorities and physicians#

!onclusion0 The ne2 findings are especially significant because they suggest that targeted treatment for insomnia 2ill increase the likelihood and speed of reco(ery from depression# 9ey 2ords0 Insomnia, relationship, depression, primary care# !:$$ES&:NDIN4 A'T):$ Statharou Angeliki Theoklitou ; &#!#0 ;<= Athens, 4reece Tel07>?" ?@> "ABA, A@>B"<< B; Email0 angsta"Chotmail#com

INT$:D'!TI:N

nsomnia *sleep

disorder+ is

high costs of medication, and fre8uent (isits to the doctors as 2ell as fre8uent use of health care ser(ices# Studies indicate that depression and insomnia are medical conditions, 2hich often
,"

linked to and is often a prodromal symptom of depression# ,oth insomnia7

as a symptom of many disorders, and depression7 as a disorder itself, ha(e an estimated high economic cost# The costs are either direct or indirect, i#e# reduced

coe3ist# Sleep disturbances re8uire early treatment since they are a risk factor and often precede psychiatric disorders#>, <
&age D >;B

daily functioning, absence from 2ork,

Insomnia and depression in primary psychiatric care

)EAET) S!IEN!E F:'$NAE

Sleep Disorders Sleep is of (ital significance for the body
and constitutes a normal condition# Hor e3ample, a " year old child sleeps around B hours, a person "=7<? years old sleeps around ;#= hours, 2hile an older
;

.olume A, Issue > *Fuly 5 September "? "+ &atients usually find it difficult to sleep

or their sleep is interrupted# Sleep disturbances usually cause reduced cogniti(e functioning, reduced attention and concentration, fatigue, reduced
B

performance at 2ork, accidents 2hile dri(ing, and increasing use of health hours# ser(ices#
@

person sleeps around A#=

Insomnia is the most common sleep disorder# It is estimated that >?I of adults e3hibit symptoms of insomnia# It is more pre(alent in 2omen and the elderly# The need to sleep may be reduced or increased, depending on the indi(iduals daily acti(ities# )o2e(er, one

According to the Diagnostic Statistical %anual7I. *DS%7I.+ insomnia is JacuteJ 2hen the symptoms persist one to three days, 2hile it is considered KchronicL 2hen the symptoms persist three days a 2eek and for four 2eeks or more# significant
B

Insomnia is a common disorder 2ith socio7economic conse8uences# 'sually it is difficult to diagnose insomnia early since it co7e3ists 2ith other pathological conditions# In a
?

in four adults e3periences some type of

insomnia, particularly difficulty falling asleep or going to sleep again after

2aking up#
Sleep disorders e3hibit an ad(erse effect on health and are a common symptom in

random sur(ey in the 'SA, about >>I of adults reported sleep disturbances# In Europe it appears in <7""I of the general

adults and especially in the elderly#

Emotional distress and e(eryday problems are usually factors that contribute to insomnia# %ost often, the causes of insomnia are associated 2ith the use of coffee, tobacco, alcohol, large dinners, medication, etc# Asthma,

population and lasts appro3imately "7A years# Despite these findings, only a small percentage of
"

people seek

assistance# $umble et al#, studied patients 2ith breast cancer 2ith and 2ithout insomnia# They found that patients 2ho suffered from insomnia presented more fre8uently fatigue, se(ere pain, an3iety, depressed mood and lo2 8uality of life# They concluded that clinicians in these cases should not
&age D >;@

rheumatic pains etc are also contributing

factors of insomnia#<,=
The pre(alence of insomnia in the population is high# The main features are

reduced sleep or poor sleep 8uality#

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Quarterly scientific, online publication by Department of Nursing A, Technological Educational Institute of Athens

only treat pain but sleep disturbances as 2ell# Depression

The rate of depression, 2orld2ide, is 8uite high and usually both depression and depressi(e symptoms are not

or bulimia, increased or decreased body 2eight, impaired concentration and psychomotor slo2ing, psychological and somatic distress, and negati(e affect *ideas 6 thoughts of guilt, 2orthlessness, death 2ishes+#
<

diagnosed in some situations, especially in the elderly# The diagnostic criteria for depression in the elderly ha(e certain characteristics such as0 the depressi(e mood is not the ma1or symptom manifested by the elderly, and the se(ere reduction in functioning caused by insomnia is sometimes misinterpreted as a result of old age# Depressi(e

Insomnia and depression The relationship bet2een insomnia and depression has troubled doctors for years# It 2as pre(iously thought that insomnia 2as often a symptom of depression# )o2e(er, it is suggested that insomnia is not 1ust another symptom of depression# Studies conclude that insomnia is a risk factor for initiating depressi(e episodes or repeating

symptomatology is attributed to aging by

both physicians and family, but also by the patient himself# 'sually depression may be manifested predominantly 2ith somatic symptoms and treatment is focused on alle(iating these symptoms# The physical conditions appear to play a catalytic role in the emergence of

episodes# It appears that insomnia occurs prior to the manifestation of depression in patients# In other 2ords, people 2ith insomnia but 2ithout depression are more likely to de(elop depression later on#
=

Depression occurs in a gro2ing number of people in modern society# /hat constitutes though a reasonable concern such as is that sleep depri(ation for many young adults may not only be a result of a sleep disorder, but it may be that they limit the time a(ailable for sleep# Sleep depri(ation de(eloped across time in young adults caused by their lifestyle can bring depressed mood and depression# It is e(ident that insomnia is not 1ust a risk
&age D >B?

depression in old age#

Depression is also (ery common in

neurological

problems

&arkinsonOs disease and in patients 2ith

stroke# Diagnosis is difficult since the symptoms of depression are (eiled by the neurological symptoms# The diagnostic
>

criteria of depression, include mood disturbances, anhedonia, insomnia or hyperinsomnia, loss of energy, anore3ia

Insomnia and depression in primary psychiatric care

)EAET) S!IEN!E F:'$NAE

the disorder in the long run# Fules Angsts studied a sample of =@
A

.olume A, Issue > *Fuly 5 September "? "+

factor for depression,their psychiatric problem, or they cannot but can perpetuate e3ternaliPe their emotional distress#
"?

$esearchers insomnia
somatic

report and

that

although coe3ist,

depression

patients

2ith

psychiatric,

ho2e(er, it is important to understand the reason for this coe3istence# 'ntil recently it 2as considered that depression causes insomnia# )o2e(er, studies sho2ed that in cases 2here patients manifested depression and insomnia their 2hen depressi(e they treatment symptoms 2ere gi(en although 2ere pharmacological

symptoms as 2ell as sleep disorders# The study 2as conducted 2ithin "? years during 2hich the patients 2ere e(aluated in a series of A inter(ie2s# The results sho2ed that insomnia is a common symptom of depression, most often manifested before depression and is a risk factor e(en after a long period of time# Another epidemiological study

ameliorated this 2as not the case for their insomnia# %ichael &erlis, director of the Sleep $esearch Eaboratory of the 'ni(ersity of $ochester, reported that the focus should be in treating insomnia 2hich 2ill outcome of increase the treatment depression# :ngoing

reported that people 2ith insomnia are at a high risk for a depressi(e episode 2ithin >#= years, e(en if they dont ha(e

a psychiatric history#

,et2een "??? and "??> in Italy t2o obser(ational studies on insomnia 2ere conducted, the %orfeo I and %orfeo II# The results sho2ed a high incidence of insomnia, as 2ell as a high impact in health and public resources and conse8uently e3cessi(e use of health

in(estigation of the connection bet2een insomnia and depression through clinical trials and research can help impro(e sleep disorders#
"

Sleep disturbances are common in bipolar disorder# Ele(en studies *sample0 A> patients, diagnosis0 bipolar disorder+ sho2ed that insomnia 2as the most common symptom precursor of mania *;;I of patients+ and the si3th most common symptom of bipolar disorder *"<I of patients+# %oreo(er, induced
""

ser(ices#

B, @

:ther studies report that patients from non7/estern cultures and de(eloping countries e3press somatic complaints and deny any psychological problems, more often than patients from /estern cultures# This can be e3plained by the fact that they are not 2illing to e3pose

sleep depri(ation can trigger manic or

&age D >B

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Quarterly scientific, online publication by Department of Nursing A, Technological Educational Institute of Athens

hippomanic symptoms in a large number

of patients#"> In addition to the fact that it is a risk factor for a depressi(e episode, 2hen insomnia is not treated early, it can perpetuate depression in elderly patients, especially those 2ho

impro(ing the 8uantity and 8uality of sleep leads to impro(ed 8uality of life# In the community, health care ser(ices treat insomnia, 2ith proper attention, as a public health problem# The issue that must be addressed is the diagnosis 2hich leads to the immediate attention and

ha(e been treated only for depression#

Insomnia is associated 2ith reduced

"<

treatment of insomnia as 2ell as the conse8uences of prognosis# No2adays 2e kno2 that insomnia can cause psychiatric disorders# In primary health
sleep#

8uality of life and depression# In a study, by the American Society of Sleep * @@ +,

??? indi(iduals 2ere e3amined for the effects and 8uality of

care, there is concern about the ability of physicians to detect insomnia early either as a disorder or as a precursor symptom of depression# )o2e(er a study conducted by the /orld )ealth :rganiPation sho2ed that more than half of people suffering from insomnia 2ere diagnosed early in the &rimary )ealth !are# $EHE$EN!ES #!ochran ), Diagnose and treat primary insomnia# "??>Q"B0 >7"@# "#Daley %E, Ee,lanc %, %orin !%, The impact of insomnia on absenteeism producti(ity, and accident rates, &rogram and abstracts of the Association Societies
th

!lassification 2as based on three categories, namely chronic insomnia, occasional insomnia, or absence of insomnia# The results sho2ed that those 2ho suffered from insomnia reported

decreased concentration and memory, increased irritability, impaired daily

acti(ities and reduced pleasure in family and social relationships# The study concluded that chronic insomnia tends to be associated 2ith 8uality of life and

depression# !onclusion

Nurse &ract#

"=

%any of adults suffer from insomnia, although most of the patients do not mention it during their (isit to the

doctor# Therapy can impro(e 8uality of

life for many patients# Sleep disturbances are a precursor to mental and physical

&rofessional

Sleep

@ Annual %eeting, Fune

B7">, "??=# >#Eynch HE, !larke 4N, Estimating the economic burden of depression in
&age D >B"

illness or both# In some patients,

Insomnia and depression in primary psychiatric care

)EAET) S!IEN!E F:'$NAE

children and adolescents# Am F &re( %ed# "??AQ> *A Suppl +0S <>7= #
<#Eiu M, ,uysse DF, 4entPler AE, 9iss E, %ayer E, 9apornai 9, .etrR A, 9o(acs %# Insomnia and hypersomnia

.olume A, Issue > *Fuly 5 September "? "+

study#

F Am ,oard Ham %ed#

"??;Q"?*<+0>A=7>;<# ?#!osta e Sil(a FA, !hase %, Sartorius N, $oth T# Special report from a
symposium held by the /orld )ealth

associated childhood "??;Q>?* +0B>7@?#

2ith depression#

depressi(e Sleep#

:rganiPation Hederation of

and Sleep

the

/orld $esearch

phenomenology and comorbidity in

Societies0 an o(er(ie2 of insomnias and related disorders0 recognition, epidemiology, A# and rational

=#%orin !%, Ee,lanc %,

Daley %,

4regoire F&, %Srette !# Epidemiology of insomnia0 &re(alence, self7help treatments, determinants beha(iors# %edicine#"??AQ;*"+0 ">7 >?# A#$oth T# &re(alence, associated risks,
and treatment patterns of insomnia# F !lin &sychiatry# "??=QAA Suppl @0 ?7

management# Sleep, @@AQ @*=+0 < "7 and Sleep #/inkelman F, &ies $# !urrent

consultations, of

help7seeking

patterns and future directions in the treatment of insomnia# Ann !lin &sychiatry# "??=Q ;* +0> 7<?# "#$umble %, Edinger FD, 9eefe HF # A
pilot study e3amining the utility of the cogniti(e7beha(ioral model of insomnia in early breast cancer patients# &rogram and abstracts of

>Q 8uiP <"7># ;#Sateia %F, No22ell &D# Insomnia# Eancet "??<Q >A<*@<<@+0 @=@7;> B#American
Diagnostic

the Association &rofessional Sleep Societies @ Annual %eeting, "??=Q

th

&sychiatric
criteria

Association#
for primary

Fune B7"># ># B )ellinic !ongress of &sychiatry, "??< *4reek edition+ <#)eok 9E, )o $# The many faces of depression# &sychiatry# "??BQ" *A+0=<?7=#
and depression0 a multifaceted

insomnia# Statistical American

In0

Diagnostic of

and %ental

%anual

Disorders# <th ed# /ashington, D!0 &sychiatric geriatric Association, @@@# @#Alattar care0

!urr :pin

%, )arrington F, %itchell !, A North !arolina family

Sloane &# Sleep problems in primary

practice research net2ork*N!7H&7$N+

interplay#

!urr &sychiatry $ep#

"??@Q *A+0<>;7<"#
&age D >B>

=# %anber $, !hambers AS# Insomnia

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Quarterly scientific, online publication by Department of Nursing A, Technological Educational Institute of Athens

A#/ebsite

0 222#medicalne2stoday#com6ne2slett ers#php, Eink ,et2een Insomnia And Depression In Toung Adults 7 Ne2 Study In The Fournal SEEE&, "??B# Accessed 0 7 ?7"??B# ;#,reslau N, $oth T, $osenthal E,
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Insomnia And Depression $e(ealed, "??=# ""#Fackson A, !a(anagh F, Scott F# A

systematic re(ie2 of manic and depressi(e prodromes# F Affect

Disord# "??>Q;<0"?@7" ;# ">#.oderholPer ', )ohagen H, 9lein T,

Fungnickel F, 9irschbaum !, ,erger

%, $iemann D# Impact of sleep

depri(ation and subse8uent reco(ery sleep on cortisol in unmedicated

adults# ,iol &sychiatry# < 7B#

@@AQ>A*A+0

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Insomnia and Depression0 /hich

B#TerPano %4, !irignotta H, Sommacal

S#

Studio

%orfeo

"0sleep

dissatisfaction and insomnia in a

primary care setting# Sleep, "??<Q ";

Suppl#0 =;<A# @#TerPano %4, &arrino E, !irignotta H, Herini7Strambi E, 4igli 4, $udelli 4, et al# Studio %orfeo0 insomnia in primary care, a sur(ey conducted on the Italian population# Sleep %ed# "??<Q= * +0 A;7;=# "?#4onPVleP )%, .ega /A, /illiams D$,
Tarraf /, /est ,T# Neighbors )/#

!omes

HirstU Sleep

$esearch

:nline#"??>Q=*"+0 ;7B #

"A#TerPano 4%, &arrino E, ,onanni E,

!irignotta H, Herrillo H, 4igli 4E, et al#
Insomnia in 4eneral &ractice# A

Arch 4en &sychiatry# "? ?QA;* +0>;7 <A# " #/ebsite 0 222# Science gogo#com
%el(ille 9 , $elationship ,et2een

!onsensus $eport &roduced by Sleep Specialists and &rimary7!are &hysicians in Italy# !lin Drug In(est# "??=Q"=* "+0;<=7;A<#

&age D >B<

Insomnia and depression in primary psychiatric care