Sleep and depression

Federica Provini MD (

Dr. Provini of the University of Bologna and IRCCS Institute of Neurological Sciences of Bologna received speakers' fees from Eisai Japan and Italfarmaco and consulting fees from Zambon.

Antonio Culebras MD, editor. (

Dr. Culebras of SUNY Upstate Medical University at Syracuse received an honorariums from Jazz Pharmaceuticals for a speaking engagements.

Originally released December 23, 1994; last updated August 31, 2020; expires August 31, 2023


Sleep disturbances are common in psychiatric disorders. It has been established that 4.4% to 20% of the general population suffers from a major depressive disorder, which is frequently associated with a dysregulation of normal sleep-wake mechanisms (Pandi-Perumal et al 2020). Disturbances of circadian rhythms are a cardinal feature of psychiatric dysfunctions, including major depressive disorder, suggesting that biological clocks may play a role in their pathophysiology. In addition, the habit of sleeping at a time that is out of phase with the body's other biological rhythms is a common finding in depressed patients (Pandi-Perumal et al 2020). Depression is associated with longer sleep latency, frequent and long awakenings, and/or early morning awakening associated with poor sleep satisfaction. Sleep disturbance associated with depression sometimes responds to treatment of the underlying depression. Some antidepressants, such as mirtazapine, directly improve sleep quality. Unfortunately, most antidepressants, including the selective serotonin reuptake inhibitors and duloxetine, have the side effect of insomnia. Adjunctive medication is often necessary to treat depression- or antidepressant-associated insomnia. The author discusses the evaluation and treatment of sleep disorders associated with depression.

Key points


• Sleep disorders are commonly associated with psychiatric disorders.


• A sleep complaint could be the heralding symptom of a psychiatric disorder.


• Insomnia can lead to depression and/or common causalities underlie both disorders.


• Prevention of sleep disturbance is best achieved by preventing the onset of depression.

Historical note and terminology

Sleep disturbance in depression has been described at least as far back as the ancient Greeks. Throughout history there have been great numbers of famous people who are known to have suffered from insomnia and depression. It is a well-known fact that for most of his life Winston Churchill suffered from insomnia and depression that persisted until old age. Churchill referred to this depressive state as his "black dog." The famous British mathematician, astronomer, and philosopher, Sir Isaac Newton, 1 of the leading pioneers of scientific discovery, was also known to have suffered from inability to sleep and depression.

Mood disorders, including depressive disorders and bipolar disorders, are commonly associated with sleep disturbances. Major depressive disorder or unipolar depression is diagnosed in people who have experienced 1 or more major depressive episodes. The essential feature of a major depressive episode is a period of at least 2 weeks during which there is depressed mood or a loss of interest in pleasure, together with at least 4 of the following symptoms: (1) weight gain or significant weight loss when not dieting; (2) insomnia or hypersomnia; (3) psychomotor agitation; (4) fatigue or loss of energy; (5) feelings of worthlessness or excessive or inappropriate guilt; (6) diminished ability to think or concentrate; (7) recurrent thoughts of death, suicidal ideation, or a specific plan to commit suicide. The Diagnostic and Statistical Manual of Mental Disorders (DSM-V) criteria for major depressive episode include insomnia or hypersomnia nearly every day.

Insomnia is seen in 80% to 85% of patients with depression. A systematic review suggested insomnia is bidirectionally related to anxiety and depression (Alvaro et al 2013). People with insomnia have significantly higher levels of depression than people not having insomnia; increased insomnia frequency and increased numbers of awakenings are related to increased depression and anxiety, which is also among adolescents and university students (Peltzer and Pengpid 2015).

Less frequently, in about 15% to 20% of cases, patients with depression complain of hypersomnia, with prolonged sleep episodes at night or increased daytime sleepiness and fatigue.

Depression may be also associated with other sleep disturbances, such as restless legs syndrome, obstructive sleep apnea syndrome (LaGrotte et al 2016; Sforza et al 2016), and narcolepsy (Dauvilliers et al 2009; Alasim et al 2020).

The content you are trying to view is available only to logged in, current MedLink Neurology subscribers.

If you are a subscriber, please log in.

If you are a former subscriber or have registered before, please log in first and then click select a Service Plan or contact Subscriber Services. Site license users, click the Site License Acces link on the Homepage at an authorized computer.

If you have never registered before, click Learn More about MedLink Neurology  or view available Service Plans.

Find out how you can join MedLink Neurology