The Relationship Between Insomnia, Anxiety, and Depression

Have you ever found yourself tossing and turning more than usual at night because you’re anxious about a big test coming up, a move, a medical procedure, or some other event? Worrying can make it hard for the brain to relax, even at night, when it needs to relax in order for you to be able to fall asleep.

It happens to everyone from time to time, but if you have a mental health condition that causes constant worry or stress — as can be the case with anxiety or depression — it can trigger consistent problems with sleep or insomnia (trouble falling asleep, waking frequently during the night or before you want to — and before you’ve had enough sleep — in the morning), explains David Neubauer, MD, an associate professor of psychiatry and behavioral sciences at Johns Hopkins School of Medicine in Baltimore.

Sleep patterns, including insomnia, are affected by any number of physical, mental, emotional, and even social issues. When it comes to the link between insomnia and mental health, the relationship may best be described as bidirectional, meaning one can worsen the other and vice versa. As with the proverbial chicken and egg, it’s not always easy to tell which came first.

“The formula varies — some start off with insomnia that develops into depression, while others start off with depression that leads to insomnia,” Dr. Neubauer says.

Bipolar disorder, depression, stress, or anxiety, all increase your likelihood of developing insomnia. (2,3) At the same time, as many as 40 to 50 percent of people with insomnia also have a mental health disorder. (4) A meta-analysis that collectively included 172,077 individuals found that those with insomnia had a twofold increased risk of developing depression compared with individuals without insomnia. (5)

The important point to know about this bidirectional relationship is that whatever the initial cause and the symptoms (whether insomnia is causing a mental health problem or vice versa), either can make the other worse. That means if you started having trouble sleeping, it persisted, became insomnia, and as a result you developed a problem with constant anxiety — that anxiety can in turn make your sleep problems worse, too.

“There does appear to be a circular relationship between sleep health and mental health,” says Neubauer. “Worse sleep or mental health can have a negative impact on the other.”

The flip side is that addressing one of the problems (likely the one you started experiencing first) can help the other one go away, too. For instance, for that person who developed insomnia that triggered constant anxiety, getting treatment for that insomnia (that allows he or she to get back on a healthy sleep schedule) may help the anxiety symptoms get better, too. “The good news is that improvement in either can be beneficial for the other,” Neubauer says.

And knowing about this relationship means that doctors can be on the lookout for one when they see the other. “When someone comes in with persistent insomnia, we should look for mental health issues,” says Neubauer.

Just because you’re having trouble sleeping doesn’t mean you have depression, anxiety, or any other mental illness, nor does it mean you’ll develop one of those problems. But sleep problems do increase your risk of developing a psychological condition, so it’s important to do what you can to address either problem so it doesn’t bring on other symptoms, Neubauer explains.

While doctors know a lot about the anatomy of the nervous system and neurophysiology, biologically they don’t yet have a clear understanding of the exact brain processes responsible for regulating sleep and mood and anxiety levels, Neubauer says.

“There are overlapping brain regions and neurotransmitters among these domains, but it is unknown exactly how they interact or cause difficulties for certain people,” says Neubauer. “And genetic influences and life experiences likely are prominent, too.”

That means just because someone has insomnia, it doesn’t mean he or she will develop anxiety or depression, because more factors than just the sleep problems are related to mood disorders, says Neubauer. “But we know that the risk increases.”

If you have insomnia, you may notice the following symptoms in addition to trouble sleeping that could be early warning signs of compromised mental health. All of these symptoms are ones you should discuss with your doctor or healthcare provider:

• Feeling sad or depressed
• Lack of interest in usual activities
• Lack of appetite
• Fatigue
• Stress and anxiety
• Feelings of worthlessness or guilt
• Difficulty concentrating
• Irritability
• Recurrent thoughts of death

Your doctor can help you parse out the causes of your sleep or mental health problems, and suggest the best treatment strategies for you to try, as well as offer advice on how to mitigate potential problems before they get worse. “Early consultation may prevent significant future impairment,” says Neubauer. “A healthcare professional will help with education about good sleep habits and may recommend cognitive-behavioral therapy for insomnia or possibly the use of a medication.”

Likewise, having a mental health problem doesn’t necessarily mean you’ll develop insomnia — it just adds one more factor that raises your risk.

That means if you’re managing a mental health condition, such as anxiety, depression, bipolar disorder, or something else, it’s important to practice good sleep hygiene (practices that promote healthy sleep). This strategy helps mitigate your risk of developing sleep problems, Neubauer says.

Good sleep hygiene means keeping regular bedtime and wake-up hours, allowing sufficient time in bed, developing a relaxing evening routine, avoiding caffeine in the afternoon and evening, and refraining from alcohol. (6) And if you find yourself tossing and turning in bed, worrying and frustrated about not sleeping, don’t make yourself lie there for hours. Instead, get up and do something soothing like meditating, doing yoga stretches, listening to soothing music, or even writing a to-do list, Neubauer suggests.

“Avoid extended time in bed while [you’re feeling] frustrated and worrying,” he adds. He suggests writing down what you’re worried about or what you need to get done the next day so that you don’t have to think about these things once you’re in bed.

It’s also worth keeping in mind that stress and anxiety cause sleep problems for everyone, whether or not you have insomnia. “We vary in how much stress and anxiety affect us, and the degree to which they lead to serious sleep difficulty,” says Neubauer. “Ideally, stressful situations resolve quickly and the associated anxiety and sleep disturbance rapidly improve.”

But if you do start to have trouble with sleep, especially repeated problems, talk to your healthcare provider about other solutions.

“Sometimes difficulty falling asleep or staying asleep persist independently after the initial stress has gone away,” Neubauer says. In these cases that worry can itself become a self-fulfilling prophecy, and can lead to insomnia that shifts from worrying about a particular problem to worrying about whether they will be able to sleep, he says. If that happens, you may want to speak with your doctor about ways to deal with your worry about your ability to fall asleep and stay asleep.