For most people, getting a good night's rest is essential for mental health
and wellness. When we talk about good "self-care," taking care of our
bodies is important, and sleep is a big part of that. Feeling rested and
energized puts us at our best and can help us bring our best self to the table
in dealing with stressors and conflicts during our day. Poor quality sleep or
not enough sleep can impair our ability to think clearly or feel more calm and
rational when coping with life's daily challenges.
Anxiety/Depression and Sleep
For people with depression or anxiety issues, getting good quality sleep in
the right amounts is especially important and, at times, elusive. Anxiety or
worries can make it difficult to fall or stay asleep, nightmares or bad dreams
may impair the quality of sleep, stress can potentially increase the likelihood
of teeth grinding and clenching, and depressed mood can make it difficult to
want to get out of bed in the morning. Medications can also play a role in
making sleep problems worse or better.
Sleep is our time to rest and repair from the day, and prepare for the next
day ahead. Finding rituals that help your mental health in service of laying
aside your worries in time for bed is critical. As part of practicing good
mental health, you may want to develop a practice that allows you to learn
greater relaxation techniques and reduce stress. Examples of this may include
yoga, meditation, prayer, 12-step meetings, a martial arts or tai chi practice,
journaling, working out regularly, or attending weekly therapy sessions. Deep
breathing exercises and guided meditations can be downloaded to an iPod or
similar device, and can help you learn to let go of stress and worry. Often
stress manifests not just in the mind but in the body as well. Sleep interference
can be an example of this, but these stressors can run even deeper. Headaches,
jaw pain, backaches, shoulder pain, etc. can be the result of holding onto
mental stress in unconscious clenching and tightening of certain muscle groups.
Learning ways to de-stress mentally while developing a full-body awareness is
an important component to regaining a restful night's sleep.
For those clients with the opposite problem (e.g. depression or avoidant
anxiety), sometimes you may find yourself over-sleeping as a form of escape, or
staying in bed excessively, avoiding the day. It seems counter-intuitive, but
over-sleeping actually drains us of a lot of energy! Good sleep hygiene habits
(see below) are essential- only using your bed for a prescribed 8 hours of
sleep, and getting up at a set time with an alarm (or several) is needed. Limit
pressing the "snooze" button to a small number. Developing
techniques such as having a coffeemaker set to a timer, counting to ten and asking
yourself to sit up in bed, etc. can help. Changing these habits can be
difficult, but making this commitment to yourself it a critical part of getting
your energy levels back in a normal range.
Good "Sleep Hygiene"
You may or may not have heard of the terminology "good sleep
hygiene," but basically it just means creating a lifestyle and environment
that is most conducive for sleep.
1.) Create a bedtime routine and stick to it.
Any "ritual" you can create- from changing into pajamas, brushing
your teeth, etc. can help prompt your brain it is time for shut-down mode. If
you stick to the same routine, going through your wind-down habits in the same
order each night, you will help signal your brain that it is time for sleep.
2.) Use your bed for sleep and sex, and nothing else.
Stop giving yourself permission to "hang out" in bed. Lying down in bed should be your body's cue that it is time to go to sleep.
The more you associate your bed as a play area, the more stimulation you are
bringing to bedtime- not a good thing.
3.) No electronic devices before bed, or in bed.
It's tempting these days to wind down in bed, relaxing after work with
movies in the bedroom, ear buds to listen to music, laptop for web surfing,
etc. What we might not think a lot about is how these screens refresh. You
might have noticed if you are standing outside a neighbor’s apartment after
dark, how the T.V. in a dark room flickers in a certain way. Often when we are
watching thee moving images, we don't think about the way that this
bright-plus-dim flickering can be activating for the brain, but it is. You
wouldn't put a strobe light in your bedroom to help you fall asleep, would you?
The same principle applies here. The screen on our internet also refreshes in a
blinking way- too fast for our eyes to consciously register, but subconsciously
it is a very stimulating activity. Taking a few minutes (10-15) for a subdued
activity like reading a book under dim light would be more appropriate.
4.) Dim the lights and turn off electronics several hours before bed.
This may fit in with a wind-down ritual, but basically beginning a create a
dimly lighted zone where you're spending quiet time winding down is the ideal
nighttime activity. Keeping every light in the house blazing while you listen
to music and answer e-mail will likely have the opposite effect.
5.) Avoid big meals several hours before bedtime, and caffeine-containing
products at least 6-8 hours before bedtime.
We may think of caffeine as a fairly benign chemical that is in many of the
products we consume, however caffeine can take up to 8 hours to be fully metabolized
by our bodies. If you are having trouble sleeping, no caffeine after noon to
the 2:00 range is recommended.
6.) Avoid drinking water or other beverages several hours before bedtime
Oftentimes drinking water too close to bedtime will result is having to get
up in the middle of the night to relieve oneself, and sometimes once a person
is fully awake in this way, it can be difficult to fall back asleep. If you do
have to get up, it can help to have a small nightlight in the hallway or bathroom,
so you avoid turning on the overhead lights, which can also be activating.
7.) Avoid exercising too late in the evening.
Early evening- for example, right after work is ok, but later night
work-outs can actually be too stimulating for your brain, even if your body is
tired, interfering with sleep.
8.) Keep your bedroom dark at night (or wear a sleep mask), and get daylight
during the day
If you are a night-shift worker and not on a normal schedule, you may want
to look into a light therapy box that can be used to treat seasonal depression,
to help get you circadian rhythms back on track. Routine exercise can help,
too.
A Word about Medications
As a clinical social worker, I am neither licensed to prescribe medication
nor qualified to dispense or discuss potential side effects of prescribed
drugs. Having said that, I do have a wealth of experience working directly with
client's taking prescribed medications and I have noticed over the years that prescribed
medications can affect sleep. These concerns should be discussed with your prescribing
provider. You may also want to refer to my blog article on Medications and
Mental Health for further tips.
Good questions to ask might include:
Does this medication have side effects that may impair my quality of sleep?
What are the pros and cons of taking this medication in the morning, at
lunch, or at night?
What is the lowest effective dose for my condition/gender/weight, and how do
we arrive at the right dose for me?
Is this medication considered "habit forming" or do people
sometimes find they need increasing doses of this medication over time to get
the desired effect?
How long should I anticipate taking this medication?
How do you view my mental health prognosis?
Are there things that you endorse besides medication that may help improve
my sleep, well-being, or mental health (in general)?
Sleep Medications
Sleep medication prescriptions (for example, for Ambien or Lunesta) seem to
be more common these days. Some providers may have a more liberal or
conservative approach when it comes to prescriptions, including medication
type, dosage, refills, and quantity. These medicines can help for the
short-term treatment of insomnia (difficulty falling or staying asleep), but
taking them over the longer-term should be explored carefully with your doctor.
Most of these medication fall under a sedative-hypnotic category of medication,
and although the initial reports on these medicines from the pharmaceutical
companies were that these medicines weren't being abused by users, clinicians
in the field often have had different observations when talking directly to
their clients over time. Even when these medicines aren't being abused per se,
some people may find that they get more and more reliant upon them over time,
to the point where they depend on the sleep medicine in order to sleep properly
and can't fall asleep on their own. On the other hand, getting good rest is crucial
for optimal mental health and stress management, so be an informed consumer!
It's okay to take medicines that are prescribed for you and designed to help
you, but make sure you are doing so with a mindful awareness.
Here are some questions to ask:
Is this medication considered "habit forming" or do people
sometimes find they need increasing doses of this medication over time to get
the desired effect?
Should I be taking this medication daily?
How should I decide when to take my sleep medication, and when I should try
other relaxation methods instead?
Does taking my original dose diminish in effectiveness over time?
Does the effectiveness of this medication diminish if I take it with alcohol
(or other drugs)?
Am I at any risk if I mix this medicine with cocktails, beer or wine?
There are also herbal supplements available to help aid sleep, such as
schizandria, valarian root, and melatonin. Because these supplements aren't prescribed
or regulated by the FDA, your physician or pharmacist may or may not feel comfortable
recommending these options, but it would be worth it to ask them their opinion
of these alternative options.
The Role of Drugs and Alcohol
Many people report that, subjectively speaking, drinking alcohol or smoking
a joint can help them fall asleep. Although this may be true, the quality of
sleep that you get when under the influence is not the same quality of sleep
when you are sober. Alcohol effects the REM phase of sleep, and marijuana (depending
on the potency and grade) has been shown to affect various phases of the sleep
cycle as well.
When it comes to alcohol or other medications that cause a person to relax
or unwind, especially when they are taken habitually, what can often happen
physiologically is that the system starts a cycle of intoxication - relaxation
- sleep - metabolism - rebound anxiety / rebound insomnia.
What initially makes you sleepy or relaxed can end up working against good
sleep or cause heightened anxiety levels when the chemical clears from your
body as a part of a normal metabolic process. Many folks may find falling
asleep more easily after a glass or two of wine, only to awake suddenly at 3-4
am, unable to return to sleep for several hours.
I have noticed over the years of counseling clients on alcohol use in my
practice that clients often under-estimate the amount of alcohol they are
drinking, for example telling their doctor they may have 1-2 drinks per day,
not fully realizing or letting their doctor know that each drink may be made
with 2-3 shots each, which actually means you are having 4-6 drinks, not just
one or two. Mixing these larger amounts of alcohol with sleep or anxiety
medications can be quite dangerous, and the risk you are taking may have been
minimized by your doctor who may not realize exactly how much you are drinking.
When in doubt, please be explicit with your doctor about what you mean by
"one drink," and keep in mind that one drink is typically defined by
a cocktail mixed with 1.5 ounces of alcohol (one "shot"), a wine
glass with 5 ounces poured, or a 12-ounce American beer (not a pint or stronger
Belgian ale which counts as more than one).
As noted above, other issues you should be aware of include medications that
directly interfere with sleep, including caffeine-containing products (like
cola drinks or coffee, green tea or black tea, or energy drinks). Although
subjectively speaking you might not feel more alert, these substances do take longer
to fully metabolize out of your system than their subjective effects last, so
even though you might not feel "wired" you may be more
"awake" than you would like when it comes time for bed. Medications
for AD/HD, which often contain powerful stimulants can also interfere with
sleep, especially those that are extended-release for longer-lasting results.
Should you notice these medications are interfering with your normal rest, you
may want to talk to your doctor about finding the most balanced treatment
options to meet all of your needs.
Additional Tips for Clients in Addictions Recovery
These days, clients (especially in a large city like Chicago) can easily
shop around for a provider that is right for them. For clients in addictions
recovery, you have an especial responsibility to seek out a practitioner that
takes your concerns about potentially habit-forming medications seriously.
Abuse of a prescribed medication may loosely be defined as someone who is
taking a higher dose than what they need for good rest, mixing the medications
with alcohol or other drugs, or taking them for reasons other than sleep, for
example to get buzzed or to relax. If you find yourself taking a medication
earlier in the evening than your bedtime, or in larger doses even though a
smaller dose would do just fine in helping you sleep, you may be abusing your prescribed
medication.
Some doctors may not be as fully versed in addictions recovery as others,
and may not realize your potential to become dependent on medications easily,
or your potential to abuse prescribed drugs. Just because a medication is prescribed
for you does not mean that it is necessarily "safe" from an
addictions recovery point of view. For clients committed to total abstinence
from all mood- and mind-altering medications, (often known as an abstinence-based
model or disease model, or for clients in 12-step recovery), it is best to
avoid such medication unless absolutely medically necessary, and in those
cases, I encourage you to discuss your history of addictions recovery with your
provider and to discuss limiting refills or dosage to the lowest dose that will
be clinically effective to meet your needs.
Not being a medical provider, I can't recommend any one course of action, and there is no one-size-fits-all approach to recovery. I would recommend however that any client with an established chemical addictions history to be through in exploring treatment options with their doctor. Some medications not originally developed as sleep aides, such as Trazodone or Seroquel, and anxiety medications such as BuSpar may be alternative medical options for anxiety or sleep, with a reduced liklihood for abuse. I recommend exploring all of your options with your doctor, so you can stay on track with your health and wellness as well as your recovery.
I hope that you've found this post helpful, goodnight!
Additional Resources
More information on good sleep hygiene available here.
This is a terrific article on the effects of marijuana on sleep.
Additional information for night shift workers available here.
Labels: abuse of sleep medications, poor quality of sleep, self-care and sleep, sleep and AD/HD, sleep and anxiety, sleep and medications, sleep and mental health, sleep and mood, sleep habits, sleep hygiene