The age-old "how did you sleep last night" question is one we commonly ask each other, but do we ever ask each other: "how have you lived your day to optimise your sleep tonight?" Sleep is absolutely vital for optimal psychological functioning - so much so that it is often one of the first targets of a psychology treatment plan, whether the presenting issue is depression, anxiety, or stress. Poor sleep quality effects mood, anxiety, stress levels, and cognitive functioning (e.g, concentration), but we don't always link adverse emotional or mental experiences by day with a sleep deficiency overnight, and vice versa.
In NZ we have a major sleep epidemic and sleep disturbance is a common experience with most mood, stress and anxiety difficulties. Zopiclone is a sedative-hypnotic medication commonly prescribed for sleep which works by depressing the central nervous system. This effectively knocks someone out in the short-term with a superficial sleep rather than the deep repairing sleep we require. Regular use of zopiclone also causes a tolerance to form and the requirement for greater doses to get the same effect. Last year, this little pill was actually the 16th top medication prescribed in NZ, with its population of 4.471 million (2.340 million of these being females). There were 540,000 zopiclone scripts written, according to Pharmac data, with this equating one in eight Kiwi's who had a sleeping pill prescription last year. There are many substance dependancies created each year from prescribed medication such as this, not to mention the dangers of these medications when combined with other sedatives (e.g., alcohol) or the risk of overdose.
We are frequently prescribed other drugs too. One in nine NZer's and one in six NZ women are currently prescribed antidepressants, which are not solely prescribed for depression but may also be used for anxiety, insomnia, and some pain conditions. Now, that is roughly 745,000 NZer's using an antidepressant and, of those, 400,000 are female (please correct me if I'm wrong on the maths!). Antidepressant's (usually 'selective serotonin re-uptake inhibitors'- SSRI's) are said to target serotonin uptake in the brain. Serotonin is the 'up and go' neurotransmitter (brain chemical) that is thought to be impaired during depressive states. The mode of action purported to occur with SSRI use is that they allow more serotonin to hang around in the brain synapses, where it can have a desired effect (e.g., improved mood).
A concerning fact is that SSRI use increased 37% between 2007 and 2012, which may reflect increased rates of mental disorders and/or the acceptance, de-stigmatisation, and normalisation of such medication use in NZ. Yet 40% of those using SSRI medication in a NZ study reported still feeling moderately or severely depressed, and many experienced serious adverse effects including sexual difficulties, feeling emotionally numb, and difficulties getting off the medication to the extent that they felt trapped on it (Read, Cartwright & Gibson, 2014; Read et al., 2014). SSRI use effectiveness research suggests that they should only be indicated in cases of severe depression or anxiety. Yet they are prescribed in general practice for any number of life stressors, even including normal grief - so we are now medicating away our normal emotions. The published research on SSRI medications effectiveness is also rife with corrupt influences from pharmaceutical companies who profit from sales. Meta-analytic research that reviewed the overall efficacy of SSRI's (whether they work), conducted by placebo effect expert Dr Irvine Kirsch, actually found the use of these medications to be no better than that of a placebo effect (expectation and belief in the treatment; Kirsch, et al., 2008; Kirsch, 2015). The landmark book 'Anatomy of an Epidemic' and the 2005 Journal publication by Robert Whitaker is a robust and eye-opening read on this and other related departments, such as how mental illness rates have actually risen and outcomes worsened since the introduction of psychiatric medication like SSRI's (Whitakar, 2005; Whitaker, 2010). There is general controversy pertaining to these issues.
The serotonin deficiency model (which SSRI prescribing relies on as its cause and solution) has recently been contested to be overly simplistic and inadequate by some, as research unveils more about the relationship between nutrition, gut health functioning, inflammation and chronic health/mental health. This new science views depression as not being as simple as a serotonin imbalance but as having multiple contributing factors including chronic low grade systemic inflammation contributed to by diet and lifestyle stressors. Much more research is required to refine integrative models from this neuropsychoimmunological (brain, nervous system, immune/endocrine systems) perspective, but it's clear that these interrelated systems interact with stressors arising from diet and lifestyle in our changing world (Greenblatt & Brogan, 2015).
Sleeping pill and SSRI use is certainly an individual choice and these meds may play an important role for some in some circumstances, however possible physical contributors to low mood and sleep disturbance don't often get sufficient examination first. And so the opportunity to prevent the need for serious medication gets missed. To sleep well we need to produce melatonin in the evening and this requires a series of systems to be working well in the body. Some examples that can interfere with this delicate process, that are too often overlooked (especially in women), include B12, Iron, Zinc, Magnesium, or other nutrient deficiency, not eating enough protein, processed food additives, antibiotic overuse and poor gut health, thyroid and adrenal problems, hormonal contraception effects, or lifestyle factors like chronic stress, loneliness, alcohol use, or lack of sunlight and exercise. Those eating late at night or with blood-sugar disturbance are also vulnerable to broken sleep. This is due to blood-sugar crashes causing cortisol to spike and cause wakefulness through the night, when you really need to be out-to-the-count in order to be on form for the next day.
The See-saw Effect
With lack of sunlight exposure, sedentary workdays, caffeine and alcohol use, not to mention screen time into the wee hours our circadian rhythm's (the sleep-wake cycle) literally don't know whether it's day or night anymore. Yet melatonin (the 'get sleepy hormone') and our old friend serotonin are like a see-saw operating in tandem. Problems at one end will affect the other, hence sleep disturbance and low mood or anxiety often go hand in hand. Further, melatonin plays a role in regulating other hormones and so more widespread dysfunction to hormones can ensue (women's health psychiatrist Dr Kelly Brogan describes the endocrine system as a spider web, that "when you yank one side the whole thing moves"). Jamie Scott, Nutritionist and President of NZ's Ancestral Health Society gives an excellent explanation on what's required to optimise melatonin, sleep, and serotonin through some simple daily habits to add in before lunch as well as habits to foster after lunchtime. One way to increase the brains capacity to produce melatonin in the evening is to use an App like F.lux if you do need to be on screens in the evening (although it's even better to switch off and unwind for the several hours before planning to go to sleep). Of course there is a chicken or egg situation here, because mood, anxiety, and degree of stress will also impact on getting a good nights sleep, therefore relaxation and mindfulness skills are an important piece of the jigsaw.
Nutrition matters in melatonin and serotonin production as we require micronutrients (vitamins and minerals) and certain macronutrients (especially protein and quality fats) as precursors to make these in our body. Those eating a largely processed diet, taking certain medications, drinking lots of caffeine and/or alcohol, who are chronically stressed, sedentary, and have difficulties unhooking from thoughts or struggling with unresolved trauma may be vulnerable to accruing nutrient deficiencies over the years. Women can be disproportionately affected due to further stress from pregnancy and breastfeeding, and are more prone to hormonal imbalance (e.g., thyroid) then men. Even those eating a relatively whole food and nutrient dense diet may acquire deficiency, as our food supply has been affected by depleted soil (e.g., magnesium), pesticides on produce and other toxicants, or those eating vegetarian or vegan diets (B12 is only available in animal products). Nutrient deficiencies are slow and insidious, creeping up and appearing first with what appears to be psychological symptoms (most commonly insomnia, anxiety, fatigue, cognitive changes, and low mood or irritability).
NZ is home to internationally leading research on micronutrient treatments for psychological difficulties, conducted at Canterbury University, and led by Professor Julia Rucklidge. This is some of the most exciting research and her TEDx talk below, conducted in November 2014, has recently hit a quarter of a million views - this suggests people are interested in learning about nutrition and mental health. Her teams research on micronutrients and B vitamins in stress and anxiety after the Christchurch earthquake's is particularly relevant, as is a new study on micronutrient treatment for insomnia (Lothian, Blampied, & Rucklidge, 2016; Rucklidge et al, 2011, 2012). These studies support the effectiveness, accessibility, affordability, and low risk nature of micronutrients for such difficulties.
Improve Your Sleep and Mood One Bite at a Time
The relationships between impaired sleep and low mood, stress, or anxiety can be a challenge to unravel. Which comes first - mood or sleep problems? Comprehensive assessment and traditional psychological considerations and therapies are often important in ruling out possible causes to sleep problems (e.g., sleep apnea), especially with long-term or severe problems. But in most cases, short of grabbing a sleeping pill or other medication, why not try some DIY improvements:
- Be aware of stress and foster a routine that builds enjoyment, connection, and relaxation. Make the bedroom a no-screen zone. Learn mindfulness strategies to unhook from thoughts of the day that's been and the day to come. Engage in some stretching exercises - Yin Yoga is great to unwind.
- Take a caffeine holiday for a month and then if caffeine is to be added back in, trial it in the morning and limit intake. Notice the effects that caffeine has on mood/anxiety and sleep once it's re-introduced. Be wary of de-caf - most of these have chemicals that can also be activating on the stress response.
- If you're struggling with mood and/or sleep then a months break from alcohol is also recommended - notice what this is like and seek assistance if stopping is too difficult, it can be one of the hardest habits for people to break and you may have to recruit those you live with as support (i.e alcohol free zone at home).
- Check B12, Iron, Folate and other common culprits - and supplement under health professional guidance if indicated (read here for more on B12 in particular). Magnesium and Zinc are two other nutrients worth exploring. Look up gut healing protocols to get to the underlying reason for deficiency which may include food intolerances.
- Eat food - nutrient dense with a good amount of protein. Sugar and stimulants, especially in the evening, wreck havoc with sleep and adversely affects mood and anxiety in the long run.
- Read Jamie Scott's lifestyle guides on working with your body and its natural sleep-wake cycle - mornings and afternoons, and if you are shift worker then Dr Anastasia Boulais (who knows a thing or two about rocking it as a shift worker!) has a helpful two-part blog on it here.
- NOTE: if you are already using an SSRI or sleeping pill talk to your prescriber before making any changes to what you take. And seek assistance if problems are not remitting or things are worsening.
So how are you going to live today in order to optimise your sleep tonight?
Kirsch, I., Deacon, B.J., Huedo-Medina, T.B., Scoboria, A., Moore, T.J., & Johnson, B.T (2008). Initial severity and antidepressant benefits: A meta-analysis of data submitted to the Food and Drug Administration. PLoS Medicine, 5 (2), E45.
Read, J., Cartwright, C., Gibson, K., Shiels, C., & Haslam, N. (2014). Beliefs of people taking antidepressants about causes of depression and reasons for increased prescribing rates. Journal of affective disorders, 168, 236-242.
Rucklidge, J. J., Andridge, R., Gorman, B., Blampied, N., Gordon, H., & Boggis, A. (2012). Shaken but unstirred? Effects of micronutrients on stress and trauma after an earthquake: RCT evidence comparing formulas and doses. Human Psychopharmacology: Clinical and Experimental, 27(5), 440-454.
Rucklidge, J., Johnstone, J., Harrison, R., & Boggis, A. (2011). Micronutrients reduce stress and anxiety in adults with Attention-Deficit/Hyperactivity Disorder following a 7.1 earthquake. Psychiatry research, 189(2), 281-287.