Depression and sleep: why you sleep too much or too little

“I sleep ten hours and wake up feeling like I’ve been hit by a train.”

“And I’m staring at the ceiling at four in the morning, waiting for it to get light.”

Two sentences that could be spoken by two people with the same diagnosis. One sleeps too much, the other too little, and both feel that something is wrong with their sleep in a way nobody quite understands. When people think of depression, they think of sadness, emptiness, loss of drive. They rarely think of the bed. Yet sleep is one of the first places where depression shows itself — and often one of the last places it leaves.

In this post I will explain why depression reaches so deeply into sleep, why it shortens it for some people and lengthens it for others, why the relationship between the two runs in both directions, and what you can do starting today. And because this is about depression, I will say at the start something I will repeat at the end: your GP and a psychiatrist are important people to turn to when you are depressed, not a last resort.

Sleep is not a side effect of depression

For a long time sleep problems were treated as a symptom that would disappear on its own once mood improved. Treat the depression first, the thinking went, and sleep will follow. Today we know the picture is more complicated.

The great majority of people with depression have trouble sleeping. In a review published in 2005, Tsuno, Besset and Ritchie estimated that around three quarters of people with depression have symptoms of insomnia, while a significant share — especially younger people — report sleeping too much. So sleep almost always changes in depression. The only question is in which direction.

More important than how often this happens, though, is the realisation that insomnia is not only a consequence. A large meta-analysis published in 2011 by Chiara Baglioni and colleagues pooled longitudinal studies that followed people over several years. They found that a person with insomnia who was not depressed at the start later had roughly two and a half times higher odds of developing depression than a person who slept well.

This means sleep is not just a mirror of mood. It is also one of the levers that moves it.

Too little: insomnia and early waking

Insomnia in depression has several faces. Some people cannot fall asleep because their thoughts go round in circles — about what they did wrong, what they cannot manage, what they will mess up again tomorrow. We call this circling rumination, and at night, when there is nothing to pull attention elsewhere, it is at its loudest.

Others fall asleep without difficulty but wake in the middle of the night and then lie awake for a long time. The pattern most typical of depression, however, is early morning waking: a person wakes two or three hours before the alarm and cannot get back to sleep. It is four o’clock, it is dark outside, and the whole day ahead is already running through their head — and none of it looks manageable. Psychiatric manuals count early waking among the signs of the so-called melancholic form of depression, together with mood that is worst in the morning.

If you keep waking at three or four, some of this is also described in Waking at three: what cortisol and a racing mind are telling you. Waking on its own is not a sign of depression — but it becomes important information when it comes with hopelessness, loss of pleasure and a sense that the day is not worth it.

Too much: hypersomnia and leaden tiredness

The other side gets talked about less, because it seems less serious. Who would complain about sleeping too much? But people who live with it know there is nothing pleasant about it. They sleep ten, twelve hours, nap during the day as well, and still never wake up rested. The body feels heavy, as if made of lead. Getting out of bed is an effort others cannot see.

Excessive sleep — hypersomnia, in clinical terms — is more common in younger people, in the seasonal form of depression and in so-called atypical depression, where it is often accompanied by increased appetite and marked sensitivity to rejection. If your mood drops every winter and your sleep lengthens, read Seasonal affective disorder: why winter pulls you under.

It is important to know that sleeping long hours in depression is not laziness and not “running away from life”, as loved ones sometimes like to call it. The sleep is often shallow and fragmented, so there is a lot of it but it restores little. At the same time, the bed really can become a refuge from a day that feels too heavy — and that is worth noticing without judgement.

What happens in the brain

Research on sleep in depression shows a few patterns that keep recurring. REM sleep, the phase in which we dream most vividly, starts earlier than usual in many people with depression and is longer and more intense in the first part of the night. There is often less deep, slow-wave sleep. Sleep is more broken, with more frequent brief awakenings. You can find more about this phase in the knowledge base under REM sleep.

The second part of the story is the internal clock. The circadian rhythm is a roughly twenty-four-hour cycle that governs when we feel sleepy and when we are alert, when body temperature rises and when we release hormones such as melatonin and cortisol. In depression this rhythm is often flattened or shifted — as if the orchestra were playing, but each instrument slightly in its own time.

The third part is tension. Depression is not only a state of slowing down; underneath it there is often a constant inner readiness for danger. The stress response system stays partly switched on even at night, which makes deep, calm sleep harder. That is why people with depression often feel exhausted and wired at the same time — tired, but not sleepy.

Why the link runs both ways

If depression spoils sleep and poor sleep raises the risk of depression, we get a circle that can turn in either direction. I have written in more detail about how poor sleep affects mood in Sleep and emotion: why everything hurts more after a bad night. In short: after a bad night the brain is more sensitive to negative stimuli and less able to regulate emotional responses. The same event that would otherwise only sting can, after a sleepless night, knock you off course.

When this repeats week after week, it builds up. You have less energy for people, for movement, for things that once brought you joy. You withdraw because you are tired. And withdrawal itself deepens depression — I wrote about how to break this pattern in Behavioural activation: how to move when there is no motivation.

There is another, less obvious reason why sleep matters so much. Insomnia often persists even after mood improves. And people in whom it remains are at greater risk of depression returning. So sleep should not be set aside as something that will sort itself out.

What this sounds like in conversation

Often sleep would not come up in a session at all if I did not ask. People see it as an unimportant detail next to the “real” problems. A conversation might sound roughly like this (composed, not a real person):

“How have you been sleeping lately?”
“I sleep. Maybe a bit badly. I wake up at four, but that’s just how it is.”
“What happens at four?”
“I lie there thinking about everything I have to do. And that I won’t manage it. Then I get up, because lying there is even worse.”
“When did that start?”
“I think … around the time I started cancelling everything. Before that I slept like a baby.”

“That’s just how it is” is a sentence I hear often. But sleep that has changed together with mood is not “just how it is”. It is information that tells us when something began — and at the same time one of the places where improvement can begin too.

CBT-I: treating insomnia helps mood as well

The best-researched psychological method for chronic insomnia is cognitive behavioural therapy for insomnia (CBT-I). It includes limiting time in bed to the time you actually sleep, linking the bed with sleep, working with thoughts about sleep and keeping a steady rising time. I have described it in detail in Cognitive behavioural therapy for insomnia (CBT-I): the method that works better than pills.

For people with depression, what is particularly interesting is that CBT-I does not only improve sleep. In a study published in 2008 by Rachel Manber and colleagues, people with depression and insomnia who received CBT-I alongside an antidepressant reached remission of depression more often than those who received the medication together with only a neutral control programme. Sleep is therefore not just a side goal — it is one of the routes to better mood.

One caution applies, though: restricting time in bed can increase tiredness and daytime sleepiness in the first weeks. With more severe depression, with bipolar disorder or with a tendency to epileptic seizures, it makes sense to do it under professional guidance, not on your own.

Exercise: a week of watching sleep and mood

Before changing anything, it helps to see what is actually happening. This exercise takes two minutes a day and you can start tomorrow morning.

1. Each morning, write down three times: when you went to bed, when you think you fell asleep and when you finally got up. It does not need to be precise — an estimate is enough. You can use the sleep diary tool.
2. Rate your mood on a scale from 0 to 10 twice: right after getting up and in the evening.
3. Write down one thing you did during the day, however small — a walk, a phone call, cooking. Without judging whether it was “enough”.
4. After seven days, look at the pattern. Do worse mornings follow shorter or longer nights? Do days with one small activity look different?
5. Take the diary to your doctor or therapist. A week of notes says more than “I sleep, sort of”.

The exercise is not treatment. But it is a way of making sleep visible — to you and to the people helping you.

Small steps that often help

A few things almost always prove useful with depression and sleep, whether you are sleeping too much or too little:

• A fixed rising time, at weekends too. If there is one rule for the internal clock, it is this — the time you get up sets it more strongly than the time you go to bed.
• Daylight in the morning. Fifteen to thirty minutes outside in the first hour after getting up, even on a cloudy day, helps synchronise the rhythm.
• The bed is for sleeping. If you have been lying awake for more than twenty minutes, get up, go to another room and come back when you feel sleepy.
• Go carefully with alcohol. In the evening it makes falling asleep easier, but it breaks up the second half of the night and makes early waking worse. More in the knowledge base under alcohol and sleep.
• Keep naps short and early, if you need them — no more than twenty minutes and not late in the afternoon.

None of these will cure depression. But each one strengthens a little the internal clock that depression loosens — and when the clock is steadier, everything else is sometimes a little easier too.

When sleep is not the main story

I want to be honest and clear: not every bad night is down to depression, and not every better night means depression is over.

Poor sleep can have a physical cause. Sleep apnoea, restless legs syndrome, thyroid disorders, chronic pain, hormonal changes and some medications can cause both insomnia and daytime tiredness that closely resembles depression. Loud snoring with pauses in breathing, for example, is a reason to see a doctor, not to start psychotherapy. That is why your GP is the first port of call when sleep changes for a longer period.

Medication can change sleep in both directions. Some antidepressants improve sleep, others make it worse at first or cause daytime drowsiness. That is not a reason to stop them on your own, but a reason to talk to the psychiatrist or doctor who prescribed them. I have written about how medication and psychotherapy complement each other in Antidepressants and therapy are not rivals.

Better sleep is not necessarily a sign of better mood. In some people, especially those with bipolar disorder, a sudden need for very little sleep together with increased energy is a warning sign, not progress. If you are sleeping three hours and feel unusually full of energy, tell your doctor.

Sleep is not the only lever. In some people sleep settles but depression remains, because its roots lie in relationships, loss or long-term overload. Then sleep is a help, not the solution — and the work happens elsewhere.

When to seek help — and where

If your sleep changes for several weeks and at the same time you lose pleasure, drive, hope or your sense of self-worth, see your GP. They can rule out physical causes, assess whether this is depression and, if needed, refer you to a psychiatrist. A psychiatrist is an important person to turn to in depression, not only for medication but also for an assessment of what you need. Psychotherapy is often part of that path, not a substitute for it.

I have described how depression differs from ordinary low mood in Depression is not sadness: how to tell them apart and why it matters. How the body carries depression — including through tiredness that sleep does not fix — is the subject of Depression and the body: pain, fatigue and digestion. If mornings are when it grips you hardest, you may also find Why mornings are the worst helpful.

If the night hours are when thoughts come that it would be better if you were not here, you are not alone and you do not have to wait for morning. In Slovenia, call the mental distress helpline on 01 520 99 00 (every day from 7 pm to 7 am) or the Samaritan helpline on 116 123 (24 hours a day). If you are in immediate danger, call 112.

What to remember

• Sleep almost always changes in depression — it shortens for some people, lengthens for others, and does both for some.
• The link runs both ways: insomnia raises the odds of later depression by roughly two and a half times, and depression makes sleep worse.
• Early morning waking is one of the more typical signs of depression, but not proof of it.
• In people with depression and insomnia, CBT-I improves sleep and helps mood at the same time.
• A change in sleep that lasts several weeks is a reason to see your GP; a psychiatrist is an important person to turn to in depression.