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 a 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 is 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, earbuds 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 these 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 in 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 your 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 clients 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 overtime 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 medications 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 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 overtime 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 to 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 schizandra, valerian 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 affects 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 addiction 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 addiction 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 anyone 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 addiction history be thorough in exploring treatment options with their doctor.  Some medications not originally developed as sleep aids, such as Trazodone or Seroquel, and anxiety medications such as BuSpar may be alternative medical options for anxiety or sleep, with a reduced likelihood 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 For Help With Sleeping

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.