View episode transcript

Featured Guest

Dawn Dore-Stites, Ph.D.

Objectives

• Understand the interplay between depression and sleep.
• Review non-pharmacological interventions for insomnia.
• Understand how cognitive behavioral therapy can improve sleep.
• Review possible medications for insomnia.

Resources

• Effectiveness of clonidine in child and adolescent sleep disorders (Psychiatry Investigations)
• Pharmacotherapy for insomnia in children and adolescents: a rational approach (Uptodate) 
• Time for bed: parent-set bedtimes associated with improved sleep and daytime functioning in adolescents (Sleep)

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Transcript

Syma Khan:

Hello, and welcome to Breaking Down Mental Health with myself, social worker, Syma Khan, child and adolescent psychiatrist, Dr. Heidi Burns, and nurse practitioner, Dr. Christina Cwynar. Unfortunately, Dr. Burns is unable to join us today.

We are very excited to have Dr. Dawn Dore-Stites join us today for our discussion about sleep and depression. Dr. Dore-Stites is a pediatric psychologist at University of Michigan Health/Mott Children's Hospital. Pediatric psychology blends clinical child psychology and health psychology principles to work with patients with acute or chronic medical conditions. Within sleep, she frequently works with adolescents struggling with comorbid conditions such as anxiety or depression.

Dr. Dore-Stites, let's start by talking about what constitutes as good sleep.

Dr. Dawn Dore-Stites:

So, good sleep is more than just getting enough sleep. There is subjective sleep and the perception of sleep, but also objective. And most of us focus on how much sleep you get as being good sleep. So, the traditional is eight hours for an adult is good sleep. However, we also know it has to be a regular sleep schedule. So, for example, if you have someone who does shift work, they may get eight hours of sleep, but if they're sleeping one time period from 10:00 to 6:00 in the morning and another time period from noon to 8:00, that is still going to feel unsettling to them. And so, they may not perceive that as the best sleep.

We also know that your sleep has to be aligned with your circadian rhythms and your circadian rhythms in a really simplistic way is your body's clock. So, if you're not sleeping aligned with your body's clock, that can also cause a perception of bad sleep. And I think if you've ever experienced jet lag, you can definitely resonate with that. So, for example, I flew to Paris when I was like 20, slept on the plane for eight hours because I was 20, and I could do that, and got up in Paris and it's a totally different time zone, light exposure. I felt horrible even though I had slept eight hours, because it wasn't aligned with my circadian rhythm.

For kids and teenagers, they also need more sleep than a lot of adults may think. So, for school age children getting nine to 11 hours a night and for teenagers eight to 10 hours a night, which is almost impossible with schools start times, is critical for them to feel good about their sleep.

I think subjectively, when you ask a person do they feel well rested? Do they feel vital when they wake up in the morning? I always think of those mattress commercials where people pop up and they're stretching their arms and it's a bright day. That feeling of vitality is that subjective indicator of sleep. And there can be a real discrepancy between a person getting an objective, good sleep, regular sleep, and their subjective perception, which can also be influenced by things like depression, anxiety, and stress.

Dr. Christina Cwynar:

Thank you for that definition of good quality sleep. And as mental health providers, I think maybe we're a little bit more in tuned to some of these factors. And I know when I'm talking to children or adolescents about their sleep, I'm asking, "Well, not only how many hours do you think you're getting, but are you waking up or how long does it take you to fall asleep? What's waking you up? Can you return to sleep?" And all those little factors that help me understand their sleep experience a little bit more.

So, can you give us a little bit of an insight of how does depression affect sleep on more of a biological level?

Dr. Dawn Dore-Stites:

So this is definitely not my area of expertise, but I dug into it a little bit because I think that when you learn about that intersection of depression and sleep, it can demystify things and make symptoms not so scary.

So, sleep is very complicated, as is depression. And I think there is a lot of predominant hypotheses about how depression manifests and likely it's going to be that there are several pathways that can cause depression. Some of the ones that I got to be up to speed on in preparation for today, there's inflammatory markers that are present in depression. There are genetic factors. There are biochemical factors. And there's also circadian rhythm issues with depression.

And in all of those areas, the pathways to depression often intersect and have a dance with all of the neurological pieces of sleep too. So, for example, the neurochemicals involved in depression are also involved in the sleep process, and that explains probably why oftentimes you see individuals with depression have symptoms related to sleep.

I think intuitively it makes sense to us if you've ever had a period of short sleep, like you're studying for exams and you go a couple of weeks without sleep, you can feel edgier, more irritable, more depressed. But I think it's harder for someone who's in the midst of depression to understand, "Why is my sleep also a mess?" And I think if you think about it in a really basic way that sleep is housed in the brain, depression is housed in the brain and they sometimes have a really vicious dance with each other to the point where you can't necessarily see what precedes the other.

Syma Khan:

So, one thing that we hear a lot about is REM sleep and about sleep cycles and we talked a little about our circadian rhythms, but is there anything else that you'd like to reflect on that in terms of neurobiology of sleep?

Dr. Dawn Dore-Stites:

Sure. So, all of us have about 90-minute sleep cycles. And what happens is you go from lighter stages of sleep to deeper stages of sleep into REM. And REM sleep is the part of your sleep that's commonly known as dreaming sleep. Physiologically, you're essentially paralyzed. There's really no muscle movement whatsoever, but your brain and your eyes are very active. This is where nightmares occur. This can be the part of sleep that people will wake up after experiencing a nightmare, because it's at the end of the sleep cycle and you're shifting to another one. And for most people, this occurs in the later parts of the night of sleep.

In depression, there are fairly robust data that shows that REM sleep in particular is disrupted when you're in the midst of depression. And so, what you'll see is that it'll take longer for a person to enter REM in the course of a night, and there will also be some increased REM periods. All of that can lead to your sleep not feeling very restful, that you wake up the next morning and it just doesn't feel quite right because your sleep architecture or the sleep cycling isn't following that normal pattern that we see with good consistent sleep.

Syma Khan:

So again, that correlation strongly, right, between both of these things really, depression impacting sleep, sleep impacting depression, and the need to co-manage both of those oftentimes for our patients?

Dr. Dawn Dore-Stites:

Most definitely.

Dr. Christina Cwynar:

I like that description of how it's a dance and there's just all these neurotransmitters, these hormones that are maybe depleted or in excess and just fighting with each other. So, the sleep's off, the mood's off and they interplay with each other.

So, let's talk a little bit more about some non-pharmacological interventions that healthcare providers can teach children, adolescents or even their families to help those adolescents or children to improve their sleep.

Dr. Dawn Dore-Stites:

I think that the first thing is that helping families and kids view sleep as not only a pillar of health but the foundation of all the other pillars. So, if you don't get good sleep, you're probably not going to eat well, you're probably not going to exercise, you're probably not going to meditate and do all the things to relieve your stress. So, viewing sleep as a foundation for all of those other good health behaviors, I think is critical.

And that this is a public health crisis. Adolescents in our nation are described as the most sleep-deprived amongst the world, and I think that that drives home the fact that their health is really being compromised. And I don't say that to be extreme or dramatic. I say it because I think when you look at sleep and the impact it can have on a teenager or a child, we want to have them have great sleep because it affects so many areas of their lives and it can really set them on a different trajectory.

And when we look at sleep data, about three quarters of 12th graders do not even get eight hours of sleep on a school night because of early start times, homework, extracurriculars, all of that other good stuff. There are also biological factors at play for adolescents. So hormonally, they become more of a night owl, a lot of them, and so they have trouble falling asleep and they push it later and later and then on weekends it's even later and later, and sleep in. So, all of those factors, the use of electronics, all of those can also inhibit good sleep.

The second thing I'd like to do is identify how to recognize poor sleep, especially among children. Children don't have the same symptoms of sleepiness as adults. So, often they'll be tired and wired. They will be bouncing off the walls. I joke, one of my children I can know about 7:45, as soon as they start talking excessively and they are running around the room, I'm like, "Oh, I missed the sleep window right there. They need to go to bed."

And so, a kid who's tired and wired maybe looks hyperactive in the classroom, bouncing around. They may be trying to push themselves awake. That can be a marker of sleepiness. If they have to be woken up in the morning. If they're napping. Some of my kids will nap. Even the school-age kids will fall asleep in class, especially after lunch or recess.

For teenagers, their sleepiness looks very similar to an adult. So, they'll be falling asleep in class. I say this because a lot of parents won't recognize the need for non-pharmacological interventions because they don't view their kids as sleepy. They view their kids as hyper. Or, I'm using air quotes and I know you can't see that on a podcast, but lazy, that they just don't want to get up in the morning and face school. But these can actually be markers of suboptimal sleep.

So, I use this information with providers and with parents to try to make sleep a priority. And in a lot of families it may not be. We are not reinforced for resting in our culture, and it is really critical to find some time before bed to relax, recuperate, rest. So that you're not going from the 80 miles an hour you're going during the day to just going to sleep.

So, I think the first thing is to make sleep a priority and find some time before bed that is restful and relaxing. Routines, especially for younger kids, having three to five activities that they do every single night, that cues your body that it's time for sleep. And it could be something simple like brush teeth, brush hair, get in pajamas. I'm always amazed at the number of kids who don't change out of their clothing to get ready for bed. They don't wear pajamas. And that can send a really strong bodily cue that, "Oh, you're not really sleeping, it's not time for sleep."

Finding calming activities like reading, music, audiobooks, and putting down electronics is important. For my teenagers, if they're resistant to putting down electronics, like that's too much. We talk about passive electronic use, like watching a show or listening to music versus active, which is engaging on social media or gaming, as a first step to try to help that routine.

We also talk about the sleep environment. So during COVID, the number of my patients who laid in bed all day doing their online schooling was mesmerizing. They didn't get out of their cave all day long except to maybe go to the bathroom. And so getting out of bed, having a sleep environment that is just for sleep. So, your bed is just for sleep and other areas of your room can be used for homework.

Cool, dark and quiet. One of my favorite baby shower gifts is to give parents white noise machines. I think they're critical because they mask all the ambient noise that may wake up a kid. And even as an adult, using a white noise machine can mask some of that. So, having a sleep environment that's conducive to sleep.

And then the final thing I talk about are schedules. So, with my teenagers, the conversation is often about avoiding naps, which is so very hard because they're so sleep-deprived. But having regular bed and wake times. And we know that parents who set bedtimes, even for teenagers, there is a pretty significant reduction in depressive symptoms. So, encouraging parents to set some limits, even if they're passive limits, like turning the router off at 10 or 11. Those can be critical to the health of a kid or a teenager.

It should be important to know that just changing schedules or just changing the sleep environment. I have so many families who just get a new mattress. That isn't going to necessarily help things automatically. It takes a long time and it really has to be something that's done consistently. So, usually these things are not done standalone. Usually they're done with other things as well.

Syma Khan:

I really appreciated all those little tips and tricks that you shared and thinking through a multifactorial intervention. Right? So, developing that routine, thinking about the behaviors that we're seeing, modifying the environment. That good sleep takes effort. And I think as you said, oftentimes we're not prioritizing that, but it is so critical to our health, to our well-being that we get good sleep. And especially for children and adolescents when their brain is developing, that's an essential time for them for their brain to really rest and be able to process what they're learning and gaining every day.

Dr. Dawn Dore-Stites:

Definitely. You're preaching to the choir. Most definitely.

Syma Khan:

So, Dr. Dore-Stites, can you share a little bit about how you use cognitive behavioral therapy to improve sleep?

Dr. Dawn Dore-Stites:

So, cognitive behavioral therapy for insomnia, it's called CBTI, is a very well researched intervention and it's a package of things. So, it's not just one element. It includes things like modifying the sleep schedule so that you're a little bit sleep-deprived, to smoosh your sleep together and chase out some of the wakeups in the middle of the night. It's strategies to help make your bed more linked to being drowsy and sleepy rather than alerting and stimulating.

So, it's a package of interventions and it's very, very well-researched in adults, including several populations with special needs. Veterans who have trauma histories, individuals who have comorbid psychiatric or medical conditions, but it's not studied much in adolescents. And there's a couple things that really pop up for researchers in this area. One is that CBTI really relies on sleep restriction.

So, what that means is you do sleep logs for a couple of weeks and then as part of the intervention, you shave off a little bit of your sleep with the thought that you'll fall asleep more quickly and that you'll likely stay asleep longer because your sleep is smooshed together. We hate to do that much with adolescents, A, because they may be out on the roads newly driving, they're learning, they're at higher risk for depression. So, there's a real concern about restricting their sleep too much. That said, there are some researchers, especially out of Indiana, who are doing research looking at modifying CBTI for this population because we really find that the strategies are valuable and we don't want to withhold them from adolescents. We want to think about how we can modify them.

Dr. Christina Cwynar:

We talked a lot about the different non-pharmacological things that families and providers can implement for patients who are having difficulty sleeping and a little bit about CBTI, but are there other factors that maybe affect sleep and mood that healthcare providers don't often think about, that could be related?

Dr. Dawn Dore-Stites:

So, I think number one thing is that similar to adults, there's often a bidirectional relationship between depression and sleep. So, I mentioned that vicious dance. It's often really hard to know what came first or what is the predominant factor because they become very linked. And so, I keep that in mind because there may be times in treatment that I might be deferring to the provider who's doing more of the depression management than doing more on sleep. And so, dancing back and forth upon what the treatment interventions are instead of if it's a straightforward sleep patient, I just power through and do those sleep interventions.

I think the second thing is that getting to know a patient's sleep schedule is critical if you're doing depression treatment because when you start to see, especially early morning wakings or their sleep starts to shorten, I start to get very concerned because they're spending a lot of time up in the middle of the night. And I think we can all appreciate that in the middle of the night your brain goes to dark places and you can wake up the next morning and go, "What was I thinking?"

So, if you have a teenager who's already in the midst of depressive symptoms and they're in the middle of the night and they're feeling alone and isolated and sleep-deprived, that can be a really high risk time for them. So, as a depression provider, making sure that you know their sleep and you're knowing if there's changes. We do know that sleeping less than eight hours of sleep at night is associated with a threefold increase in suicidal ideation. And when you start to get less than four hours a night, you start to see an increase in suicide attempts that require treatment.

So, there seems to be a very strong relationship there, and I think as any provider in healthcare, assessing sleep just as much as you assess access to means to commit suicide or thoughts of hopelessness, I really think it's a critical piece to assess as well.

The last factor I really consider is the impact on the family. So when I talk to many of my, especially teenage patients who have trouble waking in the morning, they talk about that the mornings are just wrought with conflict. That they're starting off the morning getting yelled at. That they're getting yelled at for something they don't feel that they can do, which is just wake up. They're getting accused of not wanting to go to school. And many of them will say, "I want to go to school, I just can't wake up."

And so, the morning starts out with this huge conflict between the parents and it really carries on through the day. It's hard to just take that off at the end of the day. And so, a lot of my families will talk about the stress that it causes the entire family when there's a sleep disorder, or the parents being late to work because they have to drive their child to school. All of those are things that I think are under-recognized as part of the sleep problem.

Syma Khan:

And even as a behavioral health provider, I was not aware of the significant correlation between sleep and suicidal ideation or even attempts. And so, I think it is an important factor in our assessments and our treatment and our treatment planning that we should be thinking about. And in particular, I think in pediatric settings where we may be treating mild to moderate symptoms of depression, to maybe monitor that and really track it along with when we're assessing for, "Are you having these suicidal thoughts? Are you having these other kind of concerns?" But really doing a deeper dive into sleep because it is so important. And it can be an easy recommendation to pass along to families that over time can really change how the family system works around sleep. It can be difficult to take these steps, but it seems like really so integral to wellness.

Shifting gears a little bit, when do you recommend thinking about pharmacology for sleep?

Dr. Dawn Dore-Stites:

So, I think I look at it in two ways. I think there are medications specifically for sleep and in certain situations I think they can be helpful, especially if you're working on behavioral interventions to help with sleep.

So, the situations I think about are if there's extreme stress in the family related to sleep, I often see this in my patients with, for example, autism, where they wake in the middle of the night and the parent's sleep is very disrupted or they have trouble falling asleep.

Also, if the depressive symptoms are severe, because I know that helping them get good sleep could relieve them of some of the depressive symptoms, not all of them, but part of them. And I will sometimes reach out to prescribing providers to consult around sleep medications that might help give them a hook, a little bit of temporary relief.

Also, nightmares related to trauma. There are good behavioral interventions for nightmares related to trauma. However, sometimes the intensity of the nightmares can be so severe and if they're also working on exposure based treatments in trauma therapy, that medications that can alleviate some of that while we work on the behavioral interventions can be helpful.

In patients with comorbid depression, I also look at it from the standpoint of their pharmacologic interventions for depression. So, if we know that their depressive symptoms are not well controlled during the day, then I reach out to prescribing providers about how to optimize their antidepressants so that we can help them during the day because we also know that that can help good sleep. Better depression control can also lead to better sleep.

Syma Khan:

It speaks to that bi-directional relationship that's so important.

Dr. Dawn Dore-Stites:

Most definitely.

Syma Khan:

Well, since we have the expertise of Dr. Cwynar to talk a little bit about medications, maybe we can talk specifically about some sleep medications that may be indicated for children and adolescents. Dr. Cwynar, can you tell us a bit about how melatonin works and how to dose it and when to administer it?

Dr. Christina Cwynar:

Yeah. So, I want to start this conversation off by saying we'll talk a little bit about medication, but truly the emphasis around sleep is the non-pharmacological. That's really the intervention that people need to focus on. And medication is really a tool, like Dr. Dore-Stites said, to get us to that end to work on these other interventions. And right now, we'll talk about some of the medications that we traditionally use a little bit more for sleep and not the antidepressants. You can refer back to an earlier episode about those medications.

But melatonin in particular is a hormone that is made naturally in your brain and it helps control your sleep cycle. It is tied to the amount of light that is around you and the levels increase in your brain as the sun sets and they stay high during the night and then they drop in the early morning to help wake you up. So, melatonin supplements can help with the initiation of sleep, but that takes time and it also needs to be coupled with that good sleep hygiene practices to be the most effective.

So, melatonin can be used in young children. For a child around the age of five, you can give one to two milligrams. For a child between the ages of six to 12, between one to three milligrams. And then 13 and above, one to five milligrams. Oftentimes, you'll hear providers prescribing higher. You really don't need higher doses than that. And oftentimes we're quote-unquote, "overdosing" individuals with melatonin. Even some of these doses are a little bit on the higher ends. You just need that tiny little boost to get your melatonin activated there. And you need to be cautious about not overdosing individuals with melatonin because that can also have dangerous consequences.

Syma Khan:

When would you consider trazodone?

Dr. Christina Cwynar:

Yeah. So, as we move out of the supplement realm here and talk a little bit about some of these other medications that are used for sleep, I should note that none of these are FDA approved for children and sleep, but they are studied, they are commonly prescribed for this indication, but they just don't have that FDA indication.

So, trazodone falls within a class of medication known as serotonin antagonist reuptake inhibitors, that works by blocking serotonin at the 2A and 2C receptors in addition to the reuptake of serotonin. So, this mechanism of action requires really high doses for it to achieve the antidepressant effects. So, it was originally developed for that effect, but we discovered that at lower doses it has a potent action at the serotonin 2A antagonist of histamine and alpha 1 receptors, and it's the blocking of this arousal system that can lead to sedation. So, it is very popular to use as a sleep aid both in children, adolescents and adults.

So, for children, the dosing range is between 12.5 to 100 milligrams per night and for adolescents between 25 milligrams to 100 milligrams per night. There are different dose ranges if you're using it as an antidepressant. Again, starting on the lower end and working up towards effect for the use of trazodone.

Syma Khan:

Thanks for sharing about those medications. I think sometimes people also consider using clonidine and hydroxyzine to support with sleep. Can you tell us a little bit about those?

Dr. Christina Cwynar:

Yeah. So, let's start with the clonidine. So, the exact mechanism of clonidine in the induction of sleep has not been well established, but it's hypothesized that clonidine induces somnolence by decreasing norepinephrine release through the activation of the alpha adrenergic receptors in the central nervous system.

And despite clonidine being widely utilized as a sleep aid for children and adolescents, there is only a few studies that look at how it affects sleep patterns. So, one study by Jing and colleagues in 2022, so fairly recently, found that clonidine significantly improved subjective sleep quality, sleep latency, and sleep disturbances after treatment. It also found that it was more effective if consistently taken for two weeks or more. And this study did note that clonidine was less effective for individuals with higher levels of anxiety or depression. And clonidine is often also helpful for individuals with ADHD, developmental delay, autism spectrum disorder, various genetic syndromes or trauma. Like Dr. Dore-Stites said earlier, it is one of those agents that we do use for PTSD-related nightmares along with another closely related agent, prazosin.

And then the hydroxyzine. This is an antihistamine that in psychiatry we often use for anxiety, but it works by decreasing activity in the central nervous system, which leads to being helpful with inducing sleep, particularly if an individual is anxious. It also increases levels of serotonin, which can ease an individual's anxiety and produce calm. While it's not FDA-approved for insomnia, there is research that shows that it is helpful for sleep problems related to anxiety and PTSD.

Syma Khan:

Thank you so much for that summary, Dr. Cwynar, of the different types of medications that providers can consider to support with sleep. I really appreciate it starting that conversation by recognizing that medications can be a tool to help, but we really need to remember the behavioral health interventions and those routines that we need to develop around sleep and promote good sleep and make sure we're helping to prioritize that in our lives and the lives of our patients and families that we work with.

So, in closing, is there anything else that you'd like to share with us today?

Dr. Dawn Dore-Stites:

I think number one, make sleep at the top of your mind. So, whether you're struggling with the depression or not, talking to your child's pediatrician, getting observations from the school about any indicators of sleepiness can really make a huge impact because intervening early on sleep can again help them set on a different trajectory for learning, for mood, for growth, everything. So, really make it at the top of your mind as a parent or a provider.

Dr. Christina Cwynar:

Yeah. And I think that reflection is really important, because even when we think of Maslow's hierarchy, it is one of the basic needs we have, right along with food and water. So if we're not getting good sleep, we can't achieve those higher levels of functioning. It's very important.

Syma Khan:

And I think we often think about in the treatment of depression, a lot of other things. So, getting a routine of getting up, brushing your teeth, those types of things. But I think that sleep routine should also be that priority. And I feel like I'm walking away with tips to improve my sleep too and hopefully get good sleep and feeling more rested in the morning.

Dr. Christina Cwynar:

Thank you so much for joining us today and sharing your expertise. We really appreciate your time.

Dr. Dawn Dore-Stites:

Thanks for having me. This was really fun.

Dr. Christina Cwynar:

As this is our last episode of the season, we wanted to take a moment to thank those that made the season possible. Thank you to all our coworkers who are covering service while we are here recording. And thank you to Joe Hallisy and his team, Kat Bergman, Rebecca Priest, Miranda Trotman, Bryan McCullough, the myCME team, and many others who I'm sure I forgot to mention today. We really appreciate you.

Thank you to everyone that tuned in this week. Nurses, social workers and physicians can claim CMEs and CEUs at uofmhealth.org/breakingdownmentalhealth. You are able to do this anytime within the first three years after the initial air date. We hope you will join us next season.

Syma Khan:

I feel like I learned a lot.