Dr. Anne Marie Morse on How Sleep Disorders Impact Mental Health

Sleep quality is critical for positive mental health, and sleep disorders can worsen mental health conditions. Similarly, mental health problems can result in poor sleep. Neurologist and sleep expert Dr. Anne Marie Morse explains the bidirectional relationship between sleep and mental health, and how she addresses both problems with her patients. In the words of Dr. Morse: “The duration, quality and timing of sleep can actually be predictive to the development of adverse mental health outcomes.”

How is sleep associated with mental health?

There’s many times that we are reflecting as a country that we’re seeing very alarming statistics around the mental health crisis that currently exists. We’ve blamed it on COVID. We’ve blamed it on a variety of different things, but the reality is we can’t escape the fact that many individuals, and maybe even you yourself, who is listening to this, may be struggling with mental health difficulties. This isn’t by accident. It may very much be related to the design of how we’re meant to live. And that really is with appropriate sleep health, getting the right duration, quality, timing, and regularity of sleep. When I reflect on the statistics of the past 10 years, where in 2014 the CDC declared that the United States is at a major public health crisis because of the epidemic proportions of adults with sleep disorders representing one in five at the time. And now with the most recent Gallup polls demonstrating that more than 60% of US adults are experiencing insufficient sleep. “Trying to get away” with less than the age appropriate, optimal number of hours of sleep.

The reason I highlight this is because we recognize that sleep and mental health has a bidirectional relationship. The duration, quality and timing of sleep can actually be predictive to the development of adverse mental health outcomes. We also recognize that those who are experiencing mental health difficulties will be at higher risk for the worst outcomes that we can possibly imagine, such as suicide and death. What do I mean by this? For individuals who are experiencing symptoms of depression and they’re having frequent maternal awakenings, insufficient duration of sleep, or things like nightmare disorder. These can actually be risk factors for suicide attempts and completion. The call to action that we have is not looking at sleep as a co-morbidity to mental health or a luxury for some of us to potentially entertain. We’re looking at the opportunity to utilize sleep as a tool, whether there’s pre-existing or diagnosis of mental health conditions, or whether we’re trying to actually mitigate the development of it.

When we’re optimizing our sleep, we’re optimizing our ability for our brain actually to work at its highest degree of function. When we’re having sleep deprivation, it actually is negatively impacting our frontal and prefrontal cortex. Areas where is responsible for executive decision-making, our impulsivity, our judgment, our mood. We tend to be more likely to be susceptible to decisions that we wouldn’t normally have. We see that this bidirectional relationship exists across mental health disorders like depression, anxiety, bipolar disorder, schizophrenia, and even in other acquired disorders like substance use disorder. When there is a sleep disorder, it makes it a lot harder to recover from substance use disorder. And even when abstaining, if there is a sleep disorder, it increases our likelihood for relapse. Again, it is not a matter of stigmatizing or making it a luxury to get the right duration of sleep. It’s a matter of us saying, let’s step up to the plate and hit it out of the park by embracing sleep as something that we can utilize to live our best lives.

As a neurologist and sleep specialist, what steps do you take with your patients to address both problems?

As a neurologist, it’s really important to recognize that sleep disorders are highly pervasive across neurologic disorders. It also is important to recognize mental health disorders may be present as well. Why? It’s not by accidents, it’s by design. All three of these disciplines share the same organ, my brain. And so when we’re looking at any type of brain dysfunction, it now increases my susceptibility to having these other conditions. Very frequently in medicine, we reference these as comorbidities. However, I sometimes will challenge that and say, this is a part of the morbidity of experiencing these disorders. So because of this, it is really important for me to frame out my clinical practice as well as my teachings to my residents as to make sure we are asking about all the hours of the day. We can’t limit our understanding of what our patients are experiencing by just being able to ask them questions that they can report on when they’re awake.

It’s important for me to understand what time are you going to bed? How long is it taking you to fall asleep? If it’s greater than 30 minutes, what’s the reason? How many times a night are you waking up? And note that I ask how many times a night, not do you wake up? Normalize it so that people are able to feel that it’s okay for me to be honest with you. When they share that they are waking up in the middle of the night, I want to know why and for how long. And then of course, understanding what time are you waking up in the morning and how long does it take you to get out of bed? Those simple questions by themselves, give me some insights to the duration, the timing, the regularity, the quality, and will help me to set them on the right path forward to what the right solutions might be.

This may include further testing to understand what diagnosis may be causing the problems they’re experiencing with sleep. It may help in refining the treatment plan, not only for their sleep, but potentially the primary diagnoses that I am accounting for. And at the end of the day, it is providing my patients that I’m partnering with the ability to understand, one, that I care about their full 24 hours of their day, but what they’re experiencing matters. And that the impact of their night has on their day. Again, separating the difference between the two really is arbitrary and we really are being neglectful when we’re not considering how the patient’s night can actually lead to their best days and their best outcomes.