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A vital clinical common denominator in both anxiety and depression is the disturbance of sleep pattern. Of course, this may be atypical, due to the combination of both conditions, but in order to help the diagnosis, a few simple questions by the general practitioner can give a clue to the underlying cause of the symptoms. One simple questionnaire which has been encompassed in the Leeds Sleep Evaluation Questionnaire by lan Hindmarch, the Professor of the Psychopharmacological Research Unit at Leeds, is now accepted as a good basic format. This really asks: (A) How difficult was it going off to sleep? (B) How many times did they wake during the sleep period? (C) How easy or difficult was it to wake up? (D) How did they feel on waking up and (E) How is their coordination and balance on getting up?

The Normal Structure of Sleep

In order to understand the intricacies of the sleep pattern, it is essential to realize the basic structure of sleep. In 1937, it was discovered that in terms of EEG observation, sleep was composed of a series of consecutive stages. These stages alternated spontaneously throughout the night. During the first stage as one goes off to sleep, now known as the non-REM (rapid eye movement) period, the EEG shows a slow wave pattern, associated with a larger amplitude than the so-called “REM” period. It is known that during non-REM sleep, the patient has normal muscle tone, blood pressure, and breathes normally. This is followed by a period when the eyes are seen to move from side to side, constituting the REM stage. During REM sleep, respiration is often irregular and blood pressure rises. At the same time dreaming takes place, as does penile erection and vasodilation of vessels of the vagina. Perhaps the most important physiological change is the loss of muscle tone during REM sleep. This may well have some bearing on the spontaneous deaths of overweight men, who die during the early hours of the morning and may be due to sleep apnoea, causing cerebral or myocardial anoxia.

After about half an hour, the first REM period occurs and lasts perhaps 15 minutes. As the night goes on, the density of REM periods increases so that the normal pattern involves dreaming at the latter part of the night’s sleep. If the patient is disturbed during their normal sleep pattern, it is not surprising to find that there are subjective symptoms during the day. It is very useful therefore to know the occupation of a patient. They may well be involved in shift-work where their sleep pattern is disturbed. The effect of the circadian rhythm on sleep is vital and this is a factor which causes prolonged sleepiness and cognitive function impairment in people who fly across time zones.

The Significance of Dreams

The classic change in depression is thought to be early morning wakening. However, this is not really true and the depressed patient may well find that frequent wakening during the night causes them far more distress. A simple question on the type of dreams, if they can recall their dreams, may well give a clue to their state of mind. The depressed patient tends to have morbid dreams, which impinge on the thoughts during their wakefulness. An anxious patient however, can find difficulty in getting off to sleep and lie for a long period of time ruminating over their anxieties. It is not surprising, therefore, to find that a combination of anxiety and depression causes considerable sleep disturbance. This results in low mood during the day, in association with lethargy, poor concentration and inability to cope with the mundane activities of the day-to-day work.

Certain all -too-common conditions occur in general practice which encompass the sleep disturbance just described.

Maritial Problems

Common warning signs, which are mostly presented by the women are irritability, insomnia, fatigue, and a sense of misery. So often either party will present with a camouflaging – story, which may be social, emotional, sexual, intellectual or spiritual. The behaviour associated with these emotions may lead to alcoholism or violence. The emotional stress experienced by both parties can easily lead to a reactive depression in either the husband or wife.

Alcohol - A Poor Hypnotic

As a form of escape the sad or lonely person, who may or may not be anxious, resorts to alcohol as a hypnotic. Alcohol is a satisfactory inducer of sleep, but, unfortunately, the breakdown products are cerebral stimulants, which results in early awakening, which, in turn, thrusts the individual into the awareness of his problems.

A Vicious Cycle In Pregnancy

Pregnancy can frequently create problems of insomnia in those to sleep neurotic personalities, who have previous psychiatric disorders. An inability to cope with the physical discomfort and disturbed sleep pattern may lead to sleep disturbances. Antenatal anxiety may well lead to postnatal conditions. These are divided into three main groups: (A) the “four day blues”, (B) postnatal depression – which is amenable to treatment with the appropriate antidepressants in a domiciliary situation, and (C) puerperal psychosis, which is a potentially pre-suicidal state, and invariably needs hospitalization. Factors such as loss of earning, social isolation, loss of apparent attractiveness and cramped accommodation add to the stress of the new mother. Frequently, poor sleep adds to weariness during the day and a vicious circle develops which pre-disposes to anxiety and postnatal depression. In this situation, the GP needs all his ancillary help and social back-up to give such patients the help they need.

The Ghastly Awakening

Most people come to terms with the grief of bereavement without too much trouble. However, the risk of physical and mental illness during this period is six times that of normality. The bereaved patient passes through seven stages all of which may overlap. These are (1) shock (2) denial (3) depression (4) anxiety (5) guilt (6) hostility and (7) reintegration. The period of shock and denial are relatively short, but depression and anxiety can be most distressing. The sleep pattern is often disturbed with unpleasant dreams, which may well involve the thoughts of the deceased still being alive. On waking the bereaved patient experiences a ghastly realization that their loved one is dead and this can lead to a protracted feeling of low mood and sadness. The GP can skillfully use the family to support each other in such situations.

Disordered Neuro - Transmission

Epilepsy has a clear link with depression and epileptics are not surprisingly prone to develop both types. Suicide is four to five times more likely to occur in epileptics and temporal lobe epileptics are twenty five times more likely to commit suicide than the average person.

Various factors such as loss of self-esteem, the shamefulness of disabling fits, ensuing unemployment and a loss of social independence from losing their driving licence, may all have a profound effect on these patients. The relationship between epilepsy and depression is not clearly understood. Nocturnal epilepsy clearly has a disturbing effect on the sleep pattern and, of course, the GP is confronted with the disturbed sleep of the patient’s partner, who is just as important.

The Un-Waged

Unemployment and retirement may well lead to a social isolation, in which the individual misses the company of work-mates and the regular journey from his home to work place. The reduction in the family income can result in extra anxieties with regard to financing the family budget. All too often, retired couples move to a different part of the country and lose essential contact with their close friends. Being elderly is often a barrier to making new friends in a new environment, leading to an anxiety state and reactive depression.

Sexual Frustration Leads To Insomnia

Sexual frustration as a result of conditions such as premature ejaculation, failure to sustain an erection, or frigidity in the female can lead to an anxiety state in both parties. Insomnia frequently occurs in these unfortunate patients, and it is essential for the GP to elucidate the problem and then instigate the appropriate referral for counseling or psychological help.

A Physical Problem

Physical disease such as a progressive advanced malignancy and myocardial infarction are frequently associated with depression and poor sleep pattern. Fear of death or spreading disease, gradual incapacity, intractable pain; fear of abandonment and general loss of self-esteem all combine to induce reactive depression. The general practitioner is in the ideal situation to recognize and appropriately treat this condition before it progresses too far. The fundamental help given by caring relatives, nurses, and social workers, in association with the sympathetic GP, can enable the patient with an incurable condition to feel a sense of belonging and sustain their mood.

Cat-Naps For The Elderly

Finally, an increasing section of the community, namely the elderly, are prone to poorer sleep patterns. Sleep may be of shorter duration, with frequent wakening, and early morning cessation. Catnapping, as so often seen in the elderly, may be regarded as a compensation for the poor total sleep time during the night. Morning cat-naps possess a greater preponderance of REM sleep, whereas the afternoon naps tend to have more slow-wave sleep. Patients should be reassured that dropping off to sleep during the day is no bad thing. However, it is important not to miss a diagnosis of depression in the elderly and this is often confused with dementia. Fundamentally, the symptoms of dementia are more gradual, progressive and incurable. The loss of memory, concentration, and cognitive function may well precipitate the super-added depression which is amenable to treatment by the appropriate antidepressant.