Sleep disorders and depression: brief review of the literature, case report, and\nnonpharmacologic interventions for depression
A 65-year-old Caucasian woman was referred to our Psychiatry Unit for consultation. She told us\nthat since childhood, every year in spring and in the evening towards bedtime, she suffered from\nmental illness with feelings of guilt about her daily activities. Awareness of the recurrence of\nthese periods meant that, since she was young, she feared the month of April because it coincided\nprecisely with her subjective and objective behavioral disorder. At school, she often felt so ill\nand impatient that one day she obtained the teacher’s permission to go home before the end\nof the lesson. This made her feel guilty. On another occasion, again in spring, she recalled that\nwhile she was walking along the main road, she suddenly experienced a strong “sense of\nloss” and was nearly run over by a car. She also remembered having often felt envious of a\nclassmate who always had lots of sweets and coins. Indeed, on one occasion, she tried to steal a few\ncoins from her school friend because of a strong desire to buy sweets. The girl was therefore\nscolded by the teacher in front of the whole class and this provoked a deep sense of guilt and\nshame. These episodes of guilt and awkwardness in interpersonal relationships associated with\ndepressive feelings were present every spring. Indeed, she remembered having suffered from severe\npain in her eyes and having feared becoming blind; this discomfort disappeared alone after a few\nweeks. At the age of 40 years, the patient reported her problems to her general practitioner who\nprescribed paroxetine, but the patient refused it.\nThis peculiar pathologic phenomena continued to occur until the discomfort perceived by the\npatient obliged her to contact our Unit. We decided to adopt a psychoeducational approach because of\nher refusal to take drugs. We advised her to get out of bed immediately, and go to a secluded area\nof her house and do some housework if she were to wake up in the middle of the night with negative\nthoughts. She usually woke up between 2 am and 4 am, and as soon as she left her bed, the negative\nthoughts vanished and were replaced by her household duties. After performing these activities, she\nwas able to go to work and be productive. She returned home at 2.30 pm, and after lunch had a nap.\nOnce she was in bed, she plunged into a deep sleep and woke up around 6.30 pm, still feeling drowsy.\nThis feeling disappeared after about 15 minutes. In the following days, at times she would wake up\nduring the night, while other nights she slept peacefully. In any case, whenever she woke up in the\nmiddle of the night, she performed some domestic activities.\nThis patient, even though she felt different from other people because of the peculiarities in\nher sleep-wake cycle, did not complain of any depressive symptoms. In this case the wakefulness by\nitself (accompanied by some goal-directed activities such as washing, cooking, and ironing) probably\nimproved her mood. It is well known that if a patient with major depression is stimulated to be\nactive, their mood can improve at least for a short period. That said, the emerging hypothesis is that “the early morning\nawakening” is a form of biological remedy against depression. Hence, sleep deprivation could\nbe a strategy to apply, especially in senile depression. In the elderly, sleep is frequently\npolyphasic. Finally, given that the clinical value of insomnia should not be underestimated, it\nwould be natural to question whether the aim to treat insomnia with the objective to observe a\nsocially agreed circadian rhythm is correct or whether insomnia should be “accepted”\nand considered a spontaneous expression of a biological remedy against depression.