Review Article

Sleep, Sleep Disorders, and Mental Health: A Narrative Review

Nathan E. Howarth1, Michelle A. Miller2
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1
University of Exeter Medical School, Exeter, UK, 2Warwick Applied Health, Warwick Medical School, University of Warwick, Coventry, UK

Abstract
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Evidence suggests that sleep is a vital component of physical and health well‑being. However, while sleep problems are present in individuals
with mental health problems such as depression, it has not been clear whether these conditions are independent or whether they might be
causally related. Indeed, if sleep or sleep disorders predispose or modify onset and outcomes of mental health issues, treatment of these factors
could be explored as new mental health prevention or treatment options. The aim of this review was to examine in detail the bidirectional
relationship between sleep, sleep disorders, and mental and physical health and well‑being. It has considered the evidence that sleep architecture
disruption, occurring through both quantity, quality, and timing of sleep as well as through the presence of sleep disorders may both influence
mental health and well‑being as well as be disrupted by both physical and mental health conditions. Also, the review has explored the effects
of sleep disruption on mental health and performance through fatigue, mood, and vigilance. The review has considered the bidirectionality
between sleep, sleep disorders, and mental health to examine how these may lead to or exacerbate mental health disorders such as affective,
anxiety, autism, depressive and schizophrenia disorders but also considers how these conditions can affect sleep. The review highlights that
poor sleep or the presence of a sleep disorder can increase the risks from mental health conditions such as suicidality. Furthermore, mental
health conditions such as anxiety and worry can cause racing or repetitive thoughts that can keep an individual awake, leading to shortened
sleep. It is important that sleep and sleep disorders are considered potential modifiable factors that could improve mental health outcomes. The
important interconnect between both physical and mental health and sleep, in patient evaluations, also needs to be considered as these may
affect treatment pathways and patient outcomes. Further, more robust and perspective research is required to establish the triad relationship
of physical, mental health, and sleep.

Keywords: Cardiovascular diseases, depression, mental health, seep, sleep disorders, sleep wake disorders

Introduction The aim of this review was to examine in detail the bidirectional
association between sleep, sleep disorders, and both mental
Sleep is fundamentally important for good physical and
and physical health and well‑being to determine if they are
mental health and well‑being. Good sleep quality and quantity
causally related [Appendix 1]. Thus, to then consider whether
and absence of sleep disorders are also key components of
the treatment of sleep disorders might then be an important
emotional regulation,[1] memory committal,[2] physiological
factor in the onset, progression or outcome of mental health
recovery,[3] and relaxation.[4] Sleep disturbances and, in
conditions. Subsequently having key clinical implications for
particular, insomnia often co‑occur with mental health
the effective treatment of these conditions.
disorders. Moreover, sleep disorders including insomnia,
hypersomnia, and fatigue are part of the diagnostic criteria
for depression. While it is not clear if these conditions are Sleep Architecture Disruption and Mental
causally related or independent of one another, longitudinal Health
studies have demonstrated that sleep disturbances often begin
Sleep is a complex arrangement of biological processes
before the onset of depressive symptoms. Furthermore, sleep
for neurological and physiological recovery. During sleep,
problems can affect the response to treatment in depression.[5]
However, there may be individual susceptibility to the adverse
Address for correspondence: Mr. Nathan E. Howarth,
effects of disrupted sleep.
University of Exeter Medical School, Stocker Road, Exeter EX4 4PY, UK.
E‑mail: [email protected]
Received: 21-03‑2024; Accepted: 26‑06‑2024; Published: 25-07-2024

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DOI:
10.4103/hm.HM-D-24-00030 How to cite this article: Howarth NE, Miller MA. Sleep, sleep disorders,
and mental health: A narrative review. Heart Mind 2024;8:146-58.

146 © 2024 Heart and Mind | Published by Wolters Kluwer - Medknow

 Howarth and Miller: Sleep, sleep disorders, and mental health

the body goes through multiple sleep cycles. Split into two The external cues influence circadian entrainment by the central
predominant sections, nonrapid eye movement sleep (NREM), clock or suprachiasmatic nucleus (SCN). The SCN is also
or slow‑wave sleep (SWS) of which has three stages (N1–N3) influenced by the peripheral clocks which are in turn influenced
characterized by both light and deep sleep and one stage (N4) by external cues of exercise or food and drink consumption and
of rapid eye movement sleep (REM).[6] REM sleep is a behavior internal cues with circadian genes, such as CLOCK, BMAL1,
state whereby most dreams occur; it is also a paradoxical state, and PERIOD3.[22‑24] The external and internal cues and central
with muscle paralysis and the suspension of consciousness and peripheral clocks work in tandem to regulate physiological
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despite cerebral cortex activation. REM sleep is, associated functions, wakefulness, and peripheral tissue activity.[12,25,26]
with memory and behavior development.[7,8] REM cycles vary
by length and by timing during the night, with the tendency to Circadian Sleep Disruption and Mental Health
have more REM sleep later into the night.[9]
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One of the main factors that entrain the clock is natural

The cycling of REM and NREM sleep is characterized through light. Disruption of this circadian clock can affect mood and
ultradian rhythms forming REM pressure.[10,11] Although emotional regulation[27,28] and is also closely related to mental
ultradian rhythms are themselves a rhythm based on sleep health disorders.[28,29] Circadian disruption occurs when the
achievement, they are influenced by the drive to induce sleep environmental signals such as the phase of the light–dark
through “Process C,” circadian rhythm, and the sleep‑wake cycle are misaligned with the internal body clocks. This may
dependent homeostatic drive “Process S.”[12] occur because of shift work or travelling through time zones
or because of having different sleep times on work and social
Fragmentation of REM sleep has the potential to mark days (social jet lag)[29] or through seasonal disruption and
posttraumatic stress disorder (PTSD).[13] In a large meta‑analysis clock time changes.
of polysomnography studies, the relationship between sleep
architecture and mental health disorder was examined. Shift work
The study indicated that sleep depth and REM pressure Shift work is often associated with working a night shift, which
alterations were associated with affective, anxiety, autism, leads to a later onset of sleep than normal circadian rhythms
and schizophrenia disorders.[14] Reduced SWS has also been working against the drive for sleep. A recent meta‑analysis
associated with insomnia,[15] mood, and anxiety disorders,[16] demonstrated that nurses working night shifts had an
generalized alterations of SWS are present in psychosis and increased likelihood of depression.[30] In a separate study, shift
neurodevelopmental conditions,[17] and anxiety.[14] Similarly, workers were shown to have a high prevalence of anxiety
in adults with depression and schizophrenia, decreased and depression.[31] Parasomnias are also reported to be more
slow‑wave, or deep sleep, is associated with the severity of prevalent in rotating shift and night shift workers compared
symptoms and hospitalization.[18] to daytime shift workers.[32] Poorer moods and well‑being are
also reported in shift workers compared to non-shift workers.[33]
Sleep architecture is disrupted in depression, with disinhibition In a UK BioBank study, shift working was shown to increase
of REM sleep, and NREM sleep impairment with decreased the risk of depression and anxiety. However, among the shift
amounts of N2 sleep. Some patients have less SWS, along workers, there was no significant difference due to night shifts
with changes in sleep continuity, which might be linked to or nonnight shifts.[34]
the hypothalamic–pituitary–adrenal (HPA) axis.[19] A UK
BioBank study of 91,105 participants demonstrated that the Travel and social jet lag
extent of disrupted circadian rhythmicity of rest‑activity cycles Airline travel can lead to sleep disruption and jet lag. Often
was associated with an increased lifetime risk of depression traveling quickly across time zones causes jetlag as individuals
and bipolar disorder, though the cause of this association is are eating and sleeping out of synchrony with their normal
unknown.[20] circadian rhythm.[35,36] Early evidence from a study conducted
in Israel demonstrated that psychiatry episodes increased with
An individual’s chronotype also determines their natural jet lag; foreign patients were more likely to have psychiatry
inclination to go to sleep. The preference can be split into going episodes with flights over 7 h or when more than three time
to bed early and getting up early (larks) or going to bed late and zones were crossed.[37] Flight attendants in the USA have been
getting up late (owls). It is determined by several factors including found to have greater levels of sleep disorder and depression
genotype, age, and gender, although most individuals have an compared to the general population.[38] More recent research
intermediate sleep schedule. It has been reported that individuals demonstrated that international air crew had increased levels
with the evening chronotype have an increased risk of depressive of depression symptoms compared to domestic air crew. Jet
symptoms and depressive disorders.[21] lag is implicated in mood and performance among athletes,
In general, individuals have a circadian rhythm circle that who need to travel.[39,40]
regulates sleep and wakefulness which is >24 h. This means the Social jet lag can occur without travel and is often used to
internal biological clocks need to be constantly entrained to the describe the feeling that occurs when a person, who has slept
external environment and 24‑h day cycle. This regulation occurs in longer at the weekend, has to get up early on a weekday for
via external cues (“Zeitgebers”) from sunlight and temperature. work.[41] In adolescents, the misalignment between sleep timing

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 Howarth and Miller: Sleep, sleep disorders, and mental health

on the weekend and school week, resulting in social jet lag, performance, and vigilance.[58‑60] In total sleep deprivation
was independently associated with anxiety symptoms.[42] Office laboratory studies, individuals may, at first, demonstrate
workers demonstrating social jet lag on a weekend were more sleepiness, anxiety, and decreased emotional capacity, but
likely to report job stress.[43] In South Korea, social jet lag was after 24–48 h, this may lead to temporal disorientation and
associated with increased risk of depressive symptoms, even hallucinations, and after 72 h, it may result in impaired sensory
more when the social jet lag was over 2 h.[44] Further research responses and acute psychosis.[61]
suggests that greater levels of social jet lag are associated with
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Several epidemiological studies have looked at the effect of

increased symptoms of depression across 20 days.[45] Japanese
sleep on mental health and it has been suggested that sleep
research has demonstrated that social jet lag and sleep debt
deprivation is associated with major depressive disorder[62]
worsen depressive symptoms with a “U‑shaped” distribution
of sleep duration and depressive score.[46] and that short sleep and insomnia may lead to a high risk of
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depression.[61] In older adults, a meta‑analysis has demonstrated

Seasonal disruption and clock changes that sleep quality is associated with probable depressive
During the year, there are seasonal variations in the amount of symptomatology.[63] In participants (n = 84,404) from the
sunlight and the weather. Light plays in circadian rhythms, so UK Biobank, it was shown that a “U‑shaped” relationship
it is not surprising that there are adjustments in sleep quality was found between sleep duration and diseases including
and quantity throughout the year. The dark hours in the Arctic diabetes, hypertension, heart disease, and depression; short
Circle have been associated with greater delayed sleep and and long sleep durations, along with fragmented sleep,
impaired mood.[47] Further, the amount of light, which varies were associated with increased odds of disease.[64] In the
over the seasons, impacts mood and sleep through the SCN.[48] English Longitudinal Study of Aging, short sleep (<5 h)
Between March and November in the US and UK, the clocks over an 8-year follow-up increased the risk of depression.[65]
move forward ahead of the time zone. This is known as A recent meta‑analysis suggested that sleeping less or more
daylight saving time in the US and British summer time in than 7 h compared to sleeping compared to 7 h of sleep was
the UK. The acute variation in time and the changing of the associated with higher levels of depression.[66] In the USA, a
clocks is thought to be associated with changes in sleep, mood cross‑sectional study reports a U‑shaded distribution of sleep
disturbance, and suicide; acute sleep deprivation in March and risk of depression with both short sleep and long sleep
due to the clocks moving forward is likely to affect the frontal associated with depression.[67] Also, analysis of UK BioBank
lobe and the ability to make judgments.[49] Over 70 countries data shows a U‑shaped association between sleep length and
have similar biannual changes in time, evidence suggests mental health, with those sleeping six to 8 h a night having
that it impacts sleep and mood especially when clocks move fewer mental health conditions compared to those sleeping
more than an hour forward.[50] Further evidence suggests that less than six hours and more than eight hours.[64]
moving the clocks forward worsens sleep quality, decreases
sleep, and can increase depression.[51] Additionally, in a 7‑year Among a cardiovascular health study, sleep disturbances
study, permanent daylight saving and clocks being ahead of relating to difficulty falling asleep, frequent awakenings, waking
time for Russian school children increased seasonal affective up too early, and daytime sleepiness were associated with
disorder (SAD).[52] depression.[68] The glymphatic system is a key waste‑removal
system that is effective and most prominent in slow sleep waves;
Seasonal affective disorder both mood disorders and sleep disruption show alterations in the
SAD is characterized as a mood disorder with an onset glymphatic system. In major depression disorder, glymphatics
consistent with the autumn and winter months which resolved disruption impairs the removal of reactive oxygen species.[69]
in the spring and is related to sleep timing changes and This signals a potential mechanism for sleep disruption and
hypersomnolence.[53] Early research demonstrated that SAD mental health disorders. The glymphatic dysfunction is
is defined by the hypersomnia in the winter months, with associated with neurological disorders.[70] Further research
decreased delta wave sleep and increased REM density.[54] shows that sleep is associated with oscillations that influence
Evidence also suggested that a lower core body temperature the cerebrospinal fluid (CSF) flow.[71]
and lower melatonin secretions are a key in the circadian
disruption in SAD.[55] A recent meta‑analysis has demonstrated In a study looking at sleep disturbances and the AtRisk Mental
that there is altered REM sleep amount and latency but no State (ARMS) in youth, it was shown that ARMS individuals
altered SWS in SAD.[56] report impaired sleep quality and reduced sleep quantity
compared to healthy controls. Furthermore, sleep disturbances
were associated with attenuated psychotic symptoms and
Sleep Loss, Quality and Quantity, and Mental functional outcomes cross‑sectionally and longitudinally.[72]
Health Beyond clinical and subclinical mental health conditions,
An individual’s requirement for sleep may vary, but in general, sleep length has been associated with changes in mood. In
it is expected that an adult requires around 7 h of sleep per adolescents, deeper sleep and higher sleep efficiency are
night.[57] A bad night’s sleep due to insufficient, poor quality, associated with greater mood.[73] Moreover, a meta‑analysis
or mis‑timed sleep leads to fatigue, depressed mood, impaired in adolescents demonstrated that sleep duration has the

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 Howarth and Miller: Sleep, sleep disorders, and mental health

largest relationship with positive moods, when being linked Sleep Disorders and Mental Health
to anger, depressive, negative affect, and anxiety.[74] Deeper
Sleep disorders have an impact on mental health, but likewise
and higher sleep efficiency are associated with happier moods
mental health disorders can influence sleep (see next section).
in adolescents.[73]
In army veterans, those with serious mental health disorders are
An experimental study of male teenagers found that restricting more likely to have a sleep disorder.[86] Nightmares and dreams
sleep to 5 h decreases happiness and increases anger, confusion, have also been linked to a relationship of mental illness.[87]
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and depression. Importantly it took more than 2 days for their Moreover, sleep disturbances and sleep disorders potentially
mood to recover to their baselines. In the same study, teenagers can lead to further neurodegenerative disease.[88]
sleeping for 10 h saw an increase in happiness.[75] A study of
sleep duration across the lifespan demonstrated that sleep loss Insomnia
Insomnia is a sleep disorder characterized by difficulty falling
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through deprivation or restriction increased negative mood and

emotions.[76] Sleep length might interact with the underlying asleep, staying asleep, or both. As well as, being a sign of mental
sleep architecture which could influence mood. health conditions, it can be a predictor for depression.[89] This
reinforces the importance of emotional regulation during
Sleep length and mental health is influenced further by sleep. Insomnia has also been associated with increases in
social factors and was particularly influenced by the cardiovascular disease (CVD) and CVD mortality.[90] In a
COVID‑19 pandemic. In a US study, even after adjustment for 10‑year cohort study, insomnia symptoms increased the risk
covariates (age, sex, race, education, income, and body mass of ischemic heart disease and was associated with those with
index), in the 1st year of the pandemic, it was found that higher hypertension.[91] A recent review of meta‑analyses of prospective
socioeconomic deprivation was associated with shorter sleep studies investigating the association between insomnia and
and poorer mental health. Individuals in areas of the highest multiple health outcomes showed that insomnia was mostly
socioeconomic deprivation were 60% more likely to sleep 6 related to cardiovascular outcomes (atrial fibrillation, CVD,
h or less and 50% more likely to have more than 14 days of coronary health disease, myocardial infarction, and stroke)
poor mental health.[77] and mental health disorders (anxiety, depression, suicidal
Sleep loss and sociability ideation, attempts, and death). Insomnia was also associated
Sleep loss is associated with loneliness, social isolation, with an enhanced Alzheimer’s disease risk.[92] Insomnia has
and withdrawal which could signal that sleep influences the a bidirectional relationship with emotional dysregulation. It
regulation of interpersonal interactions.[78] In close social is thought insomnia disinhibits the limbic system, which tips
relationships, sleep quality can predicate the nature of the the balance towards mood and psychiatric disorders. In turn,
tie between the individuals and mental health conditions can mental health conditions influence the prevalence of insomnia.
influence this relationship. Poor sleep which is associated Importantly, digital technology also increases insomnia.[93]
with aversive ties and good sleep quality was associated A review of early literature has suggested that sleep
with supportive ties. Depression increases poor sleep which disturbances relate to suicide risk in mental health disorders.
increases the aversive friendship ties.[79] Sleep difficulties In some cases, insomnia and nightmares showed a unique risk
and sleep loss resulting in social isolation are an important of suicidality.[94] More recent meta‑analyses demonstrate that
consideration given loneliness is associated with psychiatric sleep disturbances and insomnia increase suicide ideation.[95‑97]
disorders.[80] Recent research has also demonstrated that sleep
duration can decrease socialization and social activity can In depression, insomnia is an indicator of suicidality.[98] Also
predict sleep length and sleepiness. Social activity in the middle delayed sleep timing increases suicidal ideation in depression
of the day has the greatest increase in sleepiness.[81] with insomnia.[99] In schizophrenia, suicide attempts increased
with insomnia.[100] Early evidence has demonstrated that
Sleep loss and emotional regulation nightmares have a five times greater risk for suicidality.[101]
Bidirectional relationships in processing stress, emotions, More recent meta‑analysis of suicide attempt was 81% higher
and sleep exist. Sleep gives the capacity to process stress in those experiencing nightmares.[96,97,102] In adolescents,
and emotions. Whilst decreased sleep quality and quantity meta‑analyses also demonstrate that suicide ideation and
decreases the capacity to manage stress and emotions. Poor attempts were increased in sleep disturbances, and depression
sleep has been directly correlated with stress, anger, hostility, did not moderate this relationship.[103]
and verbal aggression.[82] The emotional regulation with
sleep also extends into psychiatric disorders with emotional Obstructive sleep apnea
functional deficits with insufficient sleep.[83] Early research Obstructive sleep apnoea (OSA) is characterized by complete
pointed toward sleep loss disconnecting the amygdala from or partial obstruction of the airway resulting in intermittent
the prefrontal cortex.[84] The association of sleep and emotional hypoxia. OSA has been related to mental health conditions and
function was further synthesized. REM sleep allows for mood.[104,105] In their review, Gupta and Simpson[104] suggested
the consolidation of affective information in subconscious psychotic conditions develop from sleep fragmentation caused
memory. Therefore, REM sleep is important for homeostasis by OSA, as it induces inflammation and neurotransmitter
of affective brain function.[85] imbalance. This is thought to dysregulate the sympathetic

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 Howarth and Miller: Sleep, sleep disorders, and mental health

nervous system and HPA axis. Garbarino and Magnacvita[106] correlated with depressive mood and suicidal ideation.
found that in in the workplace, there was an association with However, after adjusting for depressive symptom severity
metabolic syndrome, OSA, and psychological disorders. A insomnia and suicidality were insignificant. This study suggests
recent systematic review of OSA patients and health‑related the necessity of an integrated treatment approach to suicidal
quality of life found that those who have untreated OSA ideation in patients with COMISA.[127]
have lower emotional adjustments and poorer psychologic
adjustment to illness.[107] A study of 8,030 individuals in Korea Parasomnias
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also demonstrated that OSA was associated with a higher risk The abnormal movement, nightmares disorders, REM sleep
of both depression and stress.[108] behavior disorder, and sleep eating are collective parasomnias.
Except for REM sleep behavior disorder which is linked to
OSA is also associated with suicide risk and self‑harm. Within Parkinson’s disease,[128] the remaining parasomnias are linked
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a US survey, sleep apnea was associated with self‑reports of with anxiety, stress, and emotions.[129‑131] Parasomnias are split
suicidal ideation, planning, and attempts.[109] In Denmark, the into REM and NREM parasomnia.[132]
sleep apnea increased the risk of suicide and self‑harm.[110]
In Taiwan, similarly, sleep apnea was associated with an Sleep paralysis a form of REM parasomnia is a temporary
increased risk of suicidal attempt.[111] Furthermore, in Taiwan, inability to control the body. It occurs in the hypnopompic
adolescents suspected of having pediatric OSA had an (before waking up) or hypnagogic (before falling asleep) stage
increased risk of suicidal ideation.[112] Patients with both major of sleep. Sleep paralysis has been associated with anxiety
depressive disorder and OSA in a longitudinal study in the US and PTSD.[133] A systematic review of sleep paralysis has
demonstrated that there is an increased risk of suicidal ideation associated the experience with stressful life events, anxiety,
and attempt; in both groups of OSA with or without depression, and depression symptoms.[130] Further discussion suggests sleep
suicidal ideation was above 40%.[113] OSA was also found in paralysis is related to poor sleep and nightmares.[134]
25% of 125 patients who had major depressive disorder and Nightmare disorders are also associated with REM sleep.[132]
suicidal ideation.[114] Further in comorbidity PTSD and OSA, In a systematic review, nightmares were increased in mood
the severity of OSA was associated with suicidal ideation.[115] disorders and psychosis disorders. [135] Further evidence
Social support is key in mental health and suicidality, but in suggests that nightmares are associated with PTSD.[136] A
149 OSA patients, where 20.1% had suicidal ideation, social recent follow‑up study of 40,902 participants found that
support did not make a difference to their suicidality.[116] having nightmares was associated with higher incidence rates
The most common form of treatment for OSA is with continuous of depression.[137]
positive airway pressure (CPAP). In their meta‑analysis of nine Sleep terrors, or night terrors, are associated with NREM
CPAP studies, Yang et al.[117] demonstrated that 4 h of CPAP sleep. It involves the vocalization of panic and terror and
per night improved mental health symptoms. Evidence in movements while not aroused.[138] Sleep terrors are associated
mice studies suggests CPAP treatment restores the glymphatic with childhood and PTSD. In children, night terrors, alongside
system and CSF flow.[118] Human CPAP studies are required nightmares, can increase the odds of experiencing later
to confirm such associations and whether this is linked to the adolescent psychosis.[139] More recent evidence in children has
improvements in mental health. shown that sleep terrors were associated with more reactive
Untreated OSA can affect not only the sleep and daytime behavior, anxiety, and depression symptoms.[140] Beyond
functioning of an individual with the condition but also that childhood, sleep terrors are frequently associated with PTSD,
of a bed partner.[119] Bed partners of untreated OSA have and a sign of PTSD that requires attention.[141,142]
increased depressive scores.[120] It has been shown that when
Narcolepsy
the condition is treated with CPAP, bed partner anxiety and
Narcolepsy is a rare neurological disorder interrupting the
depression decreases.[121]
normal sleep circles causing periods of involuntary sleep,
Comorbid insomnia and sleep apnoea reduced REM sleep, and sleep paralysis. It is also associated
Insomnia and sleep apnea can co‑occur as Co‑Morbid Insomnia with catalepsy, the involuntary sleep induced by emotions.
and Sleep Apnoea (COMISA). The prevalence of insomnia In a research from Spain, patients with narcolepsy had triple
in OSA ranges between 6% and 84% and OSA in insomnia the rate of anxiety and depression compared to the general
ranges between 7% and 69%.[122,123] In a recent Australian population.[143] In 9,312 patients in the United States, compared
study, mental health conditions were significantly higher in to controls, patients with narcolepsy had higher rates of mood
COMISA patients than controls.[124] In men, COMISA has a disorders, depression, and anxiety.[144] In a recent systematic
greater prevalence and severity of depression compared to review and meta‑analysis, patients with narcolepsy have
OSA and insomnia alone.[125] Research across both genders a significantly lower level of mental health and emotional
shows increased depression with COMISA.[126] In a study of quality of life score than the general population, with the
117 subjects with untreated OSA, it was found that the overall review also demonstrating that narcolepsy was associated
prevalence of suicidal ideation was 20.5%. For subjects who with lower mental health quality life scores compared to
reported insomnia, the severity of insomnia was positively epilepsy, multiple sclerosis, diabetes, and hypertension.[145]

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 Howarth and Miller: Sleep, sleep disorders, and mental health

Some evidence in case reports also describes narcolepsy being to consider the physical health, sleep, and mental health of all
present in diagnosed psychiatric disorders, increasing the patients. With especially attention those who are less likely
need to consider sleep assessment especially in nonimproving to look after their well‑being.
psychiatric disorders with excessive daytime sleepiness.[146] In
catalepsy, the emotional regulation is believed to be impaired Neurological conditions
for narcolepsy patients.[147] Ischemic and hemorrhagic strokes are a leading cause of
death and disability. Patients who have had a stroke can
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Restless leg syndrome report frequent rates of sleep disordered breathing, insomnia,
A neurological disorder that frequently impacts sleep, RLS is hypersomnia, and poor sleep quality.[163,164] Sleep disorders like
the urge to move the legs and is accompanied with an unpleasant sleep apnea and RLS have an adverse effect on functionality
crawling or creeping sensation.[148] RLS disproportionately after a stroke.[165] Furthermore, poor sleep has been shown to
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affects women.[149] Depression and anxiety have been found have an adverse impact on their rehabilitation.[166,167] Following
to be higher in RLS than healthy controls.[150] In the Wisconsin a stroke, depression and anxiety are also reported. Together
Sleep Cohort, daily symptoms were associated with elevated both have a relationship after a stroke. In 1,619 Chinese
depression and anxiety.[151] In a Swedish cohort, RLS has been stroke patients, persistent sleep disturbance is associated
associated with a greater risk of depressive symptoms among with an increased risk of both depression and anxiety.[168] In
2,608 men.[152] In a recent Danish study, RLS is associated with 100 community patients, 4 months after a stroke, it has been
an increased risk of depression and decreased health‑related reported that mood impacts following the stroke were related
quality of life, and poor sleep is also detrimental for RLS, to sleep impairment.[169] Evidence from 1,369 patients suggests
suggesting a possible triadic link.[153] Kallweit et al.[154] also that sleep duration <6 h increases the risk of depression after
report a worse quality of life for psychiatric conditions when a stroke.[170] In a study of both stroke survivors and their
they had RLS. An increased risk of suicide and self‑harm caregivers, poor sleep quality and depressive symptoms were
has been shown in RLS patients within the United States.[155] correlated in both the survivors and caregivers.[171]
Moreover, in a study of 549 untreated patients with RLS, it
was found that the frequency of depressive symptoms(32.5%) Concussion
and suicidal thoughts (28%) was 10‑fold and 3‑fold higher, Concussion, an acute brain injury caused by a directed or
respectively, in patients with RLS than controls. Suicide risk indirected exposure of forces to the head, can both cause sleep
was associated with depression, impulsiveness, and RLS and mental health disturbances.[172] Theadom et al.[173] found
severity. Whilst RLS treatment improved depressive symptoms that when there was poor quality sleep, anxiety and depression
it did not improve the suicidal thoughts. There is an importance were significantly higher compared to those recovering from
in detecting these symptoms in young women to improve RLS a concussion without poor sleep. Previous sleep disorders
management.[156] diagnosed within concussion athletes increased the levels of
anxiety and depression.[174] Some evidence has also suggested
Interrelationship between Sleep, Mental Health, that the co‑occurrence of mental health symptoms and
daytime sleepiness increases symptoms in postconcussion
and Physical Health Conditions syndrome.[175]
Given the bidirectional associations between sleep and mental
health, we will now also consider their relationship with Cerebral palsy
physical health [Figure 1]. In neurological disabilities, sleep and mental health also overlap.
In cerebral palsy, sleep quantity and quality is also related to
Cardiovascular conditions motor function and visual impairment.[176] Anxiety and depression
The relationship between sleep and CVD risk is well are higher in children with cerebral palsy and evidence suggests
established, with shortened sleep and poor‑quality sleep.[157] that shortened sleep duration increases the risk of anxiety and
Further, there is evidence to suggest that anxiety, depression, depression. The risk of anxiety and depression further increased
PTSD, and schizophrenia increase the risk of coronary with decreased physical activity.[177] Lang et al.[176] reported that
heart disease[158,159] and that those who have CVD may have sleep problems in children with cereal palsy were related to
increased risk of poor sleep and mental health. In Canada, poorer caregiver sleep quality. The poorer quality of sleep for
a prospective study in 33,445 individuals demonstrated caregivers in turn was related to poorer psychological health
that a sleep disorder and depressive symptoms increased and well‑being for them. Increased nighttime disturbances
the risk of developing heart disease.[160] In a cross‑sectional for caregivers of children with cerebral palsy have also been
study, poor sleep has been shown to be associated with associated with increasing maternal depression.[178]
depression and anxiety among individuals with CVD, but
further longitudinal studies are required to demonstrate any Dementia
cause–effect relationships.[161] In a recent Chinese study of 348, Within the context of dementia, sleep and mental health
sleep disturbances with anxiety and depression were greater have similar relationships with sleep and mood. Treatments
for stable angina than those with acute coronary syndrome.[162] centered around sleep can improve mood. There is evidence of
With the interaction of sleep, mental and CVD there is a need a relationship between sleep, mood disorders, and dementia;

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 Howarth and Miller: Sleep, sleep disorders, and mental health
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Figure 1: A representation of the different interactions between sleep and mental health and physical health conditions

in the UK BioBank those with sleep <6 h and had a low mood sensitivity. This gives a bidirectional relationship between
index had a higher risk of dementia.[179] Sleep and mood for pain and sleep impacting mental health. Those defining
those with dementia is also important given the globalized themselves as poor sleepers have been shown to have increased
impairment experienced within dementia. Light therapy for pain sensitivity and attention to pain. The increase in pain
Alzheimer’s disease and related diseases improves both mood in poor sleepers increases depressive symptoms.[188] Those
and sleep quality.[180] Similar results were shown in a systematic with chronic physical pain have increased sleep complaints
review of earlier studies around light treatment improving sleep and depressive symptoms. This suggests there is a link in the
duration, mood, and cognition in Alzheimer’s.[181] Although regulation of emotions through sleep is important physical pain
there is limited evidence on sleep and mood alone in dementia and internalizing symptoms.[189] Other research also suggests
patients, light therapy resulting in improvements in sleep, that nighttime sleep is associated with the next day’s mood
mood, and circadian rhythms,[182,183] highlights the involvement and pain.[190] Chronic pain and mood complaints are also
of sleep in dementia symptomatology. associated with insomnia and sleep complaints.[191] Improved
sleep quality can pain and depression symptoms, which
Epilepsy reinforces that sleep plays a key role in mental health and
Encompassing various forms of complex neurological disorders, physical wellbeing.[192] The role sleep plays in mental health
epilepsy broadly represents the seizure activity induced by the continues in perioperative health. Recovery from operations
dysfunction in brain waves. Seizure activity frequently occurs increases with sleep disorders and higher levels of mental
overnight, disrupting sleep. Meta‑analysis of children with disorders.[193] In a recent study of bariatric surgery, sleep
epilepsy demonstrated that behavior difficulties can be related disturbance among patients was associated with self‑harm.[194]
to sleep disruption and excessive daytime sleepiness, which Nonpharmacological sleep treatments in chronic pain patients
might also be caused by coexisting sleep disorders.[184] A recent are associated with large improvements in sleep quality, small
meta‑analysis of sleep disruption in adolescents and children reductions in pain, and moderate improvement in fatigue. This
found that sleep disturbance is common and so are a vast array suggests nonpharmacological sleep interventions may represent
of sleep disorder and highlights the potential impact on quality a fruitful avenue for optimizing treatment outcomes in patients
of life.[185] Adults in Ethiopia with epilepsy who have anxiety with chronic pain.[195]
and experience stressful life events were more likely to have
adverse sleep quality which can cause seizure activity.[186] Women’s health
Furthermore, sleep disturbance in those with epilepsy decreases Across the menstrual cycle, women can experience changes
their mental health and emotional well‑being.[187] in sleep. Evidence suggests changes in sleep quality in the
luteal phase, with increased sleep fragmentation.[196] In a
Physical pain Korean population based‑study, women who sleep <5 h a
During sleep, the brain undertakes numerous neurological night had increased levels of depressive mood with irregular
activities that are vital in mood, mental health, and neural menstruation. [197] Mood is often reported as fluctuating

152 Heart and Mind ¦ Volume 8 ¦ Issue 3 ¦ July-September 2024

 Howarth and Miller: Sleep, sleep disorders, and mental health

during menstruation. A recent study of 72 women found mental health conditions and physical health conditions so that
good‑quality sleep related to more positive moods during appropriate treatment regimens are developed. The research
menstruation.[198] Those experiencing premenstruation syndrome should attend to how that triadic relationship also impacts
and premenstruation mood disorder can experience symptoms health outcomes and recovery in the long‑term for patients.
up to several weeks before menstruation and can experience
insomnia.[199] Further insomnia is frequent in premenstruation
Author contributions
Both authors designed and defined the criteria for the review.
dystrophic disorder, a condition which effects mood and has
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been shown to have the greatest effect in the late‑luteal phase.[200] Both contributed to the selection of papers for inclusion in the
manuscript. Both drafted, reviewed, and edited the document
Sleep requirements for women dramatically change during before submission. The final manuscript was reviewed, edited,
the menopause as opposed to the continuous decline in sleep and approved by both authors.
nYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC4/OAVpDDa8KKGKV0Ymy+78= on 10/01/2024

requirements in males.[19] In and around the menopause sleep

disorders increase especially insomnia and sleep disordered Ethical statement
breathing.[201‑203] The menopause is often related to mood Ethical statement is not applicable for this article.
changes and increased levels of anxiety and depression. In Italy, Data availability statement
menopausal women with insomnia were associated with greater Data sharing is not applicable to this article as no datasets were
prevalence of mood disorders.[204] In a recent Taiwanese study, generated or analyzed during the current study.
depressive symptoms were associated with longer sleep‑onset
latency and lower sleep efficiency, mimicking the potential Financial support and sponsorship
insomnia.[205] In Brazil, more serve menopause symptoms were Nil.
associated with poorer quality sleep and a higher prevalence of
Conflicts of interest
mental health disorders.[206]
Mr. Nathan E. Howarth is an executive member of the British
Sleep Society. Prof. Michelle A. Miller receives royalties
Treatment of Sleep and Sleep Disorders in from Oxford University Press for two textbooks. She is Chief
Mental Health Conditions Investigator on the NIHR FOUND Trial (NIHR203393). She
is also an executive member of the British Sleep Society. There
A recent systematic review of trials investigating the use
are no conflicts of interest.
of cognitive behavioral therapy for insomnia (CBT‑I) for
the treatment of depression has demonstrated that CBT‑I
presents a promising treatment option. It suggested that References
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 Appendix 1
Search Terms
• Sleep
• Sleep Disorder
• Sleep Quality
• Sleep Quantity
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• Sleep Length
• Sleep Architecture
• Narcolepsy
• Sleep Apnoea
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• Obstructive Sleep Apnoea

• Restless Leg Syndrome
• Parasomnias
• COMISA
• Mental Health
• Anxiety
• Depression
• Bipolar Disorder
• Paranoid Schizophrenia
• Cardiovascular Disease
• Stroke
• Dementia
• Cerebral Palsy
• Concussion
• Menstrual Cycle
• Menopause
• Pain
• Epilepsy