Psychiatric Annals

Guest Editorial Free

Bi-Directional Relationship Between Sleep Problems and Psychiatric Disorders

Khurshid A. Khurshid, MD, FAASM

Sleep is an important biologic mechanism that is vital for daily healthy functioning. Although sleep disruption can be a symptom of a psychiatric disorder, disrupted sleep can also cause or exacerbate the condition. Thus, there exists a bidirectional relationship between sleep and emotional well-being, which is explored in this issue of Psychiatric Annals. Insufficient sleep can result in impaired attention, alertness, concentration, reasoning, and problem-solving. Lack of sleep reduces a person's productivity and efficiency during waking hours. Research suggests that a healthy sleep pattern is important for learning and memory consolidation. If a person doesn't get enough sleep, it will be a challenge to retain what was learned and experienced during the day. Self-reported and objective sleep disturbances are common in psychiatric disorders.1

A healthy adult enters sleep and passes through stages N1, N2, and N3 followed by rapid eye movement (REM) sleep. With each stage, from N1 to N3, sleep becomes deeper and brain waves increase in amplitude and decrease in frequency. After stage N3, one enters REM or active sleep. Not only does one transition through the different stages of sleep, but also the amount of time one spends in each stage changes throughout the night. Generally, nonrapid eye movement sleep is most prevalent during the first half of the night, with REM sleep most commonly occurring during the second half of the night.2

Sleep disturbance can add to the burden of a psychiatric disorder. Untreated sleep problems cause symptoms that could be misinterpreted as an underlying psychiatric disorder. For example, an untreated sleep apnea can lead to symptoms of fatigue and poor energy akin to those of untreated depressive disorder. Insomnia can be a symptom, cause, or associated condition in a patient with depression and anxiety disorders. Comorbid sleep disorder could also lead to incomplete resolution of depressive symptoms and possibly treatment resistance.3

Untreated sleep disorders, like obstructive sleep apnea (OSA), could also cause or worsen depressive symptoms. There is higher prevalence of depression in people with sleep-disordered breathing in clinical and community samples.4 The symptom overlap between depression and OSA may explain the underdiagnosis of OSA in patients who are depressed. A missed diagnosis in patients with depression may be responsible for treatment resistance. The relationship between depression and OSA is complex and warrants further study. Several pathophysiologic mechanisms provide a reasonable explanation for how OSA could cause depression. Increased understanding of the relationship between these two disorders will likely improve clinical outcomes.

In the first article of this issue, “Sleep Problems and Disorders in Patients with Depression,” Drs. Marc Ettensohn, Yarelis Soto, Bruce Bassi, and myself review various sleep disorders in depression and elucidate the significance of these problems. We also indicate that patients who present with complaints of insomnia are more likely to have depression, and those with chronic insomnia are at a higher risk for subsequent development of depression. Persistent insomnia is a risk factor for relapse of depressive disorder, substance use abuse, bipolar disorder, and psychotic disorders. Insomnia is also a risk factor for suicide, and treatment of insomnia decreases that risk.5

The next article, “Sleep Problems and Disorders in Patients with Anxiety Disorders” by Drs. Edwin K. Simon, Zafeer H.K. Berki, George C. Gettys, and Chandragupta Vedak, discusses sleep problems and disorders in patients with anxiety disorders. The authors explain that treatment of insomnia improves the outcome of anxiety disorders, as well as describe the relationship between OSA and panic disorder.6

In the third article, “Sleep Problems and Disorders in Children and Adolescents with Attention-Deficit/Hyperactivity Disorder” by Drs. Lalita D. Ramnaraine, Mariam Rahmani, and myself, we systematically discern and summarize data regarding sleep dys-functions in young patients with attention-deficit/hyperactivity disorder (ADHD).7–9 We discuss that patients with ADHD are more susceptible to sleep disruption resulting from poor sleep habits and other disorders, and that adequate sleep is important but seems to be especially vital in patients with ADHD.

The final article, “Sleep Disturbances and Substance Use Disorders: A Bi-Directional Relationship” by Drs. Anjum Ara, William Jacobs, Ishrat Ali Bhat, and W. Vaughn McCall, provides an updated review of the various psychiatric sleep disturbances. They also provide recommendations for evaluation and management.

Untreated sleep disorders and chronic sleep deprivation not only lead to or exacerbate psychiatric disorders but also increase the risk of various medical disorders like cardiovascular disease, hypertension, stroke, diabetes, obesity, depression, and sexual dysfunction.10 The far-reaching effects of sleep disorders and deprivation underscore the need for evaluation and treatment of sleep problems in patients with various psychiatric conditions.

It is our intention, with this issue, that clinicians become knowledgeable about the bi-directional relationship between sleep and psychiatric disorders. The evaluation and subsequent treatment of sleep problems and psychiatric disorders are important to help improve symptoms as well as prevent mortality and morbidity.


  1. Rumble ME, White KH, Benca RM. Sleep disturbances in mood disorders. Psychiatr Clin North Am. 2015;38:743–759. doi:10.1016/j.psc.2015.07.006 [CrossRef]
  2. Carskadon MA, Dement WC. Normal human sleep: an overview. In: Kryger MH, Roth T, Dement WC, eds. Principles and Practice of Sleep Medicine. 4th ed. St Louis, MO: Elsevier; 2005:13–23. doi:10.1016/B0-72-160797-7/50009-4 [CrossRef]
  3. Roest AM, Carney RM, Stein PK, et al. Obstructive sleep apnea/hypopnea syndrome and poor response to sertraline in patients with coronary heart disease. J Clin Psychiatry. 2012;73(1): 31–36. doi:10.4088/JCP.10m06455 [CrossRef]
  4. Ong JC, Gress JL, San Pedro-Salcedo MG, Manber R. Frequency and predictors of obstructive sleep apnea among individuals with major depressive disorder and insomnia. J Psychosom Res. 2009;67(2):135–141. doi:10.1016/j.jpsychores.2009.03.011 [CrossRef]
  5. Ağargün MY, Kara H, Solmaz M. Sleep disturbances and suicidal behavior in patients with major depression. J Clin Psychiatry. 1997;58(6):249–251. doi:10.4088/JCP.v58n0602 [CrossRef]
  6. Su VY, Chen YT, Lin WC, et al. Sleep apnea and risk of panic disorder. Ann Fam Med. 2015;13(4):325–330. doi:10.1370/afm.1815 [CrossRef]
  7. Khurshid KA, Khan AA. Delayed sleep phase disorder and attention deficit and hyperactivity symptoms in a teenager. Atten Defic Hyperact Disord. 2009;1(2):211–213. doi:10.1007/s12402-009-0014-2 [CrossRef]
  8. Cortese S, Brown TE, Corkum P, et al. Assessment and management of sleep problems in youths with attention-deficit/hyperactivity disorder. J Am Acad Child Adolesc Psychiatry. 2013;52(8):784–796. doi:10.1016/j.jaac.2013.06.001 [CrossRef]
  9. Hiscock H, Sciberras E, Mensah F, et al. Impact of a behavioral sleep intervention on symptoms and sleep in children with attention deficit hyperactivity disorder, and parental mental health: randomized controlled trial. BMJ. 2015;350:h68. doi:10.1136/bmj.h68 [CrossRef]
  10. Pandey A, Demede M, Zizi F, et al. Sleep apnea and diabetes: insights into the emerging epidemic. Curr Diab Rep. 2011;11(1):35–40. doi:10.1007/s11892-010-0164-9 [CrossRef]

About the Guest Editor

Khurshid A. Khurshid, MD, FAASM

Khurshid A. Khurshid, MD, FAASM, is currently Chief of the Neuromodulation and Sleep Disorders Program in the Department of Psychiatry at the University of Florida (UF). He is also the Medical Director of the Med-Psych and ECT Unit at UF and Shands Hospital. Dr. Khurshid also runs a clinic for treatment-resistant depression at Shands Springhill outpatient clinic.

Prior to joining UF, Dr. Khurshid was the Director of the Sleep Disorders Center at Howard University Hospital in Washington, DC. He was also the Medical Director for Inpatient Psychiatry at Howard University Hospital as well as an Associate Professor in the Departments of Psychiatry and Neurology at Howard University.

He received his Doctorate of Medicine in Psychiatry from All Institute of Medical Sciences (New Delhi, India), and completed his residency training in Internal Medicine and Psychiatry at Southern Illinois University School of Medicine (Springfield, IL). Dr. Khurshid then completed a Fellowship in Sleep Medicine and Circadian Rhythm Disorders at The University of Chicago.

Dr. Khurshid has positively contributed to the discipline of psychiatry and sleep medicine in the state of Florida as well as on a national level. He has been a Fellow member of the American Academy of Sleep Medicine and a former chair of its Insomnia section.

Address correspondence to Khurshid A. Khurshid, MD, FAASM, Department of Psychiatry, University of Florida College of Medicine, 4037 NW 86 Terrace, Gainesville, FL 32606; email:

Disclosure: The author has no relevant financial relationships to disclose. 


Sign up to receive

Journal E-contents