Keeping Us Up At Night: Stress, Sleep, And Mental Health

Keeping us up at night: The expensive interplay between stress, sleep, and mental health

America’s super-high stress levels ratchet up healthcare costs at every turn. Stress contributes to many of our most vexing chronic physical illnesses—heart disease, obesity, diabetes, and others. But it is also intricately connected to mental health issues, a growing burden on the U.S. healthcare tab. In 2020 alone, public and private spending on mental health treatment topped nearly $280 billion. 

An often-overlooked culprit in these expensive challenges: the complex interplay between stress and sleep and mental health.  The effects of stress on sleep are a double edged sword - stress makes it difficult for people to get the restful sleep they need for optimal mental and physical health. Perversely, the lack of sleep increases a person’s stress levels.

The mental health crisis in America is a population health concern. Efforts that lower stress—and allow people to get adequate sleep for brain health, tissue repair, hormone regulation, and more—are a prime opportunity to improve health outcomes. Improved outcomes can help reduce the costs by lowering the burden of chronic diseases.

Survey: U.S. stress at unprecedented levels

Acute or short-term stress stems from the demands and pressures of immediate or upcoming situations. Chronic stress, on the other hand, reflects unending despair or hopelessness resulting from factors such as poverty, family problems, or traumatic early childhood experiences.

The American Psychological Association (APA) has conducted the annual Stress in America survey since 2007. In 2020, it sounded an alarm, saying the stress associated with the COVID-19 pandemic, combined with other stressors, is getting to be too much: “We are facing a national mental health crisis that could yield serious health and social consequences for years to come.”

Since then, the situation has only grown worse.  In the APA survey fielded early this year, more than 80% of adults cited stress over money and war, eclipsing any other issue asked about in the history of the Stress in America poll.  Other top sources of stress included supply chain issues and global uncertainty. 

The number of people reporting significant stress in 2022 is “stunning” compared to survey results in previous years, said APA Chief Executive Officer Arthur C. Evans Jr: “These data suggest that we’re now reaching unprecedented levels of stress that will challenge our ability to cope.”  

Exploring sleep and mental health - the wide range of effects of stress on sleep

All that stress is causing us to lose sleep. Insomnia–the clinical term for trouble falling and staying asleep–is as common as is it frustrating. While sleep aids may provide symptomatic relief, the root issues underlying sleeplessness remain more elusive and addressing them is of critical import to our nation’s health.

Up to half of all adults experience short-term insomnia, which generally lasts for a few days or weeks and is often triggered by stress. Insomnia is considered chronic when sleep difficulties occur at least three times a week for three months or longer. Between 10 and 15 percent of adults are afflicted with chronic insomnia disorder, meaning the problem causes distress or impairment. 

Beyond insomnia, several other sleep disorders have a direct relationship to stress: 

• People with obstructive sleep apnea, caused by the blockage of airways during sleep, may experience psychological symptoms including depression, anxiety and stress.  Experts estimated that sleep apnea, often undiagnosed, afflicts more than 29 million American adults, or 12% of the population.
• Narcolepsy, characterized by excessive daytime sleepiness, loss of muscle control, sleep paralysis, and hallucinations, is often triggered by sudden strong emotions, including laughter and stress.
• The symptoms of restless leg syndrome–an uncontrollable urge to move the legs, typically in the evening or nighttime–can be made worse by stress. 
• Parasomnias, including sleep terrors, sleep walking, sleep talking and sleep-related eating disorders, may be related to post-traumatic stress.

Understanding this link between sleep and mental health, it’s no wonder that OTC and prescription sleep medications are among the top-selling medications in the U.S.

Sleeplessness is a public health epidemic

Adults need at least seven hours of restorative sleep each night, yet that’s only a dream for many people. Insufficient sleep is so prevalent that it is considered to be a global public health epidemic, albeit often unrecognized and under-reported despite its high economic costs. 

About 70 million Americans suffer from chronic sleep disorders associated with injuries, chronic diseases, mental illnesses, increased health care costs, and lost work productivity, according to the Centers for Disease Control and Prevention (CDC).

The burdens of stress and sleeplessness both contribute to health disparities experienced by racial/ethnic minority groups in comparison to White people. Stress related to experiences of racism can contribute to adverse birth outcomes, for example, and perceived discrimination or racism is a risk factor for cigarette smoking, alcohol/substance use, and other unhealthy behaviors.

Meanwhile, inadequate sleep and sleep disorders disproportionally affect socially disadvantaged and marginalized individuals and new research suggests that social stigma is associated with sleep deficiency.

These factors play into the high rate of chronic and persistent mental illness among Black Americans and the need to improve behavioral health access for Black people and other historically marginalized populations. 

Poor sleep contributes to depression; depression causes poor sleep

Historically, the relationship between sleep and mental health has been seen as cause and effect: Mental distress leads to sleep problems. But the effect of stress on sleep is actually more complicated than that, prompting experts to suggest that the relationship between sleep and mental health problems is more circular than causal.

People with insomnia are at least 10 times more likely to experience clinically significant levels of depression than those who sleep well.  And up to 90 percent of patients with depression complain about the quality of their sleep.

Physical health also requires healthy sleep

Nearly 40% of US adults report falling asleep during the day without meaning to at least once a month, according to the CDC.  Dozing off during a virtual work meeting might be harmless but daytime drowsiness can be deadly. Falling asleep while driving is attributed to nearly 100,000 traffic accidents, resulting in more than 1,500 deaths and 70,000 injuries each year. 

Moreover, sleep deficiency is associated with many of the chronic health conditions that afflict half of all U.S. adults, racking up our huge healthcare tab:

• Heart disease
• Kidney disease
• Hypertension
• Diabetes
• Stroke
• Obesity

Improving sleep leads to better health outcomes

The good news is that sleep problems can be successfully addressed, leading to better mental health. That’s great for patients—and mental health providers and primary care physicians alike—because better mental health is directly connected to better physical health outcomes.  

A recent analysis of 65 randomized controlled trials investigating 72 interventions to improve sleep found that healthier sleep does lead to better mental health. 

In this analysis exploring the relationship of sleep and mental health, improving sleep led to: 

• Better composite mental health (a measure of all mental health outcomes reported across studies), depression and anxiety  
• Reduced stress
• A reduction of psychosis symptoms, such as delusions and hallucinations

Better still, the study found a “dose-response” relationship: the greater the improvement in the quality of sleep, the more improvements in mental health. 

The APA calls for a population health approach to tackle the nation’s mental health crisis. By including interventions that address sleep, providers may be able to improve patients’ physical and mental health outcomes, reducing the need for the costly treatments they require.

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