eye opener

Why a lack of sleep makes us depressed ... and what we can do about it

The physical symptom that links the lack of sleep and depression may be inflammation.

Historically, insomnia has been thought of as secondary to other disorders such as depression. The idea was that you became depressed – and that your sleep got messed up as a consequence. This might involve difficulty falling asleep, excessive time awake at night or waking up earlier than hoped.

This may make sense to those who have experienced depression and found that thoughts of distressing events such as of a deceased loved one, or previous failures, keep them awake at night. The possibility that depression leads to insomnia is also consistent with research in which I have been involved – where we found that adults with insomnia were more likely than others to have experienced anxiety and depression earlier in life.

But could things really be the other way around? Could poor sleep be making you depressed? Over the past decade or so it has become increasingly clear that disturbed sleep often comes before an episode of depression, not afterwards, helping to do away with the notion that sleep problems are secondary to other disorders.

This is not too hard to relate to either – just think about how you feel after you have slept poorly. Perhaps you feel tearful or snap at those around you. The literature seems to back up the idea that our ability to regulate our emotions is reduced after a bad night’s sleep. Insomnia has also been shown to predict depression defined according to diagnostic criteria.

So why does poor sleep lead to depression? Lots of different mechanisms have been proposed. To give just a few examples, let’s start by thinking about our behaviour. I, for one, am more likely to cancel an evening out with friends or an exercise class after a poor night’s sleep. This could be part of the problem, as such events are exactly those that may help to keep depressive symptoms at bay.

If we think about what happens to the brain when we miss sleep, there are clues as to why sleep and depression are linked. One study on this topic focused on an area of the brain called the amygdala. This is an almond-shaped structure located deep in the brain that is believed to play an important role in our emotions and anxiety levels.

It was found that participants who had been sleep deprived for approximately 35 hours showed a greater amygdala response when presented with emotionally negative pictures when compared to those who had not been sleep deprived. Interestingly, links with parts of the brain that regulate the amygdala seemed weaker, too – meaning that the participants were perhaps less able to control their emotions. Such findings could help to explain how poor sleep may actually cause difficulties such as depression.

Inherited insomnia

Over the years, my own work has taken a behavioural genetic perspective in an attempt to understand the links between poor sleep and depression. From my twin research and work led by others it seems that poor sleep and insomnia symptoms could be, to some extent, part of the same genetic cluster – meaning that if we inherit genes which make us susceptible to insomnia, we may also be vulnerable to depression.

When trying to explain the link between sleep and depression, I’m also intrigued by recent work on the immune system and depression. Studies have found that those suffering from, or at risk of, depression may show high levels of inflammation in their bodies. Their immune systems appear to be in hyper-drive as if they’re fighting infection or healing from injury. When we disturb or restrict sleep we may also experience inflammation, so perhaps inflammation could also help to explain the link between sleep and depression.

So what can we do about it? It has been proposed for some time now that by improving sleep we can perhaps prevent or treat depression. Recently, data have started to emerge from studies suggesting that this may indeed be the case. For example, researchers at the University of Oxford in collaboration with the psychological therapy provider Self Help Manchester evaluated whether an online treatment for insomnia reduces symptoms of anxiety and depression. They advised people with these difficulties to take steps such as keeping a consistent wake time, getting out of bed when they can’t sleep, and challenging beliefs that a bad night’s sleep is incapacitating.

They found that both anxiety and depression symptoms were reduced after insomnia treatment. Other groups are currently looking at whether by improving our sleep we can reduce other types of psychiatric difficulties, too. But even before this work is complete, the take-home message from research to date is clear: we need to begin to prioritise our sleep.

Alice M. Gregory, Professor of Psychology, Goldsmiths, University of London

This article first appeared on The Conversation.

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What hospitals can do to drive entrepreneurship and enhance patient experience

Hospitals can perform better by partnering with entrepreneurs and encouraging a culture of intrapreneurship focused on customer centricity.

At the Emory University Hospital in Atlanta, visitors don’t have to worry about navigating their way across the complex hospital premises. All they need to do is download wayfinding tools from the installed digital signage onto their smartphone and get step by step directions. Other hospitals have digital signage in surgical waiting rooms that share surgery updates with the anxious families waiting outside, or offer general information to visitors in waiting rooms. Many others use digital registration tools to reduce check-in time or have Smart TVs in patient rooms that serve educational and anxiety alleviating content.

Most of these tech enabled solutions have emerged as hospitals look for better ways to enhance patient experience – one of the top criteria in evaluating hospital performance. Patient experience accounts for 25% of a hospital’s Value-Based Purchasing (VBP) score as per the US government’s Centres for Medicare and Mediaid Services (CMS) programme. As a Mckinsey report says, hospitals need to break down a patient’s journey into various aspects, clinical and non-clinical, and seek ways of improving every touch point in the journey. As hospitals also need to focus on delivering quality healthcare, they are increasingly collaborating with entrepreneurs who offer such patient centric solutions or encouraging innovative intrapreneurship within the organization.

At the Hospital Leadership Summit hosted by Abbott, some of the speakers from diverse industry backgrounds brought up the role of entrepreneurship in order to deliver on patient experience.

Getting the best from collaborations

Speakers such as Dr Naresh Trehan, Chairman and Managing Director - Medanta Hospitals, and Meena Ganesh, CEO and MD - Portea Medical, who spoke at the panel discussion on “Are we fit for the world of new consumers?”, highlighted the importance of collaborating with entrepreneurs to fill the gaps in the patient experience eco system. As Dr Trehan says, “As healthcare service providers we are too steeped in our own work. So even though we may realize there are gaps in customer experience delivery, we don’t want to get distracted from our core job, which is healthcare delivery. We would rather leave the job of filling those gaps to an outsider who can do it well.”

Meena Ganesh shares a similar view when she says that entrepreneurs offer an outsider’s fresh perspective on the existing gaps in healthcare. They are therefore better equipped to offer disruptive technology solutions that put the customer right at the center. Her own venture, Portea Medical, was born out of a need in the hitherto unaddressed area of patient experience – quality home care.

There are enough examples of hospitals that have gained significantly by partnering with or investing in such ventures. For example, the Children’s Medical Centre in Dallas actively invests in tech startups to offer better care to its patients. One such startup produces sensors smaller than a grain of sand, that can be embedded in pills to alert caregivers if a medication has been taken or not. Another app delivers care givers at customers’ door step for check-ups. Providence St Joseph’s Health, that has medical centres across the U.S., has invested in a range of startups that address different patient needs – from patient feedback and wearable monitoring devices to remote video interpretation and surgical blood loss monitoring. UNC Hospital in North Carolina uses a change management platform developed by a startup in order to improve patient experience at its Emergency and Dermatology departments. The platform essentially comes with a friendly and non-intrusive way to gather patient feedback.

When intrapreneurship can lead to patient centric innovation

Hospitals can also encourage a culture of intrapreneurship within the organization. According to Meena Ganesh, this would mean building a ‘listening organization’ because as she says, listening and being open to new ideas leads to innovation. Santosh Desai, MD& CEO - Future Brands Ltd, who was also part of the panel discussion, feels that most innovations are a result of looking at “large cultural shifts, outside the frame of narrow business”. So hospitals will need to encourage enterprising professionals in the organization to observe behavior trends as part of the ideation process. Also, as Dr Ram Narain, Executive Director, Kokilaben Dhirubhai Ambani Hospital, points out, they will need to tell the employees who have the potential to drive innovative initiatives, “Do not fail, but if you fail, we still back you.” Innovative companies such as Google actively follow this practice, allowing employees to pick projects they are passionate about and work on them to deliver fresh solutions.

Realizing the need to encourage new ideas among employees to enhance patient experience, many healthcare enterprises are instituting innovative strategies. Henry Ford System, for example, began a system of rewarding great employee ideas. One internal contest was around clinical applications for wearable technology. The incentive was particularly attractive – a cash prize of $ 10,000 to the winners. Not surprisingly, the employees came up with some very innovative ideas that included: a system to record mobility of acute care patients through wearable trackers, health reminder system for elderly patients and mobile game interface with activity trackers to encourage children towards exercising. The employees admitted later that the exercise was so interesting that they would have participated in it even without a cash prize incentive.

Another example is Penn Medicine in Philadelphia which launched an ‘innovation tournament’ across the organization as part of its efforts to improve patient care. Participants worked with professors from Wharton Business School to prepare for the ideas challenge. More than 1,750 ideas were submitted by 1,400 participants, out of which 10 were selected. The focus was on getting ideas around the front end and some of the submitted ideas included:

  • Check-out management: Exclusive waiting rooms with TV, Internet and other facilities for patients waiting to be discharged so as to reduce space congestion and make their waiting time more comfortable.
  • Space for emotional privacy: An exclusive and friendly space for individuals and families to mourn the loss of dear ones in private.
  • Online patient organizer: A web based app that helps first time patients prepare better for their appointment by providing check lists for documents, medicines, etc to be carried and giving information regarding the hospital navigation, the consulting doctor etc.
  • Help for non-English speakers: Iconography cards to help non-English speaking patients express themselves and seek help in case of emergencies or other situations.

As Arlen Meyers, MD, President and CEO of the Society of Physician Entrepreneurs, says in a report, although many good ideas come from the front line, physicians must also be encouraged to think innovatively about patient experience. An academic study also builds a strong case to encourage intrapreneurship among nurses. Given they comprise a large part of the front-line staff for healthcare delivery, nurses should also be given the freedom to create and design innovative systems for improving patient experience.

According to a Harvard Business Review article quoted in a university study, employees who have the potential to be intrapreneurs, show some marked characteristics. These include a sense of ownership, perseverance, emotional intelligence and the ability to look at the big picture along with the desire, and ideas, to improve it. But trust and support of the management is essential to bringing out and taking the ideas forward.

Creating an environment conducive to innovation is the first step to bringing about innovation-driven outcomes. These were just some of the insights on healthcare management gleaned from the Hospital Leadership Summit hosted by Abbott. In over 150 countries, Abbott, which is among the top 100 global innovator companies, is working with hospitals and healthcare professionals to improve the quality of health services.

To read more content on best practices for hospital leaders, visit Abbott’s Bringing Health to Life portal here.

This article was produced on behalf of Abbott by the Scroll.in marketing team and not by the Scroll.in editorial staff.