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Addressing the Sleep-Pain-Anxiety/Depression Connection
By Jennifer Morganti, ND, Director of Education for NEEDS

"A good laugh and a long sleep are the best cures in the doctor's book" — Irish proverb

DO YOU SPEND MORE TIME THINKING THAN SLEEPING SOME NIGHTS? Several polls have found that over 50% of Americans have trouble sleeping at some point in their lives. Insomnia and sleep problems are so pervasive that we have both National Sleep Week (March 7th-13th) and World Sleep Day (March 18th) to draw attention to this issue. Despite the pervasiveness, we generally fail to prioritize sleep as much as we do exercise and nutrition, even though it is just as critical to achieving optimal health. Chronic poor sleep can impair the immune system, cognitive function, and mental health. Long-term sleep deprivation can even result in death, as demonstrated in mouse studies that show that as little as two weeks without slumber will lead to their demise.

And it is not just the number of hours that we lay in bed with our eyes closed that contribute to our wellbeing. The quality of the shuteye is equally important. During the night, we cycle through REM and non-REM sleep. REM is dreamtime, and the deepest sleep occurs during stage four non-REM sleep, with the first stage being the lightest when a person can easily be awakened. If you have ever been wakened from a deep sleep where it took several minutes to regain consciousness and determine where you were, you were probably roused from stage-four non-REM sleep. Non-REM is when the body restores itself and devotes energy to the immune system to keep us healthy. Sleep medications are effective at inducing sleep, but it is not non-REM restorative sleep. So it is important to try to improve sleep quality without long-term use of pharmaceutical medications.

Sleep issues are universal, but the causes, effects, and how we experience them vary widely. Difficulty falling asleep (defined as taking greater than 30 minutes), difficulty maintaining sleep, early morning wakening, and unrefreshing sleep are different ways insomnia manifests itself. The causes of sleep deprivation are numerous: stress (ranked number one), anxiety, depression, shift-changes at work, jet lag, medical conditions (such as pain, restless legs syndrome, sleep apnea, etc.), alcohol, drugs, caffeine, side-effects of pharmaceuticals, nighttime exercise, and low blood sugar, to name a few.

Volumes could be written about how to address the wide variety of sleep issues and their causes, so we will focus on a common triad of problems—the combination of sleep deprivation, pain, and depression. Fibromyalgia is a clear manifestation of this combination. All facets are interrelated; muscle pain contributes to poor sleep, and chronic pain and sleep deprivation leads to anxiety, loss of hope, and depression. It may not be clear which symptom came first when experiencing this triad, almost like the chicken vs. the egg question. The issues of neurotransmitter imbalances, Vitamin D deficiency, and low magnesium levels can all contribute to the pain-sleep deprivation-anxiety/depression triad. We offer solutions to addressing these three key issues.

Key Neurotransmitter Imbalances
One of the common underlying threads with the pain/ depression/ insomnia triad can be low serotonin. Serotonin is a neurotransmitter that is responsible for temperature regulation, mood, sensory perception, relaxation, and sleep modulation. Low serotonin can cause anxiety, depression, insomnia, and enhanced pain perception. This explains why SSRI medications, which elevate serotonin levels by preventing it from being metabolized, can be effective in alleviating depression and sleep disorders.

The body manufactures serotonin from amino acids 5-HTP, tryptophan, and vitamin B6. Tryptophan is converted to 5-HTP, which makes serotonin. Some people have greater success supplementing with 5-HTP, others do better with L-tryptophan, which is available topically or in oral form.

GABA is an inhibitory or calming neurotransmitter. By reducing anxiety, it can calm worrying thoughts that interfere with good sleep. Sublingual GABA is good to keep by the bedside if you tend to waken for long periods in the middle of the night, because it can be taken without water and won't cause morning grogginess.

Vitamin D Deficiency
Vitamin D deficiency has been shown in several studies to be related to a higher incidence of depression, and some small studies found that high doses (and not low doses) of vitamin D3 could help alleviate symptoms. Vitamin D deficiency has become more pronounced in modern times as we spend much more time indoors, and protect our skin with high SPF creams and clothing for fear of skin cancer. As D levels have declined over the years, depression rates have increased. There are some plausible connections between vitamin D and depression; there are vitamin D receptors in the brain, indicating vitamin D has an affect on the brain and the fact that vitamin D helps make tyrosine hydroxylase, which works on the pathway that converts tyrosine to serotonin ultimately. Although research on the topic is lacking, it would be sensible to check vitamin D levels in a person who is depressed. Serum D levels (25(OH)D) should ideally be at least 50 ng/ml.

Vitamin D receptors are also located in the sensory receptors of the nervous system, linking Vitamin D deficiency to cases of unidentified pain. Research has found higher incidence of vitamin D deficiency in patients with pain, and improvement of pain symptoms with vitamin D supplementation.

Although there haven't been full-blown clinical trials conducted to prove that vitamin D deficiency is related to insomnia, there have been case reports. And with its strong association with two of the three parts of the triad, it is quite possible that resolution of vitamin D deficiency could improve sleep patterns.

Low Magnesium Levels
Magnesium has a role in hundreds of biochemical reactions that occur in the body.

It controls muscle relaxation; therefore, deficiency can result in stiff muscles and pain, as commonly seen in fibromyalgia. It makes ATP (energy), which is used by all tissues in the body, but especially the brain. Magnesium deficiency is also related to elevated anxiety. By relaxing the muscles and the mind, magnesium can improve sleep.

Conversely, sleep deprivation can lower magnesium levels. Magnesium deficiency can have a spiraling effect that hinders many bodily functions. Keep in mind that B vitamins help with proper utilization of magnesium, so a B complex formula can optimize magnesium performance. Magnesium citrate, glycinate, taurate, and chloride are all excellent forms of bioavailable magnesium.

We all recognize the refreshment that comes from a good night's sleep, but imagine the possibility of an overall improved quality of life that may take place by following these three key tips. Here's to helping you improve sleep, relieve pain, and overcome anxiety or depression!


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