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Rubin Naiman Ph.D.


Circadian Rhythm and Blues: The Interface of Depression with Sleep and Dreams Part II

Three R's for depression: Restoring rhythm, repose, REM.

So, how do we cool the psychological fever of the depression-insomnia complex? We begin by reconsidering symptoms of depression as possible endogenous healing responses. We trust our body and brain's intention to heal, to reduce the heat of excessive waking by slowing us down and opening us up. Given that some depressive symptoms might be functional, it is important to avoid symptom suppressive strategies whenever possible.

Once again, depression is part of a larger complex associated with disrupted circadian rhythms, sleep and dreams. I believe the comprehensive treatment of depression must include attention to the restoration of what I'll call the "Three R's" - rhythm, repose (rest and sleep) and REM. The basic purpose of such treatment is to provide an antidote to the relentless, dysrhythmic thrust of hyperarousal.

I believe the restoration of more natural rhythmic structures in our lives is a most critical and overlooked component in the treatment of depression. Many established therapeutic interventions are, in fact, based on rhythmic processes. Examples include breathing exercises, mantras, music therapy and, perhaps most notably, heart rate variability techniques. One could also make the argument that rhythmicity is an active ingredient in most forms of physical exercise.

To restore rhythmicity, we must intentionally entrain with a different drum -- the beat of a more natural life. We can begin by establishing personal routines and rituals as an infrastructure of daily life. The notion that life is lived one day at a time is a common spiritual tenant across many cultures. In contrast, too many lives today are lived one project, one problem, or one paycheck at a time. Reframing our lives in terms of manageable daily units defined by new morning starts and gentle evening endings can help diminish one's sense of overwhelm. Consider framing your mornings and evenings with personalized ritualized practices such as yoga, prayer, breathing exercises or meditation.

Getting rhythmic also requires tuning into nature's circadian pulses of light and darkness.

Light exposure is significantly underutilized in treating the depression-insomnia complex. The use of morning light or phototherapy for non-seasonal depression is very promising, compares favorably to drug therapies and has significantly fewer side effects. In fact, in addition to regulating circadian rhythms, morning light exposure may have a direct antidepressant effect.

At the other end of the day, dusk simulation (diminishing light exposure in the evening) gradually reduces sensory input, encourages slowing and helps dial down the excessive waking associated with the depression-insomnia complex. It also facilitates the production and release of melatonin, which conveys a sense of night to the body and brain, helps reset the body clock and plays a critical role in the mediation of REM/dreaming.

Maybe it goes without saying that maintaining a regular sleep-wake schedule, something that still irks the adolescents in many of us, is also essential to the restoration of healthy rhythms. Too many of us, however, live with a kind of low-grade, stay-at-home jet lag resulting from frequently varying our rising and bed times to accommodate changing work, family or social needs. We can glance at clocks to tell time, but our inner sense of rhythm is damaged by such behavior patterns.

I like the word repose. Derived from Latin, re + pausa, to pause again. It's about the process of slowing and stopping. Repose includes sleep as well as rest. When we look at EEG measures of rest and sleep, it's obvious that they are on a continuum. I think of rest as a kind of waking sleep. Adding repose to the excessive wakefulness of hyperarousal helps transform relentlessness to rhythm.

Just as we need to learn to walk before we can run, we must learn to rest before we can sleep well. Whatever else symptoms of depression might indicate, they reflect the psyche's insistence that we rest. If we do not suppress depression's feverish fatigue with stimulant medications, it asks that we excuse ourselves from the world of activity, turn inward, and rest. Beyond all of the complex challenges associated with it, being depressed is a psychospiritual call for deep rest.

But most of us have forgotten what true rest is, confusing it with recreation or inebriation. The kind of rest I'm talking about is not achieved by watching a movie or drinking alcohol or using marijuana. True rest practices include a range of exercises that quiet excessive waking. Examples include meditation, breathing exercises, visualization and neurofeedback. They encourage a surrender of sensory stimulation and turning inward to be with our deeper, quieter self.

Presuming that treating depression, per se, will eventually ameliorate associated sleep disorders is a mistake. I recommend all depressed individuals obtain specialized sleep evaluation and treatment. Unfortunately, most sleep specialists are prone to mask symptoms with sleeping pills rather than address the underlying factors impairing sleep. I strongly recommend consulting with a psychologist adept at providing cognitive-behavioral therapy for insomnia or CBT-I. This refers to a set of highly effective techniques for managing insomnia. You can find a CBT-I practitioner at the Society of Behavioral Sleep Medicine's web site.

Allowing ourselves to honor the call for repose not only supports healthier sleep but also opens a portal to the inner world of dreams, including the waking dream. If, as classic psychodynamic theory has long stated, depression is about the loss of our dreams, repose is a most sensible part of its treatment.

Encouraging healthy REM/dreaming is critical to the effective treatment of depression. From shamanic practitioners to depth psychotherapists, dreaming has a time-honored place in healing both physical and emotional ills. Healing our dreams will likely improve emotional processing and enhance creativity. Once again, I look at dreaming as a kind of psychological yoga --it essentially stretches and expands our consciousness. In doing so it can help us break free of the tightly constricted consciousness that characterizes depression.

Dream healing can be achieved in a number of ways. Simply intending to increase one's dreaming is a good start. Evaluate and minimize the use of REM suppressant substances and medications whenever possible. To improve recall it's helpful to intentionally attend to dreams and then bridge them into your waking world. Begin by arising slowly in the morning, lingering in your grogginess and just allowing bubbles of dream images to rise into awareness. What we call grogginess is actually a hybrid state of consciousness-part waking, part dream-that we can tap into to access our dreams. After we arise it's helpful to transfer dream memories into the waking world by noting them in a dream journal and/or discussing them with supportive people. Deciphering your dream's meaning can be interesting and useful at times. But just knowing that dreams are meaningful is more important than knowing their particular meaning. If desired, dreaming can also be potentiated through supplemental melatonin.

Although our night dreams are most obvious, I believe we also dream by day. What Jungian thinkers call the waking dream is an ebb and flow of more subtle dream-like mentation throughout the day. The waking dream, different from a daydream, is a universal phenomenon --a wonder-informed way of perceiving that senses depth, mystery, meaning and possibility quivering behind all things. In my clinical experience, waking dream work can be especially useful in addressing fatigue.

One easy and effective way of accessing the waking dream is to keep a daily journal. But instead of recording your experiences as in an ordinary diary, write about them as if they were dreams. This exercise can help gently stretch constricted consciousness. Additional waking dream practices, reviewed in more detail in my book, Healing Night, can also help expand awareness and reframe ordinary as well as difficult life events in a more ephemeral, dream reality.

In closing, I'd like to say that the suggestions offered here are meant to complement other effective psychological and psychiatric interventions for depression and should be adapted to one's individual circumstances and needs. Please discuss these with your healthcare provider and obtain their blessing before embarking on any of them.


About the Author

Rubin Naiman, Ph.D., is a Clinical Assistant Professor of Medicine at the Arizona Center for Integrative Medicine, University of Arizona.