Depression First, or Insomnia First? Wrong Question.

Which do you treat first: the depression, or the insomnia? For a long time, I had a clear answer.

When I was training, I was told not to worry about insomnia. Treat the depression. Treat the anxiety. The sleep will follow.

It was one of the most confident things I was taught, and one of the least reliable.

Sometimes the sleep follows. Often it doesn't. And for years, people have been lying awake waiting for a treatment that was never aimed at them. Today, I treat the insomnia no matter what. I don't wait.

Why it goes untreated for years

According to Statistics Canada, about 1 in 4 Canadian adults report trouble falling or staying asleep most or all of the time, up from about 1 in 6 less than a decade earlier. Yet many never raise it. In one Quebec study, fewer than half of people with insomnia had ever talked to a health professional about their sleep.

Poor sleep becomes normal. People collect tips, push through, and stop expecting it to change. In a short appointment focused on something else, sleep rarely comes up unless someone asks.

Part of the reason is how we were trained. In 2013, psychiatry's diagnostic manual recognized insomnia as a disorder in its own right. It took close to another decade, and the arrival of newer treatments, before most of us started treating it that way.

Three people, one complaint

Think about who actually says "I can't sleep" in a given week.

The first thinks it's just who they are. They've slept badly since their teens. They call themselves an insomniac, the way someone might say they're left-handed. They've never mentioned it, because they don't think it's treatable. They've just found ways to cope.

The second lost their sleep first. For months they've been waking at 3 a.m. Nobody connected it to anything. Then their mood started to slide. By the time depression is diagnosed, the earliest signal has been there for half a year.

The third got better, except for the sleep. Their depression was treated and their mood lifted. But the 3 a.m. waking never left. They were told to give it time. At this point, the insomnia has become its own problem, and it deserves its own treatment.

Three people. Three different stories. The same mistake: waiting for something else to fix the sleep.

Symptom or disorder? Often both

Insomnia can be a problem on its own, or alongside something else, and often both at different times in the same person.

Sleep is often the first thing to go when something else is starting. A 2016 meta-analysis in BMC Psychiatry, pooling 34 studies and more than 170,000 people, found that insomnia roughly doubles the risk of developing depression later.

And there is now provocative evidence that treating insomnia early may help prevent it. In a randomized controlled trial published in JAMA Psychiatry in 2021, which followed 291 adults aged 60 and older who had insomnia but no major depression at entry, those who received cognitive behavioural therapy for insomnia (CBT-I) were about half as likely to develop major depression over three years of follow-up: 12% compared with 26% in the group that received sleep education.

That's why, when someone tells me they can't sleep, my first question usually isn't about sleep.

A brain and body condition

Insomnia isn't only linked to mental health. It's associated with poorly controlled diabetes, high blood pressure, heart disease, and memory and thinking problems, and poor sleep may contribute to weight gain.

Left alone, it carries real costs: to concentration, work, relationships and mood, as well as weight, memory and blood pressure. Restoring healthy sleep matters for memory, for fighting infection, and for not lying awake anxious in the middle of the night.

What's changed in treatment

The good news is that insomnia is treatable, and effective treatment goes well beyond sleep tips.

1. Sleep habits are the starting point. No caffeine or alcohol in the evening, a cool room, and a steady routine – to suggest a few sleep hygiene tips.

2. CBT-I is the treatment of choice. It works on the thoughts and habits that keep the brain from sleeping.

3. We understand more about why some brains won't switch off. Orexin is a chemical messenger deep in the brain that keeps us awake and alert. Two research teams identified it independently in 1998. In people who sleep well, its activity drops at bedtime. In many people with insomnia, the brain stays switched on: "I can't shut my mind down," "my thoughts are racing."

4. Newer medications target that system directly. Two medications that block orexin have been approved in Canada since 2020: lemborexant and daridorexant. Older sleep medications often worked a bit like a two-by-four: people slept, but they were groggy for hours the next morning, with impaired functioning. These newer options turn down the brain's wake signal instead, are designed to wear off by morning, and help preserve the brain's natural sleep stages, including deep and REM sleep; people wake up feeling refreshed and ready to start their day. That's what got me excited.

Patients always have a choice in how we approach it. But insomnia no longer has to be something people simply live with.

What a clinician can ask in two minutes

Not a full sleep assessment. A few questions change the conversation:

When did your sleep change, and what else was happening then? Life events, mood, pain, a new medication, a physical health problem.

Which went first: your sleep or mood? The order tells you whether sleep is an early signal, a lingering problem, or both.

How would you describe your sleep patterns? Trouble falling asleep, waking up in the middle of the night or too early, or being unable to get back to sleep? Each points in a different direction.

How are you coping with sleep? What are you doing, or taking, to help you sleep? This may be screening for: over the counter meds, cannabis, alcohol, herbal products and more.

And ask every patient. Don't wait for them to bring it up.

What patients can bring

If you're the one who can't sleep, you can make that appointment more useful:

• Two weeks of notes: when you went to bed, when you woke, how long it took to fall asleep, and any caffeine, alcohol or naps.
• When it started, and what was happening in your life then.
• Which came first if your mood, stress or health has changed too.
• What you've tried, and what helped.
• How it affects your day: focus, mood, work, relationships.

And mention it, even if you've lived with it for years. Especially then.

The question underneath the question

Is insomnia a symptom or a disorder? Often both, at different times, in the same person. The mistake was never choosing the wrong answer. It was waiting to find out before treating it.

So treat both, and treat them early. If someone has been lying awake for weeks or months, that is reason enough to act.

Closing question: Clinicians, when a patient's mood improves but their sleep doesn't, what do you do next?