For adolescents, poor sleep can exacerbate mental illness and addiction

When she added up the hours she spent in bed each night, Jocelyn de Lange figured she should be feeling well rested. But most days, the 17-year-old high-school junior felt exhausted and prone to nodding off in class — even though her insides were tightly wound with a combination of anxiety and looming depression.

“I would be getting seven to eight hours of sleep,” de Lange said, “but it was never really restful sleep.” Many nights, just drifting into slumber could take a frustratingly long time, she recalled: “It would take me forever to fall asleep, mostly because my anxiety tends to get worse at night. That’s when I’m alone with my thoughts. I’d be reflecting on everything that happened that day, and it made falling asleep feel impossible.”

Many nights, to help herself fall asleep, de Lange smoked marijuana. While it seemed to help at first, she quickly discovered that she was actually feeling more tired, anxious and depressed than ever. Concerned about her escalating drug use and failing mental health, de Lange talked to her parents, who helped enroll her in M Health Fairview’s Adolescent Dual Diagnosis Outpatient Program, an intensive day treatment program for young people struggling with addiction and mental illness.

While enrolled in the treatment program, de Lange worked with Jessica Cici, M.D., M Health Fairview’s child and adolescent psychiatry medical director. During their appointments, Cici explained that de Lange’s drug use was likely altering her sleep cycle — and worsening the symptoms of her mental illness.

“Dr. Cici told me that one of the reasons my sleep was getting so bad was that when people smoke weed to help them sleep, it works at first, but after a while it ends up keeping you awake,” de Lange said. “It prevents your brain from going into REM sleep.”

The part of the sleep cycle where a person’s body rests and builds reserves for the next day, REM is an essential component of getting a good night’s rest. Because she was not getting full REM sleep, de Lange was running down her reserves, and her mental health was suffering.

“REM is where your most restful sleep happens,” de Lange said. “It’s the most important part.”

The adolescent brain is still developing, Cici said, and because of this, poor sleep can be particularly problematic for teens’ growing bodies and brains. Without enough rest, she explained, “All of us are more irritable, prone to feeling bad, having depression or having increased worry when we don’t get enough sleep. In adolescents, the problems created by sleep deprivation are only intensified.”

Michael Howell, M.D., medical director of Sleep Performance Training for Athletes at M Health Fairview and co-author of the SPI Sleep Journey app, explained that because sleep deprivation negatively impacts a person’s executive functioning and impulse control, it can be particularly hard on teens.

“Adolescents are already at a much lower baseline in terms of executive functioning,” Howell said. “When a young person is sleep deprived, they are more prone to take in information and put it into a negative filter. Say if you were left out of your friend’s group chat, if you are sleep deprived, you are more likely to think there is something malicious going on there rather than thinking that somebody just forgot to include your name on the list. When an adolescent doesn’t get enough sleep, they are more likely to have cognitive distortions.”

For many teens, chronic sleep disruptions can set up a dangerous cycle of exhaustion, depression, anxiety, and self-medication, Cici said. Because of this, she works to help the young people in her care understand the key connection between sleep and overall health.

As early as the first appointment, Cici said she brings up the topic of sleep, asking her patients to detail their sleep habits and how they think they impact the rest of their lives. During her appointments, she tries to drive home the importance of healthy sleep for an all-over healthy life.

“It’s a conversation I have with each of my patients almost every time we meet,” Cici said. “We know sleep has such significant impact on mental health for young people. We know that when people aren’t getting enough sleep it can lead to attention problems, anxiety, depression. We know ways to help people get better sleep, and I work with my patients on that.”

Unlike other changes that may be more difficult to achieve, improving sleep, Cici believes, is a relatively easy — but essential — way to make key progress in improving a patient’s physical and emotional health.

“Getting better sleep is one simple, controllable thing that we can do to help us feel better and to cope better,” she said, “but many patients have a hard time realizing how important making these changes can be.”

A common problem

A common misconception about teenagers is that they sleep like the dead — that their tendency to stay up late and sleep into the afternoon is a sign of poor decision-making or laziness, rather than a physical response to developmental changes in their sleep cycle.

For months, de Lange bought into that line of thinking, believing that her own inability to stay awake during the day was a personal failing. But when, with Cici’s urging, she took a deeper look at her sleep patterns, de Lange realized that what was happening in her brain during the nighttime hours was far from normal or healthy.

A closer analysis of her sleep revealed a distressing pattern.

“I would wake up very frequently during the night,” de Lange said. “And I wasn’t having dreams, which for me is unusual.”

With Cici’s help, de Lange realized that self-medicating with marijuana was, “working against me. When I was smoking weed at night, I would struggle to fall asleep and then when I did fall asleep I wouldn’t have very restful sleep. Even if I got eight to nine hours of sleep, which would’ve been enough for me on a normal day, I would still wake up feeling pretty exhausted.”

Cici explained that many teens who regularly smoke marijuana experience disrupted sleep cycles. With de Lange in treatment and sober, Cici began the process repairing her disrupted sleep, by outlining a list of non-medicinal sleep habits that are proven to improve sleep quality.

When she works to help adolescents who are struggling with drug addiction improve their sleep, Cici explained, “Our approach typically is that we really try to work through improving sleep hygiene, as opposed to starting on medication.” With the young adults in her programs, she continued, “We try to protect sleep, by bringing in the parents to help maintain a regular sleep and wake time; by not deviating those times on the weekend; by really focusing on what’s happening prior to sleep; by eating regularly; by making sure that they are working in some physical activity during the day, but not in the hours before bedtime; by limiting daytime naps; by turning off screens before bed; by practicing paced breathing or aromatherapy or drinking herbal tea; and by keeping the bedroom dark and cool.”

Cici instructs her young patients to try these approaches before turning to medicinal sleep aids. But if the non-medicinal approach doesn’t solve sleep problems, she feels it is warranted to prescribe a short course of sleep medication.

“Because of the link between sleep and depression and anxiety, it is important using these medications is a last resort,” Cici said. “But we do sometimes get to that point.”

Eventually, de Lange tried a short course of hydroxyzine, an antihistamine sometimes prescribed for insomnia.

“I was on hydroxyzine for about a month and a half,” de Lange said. “It started with a higher dose and slowly went down to nothing.” This approach, combined with employing some basic sleep hygiene tips, worked, she said: “My sleep is a lot more regulated now. Sometimes I still struggle to get to sleep. Usually it’s on days where I am anxious about something I have to do the next day, but now that I understand why it happens, it’s not so bad.”

With improved sleep and sobriety, de Lange has noticed an important change. “I’ve I started to dream again because my brain is able to go back into that REM stage,” she said. “I’ve noticed that on nights when I have vivid dreams I tend to have more energy the next day because my brain has been able to really get into that deep stage of REM.”

While it is a normal marker of adolescent development to want to stay up late and sleep in the next day, Howell advocates for some level of regulation. He encourages his patients — no matter what their age — to stick with the same bed and wakeup time every day of the week.

“A marker of sleep deprivation is if you sleep in later on weekends than you do on weekdays,” he said. “When you talk about adolescent kids, they all sleep in on weekends. But that often indicates sleep deprivation, which can lead to serious consequences like substance abuse, depression, suicide attempts, heart disease, malignancy — these are big things — as well as smaller things, like not doing as well on your French test or maybe trying out for the varsity baseball team and not getting picked.”

To make adolescent sleep hygiene changes stick, the motivation has to come from the teen, not their parents or guardians, Howell said.

“Often my teenage patents are there in my office with their parents,” he said. “One of the things I ask them is, ‘Who wants this the most in the room?’ If it isn’t the teen who says it’s them, I say, ‘Let’s just stop now. It only works when you want this more than your parents.’”

Howell’s approach to adolescent sleep is simple, he said: “You give the kids the tools. You say, ‘You do this on your own.’ When you cut the parents out of the picture, it works better.”

While she agrees that the true motivation for improving sleep habits must come from the adolescent, Cici also believes that parents still play an important role in building healthy, lasting behaviors.

“Teens’ brains are still developing,” she said. “In adolescents, the part of their brain that is least developed is executive function and the ability to plan ahead and understand the results of their actions. Teens, much like younger children, look to the adults in their lives to identify expectations sand structure. They actually thrive on structure.”

If parents build a strong base of expectations and healthy sleep behaviors from an early age, Cici said, “Teens will have that base to rely on as they move forward into adolescence, to make more adult decisions.”

Changes in schedules

Pandemic-fueled social upheaval and disruption have done a number on just about everyone’s sleep habits, Cici said.

“Having gone through this pandemic, we are seeing a lot more people coming to us with mental health and sleep concerns because of the lack of structure in their lives. We’re seeing more and more of that these days.”

Young people in particular seem to be struggling with the impact that drastic changes in their daily schedules have had on their sleep, she said. With altered school and work schedules, and families needing to juggle different responsibilities, adolescents’ sleep habits are often ignored or overlooked. She thinks that many families will face a rude awakening in the fall when schools return to their normal schedules and students are expected to pick up where they left off.

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It is hard to imagine a seamless re-entry for young people who, for more than a year, have been keeping erratic sleep schedules, Cici said: “I’m concerned that we’ll see the impacts of this for years to come.”

The pandemic threw de Lange’s life off course. Without the structure of in-person school, she quickly discovered that she had too much time on her hands. For a naturally uneasy person, that extra, open time was troubling.

“During the pandemic, I had more time to be anxious and overthink,” she said. “All I had was time on my hands. It was difficult to find things to do.”

Too much time on her hands meant too much time spent staying up late and ruminating. “Because of COVID, there were more things to be anxious about than there were before,” de Lange said. “If you add on to that the additional time you have to just sit there and be anxious about life, it is a recipe for disaster.”

In the fall, when she returns to Armstrong High School for her senior year, de Lange said she’s hoping to keep up the healthy sleep habits she learned in treatment.

She’s already concerned that the busy school year could make that tough.

“I wish that schools would try to advocate for students getting more sleep,” de Lange said, “because being in the teenage years, your brain is quite literally developing. You can’t do that successfully without getting enough sleep. With early school start times and sports practices that can go pretty late, it is a sad attempt at trying to advocate for mental health.”

Cici is encouraged by reports of school districts that have adjusted high school start times to better meet the sleep needs of students.

“I’m very much in support of some of the changes to school schedules that have been rolled out in Minnesota and across the country,” she said. “Adolescents have a delayed sleep cycle. Because they like to go to bed later and sleep later, it impacts their performance in school. They engage in risk-taking behaviors because they are not getting enough sleep. I think these changes are beneficial for that age group to better allow them to sleep for the recommended time of nine to 12 hours a night.”

With Cici’s encouragement, de Lange is trying to adjust her own schedule so she can meet that nine-to-12-hour goal, aiming to “try to go to bed by 9 or 10” when she has to work the next morning. “It kind of sucks, but at the same time it forces me to take a little bit of time to myself to wind down for the day and make myself tired so I can fall asleep,”

These days, de Lange said she can tell when she hasn’t had good quality sleep. “I feel even more tired and sluggish,” she said, “which is not really a good thing for somebody who already struggles with finding motivation to get through the day.”

On days when de Lange gets enough sleep, life seems much kinder. “It’s a lot easier to work through issues when they come up,” she said. “I’m sort of able to reassure myself or work through whatever thing that’s making me anxious. I just feel more energized.”

It’s like the extra hours of rest almost work to help lift her mood and boost her resilience, de Lange added: “When I get more sleep, if I’m feeling really down or depressed, I have the energy to try and get up and do something like paint or draw to distract my mind. It doesn’t feel so out of control. It’s more something I can handle.”