[SA Chris]

Me too. Normally go to bed around midnight, up at 3-4 for a pee, then about an hour to get back to sleep, and in deep sleep when alarm goes off about 7:15.

[slab_happy]

Like everything else in psychiatry, this is the subject of ongoing research and debate, and the classifications get shuffled around over time, but there's a school of thought that "melancholia" a.k.a. "major depressive disorder with melancholic features" (in DSM-5) is a distinct subtype of depression, or possibly even a different illness from other forms.

On top of meeting the criteria for a depressive episode, current criteria for "melancholic features" are that you have to have anhedonia and/or not feeling better (except very briefly) when something good happens, and also three or more out of (I quote):

    a mood defined by “profound despondency, despair, and/or moroseness,” or feeling empty
    worse depression in the morning
    waking up early, such as 2 hours earlier than usual
    intense restlessness (psychomotor agitation) or visibly slowed movements
    significant weight loss
    excessive feelings of guilt

"Melancholic" features are believed by many psychiatrists to be associated with depression that's more biological in origin, less responsive to psychotherapy (but still responsive to meds), possibly with some connection to things going wacky in the body's hypothalamic-pituitary-adrenal axis (the early morning waking may be to do with cortisol), and more likely to be severe.

The opposing school of thought says this is just bog-standard depression that happens to have a particular garnish of these secondary symptoms rather than others, but that this doesn't make a meaningful difference in treatment or prognosis.

Obviously you can also get early-morning waking as a sleep problem without being depressed at all; this is just about early-morning waking in the context of depression.

[slab_happy]

Me too. Normally go to bed around midnight, up at 3-4 for a pee, then about an hour to get back to sleep, and in deep sleep when alarm goes off about 7:15.

Oooh, biphasic sleep! If you can get back to sleep after an hour and aren't depressed, then I recommend getting a copy of A Roger Ekirch's amazing book At Day's Close and not stressing about it, because that may actually have been the normal sleep pattern for a lot of human societies pre-Industrial Revolution. It's FASCINATING.

https://www.bbc.com/future/article/20220107-the-lost-medieval-habit-of-biphasic-sleep
https://en.wikipedia.org/wiki/Biphasic_and_polyphasic_sleep

Just use the hour to read or do something else that's relaxing and won't wake you up more, and don't worry that it means you're sleeping "badly".

[jshaw]

Like everything else in psychiatry, this...

Very interesting, thank you!

[User deactivated.]

Okay next question...

20mg of Cpram made me a bit dozy a few hours after taking it, and taking an evening dose generally got me to sleep well and sleeping through the night (I tend to sleep a fair bit probably due to metabolism / DVTs / digestion).

30mg of Cpram makes me get to sleep just fine as before, but I'm consistently waking in the very early morning and struggling to get back to sleep (not too much anxiety going on, just awake), inevitably before finally falling asleep just as the alarm goes off, feeling very sluggish, struggling to eat in the mornings etc.

To try to alleviate this, I'm taking 10mg Cpram in the morning, and 20mg in the evening as before, which doesn't help, neither did taking 30mg in the evening.

So....

Are there any supplements I could take to help me sleep through the night (not just get to sleep)?

Do I just need to paint more orcs before bed?

Is this an inevitable consequence of an increased dose?

Would Escitalopram with it's apparently reduced side-effects alleviate this problem?

Obviously I have no medical advice whatsoever, but I have spent the last few years maximizing sleep quality and quantity after reading 'Why We Sleep' by Matthew Walker (a leading neuroscientist specializing in sleep). Anecdotally, after going from around 6 hours of irregular sleep up to usually a solid 8 hours (when kids allow!), I have much more energy, my mood is better, my testosterone levels 'feel' higher (no bloodwork to confirm), I'm seemingly less injury prone, and my basal metabolic rate has increased from c.2,600kCals up to about 3,000kCals to maintain my weight.

His book provides many examples of how insufficient sleep (less than 7-8 hours of actual sleep) affects almost every aspect of your physiology and psychology, as well as its links to other health problems, but the key takeaways in terms of improving sleep are:

Go to sleep and wake up at a consistent time every day including weekends. Setting a bedtime alarm is a practical step to help with this.

Get at least 30 minutes of daylight in the morning. Sitting near a window does not seem to be enough - get outside! For me this isn't always practical so I have one of those SAD lamps and blast myself with it in a morning at my desk.

Ensure your bedroom is cool and pitch black. I've installed blackout blinds to help reducing light pollution and my phone is always placed screen down in case it tries to notify me (obviously on silent).

Reduce all light exposure in the evening. Blue light and LED's appear to be particularly bad, but all light matters. Again this one is hard for me as I record/mix music using a computer in an evening. Although there's not much quality evidence supporting them yet, I wear amber tinted blue light reducing glasses for 2 hours before bed, which make me look like a weirdo, but they help a lot in my experience (much better than the blue light filter on screens which does nothing for me).

No caffeine after mid day (long half life) and no alcohol/cannabis. If you have to drink then preferably do it in a morning!

Drugs which aid sleep are actually bad for sleep quality, which is equally important as quantity. Of course, this may be unavoidable when they are needed for other issues e.g. anxiety.

Regular exercise, but not too close to bed time.

Don't eat close to bed time.

Don't drink anything for an hour or two before bed.

Most people's lives won't allow them to hit all of the above, but hopefully improving some of them could have noticeable effects after a few days. Sorry if this is all old news to you.

[SA Chris]

Just use the hour to read or do something else that's relaxing and won't wake you up more, and don't worry that it means you're sleeping "badly".

I'll have a look at the book thanks. Me reading for an hour would be fine, but not for partner!

[slab_happy]

Just use the hour to read or do something else that's relaxing and won't wake you up more, and don't worry that it means you're sleeping "badly".

I'll have a look at the book thanks. Me reading for an hour would be fine, but not for partner!

Podcast on headphones, then?

[slab_happy]

Like everything else in psychiatry, this...

Very interesting, thank you!

Yeah, it's been argued that "depression" as a diagnostic category is probably kind of like having "chest pain" as a diagnostic category would be: you've got similar symptoms that are probably caused by an assortment of different underlying conditions that need different treatments, but we don't yet have any of the knowledge when it comes to brains to identify the different conditions and distinguish the mental equivalents of heartburn and angina and heart attacks. Because, as previously mentioned, it's such a young field.

So right now, psychiatry is doing the equivalent of "Some people get chest pain! Sometimes they're fine the next day and sometimes they die. We did a study where we gave aspirin to everyone who has chest pain, and ... sometimes that seems to help?"

Hopefully in the future, people will be able to look back and laugh at how little people in the early 21st century understood any of this stuff.

[Fiend]

Thanks for the replies.

A couple of things:

This early morning waking wasn't happening on 20mg of Cpram, NOR was it happening regularly in the pre-30mg stages of my recent depression. I did often get anxiety spirals in the night before ever going on meds, but this feels different to that.

I tend to do almost all the things that Liam98 says and indeed being able to sleep even in depressive periods has previously been pretty reliable. Although I did find that last night at 5am reading on my phone about historical serial killers enabled me to get back sleep quicker than expected 

[petejh]

Another recco for the ‘Why we Sleep’ book.. really good. And the chapter describing the progression of symptoms for sufferers of a rare disease that completely stops sufferers being able to sleep -terminal in all cases - is truly horrific! (Would say the stuff of nightmares, but sufferers would do anything for the opportunity to have a nightmare).

SAChris, might be worth trying some pygeum (prunus africanis tree bark extract) if nighttime peeing is linked to prostrate. I went through a six month phase a few years ago of being woken by this, tried pygeum and it eliminated the issue v.quickly. Haven’t taken it since then and the issue hasn’t returned so it was possibly linked to stress.

[slab_happy]

And the chapter describing the progression of symptoms for sufferers of a rare disease that completely stops sufferers being able to sleep -terminal in all cases - is truly horrific! (Would say the stuff of nightmares, but sufferers would do anything for the opportunity to have a nightmare).

Oh god, fatal familial insomnia, right? Yeah, there's a horror.

[Johnny Brown]

Just use the hour to read or do something else that's relaxing and won't wake you up more, and don't worry that it means you're sleeping "badly".

I'll have a look at the book thanks. Me reading for an hour would be fine, but not for partner!

I’ve started using the red head torch I use for stargazing to read in bed without disturbing the wife. She gets to sleep fine. Petzl bindi but cheaper alternatives obvs.

[SA Chris]

Good suggestions, but she's a very light sleeper too. Will see how it goes. And thanks for the extract suggestion pete, I'll look into.

[slab_happy]

The main thing is to find something to do so you're not just lying with your eyes shut thinking about how you're still awake, because that tends to prolong the sleeplessness and make it more stressful.

Ironically, accepting it as a pattern that can be natural and normal tends to lead to being able to get back to sleep much faster.

[slab_happy]

If anyone's thinking about a lightbox, btw, this is the one I've got and you can currently get a refurbished one for 40% off:

https://www.lumie.com/products/desklamp-sad-light-refurbished

It's a handy one because, as well as lightbox-ing, you can bend it down and use it as a task light for any craft activities.

[seankenny]

I have exactly the same make and model, it works well for me too.

[SamT]

Nice one.. been perusing for ages (years even) and never got round to taking the plunge and parting with some cash.  I've struggled this year in particular (lots of other stuff going on) and was looking again.  However, never sure how much to spend, whether to believe reviews, etc etc.
Happy to have had a recommendation on here from satisfied users.. so grabbed one of these

 

[spidermonkey09]

With apologies for the dumb question, but could you use this as a desk lamp as well as a light box or is that just the model name?

[SamT]

Website seems to suggest you can indeed.

4 levels of light, so you can dim it down, and use the diffuser for more general use.

[slab_happy]

With apologies for the dumb question, but could you use this as a desk lamp as well as a light box or is that just the model name?

Yeah, absolutely.  For using it as a lightbox, you want it about 20cm from your eyes. But move it further away, stick the diffuser on it if you want, dim it and/or angle it down as needed, and it's just a nice bright light.

[SamT]

So, another dumb question.. how do you use it, practically day to day, as a light box.. 

Do you literally sit staring at it 20cm from your eyes for 30min each morning?  Sounds like a recipe for retina damage!

I'd have to juggle my morning routine somewhat to fit that in.

This is more for next year.. I'm generally feeling a lot better in Jan Feb towards spring, naturally. Especially when the weather is like today    Its Nov/Dec I generally struggle with. 

[slab_happy]

Do you literally sit staring at it 20cm from your eyes for 30min each morning?

Slightly above your eye-line, if possible. So you don't have to be staring into the light, and you can do other stuff while you get your lightbox time in.  But yeah, 20 cm (or whatever the appropriate distance is for that lightbox to get 10,000 lux).

I try to arrange mine so it's shining down into my eyes at an angle while I look at the internet and drink my coffee.

30 minutes is a "standard" dose, but I'd recommend with starting with 15 mins initially and seeing how that feels, then titrate up -- some people find they feel jittery initially, or get headaches.

(Also, just like chemical antidepressants, if you're bipolar it can flip you into being manic.)

Some people only ever need 15 mins; some people need longer than 30. You might only need it for a few months a year; some people (like me) use it year-round for non-seasonal depression.

The nice thing is that (unlike most meds) light therapy can have a very rapid effect, so you can adjust it by feel to a large degree. If you feel like you just drank five espressos, you know that was too much time!

Sounds like a recipe for retina damage!

It's not bright enough to cause damage in the short-term, but it is a legit concern whether over a lifetime the extra bright light exposure might conceivably increase the risk of macular degeneration or other problems; research isn't clear on this yet.

However, for context, it's not any brighter in lux than being outdoors on a clear day.

Advice seems to be that if you've got pre-existing eye problems, or are on meds that have a photosensitizing effect, check with a doctor.

The highest risk of eye damage comes from UV light, though, which is why good quality lightboxes (like this one) are UV-free.

[seankenny]

So, another dumb question.. how do you use it, practically day to day, as a light box.. 

Do you literally sit staring at it 20cm from your eyes for 30min each morning? 

I absolutely don’t use mine 20cm from my eyes and it has a positive effect. Even on the lowest setting it’s quite bright and I just have it across from the sofa where I have my breakfast.

[slab_happy]

Its Nov/Dec I generally struggle with.

If it's that predictably seasonal, then fingers crossed bright light therapy will really help.

[SamT]

Cheers guys..  I can probably arrange to get on my bedside, then turn it on in the morning and will try 15mins browsing while my better half is in the shower.

Will probably work out well.

Looking forward to getting one at long last.