Understanding Morning Misery in Depression

Medical Reviewer

One of the most common symptoms of depressive illness is feeling worse in the morning. There are various views as to why this occurs so I thought I'd use this post to explore some.

Ask a doctor why you feel so dreadful every morning and they will most likely point to hormonal upsets. The hormone cortisol, sometimes known as the stress hormone, is one of the biggest culprits. Cortisol fluctuates naturally throughout the day but in people who aren't depressed the hormone peaks in the morning and gradually falls-off as the day progresses. In depression this peak is absent.

The cortisol awakening response (CAR) refers to this morning peak. Within 30 minutes of waking a 50 per cent increase in cortisol occurs, the assumption here is the body is preparing to react to potential stress. It's a reasonable assumption because we know the CAR tends to be higher in people on workdays than it is on, say, free days and vacations.

People with symptoms of major depression show abnormal levels of brain serotonin and cortisol. Of course stress levels fluctuate throughout the day and so therefore does cortisol. In major depression we tend to see an absence of the morning peak in cortisol and a decrease in brain serotonin (5-HT). However, cortisol levels also tend to be erratic and subsequently there is an overall increase in cortisol. Some of the current thinking suggests that stress causes elevated cortisol levels, which lowers 5-HT function, which leads to depression.

If we think of serotonin as important for contentment and happiness then its interplay with cortisol is important. During the CAR serotonin levels are also lower and so all the miserable symptoms associated with depression are so much more acute in the morning. In other words the sense fatigue, the muddled thinking, the plummeting levels of self-confidence and pessimism and the associated frustration and anger are often at their worst after waking up. For some people these symptoms clump together in a way where it seems impossible to discriminate one symptom from another. Basically it becomes the sense of abject misery. Even some people without depression feel truly groggy first thing. They want peace and quiet, a cup of coffee and to be left alone until their head catches up.

I think one of the interesting interplays between mind and body is the role that stress appears to have. Wake to the prospect of yet another stressful day, perhaps as a caregiver or your employment, and it's easy to see how this may predispose your brain chemistry to respond in ways that may lead to anxiety disorders and/or depression.