Antidepressant-induced insomnia: treatment options.

Abstract

This column offers a question-and-answer forum to help nurses maintain their knowledge of advances in prescribing and psychopharmacology, and implications for safe psychiatric care. If you have a question related to prescribing psychotropic medications, please send it to the Editor, Mary Paquette at: mary@artwindows.com. ********** Question: I have been working with Margaret, a 39-year-old homemaker, for 1 month in individual psychotherapy. Because of persistent symptoms of major depressive illness, she was initially prescribed escitalopram 10 mg every morning. Over the past 1 to 2 weeks since initiation of this antidepressant, she has complained of worsening sleeping difficulties. What is the best approach to treating Margaret's persistent sleep disturbances? Deborah Antai-Otong answers: Sleep disturbances are common among people with major depression and are believed to occur in 90% of depressed clients (Thase, 2000). Sleep disorders associated with major depression are heterogeneous and range from hypersomnia to extreme difficulties maintaining sleep. The significance of resolving sleep problems in depressed clients is their potential to produce negative consequences on the quality of life, functional status, and psychiatric and medical co-morbidity and treatment outcomes. Most researchers submit that depression is a compelling predictor of disability, and insomnia is a principal contributor (Simon & VonKorff, 1997). Polysomnographic (PSG) analysis of people with depression reveals a pattern of sleep disturbance symptoms: disturbed sleep continuity, altered rapid eye movement (REM) sleep timing, and decreased slow-wave sleep (SWS) quantity. An early onset of the first episode of REM sleep and increased phasic REM sleep has been demonstrated on PSG recordings. Longitudinal data of electroencephalographic (EEG) sleep profiles of depressed clients indicate specific sleep disturbances (Buysse, Frank, Lowe, Cherry, & Kupfer, 1997; Thase & Howland 1995; Thase, Simons, & Reynolds, 1996): * Reduced SWS associated with reversible or state-dependent aberrations * Increased REM sleep and poor-quality sleep * Disinhibited REM sleep * Shortened REM latency * Prolonged first REM period * Increased REM density (Riemann, Berger, & Voderholzer, 2001) Additional sleep patterns include: * Frequent awakenings * Increased light sleep (stage 1) * Decreased deep sleep (stage 4) * Early morning wakening Although the precise pathogenesis of sleep disturbances in major depression is unknown, researchers submit that the same neurotransmitter systems that regulate mood, motivation, energy, and other functions may also be abnormal in depression and contribute to sleep disturbance. Serotonergic neurons play a vital part in the modulation of the onset and maintenance of sleep, and sleep disturbances in depression are linked to aberrations of serotonergic pathways. Depressed individuals successfully treated with various antidepressants, such as selective serotonin reuptake inhibitors (SSRIs), often complain of persistent sleep disturbances. The effects of antidepressants on depression are significant because prolonged sleep problems increase the risk of relapse, recurrence, and suicide, with a need to add on new medications (Armitage, 1996; Buysse et al., 1997). Stimulation of serotonin type 2 (5-H[T.sub.2]) receptors appears to underlie insomnia and sleep disturbances in sleep architecture found in SSRIs or serotonin-norepinephrine reuptake inhibitors (SNRIs). In contrast, antidepressants that block 5-H[T.sub.2] receptor sites (e.g., nefazodone, mirtazapine) alleviate insomnia and improve sleep architecture (Thase, 2000). Based on this assumption, it is preferential to prescribe antidepressants with 5-H[T.sub.2]blocking properties as part of a treatment plan for depressed clients with significant insomnia. …