Persistent Insomnia in Depression Responding to Antidepressants

Sleep problems commonly occur as part of a problem with mood disorders including depression.  Changes in sleep duration (insomnia or hypersomnia) are one of the criteria for the diagnosis of depression in the Diagnostic and Statistical Manual of Mental Disorders.  Although not absolutely required for the diagnosis, insomnia is a complaint in the the majority of subjects presenting for clinical trials in the treatment of depression.

The selective serotonin reuptake inhibitors (SSRIs) like fluoxetine (Prozac) have become one recommended strategy in the treatment of depression.  However, unlike other antidepressants, the SSRIs commonly do not have a sedative effect.  It is possible that when someone gets an antidepressant response to an SSRI, sleep disturbance also resolves.  However, in clinical practice, SSRIs commonly produce a partial remission of depression but fail to improve problems with insomnia.  So what does this type of response mean and what can be done for those with improvement in depression but residual sleep complaints.

Gulec and his research team from Turkey have some recent research on this topic posted online at the Journal of Affective Disorders.  They followed a group of adults with major depression treated naturalistically--i.e. treating psychiatrists could select the antidepressant drug although algorithms for dose and sequencing were followed.  Subjects were followed with research rating scales for a period of 52 weeks.  Some subjects responded and remained well.  Some subjects responded but had a recurrence of depression in the one year follow up period.  The key findings from the study:

• Persistent insomnia rates were high in those who had a recurrence of depression
• The recurrent groups showed the following rates of insomnia prior to recurrence: onset insomnia (difficult falling asleep) 58%, terminal insomnia (early morning awakening) 33% and middle of the night insomnia 8%.
• Only 26% of those subjects whose depression remained remitted throughout the 52 week follow up period endorsed any persistent insomnia complaint.

The authors note their study is consistent with other studies supporting insomnia as a marker for poor prognosis is depression.  Reynolds and colleagues found that subjects who remitted with an antidepressant drug (including improvement in subjective sleep) had had high rate of continued remission of depression with psychotherapy alone.  Those whose insomnia persisted were less likely to benefit from psychotherapy alone as a long term maintenance strategy.


So an important question is what to do when insomnia persists despite a general antidepressant response.  It appears this is a problem that is too important to ignore and hope it goes away.  Options appear to include adding a sedative antidepressant, switching to another antidepressant, adding a sedative hypnotic treatment for insomnia or adding cognitive behavioral treatment for insomnia.  Here there is little data to support one of these choices over the others.  A research study examining these types of options is needed to aid patients and their clinicians in the management of this common clinical situation.

Photo of Moth Hovering Over Flower Courtesy of Tim Yates

Gulec M, Selvi Y, Boysan M, Aydin A, Besiroglu L, & Agargun MY (2011). Ongoing or re-emerging subjective insomnia symptoms after full/partial remission or recovery of major depressive disorder mainly with the selective serotonin reuptake inhibitors and risk of relapse or recurrence: A 52-week follow-up study. Journal of affective disorders PMID: 21684011

Reynolds CF 3rd, Frank E, Houck PR, Mazumdar S, Dew MA, Cornes C, Buysse DJ, Begley A, & Kupfer DJ (1997). Which elderly patients with remitted depression remain well with continued interpersonal psychotherapy after discontinuation of antidepressant medication? The American journal of psychiatry, 154 (7), 958-62 PMID: 9210746