Trouble sleeping can be a common symptom in depression, but research shows that insomnia often has a separate life and requires separate treatment.
By Andrew Krystal, MD, MS
Do I need to treat sleep problems separately from my depression?
Medical opinion has long held that sleep problems occurring in the setting of major depressive disorder were symptoms of the depression and, like other symptoms, would resolve with effective treatment of the depression. It was assumed that there was no need to target treatment specifically to the sleep problems if someone was responding well to antidepressant therapy.
However, relatively recent research contradicts this long-held view. In studies looking at the sleep side of the equation in people with depression and sleep problems, insomnia frequently didn’t improve even though depressive symptoms got better with antidepressants.
Other studies have evaluated whether there are benefits to adding sleep-targeted medication therapy or cognitive behavioral therapy to antidepressant medication. The results indicate that treatment focused on improving sleep difficulties leads not only to significant improvement in sleeping, but also to better quality of life and ability to function as rated by the study participants.
Taken together, the available research lends support to separate treatment for sleep disturbances that occur with major depression.
What would treatment look like?
In deciding how to best treat sleep problems that occur with depression, you and your practitioner will have several considerations to review.
It will always be necessary to treat your depression, whether through psychotherapy such as cognitive behavioral therapy (CBT), antidepressant medication, or a combination of both. CBT involves working with a therapist to recognize and address thought patterns and behaviors that contribute to depression, such as negative self-talk and pessimistic outlook.
If you and your practitioner agree that an antidepressant is called for, the next decision will be whether to try one of the antidepressant medications that have sleep-enhancing effects or a non-sedating antidepressant plus a sleep intervention.
On the face of it, using a single medication that treats both depression and sleep problems would seem to be the most efficient and easiest strategy, and the one likely to impose less of a financial burden. However, there is a cost in terms of not being able to independently judge and adjust the dosage of the antidepressant and sleep components of the therapy.
Also, there are only a few antidepressant medications in common use that have sleep-enhancing effects, and they tend to have more side effects than the non-sedating antidepressants.
As a result, the more common approach is to prescribe a non-sedating antidepressant and consider separate treatments for the sleep problem. Options here include insomnia medications and cognitive behavioral therapy for insomnia (CBT-I). This specialized version of CBT targets maladaptive thought patterns and behaviors related to poor sleep.
WHEN TO START?
If the preferred approach is an antidepressant plus a sleep therapy, the next step is to determine whether to start both at once or whether to start with only the antidepressant to see whether sleep improves along with other depressive symptoms.
Both strategies have been evaluated in research studies and both have been shown to be of benefit. However, the benefit is experienced sooner and to a greater extent in those where insomnia-targeted therapy is initiated at the same time as antidepressant therapy.
Printed as: Ask the doctor: The insomnia equation, Fall 2017
via Esperanza – Hope To Cope
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