What medication can I prescribe for an 18-year-old patient with depression and insomnia?

From the Guidelines

For an 18-year-old patient with depression and insomnia, I recommend starting with a selective serotonin reuptake inhibitor (SSRI) like fluoxetine or sertraline to address the depression, which may also help improve sleep over time, and considering a short-term course of a non-benzodiazepine hypnotic like eszopiclone for immediate sleep concerns, as suggested by the American Academy of Sleep Medicine clinical practice guideline 1. When selecting a medication, it's crucial to consider the patient's response to the first medication, and adjust accordingly, for instance, a patient who continues to complain of wakefulness after sleep onset (WASO) might be prescribed a drug with a longer half-life, while a patient who complains of residual sedation might be prescribed a shorter-acting drug. Some key points to consider in treatment include:

• The use of cognitive behavioral therapy for insomnia (CBT-I) as a first-line treatment for insomnia, which can be effective in addressing sleep issues without medication 1.
• The importance of sleep hygiene education and lifestyle modifications, such as maintaining a regular sleep schedule, avoiding naps, and creating a relaxing sleep environment.
• The need for close monitoring of side effects, particularly during the initial weeks of treatment, with special attention to any increased suicidal ideation, which can occur when starting antidepressants in young adults.
• The consideration of sedating low-dose antidepressants, such as trazodone, for patients with comorbid depression and insomnia, although evidence for their efficacy as a sleep aid is relatively weak, and they should not be used as a sole treatment for major depression 1.

From the FDA Drug Label

Adult — The efficacy of Prozac was established in 5– and 6–week trials with depressed adult and geriatric outpatients (≥18 years of age) whose diagnoses corresponded most closely to the DSM–III (currently DSM–IV) category of major depressive disorder A major depressive episode (DSM–IV) implies a prominent and relatively persistent (nearly every day for at least 2 weeks) depressed or dysphoric mood that usually interferes with daily functioning, and includes at least 5 of the following 9 symptoms: depressed mood, loss of interest in usual activities, significant change in weight and/or appetite, insomnia or hypersomnia, psychomotor agitation or retardation, increased fatigue, feelings of guilt or worthlessness, slowed thinking or impaired concentration, a suicide attempt or suicidal ideation.

Medication Options:

• Fluoxetine (Prozac): can be prescribed for an 18-year-old patient with depression, as it is indicated for the treatment of major depressive disorder in adults (≥18 years of age) 2.
• Sertraline: can be prescribed for an 18-year-old patient with depression, as it is used to treat Major Depressive Disorder (MDD) 3.

Key Considerations:

• Insomnia is one of the symptoms of major depressive disorder that can be treated with these medications.
• It is essential to monitor the patient's response to the medication and adjust the treatment plan as needed.
• The patient should be informed about the potential side effects and risks associated with these medications.

From the Research

Medication Options for Depression and Insomnia

For an 18-year-old patient with depression and insomnia, the following medication options can be considered:

• Selective serotonin reuptake inhibitors (SSRIs) such as fluoxetine, sertraline, and paroxetine, which have been shown to be effective in treating depression and insomnia 4, 5, 6
• Serotonin norepinephrine reuptake inhibitors (SNRIs) such as venlafaxine and duloxetine, which can also be effective in treating depression and insomnia 4
• Other medications such as mirtazapine and trazodone, which can be used to treat depression and insomnia, but may have different side effect profiles 4

Combination Therapy

Combination therapy with cognitive behavioral therapy (CBT) and medication may be more effective than medication alone in treating adolescent depression 5, 7, 6

• A study found that the combination of fluoxetine and CBT was more effective than fluoxetine alone or CBT alone in treating adolescent depression 5
• Another study found that sertraline combined with CBT was more effective than sertraline alone in reducing depressive symptoms and anxiety in adolescents 6

Considerations

When prescribing medication for an 18-year-old patient with depression and insomnia, it is essential to consider the potential side effects and interactions with other medications 4, 8

• SSRIs and SNRIs can have side effects such as nausea, headache, and sexual dysfunction
• Mirtazapine and trazodone can have side effects such as drowsiness, dry mouth, and constipation
• It is crucial to monitor the patient's response to medication and adjust the treatment plan as needed 4, 5, 6