What medication can treat both depression and insomnia?

Medications for Both Depression and Insomnia

Sedating antidepressants, particularly mirtazapine, trazodone, and doxepin, are the most appropriate medications for treating both depression and insomnia simultaneously. 1

First-Line Options

Mirtazapine

• Dosage: Start with 7.5-15 mg at bedtime, may increase to 30 mg
• Mechanism: 5-HT2 receptor antagonist with strong sedative properties
• Benefits:
  • Promotes sleep, appetite, and weight gain
  • Well-tolerated in most patients
  • Improves both depression and insomnia symptoms
• Considerations: Weight gain may be significant in some patients 1

Doxepin

• Dosage: 3-6 mg at bedtime for insomnia; higher doses (25-150 mg) for depression
• Benefits:
  • FDA-approved for insomnia at low doses (3-6 mg)
  • Effective for sleep maintenance insomnia
  • Antidepressant effects at higher doses
• Caution: More anticholinergic effects than other options 1

Trazodone

• Dosage: 50-100 mg at bedtime
• Benefits:
  • Commonly used for insomnia in depressed patients
  • Little to no anticholinergic activity
  • Can be used as adjunct to other antidepressants
• Note: While the AASM suggests against trazodone for insomnia alone (at 50 mg), it is commonly prescribed and effective when insomnia occurs with depression 1, 2

Decision Algorithm

1. Assess predominant symptom pattern:

   • If sleep maintenance is the primary insomnia complaint → Consider doxepin or mirtazapine
   • If sleep onset is the primary complaint → Consider trazodone or mirtazapine
   • If weight loss is concerning → Mirtazapine may be beneficial
   • If weight gain is concerning → Trazodone may be preferable

2. Consider specific depression characteristics:

   • For depression with anxiety → Mirtazapine often beneficial
   • For depression with decreased appetite → Mirtazapine preferred
   • For depression with significant daytime fatigue → Lower doses of these medications are advised

Important Clinical Considerations

• Combination therapy: If using an SSRI or SNRI for depression that worsens insomnia, adding low-dose trazodone at bedtime is a common and effective strategy 1, 2

• Avoid benzodiazepines and Z-drugs for long-term management of comorbid depression and insomnia, as they don't address the underlying depression and carry risks of tolerance and dependence 1

• Cognitive Behavioral Therapy for Insomnia (CBT-I) should be considered alongside medication, as it enhances outcomes for both conditions 3

• Monitor closely for suicidality, especially in younger patients, during the first few weeks of antidepressant treatment 4

Special Populations

• Elderly patients: Start with lower doses (e.g., mirtazapine 7.5 mg, trazodone 25-50 mg)
• Patients with recurrent depression: May have more pronounced sleep disturbances requiring more aggressive treatment 2
• Patients with childhood-onset depression and insomnia: May be more difficult to treat and require more intensive interventions 5

Common Pitfalls to Avoid

1. Using non-sedating antidepressants alone in patients with significant insomnia (e.g., SSRIs like sertraline, fluoxetine) as they may worsen sleep problems initially 1, 2

2. Overlooking the bidirectional relationship between insomnia and depression - treating insomnia often improves depression outcomes 3

3. Using over-the-counter sleep aids (antihistamines, melatonin) which lack efficacy data for comorbid depression and insomnia 1

4. Failing to reassess both depression and insomnia symptoms regularly to adjust treatment as needed

By targeting both conditions simultaneously with a sedating antidepressant, you can improve patient adherence, quality of life, and overall treatment outcomes.