Is imipramine (tricyclic antidepressant) a recommended treatment for insomnia?

Imipramine Is Not Recommended for Insomnia Treatment

Imipramine (a tricyclic antidepressant) is not recommended as a treatment for insomnia due to limited evidence supporting its efficacy and potential safety concerns. 1

First-Line Treatment Recommendations

The treatment approach for insomnia should follow this evidence-based algorithm:

1. Cognitive Behavioral Therapy for Insomnia (CBT-I)

   • Strong recommendation based on moderate-quality evidence 1
   • Should be considered the first-line treatment for all adults with chronic insomnia
   • Can be delivered through various methods (individual/group therapy, telephone/web-based modules, self-help books)

2. Pharmacological Options (only if CBT-I is unsuccessful)

   • Use shared decision-making approach to discuss benefits, harms, and costs 1
   • First-line pharmacotherapy options:
     • Short/intermediate-acting benzodiazepine receptor agonists (BZDs or BzRAs) 1
     • Ramelteon 1
     • Suvorexant (orexin antagonist) - moderate-quality evidence shows improved treatment response 1
     • Doxepin (in low doses) - moderate-quality evidence for improved sleep outcomes 1

Role of Antidepressants in Insomnia

Sedating antidepressants (including tricyclics like imipramine) are considered second or third-line agents and should only be used when:

• Comorbid conditions are present (particularly mood disorders) 1
• First-line pharmacological options have failed

The American Academy of Sleep Medicine guidelines specifically note "little evidence supporting efficacy of sedating antidepressants" for insomnia treatment 1. While some antidepressants are prescribed off-label for insomnia, their use is not supported by robust clinical evidence.

Important Considerations and Cautions

• The FDA has only approved pharmacological therapies for short-term use (4-5 weeks) 1

• Hypnotic drugs may be associated with serious adverse effects including:

  • Dementia
  • Serious injury
  • Fractures
  • Daytime impairment
  • Behavioral abnormalities
  • Worsening depression 1

• Tricyclic antidepressants specifically carry risks of:

  • Anticholinergic effects
  • Cardiac conduction abnormalities
  • Orthostatic hypotension
  • Morning grogginess

Evidence for Specific Antidepressants

While imipramine specifically lacks robust evidence for insomnia treatment, limited research exists for other tricyclics:

• Trimipramine showed some efficacy in a small double-blind study (n=55) 2
• Doxepin (in low doses) has better evidence and is FDA-approved for insomnia 1

Clinical Decision-Making

When considering treatment for insomnia:

1. Always start with CBT-I
2. If pharmacotherapy is needed, use FDA-approved hypnotics first
3. Consider antidepressants only when comorbid mood disorders are present
4. If using an antidepressant for insomnia, choose one with better evidence (e.g., doxepin at low doses) rather than imipramine
5. Use the lowest effective dose for the shortest duration possible

The popularity of antidepressants for insomnia treatment is based more on physician beliefs than on convincing clinical data 3. Current guidelines clearly prioritize CBT-I and specific FDA-approved sleep medications over tricyclic antidepressants like imipramine.