Can nortriptyline (tricyclic antidepressant) be used to treat sleep disorders, specifically insomnia?

Nortriptyline for Sleep Disorders

Nortriptyline is not recommended for the treatment of insomnia as there are more effective and safer alternatives available with better evidence. 1

First-Line Treatment for Insomnia

• Cognitive Behavioral Therapy for Insomnia (CBT-I) should be used as the first-line treatment for chronic insomnia disorder before considering any pharmacological options 1
• CBT-I components include cognitive therapy, stimulus control therapy, sleep restriction therapy, and relaxation techniques 1
• Sleep hygiene education alone is not effective and should be used in combination with other therapies 1

Recommended Pharmacological Options (if needed)

For both sleep onset and maintenance insomnia:

• Eszopiclone (2-3 mg) is suggested as an effective option 1
• Zolpidem (10 mg) is suggested as an effective option 1
• Temazepam (15-30 mg) is suggested as an effective option 1

For sleep onset insomnia only:

• Zaleplon (10 mg) is suggested as an effective option 1
• Ramelteon (8 mg) is suggested as an effective option 1
• Triazolam (0.25 mg) is suggested as an effective option 1

For sleep maintenance insomnia only:

• Suvorexant is suggested as an effective option 1
• Low-dose doxepin (3-6 mg) is suggested as an effective option 1

Tricyclic Antidepressants and Insomnia

• Sedating antidepressants like nortriptyline are considered third-line agents for insomnia after short-intermediate acting benzodiazepine receptor agonists and should only be considered when treating comorbid conditions that might benefit from these drugs 1
• Low-dose tricyclic antidepressants (including nortriptyline) are sometimes used off-label for insomnia, but evidence for their efficacy is relatively weak 1
• The American Academy of Sleep Medicine specifically recommends against using trazodone (another sedating antidepressant) for insomnia treatment, suggesting caution with this class of medications 1, 2
• Low-dose amitriptyline (10-20 mg), which is similar to nortriptyline, has shown some benefit for sleep maintenance in observational studies, but randomized controlled trials are still needed 3

Important Clinical Considerations

• All hypnotic medications should be used at the lowest effective dose and for the shortest possible duration 2, 4
• Administration on an empty stomach is advised to maximize effectiveness of sleep medications 1
• Caution is advised if signs/symptoms of depression, compromised respiratory function, or hepatic heart failure are present 1
• Regular follow-up is essential to assess medication effectiveness, side effects, and the ongoing need for pharmacotherapy 4
• Tricyclic antidepressants like nortriptyline have significant anticholinergic side effects, sedation, and potential for cardiac conduction abnormalities that may limit their usefulness as sleep aids 5, 6
• Over-the-counter sleep aids and herbal supplements are not recommended for chronic insomnia due to lack of efficacy and safety data 1, 2

Treatment Algorithm for Insomnia

1. Begin with CBT-I as first-line treatment 1
2. If CBT-I is ineffective, unavailable, or patient is unable to participate:
   • For sleep onset and maintenance issues: Try eszopiclone, zolpidem, or temazepam 1
   • For primarily sleep onset issues: Try zaleplon, ramelteon, or triazolam 1
   • For primarily sleep maintenance issues: Try suvorexant or low-dose doxepin 1
3. Consider sedating antidepressants (including nortriptyline) only if:
   • First and second-line agents have failed 1
   • Patient has comorbid depression or anxiety that would benefit from the primary action of these drugs 1
   • Lower doses than those used for depression are employed 4