From the Guidelines
Non-insomnia causing antidepressants, such as mirtazapine, trazodone, and certain tricyclic antidepressants like amitriptyline and doxepin, are recommended for patients with depression and sleep difficulties. Mirtazapine (starting at 7.5-15mg at bedtime) is particularly sedating at lower doses due to its strong antihistamine effects, making it useful for patients with depression and sleep difficulties 1. Trazodone (50-150mg at bedtime) is often prescribed specifically for sleep even at doses lower than those needed for antidepressant effects. Among the tricyclics, amitriptyline (10-150mg at bedtime) and doxepin (10-150mg at bedtime) have sedating properties that can help with sleep. SSRIs like paroxetine may be less activating than others in its class but should still be taken in the morning. These medications work through various mechanisms including blocking histamine, serotonin, and norepinephrine receptors, which contributes to their sedating effects. When starting these medications, patients should be aware that sedation is typically strongest during the first few weeks and may diminish somewhat over time. It's also important to note that individual responses vary, and what causes sedation in one person might cause activation in another, so medication selection should be personalized.
Some key points to consider when prescribing non-insomnia causing antidepressants include:
- Mirtazapine's sedating effects are due to its strong antihistamine properties, making it a good option for patients with depression and sleep difficulties 1.
- Trazodone is often prescribed specifically for sleep, even at lower doses than those needed for antidepressant effects 1.
- Amitriptyline and doxepin have sedating properties that can help with sleep, but may have more side effects than other options 1.
- Paroxetine may be less activating than other SSRIs, but should still be taken in the morning to minimize potential sleep disruptions 1.
Overall, the choice of non-insomnia causing antidepressant will depend on the individual patient's needs and medical history, and should be made in consultation with a healthcare professional.
From the Research
Non-Insomnia Antidepressants
- The study 2 found that the lower range of the licensed dose of second-generation antidepressants, such as selective serotonin reuptake inhibitors (SSRIs), venlafaxine, and mirtazapine, achieves the optimal balance between efficacy, tolerability, and acceptability in the acute treatment of major depression.
- Another study 3 discussed the management of insomnia associated with depression, suggesting that non-sedating antidepressants like SSRIs, bupropion, venlafaxine, or duloxetine can be used, and those with persistent or treatment-emergent insomnia can be switched to a more sedating antidepressant or offered a hypnotic or cognitive-behavioral therapy as adjunctive treatment.
- A systematic review 4 compared the effectiveness of second-generation antidepressants for accompanying anxiety, insomnia, and pain in depressed patients, finding that the strength of the evidence was moderate or low, and evidence guiding the selection of an SGA based on accompanying symptoms of depression is limited.
Treatment of Insomnia and Depression
- A study 5 found that treating insomnia in patients with depression has a positive effect on mood, with moderate to large effect size improvement in depression as measured with the Hamilton Depression Rating Scale and Beck Depression Inventory.
- Another study 6 reported the remission rates for the 14 most commonly prescribed single antidepressants and found large, statistically significant differences in remission rates within subgroups of patients, suggesting that some medications are ideal for patients in some subgroups but not others.
Antidepressant Options
- The study 6 found that some medications, such as sertraline, fluoxetine, venlafaxine, bupropion, desvenlafaxine, duloxetine, paroxetine, escitalopram, and citalopram, had remission rates ranging from 4.5% to 77.86%, while others, such as amitriptyline, doxepin, nortriptyline, and trazodone, had remission rates below 11% and were not suitable as single antidepressant therapy for any of the subgroups.