A novel approach to the psychopharmacologic treatment of insomnia in depression

Depressed patients who respond to anti-depressant drugs but have persisting insomnia can be hypothesized as having one foot on the bipolar spectrum. In this hypothesis, the insomnia would respond to augmentation of the anti-depressants with anti-kindling agents (i.e., anti-convulsant drugs for the purposes of this paper) in the same way that many anti-convulsants are effective in bipolar disorders as mood-stabilizers from above (anti-manic agents) or below (anti-depressants).

Cases supporting this augmentation strategy are presented. The patients met DSM-IV criteria for recurrent major depression, depression with psychotic features, and depression NOS. There was no discernible history of mania or hypomania and all had insomnia that did not respond or partially responded to anti-depressant drugs singly or in combinations. All responded to the addition of anti-convulsant drugs.

This augmentation strategy seems to be an effective treatment for chronic insomnia in depression, but controlled studies are needed to quantify and qualify these effects. This strategy's effectiveness may be due to the anti-kindling or inhibitory effects of anti-convulsant drugs, which are often GABAergic. Since it is becoming clear that bipolar spectrum disorders are misdiagnosed as unipolar depression at an alarming rate, and since anti-depressants often have deleterious effects on the course of bipolar illness, perhaps most depressed patients should be protected with an anti-convulsant whenever they are started on an anti-depressant.