Sleep problems in depression: how do they impact treatment and recovery?

Chronic insomnia is common, although its prevalence in the general population is quite variable, depending on definitions used and the populations surveyed. Studies indicate that as many as 85% of people with serious insomnia remain untreated. Insomnia is frequently comorbid with depression, and observational studies suggest that insomnia is a high risk factor for depression. Disturbed sleep is of particular concern in patients with depression, as it can aggravate the symptoms of depression and influence the treatment response to antidepressants. Many antidepressants, including some selective serotonin reuptake inhibitors (SSRIs), can disrupt sleep architecture, particularly in the acute phase of treatment. Although this undesirable effect may not be immediately apparent in patients with depression, because of their high level of sleep disruption at baseline, it may nevertheless contribute to reduced compliance with therapy. In some patients, persistent insomnia may be a valuable clue to treatment resistance. Thus, it is essential to monitor sleep patterns in patients being treated for depression and to adequately address any sleep problems as they arise during the whole depressive episode. Optimal therapy for depression-related insomnia has not yet been established. Co-administration of a hypnotic drug such as zolpidem may help some patients avoid the sleep-disrupting adverse effect of some antidepressants. Selection of an antidepressant with sedating effects is another alternative that may be beneficial for some patients, although daytime somnolence may limit use in some cases. New SSRIs, such as escitalopram, which may be less disruptive to sleep and possibly preserve sleep continuity without sedation, may be the preferred option for some patients.