Breaking the Cycle of Insomnia and Depression: Agomelatine in Adolescent Bipolar Disorder

Adolescent bipolar disorder (BD) is frequently accompanied by persistent sleep disturbances and depressive episodes that are resistant to standard treatments. Conventional antidepressants carry a risk of inducing mania or rapid cycling, particularly in younger patients. Agomelatine, a melatonergic agonist and selective serotonergic antagonist, addresses both circadian dysregulation and depressive symptoms through a unique mechanism that does not increase synaptic serotonin, thereby potentially minimizing the risk of mood switch. Despite its efficacy in adults, its use in adolescent BD remains largely unexplored. We present three cases of adolescents (ages 16-17) with bipolar depression and chronic insomnia in whom agomelatine (25-50 mg nightly) was added adjunctively to existing mood stabilizer or atypical antipsychotic regimens. Clinical outcomes were assessed using the Hamilton Depression Rating Scale (HDRS), Pittsburgh Sleep Quality Index (PSQI), and Young Mania Rating Scale (YMRS) over a 24-week follow-up period. All three patients demonstrated clinically meaningful improvements in both sleep quality and depressive symptomatology within the first 4-6 weeks, without manic switching or hepatic adverse effects. One patient successfully discontinued sedative-hypnotic use following sleep normalization. These cases suggest that adjunctive agomelatine may offer a dual benefit of sleep regulation and mood stabilization in adolescent BD, representing a promising alternative in patients who have failed or cannot tolerate conventional antidepressants. Controlled clinical trials are warranted to confirm these preliminary findings.