Maintenance treatment of insomnia: What can we learn from the depression literature?

Department of Psychiatry, University of Pittsburgh, Pittsburgh, Pennsylvania, United States
American Journal of Psychiatry (Impact Factor: 13.56). 02/2004; 161(1):19-24. DOI: 10.1176/appi.ajp.161.1.19
Source: PubMed

ABSTRACT Insomnia and depression are common problems with profound public health consequences. When left untreated, both conditions have high rates of persistence and recurrence. Maintenance treatment for depression is fairly well established, but there is no evidence-based consensus regarding the safety and efficacy of maintenance therapy for insomnia. Consequently, long-term treatment of insomnia is driven primarily by the individual choices of patients and their clinicians. This article compares and contrasts the current state of research in the maintenance therapy of depression and insomnia and highlights gaps in the insomnia literature.

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    ABSTRACT: Summary Insomnia and psychiatric disorders are often associated. In particular insomnia is almost always present in patients with Depression. For this rea- son insomnia has been considered a symptom for the diagnosis of Depres- sion by 19 th Century's European Psy- chopathology as well as by the mod- ern system for psychiatric taxonomy based on the classification of the American Psychiatric Association. As a matter of fact, insomnia seems to be something more than a simple symp- tom or a condition comorbid with a mood disorder. As insomnia is an in important prodromic syndrome of the depressive episode and as its pres- ence after partial remission is a nega- tive prognostic factor for relapse, it has been suggested that it could be a trig- gering, vulnerability-conferring factor for development or relapse of mood disorders. As a confirmation of such a line of interpretation there are numer- ous studies on the so-called primary insomnia. Patients affected by this condition have a higher risk to develop Major Depression in their life. The risk ranges from 2 to 6 times according to the duration and severity of the insom- nia. Also, for these reasons, a new line of research suggests that a great major- ity of primary insomnias could be bet- ter categorized as mood or anxiety spectrum disorders. Insomnias, in this way, become a part of mood disorders even if they are paucisymptomatic or subthreshold if compared to full-blown mood disorders. In this case, the risk for developing major depression has to be intended as the risk of a progression from a paucisymptomatic disorder to a fully expressed one. Insomnia has to be considered and possibly treated by clinicians because of its effects on patients' quality of life and treatment compliance. This problem has become more prominent as new antidepres- sant drugs such as SSRIs and SNRIs possess low or no sedative properties. Short-term treatment with sleep-active drugs, such as the benzodiazepines or new hypnotic drugs, such as Zaleplon, Zopiclone, Zolpidem, and the newly developed Eszopiclone could be fea- sible to treat insomnia for the first 3- 4 weeks of antidepressant treatment. New data on Eszopiclone suggest that symptomatic treatment of insomnia in depression could also improve the effi- cacy of the concomitant antidepressant treatment. Even if data are not still suf- ficient to draw conclusions, new lines of evidence suggest that treatment of residual insomnia could be helpful to prevent relapse. Similarly, it has been suggested that symptomatic treatment of primary insomnia could be helpful in preventing future development of depression. In any case, symptomatic treatment improves patients' quality of life without appreciable risks for dependence or highly disrupting with- drawal symptoms if the treatment and follow-up are accurately monitored by the physician.
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