Ashwin Lewis
Sleep and depression are closely linked. Insomnia is one of the signs of depression, and an inability to sleep can be a side effect of antidepressants. However, some antidepressants can also help with sleep. For example, Doxepin (Silenor) is the only FDA-approved antidepressant for the treatment of insomnia. Other antidepressants may be used off-label as sleep aids, such as trazodone, which has sedating effects. It's important to be aware that some antidepressants may worsen or induce sleep disorders like restless legs syndrome (RLS), sleep bruxism, and sleep apnea, which may be due to antidepressant-induced weight gain. Sleep medications can help people fall asleep and stay asleep longer, and the most effective drugs do both.
| Characteristics | Values |
|---|---|
| Antidepressants that may help with sleep | Doxepin (Silenor) (FDA-approved for treatment of insomnia), trazodone, bupropion, clonidine, melatonin, ramelteon (Rozerem), daridorexant (Quviviq), suvorexant (Belsomra), SSRIs, SNRIs, TCAs, SARIs |
| Antidepressants that may worsen sleep | SSRIs, mirtazapine, quetiapine (Seroquel) |
| Sleep disorders that antidepressants may induce or worsen | Restless legs syndrome, sleep bruxism, REM sleep behaviour disorder, nightmares, sleep apnea |
| Other tips to improve sleep | Learn and practice relaxation and deep breathing techniques, write a list of activities that need to be completed the next day, avoid long and late daytime naps, get regular exercise (but not too late in the day), avoid looking at screens before bedtime |
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What You'll Learn
Antidepressants that can help with sleep
Sleep and depression are closely linked. Insomnia is one of the signs of depression, and persistent insomnia symptoms can result in an unfavourable clinical outcome, such as an increased suicide risk. Antidepressants can have a range of effects on sleep, from alleviating sleep disturbances to disrupting sleep.
Doxepin (Silenor) is the only FDA-approved antidepressant for the treatment of insomnia. It produces sedating effects at low doses and helps people fall and stay asleep. It is generally taken no more than 30 minutes before bedtime, and food should be consumed at least 3 hours beforehand to avoid slowing the drug's absorption. Doxepin may be effective in improving sleep for up to 3 months.
Trazodone is a serotonin antagonist and reuptake inhibitor (SARI) that is very often used as a sleep-promoting drug. It has sedative effects and improves sleep continuity and quality. However, its effects tend to wear off over time, and it may cause side effects such as daytime fatigue, reduced recovery rates in depression, and dry mouth.
Bupropion is another antidepressant that has been found to be surprisingly favourable for sleep. While it is activating during the daytime, it does not cause more insomnia than SSRIs and has neutral or positive effects on sleep architecture.
Other antidepressants with sedating side effects may improve sleep for people with depression, although there is limited evidence regarding their effectiveness. These include selective serotonin reuptake inhibitors (SSRIs), tricyclic antidepressants (TCAs), and serotonin and norepinephrine reuptake inhibitors (SNRIs). However, it is important to note that SSRIs can sometimes cause or worsen insomnia, and TCAs should be used in very low doses for patients with primary insomnia. SNRIs are typically prescribed when SSRIs have not been effective or when depression is accompanied by other issues such as pain disorders or certain forms of anxiety.
In addition to antidepressants, other sleep medications can be used to aid sleep. These include melatonin receptor agonists, which promote sleep by increasing feelings of drowsiness and reducing the time it takes to fall asleep. The prescription drug ramelteon (Rozerem) works similarly to melatonin and is used to treat insomnia. Orexin receptor antagonist drugs, such as daridorexant (Quviviq) and suvorexant (Belsomra), block the neurotransmitter orexin, which signals the body to wake up.
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Antidepressants that can cause insomnia
Antidepressants can have a range of effects on sleep. While some may alleviate sleep disturbances, others may disrupt sleep. It is important to note that the effectiveness of an antidepressant in improving sleep can vary depending on the patient's specific sleep disorder.
Selective Serotonin Reuptake Inhibitors (SSRIs) are a class of antidepressants that can sometimes cause insomnia and worsen sleep quality. Common side effects of SSRIs include nausea, vomiting, diarrhoea, headaches, dry mouth, sexual problems, fatigue, insomnia, and dizziness. While SSRIs are often well-tolerated, they can cause serious side effects in rare cases, such as suicidal thoughts, changes in heart rhythm, and serotonin syndrome. Celexa (citalopram) and Lexapro (escitalopram) are SSRIs that are usually well-tolerated but carry a higher risk of heart rhythm problems. Prozac (fluoxetine) and Zoloft (sertraline) may have fewer sexual side effects but are more likely to cause stomach issues.
Serotonergic antidepressants, including mirtazapine, are often used to treat insomnia. However, studies suggest that they may increase the risk of Restless Legs Syndrome (RLS), a condition that can disrupt sleep. Bupropion, on the other hand, has been found to be effective in treating RLS.
Trazodone, a sedative antidepressant, is commonly used as a sleep-promoting drug. However, its sedative effects tend to wear off over time, and it may cause side effects such as daytime fatigue, reduced recovery rates in depression, and dry mouth, which can further interfere with sleep.
Quetiapine (Seroquel) is an atypical antipsychotic with sedative effects. While it improves the deep, restorative phase of sleep, it carries too many risks to be recommended for primary insomnia. It is, however, appropriate for antidepressant augmentation.
In summary, while some antidepressants can be beneficial for treating insomnia, it is crucial to consider the potential side effects and interactions with other drugs. The choice of antidepressant should be guided by the patient's specific sleep disorder and overall health condition to ensure optimal treatment outcomes.
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Antidepressants that can cause other sleep disorders
Antidepressants are often prescribed for insomnia, even though they are not licensed for this use and there is uncertain evidence for their effectiveness. However, certain antidepressants can cause sleep disturbances. For example, selective serotonin reuptake inhibitors (SSRIs) can sometimes cause insomnia, and may need to be taken in the morning to mitigate this side effect. Other antidepressants with so-called activating effects, such as fluoxetine and venlafaxine, may also disrupt sleep.
It is important to note that the relationship between depression, insomnia, and treatment is complex. While antidepressants can have a positive impact on sleep physiology, they do not seem to improve subjective ratings of sleep quality. Additionally, studies have consistently demonstrated differences between objective and subjective sleep measures in patients taking antidepressants.
Furthermore, while some antidepressants with sedative properties, such as doxepin, mirtazapine, and trazodone, can rapidly improve sleep, they may cause problems in the long term due to oversedation. The prevalence of treatment-emergent somnolence (excessive sleepiness) was found to be very high in patients treated with mirtazapine (54%) and trazodone (46%) compared to patients receiving a placebo (18-19%).
Vortioxetine is another antidepressant that has been shown to negatively impact sleep continuity by suppressing REM sleep and increasing REM sleep latency, particularly at higher doses. However, it is important to note that the rate of treatment-emergent insomnia complaints associated with vortioxetine is lower when compared to SSRI and SNRI drugs.
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Antidepressants that can worsen existing sleep disorders
Antidepressants are often used to treat sleep disorders, but they can also have the opposite effect, worsening existing sleep problems or even inducing new ones. While there is no single antidepressant that is best for sleep, each has properties that can help or harm, depending on the patient's specific sleep disorder.
Serotonergic antidepressants, for example, can cause restless legs syndrome (RLS), which is a common issue for those with ADHD and PTSD—two conditions that frequently coincide with depression. Mianserin and mirtazapine may induce RLS in as many as 28% of patients, and SSRIs, SNRIs, and TCAs are known to exacerbate sleep bruxism and disturb muscle tone during REM sleep, potentially leading to REM Sleep Behaviour Disorder.
SSRIs, while sometimes used to treat insomnia in depressed and non-depressed patients, can also cause insomnia in some people. This may be due to their activation of serotonergic 5-HT2 receptors and increased noradrenergic and dopaminergic neurotransmission. The sedative effects of trazodone, another antidepressant, tend to wear off over time, and it carries risks such as daytime fatigue, reduced recovery rates in depression, and dry mouth, which can further interfere with sleep.
Additionally, antidepressants can induce nightmares, which may be particularly concerning for those with PTSD. Antidepressant-induced weight gain can also contribute to worsening or inducing sleep disorders, as it is a risk factor for sleep apnea.
It is crucial for physicians to be aware of these potential adverse effects of antidepressants on sleep. Understanding the complex interplay between antidepressants and sleep is essential for optimizing treatment plans and improving patient outcomes.
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Antidepressants that can help with sleep but have side effects
Antidepressants are often associated with sleep disturbances, which can cause issues with treatment compliance. Some antidepressants can alleviate sleep disturbances, while others may disrupt sleep. It is important to understand the effects of antidepressants on sleep to successfully treat depression.
Trazodone is a sedative antidepressant that is often used to promote sleep. However, its sedative effects tend to wear off over time, and it may cause side effects such as daytime fatigue, reduced recovery rates in depression, and dry mouth, which can interfere with sleep.
Mirtazapine is another antidepressant that has been associated with a risk of weight gain, making it less desirable for patients with sleep apnea. While it was once thought to improve sleep apnea through its effects on smooth muscle, this theory was not supported by clinical practice.
Bupropion, an antidepressant that is activating during the daytime, has been found to have neutral or positive effects on sleep architecture. It does not cause more insomnia than SSRIs and may be a good option for patients with RLS.
Quetiapine, an atypical antipsychotic with sedative effects, is another option for antidepressant augmentation. While it carries risks, it improves the deep, restorative phase of sleep.
It is important to note that the effects of antidepressants on sleep depend on various factors, including the type of drug, dose, time of administration, and duration of treatment. Additionally, the presence of comorbid mood disorders may require the use of recommended therapeutic doses of antidepressants.
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Frequently asked questions
There are many ways to improve your sleep without medication. You can learn and practice relaxation and deep breathing techniques, write a list of activities that need to be completed the next day, avoid long and late daytime naps, get regular exercise (but not too close to bedtime), and avoid looking at television or computer screens before bed.
The over-the-counter hormone melatonin is sometimes used to treat insomnia or sleep disrupted by depression. Melatonin receptor agonists act on the same receptors as melatonin and promote sleep by increasing feelings of drowsiness and reducing the amount of time it takes to fall asleep.
There are several prescription medications that can be used to treat insomnia. Doxepin (Silenor) is the only FDA-approved antidepressant for the treatment of insomnia. Other antidepressants such as trazodone, bupropion, and quetiapine (Seroquel) are used off-label (not officially approved by the FDA) as sleep aids. Additionally, clonidine is recommended for insomnia in patients with obstructive sleep apnea.
Antidepressants can have varying effects on sleep. Some antidepressants can alleviate sleep disturbances, while others may disrupt sleep. SSRIs (selective serotonin reuptake inhibitors), such as sertraline and fluoxetine, have been shown to disturb or fragment sleep. However, other antidepressants like trazodone, TCAs (tricyclic antidepressants), and SARIs (serotonin antagonist and reuptake inhibitors) have sedative effects and can improve sleep continuity and quality. It's important to consult a doctor before starting any medication to understand the potential benefits and risks.
Insomnia or difficulty sleeping is one of the signs of depression. If you are experiencing persistent sleep problems, it is important to consult a healthcare professional who can properly assess your condition and recommend the most appropriate treatment option. They will consider your individual needs and determine whether you require an antidepressant, a sleep aid, or a combination of both.
