From Medscape Neurology & Neurosurgery

Ask the Experts about Insomnia and Sleep Health

A 30-Year-Old Woman with Insomnia and Depression

Posted 01/02/2009

W. Vaughn McCall, MD, MS
Author Information

Question
A 30-year-old woman with insomnia and depression presents for initial treatment. She prefers medication for her depression rather than psychotherapy. The provider prefers to use selective serotonin reuptake inhibitors (SSRIs) as first-line treatment for depression. Does the patient need to be given a hypnotic along with her SSRI at the time of SSRI initiation? What are the pros and cons?

Response from W. Vaughn McCall, MD, MS W. Vaughn McCall, MD, MS, Professor, Chair, Department of Psychiatry and Behavioral Medicine, Wake Forest University School of Medicine, Winston-Salem, North Carolina

Typically, selective serotonin reuptake inhibitors (SSRIs) have been shown to disturb electroencephalogram sleep by reducing sleep efficiency, increasing stage 1 sleep, and/or increasing the number of arousals from sleep.^[1] However, many patients with depression and insomnia will state that their sleep improves over a number of weeks with SSRI therapy. The perceived improvement in sleep with SSRIs alone may be the result of (1) natural fluctuations and remission of insomnia symptoms over time or (2) a more positive appraisal of sleep as depression improves, in that patients tend to be less negative about many aspects of their lives, including sleep, as their depression improves.^[1]

On this basis it could be argued that not every patient with depression and insomnia requires a hypnotic medication at the outset of SSRI therapy. Instead, the choice of using a hypnotic can be gauged against the patient's ability to tolerate distress. As with physical pain, individuals differ in their ability to tolerate psychic distress such as depressed or anxious mood or the frustration of insomnia. If the patient seems to have a "deep psychic reserve" upon which to draw, then perhaps that patient could be treated with an SSRI alone using a wait-and-see approach, and if the insomnia symptoms are not better in a few weeks, then the idea of using a hypnotic medication can be revisited. On the other hand, if the patient seems to be "at their wit's end" at the initial assessment, then it may be best to proceed with hypnotic therapy right away as a means of relieving distress and perhaps mitigating against suicide risk. Insomnia has been identified as a risk factor for suicide,^[2] yet hypnotic medications themselves when used in overdose in conjunction with alcohol can result in death. The decision to proceed with hypnotic therapy in a patient with depression and insomnia should be coupled with a limited number of hypnotic pills and a quick return visit, ideally in days to perhaps a week