Pharmacological treatment for insomnia in patients with major depressive disorder

ABSTRACT

Introduction: Insomnia in Major Depressive Disorder (MDD) is highly prevalent and associated with increased suffering and functional impairment. Effective, evidence-based treatments for insomnia in MDD are an unmet need in clinical practice.

Areas covered: Herein, the authors provide a review of the clinical correlates, putative neurobiological mechanisms and treatment options for the management of insomnia in individuals with MDD.

Expert opinion: Sleep disturbances in MDD should be recognized as at least one of the following: (1) a domain of depressive psychopathology; (2) a consequence of rhythm disruptions; (3) a manifestation of comorbidities of sleep disturbances; (4) a manifestation of the influence of sex hormones in the brain in MDD; (5) a general medical comorbidity; and (6) a side effect of antidepressant medications. Assessment of insomnia in clinical practices is routinely performed with the use of non-structured interviews. Other methods such as standardized questionnaires and sleep diaries, along with complementary methods such as actigraphy and polysomnography are more scarcely applied. Smartphones and personal devices offer a promising strategy with the use of passive, long lasting, and ecologically valid assessments despite the lack of studies specifically targeting insomnia in individuals with MDD. New therapeutic approaches are essential, including novel targets such as orexins/hypocretins and the endocannabinoid system.

KEYWORDS:

• Major depressive disorder
• insomnia
• sleep
• mood disorders
• hypnotic

Article Highlights

• Evidence-based treatments for insomnia in individuals with MDD constitute an unmet need in clinical practices.

• Insomnia in MDD should be considered as a domain of depressive psychopathology, a medical comorbidity, or an adverse event caused by psychiatric medications.

• Innovative tools for the assessment of sleep and circadian rhythms include the use of smartphones and personal devices, which can offer reliable and ecologically valid data.

• Most strategies commonly used in clinical practices are derived from secondary analyses in randomized controlled trials.

• New molecular targets, such as orexins/hypocretins circuits and cannabinoids are a promising strategy to manage insomnia in MDD.

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Declaration of interest

E Brietzke has received speaker’s and advisory board membership honoraria from Daiichi Sankyo. She has also received research grant support from the São Paulo Research Foundation (FAPESP), the National Council for Scientific and Technological Development (CNPq) and the Coordination for the Improvement of Higher Education Personnel (CAPES). She is also the recipient of the L’Oréal For Women in Science Award. CN Soares has received research grants from the Ontario Brain Institute (OBI) and the Ontario Research Fund for Excellence (ORF-RE). He has also served as a consultant for Lundbeck, Sunovion, Bayer, Pfizer Inc and Otsuka. The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.

Reviewer Disclosures

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

Additional information

Funding

This manuscript was not funded.