Treatment-resistant insomnia exacerbates major depression

By Stephanie Leveene

Reports from a case series study indicate that patients with major depression have high rates of treatment-resistant, residual insomnia, and that insomnia during the early remission phase could lead to recurrence of depressive episodes.

The study researchers say that it is therefore important for clinicians to carefully consider treatment adherence in patients with depression who also present with insomnia in the early stages.

Kazuo Mishima (National Center of Neurology & Psychiatry, Tokyo, Japan) and colleagues regularly assessed 128 patients with first-onset major depression using the Hamilton Rating Scale for Depression (HAM-D). Residual insomnia was defined as a positive response to the insomnia questions on HAM-D while the patient was in the remission phase of their depression. The investigators also analyzed the types of antidepressants and hypnotics the patients were taking and whether any dose adjustments occurred.

Fifty-four percent of patients had three to five residual depressive symptoms while they were in the first remission phase, and of these insomnia was the most common, affecting 65% of patients.

Residual insomnia was experienced by an average of 91% of patients during depressive phases and was present for about 81% of the time, while an average 71% of patients experienced it during remission for about 37% of the time.

The researchers note that for each additional recurrence of depression, patients spent a significantly higher percentage of time suffering with insomnia, at an average of 45% in the third remission phase and beyond versus 28% in the first remission phase.

Each recurrence of depression also led to shorter remission phases and higher doses of hypnotics prescribed for insomnia and antidepressants in both the depressive and remission phases.

The findings, published in Sleep and Biological Rhythms, confirm the high rate of insomnia during both phases of major depression and the link between length of major depression and increased rates of insomnia and medication use.

Mishima and colleagues therefore suggest that the presence of treatment-resistant residual insomnia in a first episode of depression that persists during the remission phase could be considered a clinical marker for future risk for recurrence.

"Special attention to treatment adherence is important when seeing patients with treatment-resistant insomnia of early stage," they comment. "If insomnia could be mitigated in the early stage of the remission phase by adequate treatments, we might be able to prevent recurrence."

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