_Antidepressants are medications designed to improve mood and help to reverse depression, a disorder of mood and affect. Since depression doesn’t originate from just one specific area of the brain, it’s sometimes difficult to understand how this class of medication achieves the desired mood-boosting effect. _
Mood disorders result from an imbalance in the substances (neurotransmitters) that help the neurons in the brain to communicate. Antidepressants act by either enhancing or inhibiting the presence and levels of these neurotransmitters. The three neurotransmitters associated with mood disorders are: serotonin,** norepinephrine** and dopamine. There are a variety of antidepressant medications that work specifically with each one of these neurotransmitters.
Some of the most popular antidepressant medications involve serotonin. These drugs are called Selective Serotonin Reuptake Inhibitors (SSRI’s). They work by stopping the reuptake of serotonin. This allows the level of serotonin to remain and linger in the brain longer, and enhances the action of this neurotransmitter. This group of SSRIs includes Fluoxetine (Prozac) Sertraline (Zoloft), and Paroxetine (Paxil).
While these medications are specifically given to improve one’s mood, the question is whether they have other unintended consequences. One of the most widely asked questions is whether SSRIs have an effect (positive or negative) on sleep.
Are sleep patterns different in people diagnosed with depression?
Depressed individuals do tend to complain about both excessive sleepiness and insomnia, mostly the latter. When sleep study results on individuals with depression are analyzed, REM sleep seems to be most affected. REM (rapid eye movements) is the stage when we dream and this repetitive phase mostly concentrates in the latter part of the night and sleep cycle.
In patients diagnosed with depression, there appears to be a reduced time period to enter REM (REM latency), and the periods of REM are also more concentrated (increased REM density). Antidepressants correct these issues by reducing the periods of REM and increasing the time it takes to get to REM. Although these “corrections” help to improve depressive symptoms, they have been shown to cause disturbed and fragmented sleep.
What I just described are the objective findings that depression and antidepressants have on sleep, but: how do people who take these medications actually perceive their sleep quality?
A study published in the Journal of Clinical Sleep Medicine looked at data from 9,267 participants in the Rotterdam study and specifically compared those subjects who were taking SSRIs with those who did not take these medications. The subjective measure of how they slept was identified as the Pittsburgh Seep Quality Index (PSQI). It’s a written test that measures sleep quality as it is affected by psychological conditions. Surprisingly the use of SSRIs was associated with perceived better quality of sleep. This, despite what was mentioned earlier regarding objective findings of fragmented and disturbed sleep.
These (subjective) results in this new study showed that these depressed patients who were taking SSRIs felt the quality of sleep improved with the use of antidepressant medication, despite the objective findings that showed that sleep was more disrupted and there was more measurable daytime dysfunction (due to poorer quality sleep).
What could explain the subjective positive sleep evaluation offered by people taking antidepressants?
It’s not really clear, but it may be that the “feeling of better sleep quality” is associated with overall better mood feelings linked to the use of these SSRIs. Many people report improvement in sleep as part of the overall discussion regarding the feelings of general improvement in mood. It seems to be a case of a person sharing that, “I feel so much better, so yes, my sleep quality seems to have also improved.”
What about patients on SSRIs who do complain about insomnia?
For those depressed patients who do complain that they are struggling with insomnia or a sleep disorder, a separate treatment is likely necessary. In addition to a prescribed antidepressant medication, these patients may require a medication with a sedating effect to help them fall asleep. The most commonly prescribed medication is Trazodone (Oleptro), because it has also been used as an antidepressant. For those with insomnia, a medication like Trazodone would be prescribed in combination with the person’s existing antidepressant (lowered dose).
How can a person diagnosed with depression know whether their sleep problem is just temporary and caused by daily stressors, or whether they have a sleep disorder that requires medical attention?
The general rule is that if there is a sleep problem that results in regular and identifiable daytime drowsiness or a** mood disturbance** that interferes with the ability to function and conduct daily activities, the sleep problem deserves medical evaluation.
If you suffer with depression, then it is important to seek help from a health care professional who specializes in the treatment of depression. It is also important to recognize that depression and the use of antidepressants can cause sleep disturbances that need to be tracked. Some patients may also require sleep medication, and there also may be individuals who require further sleep evaluation and treatment.
Eli Hendel, M.D. is a board-certified Internist and pulmonary specialist with board certification in Sleep Medicine. He is an Assistant Clinical Professor of Medicine at Keck-University of Southern California School of Medicine, and Qualified Medical Examiner for the State of California Department of Industrial Relations. His areas of expertise in private practice include asthma, COPD, sleep disorders, obstructive sleep apnea, and occupational lung diseases.