![]() 11 These patients tend to be young and thin, so how can they have sleep apnea? The exact cause is unknown but may be related to the effects of PTSD on autonomic hyperarousal and pharyngeal smooth muscle.Īlthough insomnia is common in patients with obstructive sleep apnea, hypnoticsâparticularly benzodiazepinesâcan suppress breathing and worsen hypoxia in these cases. ![]() Newer studies have identified alarming rates of obstructive sleep apnea (40% to 75%) in PTSD. Sleep apnea is more common in overweight, middle-aged men with thick necks, but another type of patient is breaking this stereotype. 10 The risk of weight gain associated with mirtazapine also makes it less desirable in this population. That antidepressant was once thought to improve sleep apnea, through smooth muscle effects, but the theory did not hold up in practice. ![]() 8,9 The same cannot be said for mirtazapine. These theoretical advantages translated into clinical benefits in a handful of studies. SSRIs may also improve sleep apnea through direct effects on smooth muscle in the upper airway. Most apneas occur during REM sleep, and SSRIs suppress this phase of sleep. Obstructive sleep apnea is the only sleep disorder in which SSRIs may have an advantage. 7Īntidepressants in obstructive sleep apnea The dose for depression (1 to 2 mg qhs) is higher than the typical RLS dose (0.125 to 1 mg qhs). ![]() In small, positive controlled trials in both bipolar and unipolar depression, this dopaminergic agonist worked as monotherapy and as augmentation. 6įinally, there is an FDA-approved treatment for RLS that can treat depression as well: pramipexole. Although it is often used for insomnia, in some studies the risk of RLS is greater with mirtazapine than with other antidepressants. 5 Another medication to watch for in patients with RLS is mirtazapine. Although serotonergic antidepressants can cause RLS, bupropion appears to treat it, according to a randomized controlled trial. RLS is common in two conditions that often co-occur with depression: ADHD and PTSD. Dr Rao pointed out another limitation of diphenhydramine: its sedative effects tend to wear off after 3 weeks.Īntidepressants in restless legs syndrome Hydroxyzine (Vistaril) has similar effects and probably carries similar risks. 3,4 Its anticholinergic and histaminergic mechanism is the likely culprit here. The problem is that diphenhydramine worsens cognition in the short term and raises the risk of dementia with chronic use. One hypnotic that Dr Rao warned against is diphenhydramine, the sedative ingredient in many over-the-counter sleep aids from Benadryl to Tylenol PM. These sedating tricyclics can help with sleep initiation, but they do not improve sleep architecture. Two exceptions are amitriptyline and doxepin. Most of the tricyclics have similar problems as the SSRIs. Although it is activating in the daytime, bupropion causes no more insomnia than the SSRIs and has neutral or positive effects on sleep architecture. The SSRIs can cause insomnia and worsen sleep quality, but bupropion is surprisingly more favorable for sleep. It also improves the deep, restorative phase of sleep. Quetiapine carries too many risks to recommend it for primary insomnia, but it is appropriate for antidepressant augmentation (150 to 300 mg qhs). Some atypical antipsychotics have sedative effects, particularly quetiapine (Seroquel). Its sedative effects tend to wear off over time, and it comes with risks including daytime fatigue, reduced recovery rates in depression (a paradoxical phenomenon seen in adolescents), 1 and dry mouthâwhich itself may interfere with sleep. However, mirtazapine’s sedative effects are greater in the lower dose range (15 mg and below), which may not treat depression. Mirtazapine and trazodone are two antidepressants that help patients fall asleep and improve their sleep architecture. ![]() At the American Psychiatric Association’s Annual Meeting, Nikhil Rao, MD, identified antidepressants that work well with specific sleep disorders, including insomnia, restless legs syndrome (RLS), and obstructive sleep apnea.Ī sedating antidepressant makes sense for patients with insomnia and depression, but just as important is how that antidepressant affects sleep quality. It’s a common problem, but one that can be avoided by selecting the right antidepressant. Even as they improve mood they can worsen sleep, and poor sleep is both a symptom and a cause of depression. ![]()
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