Combining Insomnia, Depression Treatment May Improve Outcome By Lynne Lamberg

In people with both depression and insomnia, determining which disorder surfaced first may be key to improving clinical care.

Studying the timing of emergence of symptoms in people with both depression and insomnia may help identify differences in patients’ clinical presentation and aid treatment decisions, according to experts at the joint meeting of the American Academy of Sleep Medicine and the Sleep Research Society in Baltimore in June.

Insomnia is both a risk factor for depression and a symptom of depression, noted Rachel Manber, Ph.D., a professor of psychiatry and behavioral sciences at Stanford University School of Medicine.

Manber reported preliminary findings from the multisite Treatment of Insomnia and Depression (TRIAD) clinical trial, for which she is the principal investigator.

TRIAD, funded by the National Institute of Mental Health, seeks to determine whether combined treatment of major depressive disorder and insomnia improves depression outcome.

Started in 2008, TRIAD has enrolled about 150 participants, Manber told Psychiatric News. Recruitment recently concluded. Treatment will continue through the end of this year at Stanford, Duke University, and the University of Pittsburgh.

Participants receive 16 weeks of treatment with the antidepressants citalopram, sertraline, or desvenlafaxine. Choice of medication is based on the individual’s previous medication use, response, and tolerance. Participants also receive either cognitive-behavioral therapy for insomnia (CBTI) or desensitization psychotherapy for insomnia.

A pilot study, published by Manber and colleagues in the journal Sleep in April 2008, found that augmenting an antidepressant medication with brief, symptom-focused CBTI helped alleviate both depression and insomnia in individuals with both disorders.

About half the TRIAD participants reported at baseline that their insomnia started before their current depressive episode, Manber said. The remainder said their insomnia started at the same time as their depression or afterward. Members of both groups reported comparable severity of insomnia and depression.

In the first group, Manber said, insomnia may be independent of depression and require separate treatment.

If insomnia has emerged as a symptom of depression, she added, one might expect that treating the depression adequately will prompt the insomnia to resolve. While that often occurs, insomnia persists in some patients even after the depression remits. People who toss and turn often come to view the bed as a cue for poor sleep, she noted, and develop an insomnia disorder that needs additional sleep-focused treatment.

TRIAD participants who reported having insomnia before they experienced depression had higher scores on the Childhood Trauma Questionnaire, indicating childhood adversity such as sexual or other physical abuse. This surprising finding, Manber said, raises the possibility that events that disrupt sleep in childhood may foster both insomnia and depression later on.

In another report on TRIAD findings at the sleep meetings, Andrew Krystal, M.D., a professor of psychiatry and behavioral sciences at Duke University School of Medicine, analyzed participants’ responses to the Ford Insomnia in Response to Stress Test (FIRST).

The FIRST asks respondents about their likelihood of sleeping poorly after a bad day at work or an argument, before leaving on vacation, and in other situations. It assesses trait-like vulnerability to developing insomnia under stress.

“We were attempting to test a bias in the field that is not empirically based,” Krystal said, “that insomnia occurring in people with depression is driven by the depression and that there is a diminished etiologic role of factors that precipitate and/or perpetuate insomnia where depression or other conditions are not present.

“Our analysis appears to speak against that bias,” he said. It suggests that the same factors that seem to precipitate and/or perpetuate primary insomnia—which include dysfunctional beliefs and attitudes about sleep, worrying about sleep, stress, and anxiety—play a comparable role in insomnia that develops in people with depression.

The findings, he said, provide the first evidence that there is a trait vulnerability to developing insomnia under stress among at least some patients with major depression, similar to that in people with primary insomnia.