Vol 10, N°4 Remission in depression
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leep disturbances are nearly universal in psy- chiatric disorders, especially mood disorders. Research investigating associations between sleep and affective ill- ness has largely focused on depression and major depres- sive disorder (MDD). This paper will review cross-sec- tional associations between sleep disturbance and MDD, longitudinal risk relationships between insomnia and the subsequent development of depression, the implications of insomnia for clinical course, treatment response, and relapse in MDD, and lastly the effectiveness of targeted sleep interventions in improving sleep and depression outcomes. Although not the primary focus, findings in bipolar disorder will be briefly covered. Sleep complaints and depression are bidirectionally related As many as 90% of patients with depression will have sleep quality complaints.1 About two thirds of patients undergoing a major depressive episode will experience insomnia, with about 40% of patients complaining of problems initiating sleep (sleep onset difficulties), main- taining sleep (frequent awakenings), and/or early-morn- ing awakenings (delayed or terminal insomnia), and many patients reporting all three.2,3 Hypersomnia occurs in about 15% of patients. Sleep problems sometimes emerge as a symptom of depression or as a side effect of treatment. Insomnia occurring within major depressive C l i n i c a l  r e s e a r c h S Copyright © 2008 LLS SAS. All rights reserved www.dialogues-cns.org Sleep disturbances and depression: risk relationships for subsequent depression and therapeutic implications Peter L. Franzen, PhD; Daniel J. Buysse, MD Keywords: depression; insomnia; sleep; behavioral treatment; hypnotic; antide- pressant Author affiliations: Department of Psychiatry, University of Pittsburgh School of Medicine; Pittsburgh, PA, USA Address for correspondence:  Peter L. Franzen, PhD, 3811 O’Hara St, E-1119, Pittsburgh, PA 15213, USA (e-mail: franzenpl@upmc.edu) The majority of individuals with depression experience sleep disturbances. Depression is also over-represented among populations with a variety of sleep disorders. Although sleep disturbances are typical features of depres- sion, such symptoms sometimes appear prior to an episode of depression. The bidirectional associations between sleep disturbance (especially insomnia) and depression increase the difficulty of differentiating cause-and-effect relation- ships between them. Longitudinal studies have consistently identified insomnia as a risk factor for the development of a new-onset or recurrent depression, and this association has been identified in young, middle-aged, and older adults. Studies have also observed that the combination of insomnia and depression influences the trajectory of depression, increasing episode severity and duration as well as relapse rates. Fortunately, recent studies have demonstrated that both pharmacological and nonpharma- cological interventions for insomnia may favorably reduce and possibly prevent depression. Together, these findings suggest that sleep-related symptoms that are present before, during, and/or after a depressive episode are potentially modifiable factors that may play an important role in achieving and maintaining depression remission.   © 2008, LLS SAS Dialogues Clin Neurosci. 2008;10:473-481.