Pam Harrison

April 05, 2016

PHILADELPHIA – For adolescents with depression who have comorbid sleep disturbances, the course of depression is more severe, regardless of the treatment they receive, in comparison with those whose sleep disturbances resolve, two new studies show.

"We know that there are affective consequences of sleep deprivation in adults, and sleep deprivation in adolescents — who are already vulnerable — might exacerbate their emotional vulnerabilities as well," said study investigator Ellie McGlinchey, PhD, postdoctoral research fellow, Columbia University Medical Center, New York City.

"So we wanted to see whether a reduction in sleep disturbances might moderate an improvement in depression in these two trials," she added.

"In both studies, we found that the course of depression was much worse when sleep disturbances persisted, and we feel that sleep disturbances in depression may in fact represent a more severe, although common, form of depression among adolescents."

The research was presented here at the Anxiety and Depression Association of America (ADAA) Conference 2016.

Hypnotics Not Indicated

In two randomized trials, the investigators examined the effect of sleep disturbances on treatment response in depressed adolescents.

The first study, which included 63 adolescents, compared interpersonal psychotherapy (IPT-A) vs treatment as usual. The second study, entitled Treatment for Adolescent Depression Study (TADS), included 439 adolescents and compared cognitive-behavioral therapy (CBT) vs fluoxetine therapy vs CBT plus fluoxetine vs placebo.

"In both trials, participants were assessed throughout treatment and at posttreatment follow-up for symptoms of self-reported depression, symptoms of insomnia, and overall clinical improvement," said Dr McGlinchey.

At baseline, 66% of the TADS cohort reported having at least moderate sleep difficulties in the past 2 weeks. Although sleep did improve significantly from baseline by the end of the treatment period (P < .001), 43% of patients continued to experience sleep difficulties at study endpoint.

Very similar results were seen in the smaller IPT-A study. At baseline, 65% of participants reported that they had experienced at least moderate sleep disturbances in the past 2 weeks. Reductions in sleep disturbances from baseline were also significant over the study period (P < .05).

Again, however, 40% of patients in the IPT-A study continued to experience sleep difficulties at study endpoint.

"In both studies, adolescents whose sleep disturbances persisted over time had significantly worse depressive symptoms," said Dr McGlinchey.

In the TADS cohort, for each point increase in sleep disturbances over time, adolescents had a 2.30-point increase in scores on the Reynolds Adolescent Depression Scale (P < .001).

In the ITP-A study, adolescents had a 1.89 point increase in scores on the Becks Depression Inventory for every point increase in sleep disturbances over time (P < .001).

"It didn't matter which treatment patients got; in both studies, adolescents had more severe depression when sleep disturbances continued relative to adolescents whose sleep disturbances decreased over the course of treatment," Dr McGlinchey noted.

"And this highlights the fact that sleep disturbance should be targeted and incorporated in all types of treatment modalities."

Dr McGlinchey noted that hypnotics are not indicated in young patients, because research suggests that these drugs may harm developing brains. The best approach, she said, is to offer adolescents who are candidates for treatment a structured behavioral sleep treatment program.

Importantly, she noted, some antidepressants can make sleep disturbances worse.

"That is why we are saying a brief behavioral sleep treatment intervention can potentially have a huge impact in these adolescents who are suffering from depression," she said.

Pay Attention to Sleep

Commenting on the findings for Medscape Medical News, Moira Rynn, MD, professor for the implementation of science for child and adolescent mental health in psychiatry, Columbia University Medical Center, New York City, told Medscape Medical News that sleep problems secondary to psychiatric disorders are both common and very challenging to treat, at least in a subgroup of children.

"The work by Dr McGlinchey and colleagues clearly shows how important it is for clinicians to measure quality of sleep at baseline and to track it over time as the adolescent is treated," she said.

Dr Rynn added that more research is needed to better understand how to modify the current standard of care to address sleep difficulties in adolescents.

Dr McGlinchey and Dr Rynn report no relevant financial relationships.

Anxiety and Depression Association of America (ADAA) Conference 2016: Symposium 319, presented April 2, 2016.

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