Department of Psychiatry, University of Cape Town, Groote Schuur Hospital J-2, Observatory 7925, Cape Town, South Africa.
Adv Ther. 2011 Nov;28(11):1021-37. doi: 10.1007/s12325-011-0071-8. Epub 2011 Nov 2.
Disturbed sleep is a key symptom in major depressive disorder (MDD) and generalized anxiety disorder (GAD). First-line antidepressants, including the selective serotonin reuptake inhibitors (SSRIs) and serotonin noradrenaline reuptake inhibitors (SNRIs), may have different effects on sleep.
Data from 22 randomized, controlled trials comparing escitalopram with SSRIs, SNRIs, or placebo in the treatment of adult MDD or GAD were included. Both last observation carried forward (LOCF) and repeated measurements (MMRM) were used to analyze the sleep item of the Montgomery Åsberg Depression Rating Scale (MADRS) or Hamilton Anxiety Rating Scale (HAM-A) after 8 weeks of treatment. Sleep-related treatment-emergent adverse events were also compared across groups.
For patients with MDD (n = 5133), the treatment difference on MADRS item 4 ("reduced sleep") was significantly in favor of escitalopram versus placebo (LOCF [P = 0.0017] and MMRM [P = 0.0002]), versus SSRIs (LOCF [P = 0.0020] and MMRM [P < 0.0031]), and versus SNRIs (LOCF [P = 0.0002] and MMRM [P = 0.0352]). For the 53% of patients with MDD who suffered from sleep problems at baseline (baseline MADRS item 4 score ≥ 4), the improvement in sleep symptoms was significantly in favor of escitalopram versus placebo (LOCF [P = 0.0022] and MMRM [P < 0.0005]), versus SSRIs (LOCF [P = 0.0001] and MMRM [P = 0.0002]), and versus SNRIs (LOCF [P < 0.0067] but not MMRM [P > 0.0787]). For patients with GAD (n = 2052) the treatment difference in sleep symptoms measured by HAM-A item 4 ("insomnia") was significantly in favor of escitalopram versus placebo (LOCF [P = 0.0005] and MMRM [P < 0.0001]), but not different to paroxetine or venlafaxine. The same pattern was seen for the large proportion (67%-82%) of GAD patients reporting sleep problems at baseline (baseline HAM-A item 4 score ≥ 2). In MDD, the rate of insomnia as an adverse event after escitalopram was higher than placebo, similar to SSRIs, and lower than SNRIs.
Additional research assessing the comparative effects of antidepressants with polysomnography is needed. In the interim, from a clinical perspective, escitalopram appears to be beneficial for the treatment of sleep problems in MDD and GAD.
睡眠障碍是重性抑郁障碍（MDD）和广泛性焦虑障碍（GAD）的主要症状之一。一线抗抑郁药，包括选择性 5-羟色胺再摄取抑制剂（SSRIs）和 5-羟色胺-去甲肾上腺素再摄取抑制剂（SNRIs），可能对睡眠有不同的影响。
纳入了 22 项比较艾司西酞普兰与 SSRIs、SNRIs 或安慰剂治疗成人 MDD 或 GAD 的随机对照试验的数据。采用末次观察结转（LOCF）和重复测量（MMRM）分析治疗 8 周后蒙哥马利-阿斯伯格抑郁评定量表（MADRS）或汉密尔顿焦虑评定量表（HAM-A）的睡眠项目。还比较了各组之间与治疗相关的新发不良事件。
对于 MDD 患者（n=5133），艾司西酞普兰相对于安慰剂（LOCF [P=0.0017]和 MMRM [P=0.0002]）、SSRIs（LOCF [P=0.0020]和 MMRM [P<0.0031]）和 SNRIs（LOCF [P=0.0002]和 MMRM [P=0.0352]）在 MADRS 第 4 项（“睡眠减少”）上的治疗差异具有统计学意义。对于基线时存在睡眠问题的 MDD 患者（基线 MADRS 第 4 项评分≥4），艾司西酞普兰在改善睡眠症状方面明显优于安慰剂（LOCF [P=0.0022]和 MMRM [P<0.0005]）、SSRIs（LOCF [P=0.0001]和 MMRM [P=0.0002]）和 SNRIs（LOCF [P<0.0067]但 MMRM [P>0.0787]）。对于 GAD 患者（n=2052），用 HAM-A 第 4 项（“失眠”）测量的睡眠症状的治疗差异明显有利于艾司西酞普兰优于安慰剂（LOCF [P=0.0005]和 MMRM [P<0.0001]），但与帕罗西汀或文拉法辛无差异。在基线时（基线 HAM-A 第 4 项评分≥2）报告存在睡眠问题的 GAD 患者中，同样出现了很大比例（67%-82%）的这种情况。在 MDD 中，艾司西酞普兰引起失眠的不良反应发生率高于安慰剂，与 SSRIs 相似，低于 SNRIs。
需要进一步研究评估抗抑郁药与多导睡眠图的比较效果。在这期间，从临床角度来看，艾司西酞普兰似乎对治疗 MDD 和 GAD 的睡眠问题有益。
