Circadian rhythm disturbances Sleep-wake rhythm disturbances, including hypo- or insomnia, are present in a majority of depressed

patients suffering from difficulties in falling asleep, interrupted and shortened sleep during the night, and early awakening in the morning. In addition, hypersomnia characterizes most patients suffering from atypical depression Inhibitors,research,lifescience,medical (see above). They are rated as criteria for MDD in ICD-10, as accessory symptoms in check details DSM-IV-TR, as depressive symptoms within the HAM-D17 scale, and are included in the abovementioned CORE scale for depressive core symtoms.14 In addition specific sleep EEG patterns, such as reduced slow-wave sleep and shortened REM’ sleep latency, characterize MDD especially in the presence of melancholic symptoms.13 Sleep EEG abnormalities arc in addition strongly influenced by age and gender of the depressed patients.89 From a clinical point of view the use of antidepressants with antihistamincrgic and therefore sedating properties, eg, some TCAs or noradrenergic and specific

serotonergic antidepressants Inhibitors,research,lifescience,medical Inhibitors,research,lifescience,medical (NaSS As) or the use of nonsedating antidepressants in combination with sleep-inducing treatments, are useful. In this case, nonbenzodiazepine hypnotics, benzodiazepines, or sedating atypical antipsychotics which at the same time can augment the antidepressant treatment are suitable. Mirtazapine monotherapy significantly improves sleep parameters in addition to its antidepressant effects90 without the neceessity of additional hypnotic substances. Unfortunately, initial somnolence

Inhibitors,research,lifescience,medical and dizziness, together with increased appetite and consecutive weight gain in the long term91 may represent antihistaminergic side effects which often reduce the patients’ compliance and may sometimes even facilitate the development of a metabolic syndrome. While most antidpressants are modifying sleep profiles Inhibitors,research,lifescience,medical by suppressing rapid eye movement (REM) sleep, the only dopamine (D)2 and serotonin (5HT)2 antagonistic acting substance with antihistaminergic sedating properties without REM suppression is the TCA trimipramine.91 nearly An interesting future perspective may therefore be the use of the MiyMTo agonistic and 5-HT7c antagonistic acting antidepressant agomelatine. In healthy older men no effects on normal sleep patterns were found,93 while in patients suffering from MDD in a pilot dose-finding study94-95 symptoms related to sleep disturbances such as difficulties in falling asleep, interrupted sleep, shortened sleep, early awakening, and drowsiness decreased substantially, leading to a normalization of sleep/wake rhythms without direct sedation and without REM sleep suppression, indicating that agomelatine contributes to a normalization of disrupted circadian rhythms in depression. Depressive syndrome with comorbid pain conditions Depressive disorders and predominantly chronic pain are frequent comorbid conditions.