Effects of Antidepressants on Sleep in Post-traumatic Stress Disorder: An Overview of Reviews

Abstract

Antidepressants are a commonly used, easily accessible, and overall safe treatment option for post-traumatic stress disorder (PTSD). The present review aims to evaluate the efficacy and safety of antidepressants in treating sleep disturbances in patients with PTSD. PubMed and the Cochrane Library were searched (July 2022) for systematic reviews and meta-analyses on the treatment of PTSD. Moreover, PubMed and ClinicalTrials.gov were searched for individual trials investigating the antidepressant treatment of PTSD (up to September 2022), and reference lists of all possibly relevant identified studies were screened. Sleep-related outcomes, i.e., total sleep time, sleep quality, dreams/ nightmares, insomnia, and somnolence, were extracted independently by at least two reviewers. Metaanalytic evaluations were performed wherever possible. 39 randomised controlled trials (RCTs) were identified; data from pooled analyses, reviews, and observational studies were used for antidepressants with a weak evidence base or when their findings were deemed important. Overall, scarce data exist on the effects of antidepressants on sleep outcomes among patients with PTSD. Some evidence may support the use of amitriptyline, nefazodone, paroxetine, and sertraline for improving sleep in patients with PTSD. Τhere was a meta-analytical trend indicating improvement of nightmares with fluoxetine, less insomnia with amitriptyline and more with brofaromine, as well as more somnolence with paroxetine vs. placebo, respectively. However, data from more than 1 RCT with a considerable number of patients were only available for paroxetine. Evidence is insufficient to draw safe conclusions. More and better-designed RCTs, with consistent reporting of sleep-related outcomes, are needed.

Keywords: PTSD; Post-traumatic stress disorder; dreams; insomnia; meta-analysis.; nightmares; sleep; somnolence.

Fig. (1)

Standardised mean difference for efficacy outcome ‘sleep quality’ of all antidepressants versus placebo. Abbreviations: N = Number, Std. = Standardised, IV = Inverse variance, CI = Confidence interval.

Fig. (2)

Standardised mean difference for efficacy outcome ‘distressing dreams’ of all antidepressants versus placebo. Abbreviations: N = Number, Std. = Standardised, IV = Inverse variance, CI = Confidence interval.

Fig. (3)

Response ratio for safety outcome ‘insomnia’ of all antidepressants versus placebo. Abbreviations: N = Number, M-H = Maentel-Haenszel, CI = Confidence interval.

Fig. (4)

Response ratio for safety outcome ‘insomnia’ of all SSRIs versus placebo. Abbreviations: SSRIs = Selective serotonin reuptake inhibitors, N = Number, M-H = Maentel-Haenszel, CI = Confidence interval.

Fig. (5)

Response ratio for safety outcome ‘somnolence’ of all antidepressants versus placebo. Abbreviations: N = Number, M-H = Maentel-Haenszel, CI = Confidence interval.

Fig. (6)

Response ratio for safety outcome ‘somnolence’ of all SSRIs versus placebo without the Simon’s (2008) study. Abbreviations: SSRIs = Selective serotonin reuptake inhibitors, N = Number, M-H = Maentel-Haenszel, CI = Confidence interval.

Fig. (7)

Response ratio for safety outcome ‘somnolence’ of all SSRIs versus placebo. Abbreviations: SSRIs = Selective serotonin reuptake inhibitors, N = Number, M-H = Maentel-Haenszel, CI = Confidence interval.

Fig. (8)

Response ratio for safety outcome ‘nightmares/vivid dreams’ of all antidepressants versus placebo. Abbreviations: N = Number, M-H = Maentel-Haenszel, CI = Confidence interval.