Comment: The quality of evidence is downgraded by study quality (unclear allocation concealment), inconsistency (heterogeneity in patients, interventions and outcomes), imprecise results (few small trials) and indirectness (short follow-up time).
A Cochrane review [Abstract] 1 included 23 studies with a total of 2806 subjects. Their mean age was 47.3 years. The mean proportion of women was 60%.The follow-up time was less than 8 weeks in 16 trials and more than 24 weeks in only 3 trials.
Selective serotonin reuptake inhibitors (SSRIs) vs. placebo: Two paroxetine studies (n = 60) showed significant improvements in subjective sleep measures at 6 (p = 0.03) and 12 weeks (p < 0.001; n = 27). There was no difference in the fluoxetine study (n = 89).
Tricyclic antidepressants (TCA) vs. placebo: Five of the trials used doxepin and one trimipramine. There was a moderate improvement in subjective sleep quality over placebo (SMD -0.39, 95% CI -0.56 to -0.21; 4 trials, n = 518). TCAs improved sleep efficiency (MD 6.29 % points, 95% CI 3.17 to 9.41; 4 studies, n = 510) and increased sleep time (MD 22.88 minutes, 95% CI 13.17 to 32.59; 4 studies, n = 510). There may have been little impact on sleep latency (MD -4.27 minutes, 95% CI -9.01 to 0.48; 4 studies, n = 510). Thre were no trials on amitriptyline.
'Other' antidepressants vs. placebo: Seven trials used trazodone and one used mianserin. There was an improvement in subjective sleep outcomes for trazodone (SMD -0.34, 95% CI -0.66 to -0.02; 3 trials, n = 370). Two trials of trazodone (n = 169) measured polysomnography and found little or no difference in sleep efficiency (MD 1.38 % points, 95% CI -2.87 to 5.63).
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