Clinical reviewDreaming under antidepressants: A systematic review on evidence in depressive patients and healthy volunteers
Introduction
Antidepressants (ADs), besides antihyperlipidemic agents and analgesics, are the most prescribed drugs in the U.S.1 In 2006, the prevalence of a lifetime experience of a depressive disorder was 15.7% among U.S. residents aged 18 or older; a 35% increase is expected by 2050.2 The estimated economic burden of depression in the U.S. rose from $77.4 billion in 1990 (inflation-adjusted dollars) to $83.1 billion in 2000.3 Although ADs have a strong impact on sleep and also on dreaming,4, 5 the magnitude and characteristics of AD influence on dreaming have found little attention in efforts to map AD effects.
The importance of ADs is highlighted not only by their therapeutic use for depressive disorders but also by their use in a variety of diseases with impact on the mental state such as insomnia, anxiety disorder, post-traumatic stress disorder (PTSD), obsessive-compulsive disorder, and chronic pain.6, 7 Furthermore, there is an increasing field for cognitive enhancing and lifestyle use of ADs.8
One of the primary features of depression is disordered sleep. At the subjective level, depression is associated with insomnia,9 difficulty in falling asleep, frequent nocturnal awakenings, nonrestorative sleep, and early morning awakening. Reduction of rapid eye movement (REM) sleep latency is one of the most robust and specific features of sleep in depressed patients and considered a trait marker of depression.10, 11, 12 Numerous other polysomnographic features of altered sleep in depression have been documented, such as increases in REM density, duration of first REM sleep period, time of REM sleep, sleep latency, as well as waking time, and decreases in total sleep time, slow wave sleep, sleep continuity, and sleep efficiency.4, 9, 13
Successful improvement of depressive mood by treatment with ADs may be accompanied by different effects on sleep. Triciyclic ADs tend to improve sleep quality and total sleep time,14 while most selective serotonin reuptake inhibitors (SSRIs) tend to cause insomnia and to reduce total sleep time.15 The effects of most ADs on REM sleep are strong and relatively consistent: a prolongation of REM sleep latency and a reduction of REM sleep time.4, 16, 17, 18, 19 In patients with depression and reduced REM latencies, amitryptiline induced REM sleep suppression during the first two treatment nights, correlated with good clinical response.14, 20 However, this finding was not consistently confirmed.21 Monoamine oxidase inhibitors may virtually eliminate REM sleep,19, 22, 23 a phenomenon that neither necessarily produces a positive clinical response in patients nor causes obvious harm.19
The following features have been described in dreams of depressive patients: reduced dream recall frequency (DRF),*24, 25 reduced length of reports,26, 27 dream contents ranging from “mundane”,26, 28 “trivial”,26 to increased “masochistic”,29, 30, 31, 32 vivid, disturbing, and sometimes emerging as nightmares.9 In psychotherapeutic settings, dream content correlated with therapy outcome. In depressed female divorcees, an increase in masochism across the night was a poor prognostic sign.31 Depressed divorcees who incorporated the loss in their dreams and had stronger affects in dreams were finally better adjusted to their new life.33 High masochism scores in dreams of depressed women were related to a decreased likelihood of clinical improvement.32 Even after full clinical remission for at least six months and no chronic use of psychotropic drugs for at least two months, formerly depressive patients still showed significant negative features in REM dreams.30 This included: increased masochism, increased hostility in the environment, more inanimate objects exerting physical effort, more dreaming of the past, and shorter narratives.30
Section snippets
Rationale
Negatively altered dreams are a concomitant phenomenon of depressive disorders. The study of dream in a disease context has a long tradition, primarily in psychoanalysis. After the discovery of REM sleep34 with its undeniable link to dreams and after development of AD drugs, clear-cut data emerged that depression is accompanied by reduced REM sleep latency and increased REM sleep density35 and that most ADs have a strong REM sleep reducing effect. REM sleep reduction by ADs may have a
Methods
A systematic review40 was performed, screening the data sources Ovid MEDLINE, Cochrane Library, PsycNET/PsycINFO, Virtual Health Library, and clinical trial register websites (e.g., clinicaltrials.gov, apps.who.int/trialsearch) for articles in English, German, Spanish, Portuguese, French, and Italian. Used search terms were “dream*(-s, -ing)”, “nightmare*(s)”, and “antidepress*(-ant, -ants, -ive)”, the observation period was 1950 to August 2010. To identify further studies, reference lists of
Results
Using the search terms “dream*(-s, -ing)”, “nightmare*(s)”, and “antidepress*(-ant, -ants, -ive)”, Ovid MEDLINE retrieved 97 abstracts; three of them double citations, 10 reviews, and 35 not fulfilling abstract screening criteria (investigating PTSD 9, medications other than ADs 6, children 5, narcolepsy 4, Parkinson's disease 2, schizophrenia 2, other reasons 7). The remaining 49 papers were full-text screened and 28 full papers were considered suitable for structured data extraction according
Discussion
The reviewed studies document a clear effect of ADs on dream recall and dream content. The major finding is a decrease of DRF under ADs, a rather consistent effect in tricyclic ADs*39, 44, 52 and phenelzine,19, 53 less consistently documented also for SSRIs/SNRIs.*24, *57 ADs reduced DRF both in depressed patients14, 19, 33, 45 and in normal volunteers.35, 44, 49 Administration of SSRIs/SNRIs may increase frequency of nightmares.61 Withdrawal of tricyclic ADs,52, 64 phenelzine,53 and
Conclusions
Considering treatment process, the various classes of ADs have a different potential to reduce DRF, which is accompanied by a spectrum of impact on dream content. Especially in psychotherapy and psychoanalytic dream work in depressed patients, a more personalized approach toward AD pharmacotherapy120 may be implemented, according to patients' needs. Pharmacological effects of ADs, as well as of other psychotropic drugs, on dreaming are theoretically and clinically relevant. They should be
Acknowledgments
The authors declare no conflict of interests. The study received no funding.
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