Using Tricyclics to Treat Sleep Disorders and Depression in Children

In this occasional feature on Psych Congress Network, members of the Psych Congress Steering Committee answer questions asked by audience members at Psych Congress meetings.

QUESTION: How often do you use mirtazapine or tricyclics for sleep in children to target both symptoms of depression and sleep disturbance?

ANSWER: Evidence to support the use of tricyclics in treating depressive symptoms in children has not been impressive, and in adolescence, efficacy studies show modest support for their use. Tricyclics are often potent serotonin 5-HT_2A and α₁-adrenergic receptor antagonists, weak serotonin reuptake inhibitors, and weak antihistamine or histamine H₁ receptor inverse agonists, which may explain their effect on sleep. My clinical practice has found trazodone to be an effective sleep agent when used off-label to induce and enhance sleep onset and restorative sleep, however the improvement upon depressive symptoms apart from those seen with a good night’s sleep has not been robust. In addition, concerns about scientific reports of toxicity and adverse cardiac events in children and adolescents also point to proceeding with caution when using these agents off-label for sleep.

Mirtazapine has more demonstrated efficacy with depressive symptoms among children and adolescents, and its antagonism of adrenergic and serotonin receptors and strong antihistamine effect makes for a more hopeful choice in managing depression and insomnia in children and adolescents with both conditions. However, possible effects of the drug also include appetite stimulation, and this should be considered. It often impedes the drug’s utility in my patients who are concerned with weight gain. In my practice, it is my slightly built patients with both sleep and depressive symptoms who appreciate the appetite enhancement, making it a better choice than others. In fact, one patient who is a football player appreciated his sleep, modest improvement in depression, and bulking up.

My first choice remains melatonin for sleep in children with mood disorders due to its targeted action and mostly favorable side effect profile.

— Julie Carbray, PhD, FPMHNP, PMHCNS, Clinical Professor of Psychiatry and Nursing and Administrative Director, Pediatric Mood Disorder Program, University of Illinois at Chicago​

MORE QUESTIONS ANSWERED:

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