**7.11 Anticonvulsants**

*Updates in Sleep Neurology and Obstructive Sleep Apnea*

order to control comorbid conditions.

on diurnal excessive sleepiness [88].

hypotension, xerostomia, and priapism [90].

neuralgia), mood, and appetite [91].

*inhibitors (SNRI)*

the evening hours [92].

**7.10 Antipsychotics**

lethal in overdose [89].

Antidepressants with sedative effect as tryciclic antidepressants (TCA), mirtazapine, and trazodone are often prescribed for insomnia comorbid with pain. Such pharmacological approach showed to relieve both insomnia, depressive, and pain-related symptoms. Often they are effectively used to treat neuropathic pain. Attention should be taken however regarding their differential effects on sleep. Imipramine and desipramine are less sedating and may disrupt sleep, amitriptyline, nortriptyline, trimipramine, and doxepine lead to a reduction in sleep latency, increase of sleep efficiency, and increase in sleep duration [87]. Those properties should be taken into account either on the prescription time or in the evaluation in

Doxepin is approved as a hypnotic in doses from 1 to 6 mg and as an antidepressant in doses from 150 to 300 mg. At hypnotic doses, it reduces wakefulness after sleep onset, increases sleep efficiency, and total sleep time without next day impact

The adverse effects of TCAs are mainly due to anti-adrenergic and anticholinergic effects: orthostatic hypotension, xerostomia and xeropthalmia, constipation, and cardiac electric changes (delays in conduction). The risk of those side effects are age-related and particular care should be taken when prescribing TCAs to patients with comorbid depression and suicidal ideation because they are extremely

Trazodone, a type 2 serotoninergic, histaminergic and alfa1-adrenergic antagonist acts by inhibition of serotonin reuptake. As other antidepressants, trazodone has a hypnotic function at low doses whereas antidepressant effects occur at higher doses. It improves sleep in elderly, depressed, and anxious patients and patients with post-traumatic stress and has shown clear benefit in several painful conditions. Side effects include sleepiness the next day, rebound insomnia, orthostatic

Mirtazapine, a sedative antidepressant agent, at doses of 15–30 mg, improves sleep onset, total sleep time, sleep efficiency, and wakefulness after sleep onset. Additionally, it has a positive impact on pain (recurrent headache and postherpetic

This class of drugs is both effective for depression and pain, but it is linked to sleep disruption. So, whenever needed, attention should be paid to avoid its use in

Despite the limited evidence, some off-label atypical antipsychotics drugs (olanzapine, quetiapine, and risperidone) are used for managing sleep disruption and insomnia. Self-reported and objectively evaluated outcomes suggest efficacy in increasing sleep duration, slow wave sleep and decreasing sleep latency. However, long-term safety and efficacy studies should be done in order to corroborate these findings. Meanwhile, even in low dose (<150 mg/day) quetiapine was associated to xerostomia and dizziness. Some cases of hepatotoxicity, restless legs, and akathisia were also reported. Risperidone was associated to somnolence and sialorrhea and olanzapine is suggested to be related to a degree of sedation which impacts morning

*7.9.1 Selective serotonin (SSRI) and serotonin-norepinephrine reuptake* 

**7.9 Antidepressants**

**100**

rising time [93].

GABA analogs Gabapentin and pregabalin are two anticonvulsants often used to treat chronic pain with comorbid insomnia and studies suggest positive effects on sleep outcomes as sleep latency and wakefulness after sleep onset as well as in deep slow wave sleep. Both are effective as adjuncts in depression and anxiety. Frequent adverse effects are dizziness, diurnal sedation, gastrointestinal problems, and peripheral edema [94].
