SALT LAKE CITY – Depression severity is a key factor in determining how to treat comorbid depression and restless legs syndrome, Dr. John Winkelman said at the annual meeting of the Associated Professional Sleep Societies.
The two conditions frequently occur together, and often it is unclear which is primary. Further complicating the matter of treatment is the fact that therapies for the two can be conflicting; for example, selective serotonin reuptake inhibitors (SSRIs) frequently used to treat depression have been shown to exacerbate RLS symptoms, explained Dr. Winkelman, who is associate director of the sleep disorders program at Brigham and Women's Hospital in Boston.
But the substantial morbidity and mortality that can be associated with severe depression take precedence when it comes to initiating treatment. In patients presenting with untreated severe depression and RLS, treat the depression first.
If possible, avoid SSRIs and try a nonserotonergic antidepressant such as bupropion instead, he advised.
The RLS symptoms should be treated shortly thereafter, because “the last thing a person with depression needs is to be up walking at night [as a result of RLS symptoms] and getting more and more agitated,” said Dr. Winkelman, who is also with Harvard Medical School, Boston.
In patients who have mild depression and RLS, treat the RLS first and see if the depressive symptoms improve, he suggested.
Given that about 10% of the U.S. population is on an antidepressant, it is likely that patients with RLS will present already on an SSRI for depression; in these cases, consider switching the patient to a nonserotonergic antidepressant only if the SSRI was the first drug tried in that patient.
In a patient who was treated with multiple drugs before finding one that worked for the depression or who was hospitalized for severe depression, don't rock the boat, Dr. Winkelman said. Rather, try adding a dopaminergic to treat the RLS symptoms in these patients, he said.
Another important factor to consider in patients with comorbid depression and restless legs syndrome is the effects of sleep quality and quantity on depression and RLS.
“There is quite a bit of data documenting that insomnia is an independent risk factor for incident, new-onset depression,” Dr. Winkelman noted. And there is good correlation between severity of RLS symptoms and sleep disturbance, as well.
Furthermore, in one study of more than 100 patients, there was a strong relationship between RLS-related sleep disturbance and depression, but RLS severity in itself did not predict depressive symptoms.
Similar findings have been noted in other neurologic diseases. In studies of patients with Parkinson's disease, for example, disease severity did not predict depressive symptoms, but the effects of the disease on quality of life and activities of daily living did predict depression, he explained.
This raises the question of whether sleep is a key mediator for RLS morbidity in regard to depressive symptomatology. Sleep optimization should therefore be one of the goals of treatment in these patients, Dr. Winkelman said.