title: Barriers to achieving treatment goals: a focus on sleep disturbance and sexual dysfunction.
abstract: BACKGROUND
  Patients who meet the criteria for a major depressive episode experience a constellation of symptoms, and different symptom configurations may reflect distinct underlying neurological disturbances. Similarly, the differing receptor profiles of the various antidepressants may explain relatively low remission rates and persistent symptoms even after remission. In particular, depressed patients frequently display altered circadian rhythms, sleep disturbances, and diurnal mood variation. Exploring treatments that can restore mood while having a positive impact on circadian rhythms and sleep would greatly improve the ability to treat this core features of depression.
  
  
  METHODS
  The mechanisms of action of the various classes of antidepressants, their effects on sleep and issues beyond sleep, including sexual dysfunction, are explored, along with questions relating to adherence.
  
  
  RESULTS
  Unfortunately, persistent sleep problems are among the most difficult-to-treat residual symptoms of depression. Many of the currently available antidepressants have adverse effects on circadian processes, including sleep, and may actually worsen sleep problems. Tolerability is also an enduring issue; SSRI and SNRI antidepressants are associated with central nervous sysytem and gastrointestinal effects, sexual side effects and suicidality. Improved drug tolerability would not only minimize distressing adverse effects, but would also improve adherence, thus maximizing the chances of successful treatment.
  
  
  CONCLUSIONS
  The complexity of managing a major depressive episode is well illustrated by sleep disturbance and sexual dysfunction, two core symptoms of MDD that may also be caused or exacerbated by antidepressant therapy. Future antidepressants should alleviate symptoms without adversely affecting sleep or sexual function.
authors.affiliation: Department of Psychiatry, Dalhousie University (Dalhousie Medicine New Brunswick), Saint John, NB, Canada. morra@reg2.health.nb.ca
authors.forename: Rachel
authors.initials: R
authors.lastname: Morehouse
authors.forename: Glenda
authors.initials: G
authors.lastname: Macqueen
authors.forename: Sidney H
authors.initials: SH
authors.lastname: Kennedy
mesh_terms: D000339:Affect; D000928:Antidepressive Agents / Q000009:adverse effects / Q000494:pharmacology* / Q000627:therapeutic use; D002940:Circadian Rhythm / Q000502:physiology; D003865:Major Depressive Disorder / Q000150:complications* / Q000188:drug therapy / Q000503:physiopathology; D005260:Female; D006801:Humans; D008297:Male; D020018:Sexual Dysfunctions, Psychological / Q000188:drug therapy* / Q000209:etiology; D012893:Sleep Wake Disorders / Q000188:drug therapy* / Q000209:etiology
chemical_list: D000928:Antidepressive Agents