Depression appears to be a major cause of insomnia in people with HIV

Depression appears to be a major cause of insomnia in people with HIV, according to a new systematic review of 29 studies on the topic.

Steven Reid, Ph.D., of Imperial College in London, lead author of the review, says that "given the prevalence of anxiety and depression reported in HIV infection, it is not surprising that psychiatric disorders should be associated with sleep disturbance in this group."

Patients in the last stages of HIV infection with full-blown AIDS and those who have suffered some kind of brain impairment as a result of the disease are also more likely to suffer from insomnia, the reviewers conclude in the current issue of Psychosomatic Medicine.

"The studies reviewed here illustrate that although insomnia is a frequent complaint in people living with HIV, there is considerable uncertainty about its cause and significance," Reid says.

Earlier studies suggested that patients with HIV had changes in periods of REM (rapid eye movement) and non-REM sleep, along with other sleep rhythm changes, that may have led to insomnia.

When Reid and colleague reviewed those studies, however, they found that very small numbers of participants and inconsistent findings.

More recent studies rely on patients' reports about their own sleep habits and disturbances, including whether they had difficulty falling asleep or staying asleep, their frequency of nightmares, whether they were tired in the day or whether they used sleeping pills to help them rest.

Those studies revealed a "consistent and strong relationship" between psychological problems, particularly depression, and insomnia in HIV patients, say the reviewers.

Health care workers should pay more attention to diagnosing and treating anxiety and depression in people with HIV as a way to prevent insomnia, "given that psychiatric disorders are often missed in general medical settings," Reid says.

Reid and colleagues found little evidence suggesting that a patient's viral count or other signs of infection were important risk factors for insomnia until the very last stage of the disease, when AIDS-related illnesses may have been a contributing factor to sleep disturbances.

Although HIV patients taking antiretroviral therapy often describe insomnia as a side effect of the medication, the reviewers found few published studies that examined this side effect. With the exception of one medication called efavirenz (Sustiva), Reid says there is not enough evidence to suggest that antiretroviral drugs contribute to insomnia.

Reid and colleagues identified only two studies of treatments for insomnia in HIV patients, including one study of acupuncture therapy and one study of the effects of caffeine withdrawal. The studies were small and had mixed results, the researchers say.

"There is a range of pharmacologic and behavioral treatments available for insomnia," Reid says. Behavioral treatments, he adds, "are as effective as drug treatments in persistent primary insomnia, but they have yet to be evaluated in people with HIV."

Reid and colleagues says further research is needed to learn whether insomnia adds to the disabling burden of HIV, especially in patients who have not yet developed symptoms of AIDS. Reid also says researchers should study how a patient's living conditions, along with his or her alcohol, drug and caffeine use, could affect insomnia risks.