Depression and Iatrogenic Nightmares

What would I have done….?

I want to say from the get-go that I am not having a dig at overworked, or stressed GPs who are doing their best for the patients within the 10 minutes framework the NHS allows. It’s not them, it’s the system.

Last week I saw a middle-aged woman presenting with low mood, fragmented sleep, and recurrent nightmares. Her history included multiple bereavements over a relatively short period. As far as I understand, no formal psychological assessment or bereavement counselling was offered at the time of initial presentation to her GP. Management was pharmacological and sequential.

Drilling down to beyond the depression and feelings of isolation, it seemed that the lack of sleep and vivid nightmares had become the most urgent problem, and during the last few years the following medications had been prescribed, one after another, primarily for depression and insomnia:

Citalopram (SSRI), Mirtazapine, Trazodone, Zopiclone, Daridorexant

A little flick through the BNF and other sources told me this;

Mirtazapine – Very commonly causes vivid, sometimes bizarre or disturbing dreams. This is one of its most frequently reported side effects.

Trazodone – Also commonly associated with vivid or unusual dreams and nightmares.

Citalopram – Can cause vivid dreams and nightmares, particularly when starting treatment or changing doses. This is common with SSRIs generally.

Daridorexant – Can cause abnormal dreams as it affects the sleep-wake cycle by blocking orexin receptors.

Zopiclone – Less commonly causes vivid dreams compared to the others, but can cause nightmares in some people.

Mirtazapine and trazodone are particularly notable for this effect. Many patients report very vivid, detailed, or strange dreams that they remember clearly upon waking. For some people this is merely interesting, but for others it can be distressing enough to warrant discussing with their doctor about adjusting the dose or timing of medication.

It seemed to me that the drugs that were supposed to help her though her depression were giving her the nightmares that kept her awake and terrified her.

To be honest, if I was a GP and these were the only tools I had at my disposal, I may have prescribed the same. But even though herbalists must be careful choosing herbs when patients are on a cocktail of powerful drugs, we sometimes wonder what we would have done for the patient if they had come to us with depression before all the drugs had been prescribed. At least for this patient, she wouldn’t have developed nightmares. And I have to say that helping people with low mood is tricky and herbalists are not usually counsellors or psychologists, and have to be aware of their limits of competence.

But what could I have done?

I would have wanted to support restorative sleep, improve mood and reduce the feelings of isolation, withdrawal and lack of interest in life. In depression it is often referred to as anhedonia, when people don’t get any pleasure out of life anymore.

Anhedonia is one of those terms that gets thrown around casually, but in clinical and psychological language it has a very specific meaning: a marked reduction in the capacity to experience pleasure, interest, or reward. It’s not simply ‘not enjoying things as much’, rather it’s a deeper shift in how the brain processes motivation, anticipation, and emotional reward.

Have we got herbs for this?

Passiflora incarnata [Passionflower]
Evidence-supports it action as an anxiolytic and hypnotic. Improves sleep quality without suppressing REM sleep. Particularly useful for intrusive thoughts and trauma-related insomnia.

Scutellaria lateriflora [Skullcap]
A nervine indicated for nervous exhaustion, ruminative thinking, and fragmented sleep. Helpful where sedation worsens dream activity.

Tilia europaea [Limeflower]
Mild anxiolytic, especially appropriate in grief-associated insomnia with anxiety.

Hypericum perforatum [St John’s Wort]
May be appropriate for mild–moderate depression where insomnia is present, provided no pharmaceutical antidepressants are used concurrently.

Matricaria recutita [German Chamomile]                                                                                 Chamomile contains apigenin which binds to GABA-A receptors giving a very mild benzodiazepine-like action which is non-addictive.

Plus, a lot of advice about diet because what we eat shapes not only our body and metabolism but can also shape our mind through mild but persistent inflammation of the central nervous system, which then can disrupt thought patterns.*

Herbs can contribute to the preservation of normal sleep architecture, support emotional processing rather than suppressing it, and address stress physiology rather than targeting symptoms in isolation.

Importantly, none of these herbs are strongly associated with inducing vivid dreams or nightmares, and several are traditionally used to reduce them.

This case illustrates the risks of managing grief-related depression and insomnia primarily through pharmacological escalation without addressing underlying psychophysiological mechanisms. Perhaps earlier consideration of non-pharmacological and herbal interventions, alongside psychological support, may have reduced symptom burden and avoided the development of medication-associated sleep disturbance.

Although, I will say, depression is tricky and everyone who suffers is unique, and some may need a pharmacological cosh in extremis. But possibly for those not yet completely on the edge, herbs may have a place before a series of pharmaceuticals take over.

One further point worth making is that one of the strengths of herbal medicines lies in their chemical complexity. Medicinal plants contain hundreds of constituents—alkaloids, flavonoids, glycosides, terpenes, phenolics—many of which act together rather than in isolation. This multiplicity allows for buffering effects, where potentially stimulating or sedating actions are moderated by complementary compounds within the same plant. Rather than pushing a single receptor pathway hard, as pharmaceuticals often do, herbs tend to exert gentler, multi-targeted effects across neurotransmitter systems, inflammatory pathways, and neuroendocrine signalling.

This synergy may help explain why many nervine and antidepressant herbs can support mood and sleep without the degree of REM disruption, rebound effects, or adverse dream phenomena seen with single-target drugs. In clinical practice, this buffering and systems-based action is often what makes herbs both effective and better tolerated, particularly in conditions involving nervous system dysregulation rather than frank psychiatric pathology.

_{*Liwinski, T., Lang, U.E., Brühl, A.B. and Schneider, E., 2024. Exploring the therapeutic potential of gamma‑aminobutyric acid in stress and depressive disorders through the gut–brain axis. International Journal of Molecular Sciences, 25(3), p.1512. Available at: https://doi.org/10.3390/ijms25031512}

_{Image attribution: Library of Congress, Public domain, via Wikimedia Commons.}