Nocturnal melatonin secretion and sleep after doxepin administration in chronic primary insomnia

Nocturnal melatonin secretion and polysomnographic sleep patterns were investigated in ten patients with chronic primary insomnia (age 41.3 +/- 9.5 years) and in five healthy subject, (age 27.2 +/- 0.7 years) after either a single intravenous administration of 25 mg doxepin or placebo in a randomized, double blind, and cross-over setting. In the patient group a third session was performed after a three-week open oral treatment with 25 mg doxepin daily. The single-dose administration of doxepin did not affect plasma melatonin concentrations in either the patients on the healthy subjects. After three weeks of oral doxepin intake by the patients, the area under the curve of total nocturnal plasma melatonin concentration was significantly increased by 26% and the peak values were increased by 30%. Both after the single i.v. treatment as well as after long-term oral administration, doxepin also significantly improved sleep latency, total sleep time, and sleep efficiency in the insomniacs as well as the healthy subjects, whereas the nocturnal wake time was decreased. These findings indicate that this tricyclic antidepressant not only improves sleep and but also preserves the secretion of a hormone which is believed to play a special role in the circadian sleep-wake rhythm. Long-term doxepin treatment of chronic insomniac patients not only improves sleep but also restores nocturnal melatonin secretion in these patients.

Sleep apnea syndrome and cerebral hemodynamics

The dynamics of cerebral blood flow velocity (CBFV) during sleep were investigated in the right middle cerebral artery of 10 patients with sleep apnea syndrome (SAS) (mean age, 37 years) and 10 healthy control subjects (mean age, 32 years) throughout the entire sleep period. A computer-assisted pulsed (2 MHz) transcranial Doppler ultrasonography system was modified for continuous long-term and on-line recording of cerebral hemodynamics. Concurrently, simultaneous polysomnography, continuous BP recordings, and measurement of the end-expiratory carbon dioxide were undertaken. CBFV showed comparable nocturnal profiles in both groups with decreases during non-rapid eye movement (NREM) sleep and increases during rapid eye movement (REM) sleep, indicating that the general pattern of brain perfusion during normal sleep is maintained in SAS. Sleep stage changes were not regularly accompanied by corresponding changes in CBFV. This reflected a quantitative uncoupling between cerebral electrical activity and cerebral perfusion during sleep and indicated a dissociation in the activity of central regulatory mechanisms. Sleep stage-related analysis showed slightly reduced CBFV in patients with SAS compared with healthy control subjects during wakefulness and the first NREM sleep period, suggesting depressed brain activity in the patient group. The higher CBFV values observed in patients with SAS compared with control subjects during REM sleep and sleep stage 2, both preceding and following REM sleep, underline the influence of dynamically changing sleep patterns on cerebral perfusion in these patients. Reproducible rapid decreases in CBFV were related to EEG arousals. Since apneas are terminated by arousals, these results showed that direct neuronal influences on brain perfusion during apnea are evident.

[Botulinum toxin therapy in rehabilitation neurology]

Intramuscular injections of botulinum toxin (BT) induce a localized, long-lasting paresis of the target muscle that can be graded by the BT dose administered and that is free of major side effects. With this profile, BT can be used for symptomatic treatment of various disorders caused by pathological muscle hyperactivities. These disorders occur frequently in patients in institutions for neurological rehabilitation. They are difficult to treat with conventional methods, can cause major suffering and induce substantial costs for our health care system. In the present study we therefore sought to delineate the use of BT in rehabilitative neurology. Regardless of the etiology of the particular muscle hyperactivity syndrome, five main indication groups are identified: (1) improvement of function of the hyperactive muscles; (2) relief of pain in the hyperactive muscles; (3) improvement of patient care; (4) avoidance of sequelae in joints, tendons, ligaments, and teeth; (5) various special indications.

[Ambulatory, comprehensive, behavior therapy-oriented weight reduction program (Optifast Program). An alternative therapy in obstructive sleep apnea]

We investigated the therapeutic effect of marked body weight reduction on the predominantly obstructive sleep apnea syndrome by the application of an out-patient, behaviour therapy based body weight reduction program (Optifast-program) in five of our obese apnea patients (mean overweight by Broca 53.6 +/- 24.8 kg). Mean body weight reduction was 32.7 +/- 15.8 kg after six months. The mean apnea-index of 34.5 +/- 23.1/h prior to the weight reduction dropped to 7.8 +/- 6.1/h after therapy. The mean apnea-hypopnea-index (so called "respiratory disturbance index", RDI) could be reduced from 45,7 +/- 26.0/h to 14.0 +/- 11.4/h. The best therapeutic effect on the sleep related respiratory parameters was seen in patients who reached their normal weight whereas the absolute weight reduction itself seems to be less important. Our results should encourage this causal therapy in appropriate patients.

Serotonin transporters in the rat frontal cortex: lack of circadian rhythmicity but down-regulation by food restriction

Molecular biological findings have indicated that the affinity and the density of presynaptic serotonin transporters may be subject to adaptive regulation, but the physiological conditions that may act to trigger such changes are presently unknown. By means of [3H]paroxetine binding to rat cortical membranes, we studied the influence of two physiological variables that are clearly associated with altered serotonergic activity--circadian rhythm and semistarvation--on K(D)and Bmax values of the serotonin transporter of the rat frontal cortex. No circadian fluctuations of both parameters were observed. Also, semistarvation (50% reduction of normal voluntary food intake) for 2 days had no effect on either K(D) or Bmax values of cortical [3H]paroxetine binding. Food restriction for either 7 days or 2 weeks, however, resulted in a significant, approximately 30%, reduction of the density of cortical serotonin transporters with unchanged transporter affinity. These findings indicate that long-term changes in the density of cortical serotonin transporters can be induced by long-lasting alterations of certain environmental variables. Because the duration and the radius of action of presynaptically released serotonin are governed by the efficiency of the reuptake mechanism, such adaptive changes of serotonin transporter density must be expected to cause long-term alterations of the modulatory impact of the central serotonin system on certain brain functions.

Prescribing practice with cognition enhancers in outpatient care: are there differences regarding type of dementia?--Results of a representative survey in lower Saxony, Germany

Previous studies of cognition enhancers have mainly focused on insufficiently defined groups of cognition disorders, e.g., "cerebral insufficiency". With regard to the various biological changes in senile dementia of Alzheimer's type (SDAT) and in vascular dementia (VD), which together make up the great majority of senile dementias, many authors have encouraged different studies of these types of dementias, especially since both can be diagnosed clinically with satisfying certainty. Since primary care physicians treat the majority of elderly and demented patients, they have their own experience with cognition enhancers. We were therefore interested to know, how far these physicians differ in their treatment of SDAT and VD. We performed a representative survey (response rate 83.2%; 145 family physicians and 14 neuropsychiatrists) in the Goettingen area. A written case vignette described a 70-year-old widow with moderate dementia and vascular risk factors which are easily treated with drugs. Two versions were randomly assigned, in which (version A) either a "typical" VD history or a typical SDAT history (version B) were described. After perusal, the physician was asked whether and which drugs he would choose to treat the cognitive disorders in this patient. Most frequently, piracetam (A/B: 25.6%/30.9%), ginkgo biloba (24.4%/28.4%), and nimodipine (14.1%/25.9%) were considered. Aspirin was cited by 29.5%(A) and 17.3%(B) of the physicians respectively. As far as the type of dementia was concerned, significant differences were found only for co-dergocrine, which was preferred in SDAT. The following inter-group trends were observed: family physicians considered ginkgo biloba more often than nimodipine or co-dergocrine. The results show the apparent importance of cost-and safety aspects, while the type of dementia has hardly any impact. The latter impression corresponds to the results of drug trials demonstrating no different efficacy. In our opinion, aspirin was not sufficiently taken into consideration.

Nocturnal plasma melatonin levels after flunitrazepam administration in healthy subjects

Polysomnographic sleep patterns and melatonin secretion were investigated in 5 young (age 25.6 +/- 1.1 years) and 5 middle-aged (age 49.4 +/- 5.4 years) healthy male subjects after intravenous administration of 1 mg flunitrazepam and placebo in a randomized, double-blind and cross-over setting. The area under the curve (AUC) of total nocturnal melatonin plasma concentration decreased 23.3 +/- 11.5% in young subjects (P < or = 0.05) and 39.3 +/- 5.2% in middle-aged subjects (P < or = 0.05) after flunitrazepam infusion compared with placebo infusion. Differences in nocturnal peak values of melatonin were 5.4 +/- 22.0% in young subjects (not significant) and 34.0 +/- 14.7% in middle-aged subjects (p < or = 0.05). Flunitrazepam significantly (P < or = 0.05) improved sleep latency and the number of sleep stage changes in the group of all subjects. These results show that, although the benzodiazepine flunitrazepam improves sleep, it reduces the nocturnal secretion of melatonin, and therefore alters the circadian rhythm of a hormone which is supposed to play a special role in circadian sleep-wake rhythmicity.

Lamotrigine in the treatment of nocturnal myoclonus syndrome (NMS): two case reports

In previous investigations we found an increase of D2 dopamine receptors in the striatum of patients with nocturnal myoclonus syndrome (NMS) after treatment with dopamimetics. Under the hypothesis, that, according to animal experiments, the glutamatergic system could be involved in this atypical dopaminergic up-regulation in NMS. The glutamate release inhibitor lamotrigine was tested in up to now two NMS patients. The results and the success of this approach and its implications are discussed.

[123I]IBZM SPET analysis of dopamine D2 receptor occupancy in narcoleptic patients in the course of treatment

Elevated levels of central D2 dopamine receptors were found on postmortem examination in cases of human narcolepsy. In vivo investigations using positron emission tomography (PET) and single photon emission tomography (SPET) found no changes of D2 binding in the striatal structures. To investigate whether the elevated D2 receptors in postmortem investigations are due to long-term treatment effects, we applied 123I-labeled (S)-2-hydroxy-3-iodo-6-methoxy-([1-ethyl-2-pyrrolidinyl]methyl) benzamide (IBZM) ([123I]IBZM, a highly selective CNS D2 dopamine receptor ligand) and SPET in narcoleptic patients in the course of treatment with stimulants and/or antidepressants. Before treatment we found no changes in D2 binding in 10 patients (in comparison to 10 normal controls). After treatment (performed in five patients for 3 months) we found changes in D2 binding in four of them, indicating that the results of the postmortem studies could have been influenced by long-term medications. Human narcolepsy seems not to be related to a striatal D2 dopaminergic disturbance.

[Functional palatoraphy and modified chin osteotomy in surgical therapy of sleep-related respiratory disorders with obstruction of the upper airways]

We have developed a new surgical approach, called functional palatoraphy. This procedure preserves the posterior border of the soft palate and allows a controlled repair of the soft palate. It is routinely combined with a chin osteotomy. In selected cases this procedure is an alternative to other surgical methods.

Effects of chronic treatment with methadone and naltrexone on sleep in addicts

Previous studies have described sleep disturbance secondary to chronic opiate use and abuse. Drug-dependency insomnia is of interest because chronic sleep disturbances can promote depressive symptoms which could lead to a drug relapse. For the first time we compared the polysomnographic parameters of 10 methadone-substituted outpatients and 10 naltrexone-treated outpatients. Methadone (mu-opioid agonist) produced a marked fragmentation of the sleep architecture with frequent awakenings and a decrease in EEG arousals. In comparison with methadone and controls, the naltrexone (mu-opioid antagonist) group showed the shortest sleep latency and the longest total sleep time. These data indicate that mu-agonists and mu-antagonists have different effects on sleep. The implications, especially the involvement of opioid-dopamine interactions on sleep and movements during sleep, are discussed.

Sleep disturbances in the demented elderly: treatment in ambulatory care

We report the results of a representative survey in Lower Saxony, Germany, that focused on the treatment of sleep disturbances in the moderately demented elderly. Two written sample case histories (vignettes) described either a vascular demented patient suffering from nocturnal wandering or an Alzheimer's-type demented patient without apparent psychotic or behavioral (sleep) disorder. These were randomly assigned and presented to 145 family physicians and 14 neuropsychiatrists working in private practice by a trained investigator, who then conducted a standardized interview with the physicians. The study was representative of physicians (response rate: 83.2%). In response to the question concerning how they would treat the patient's sleep disturbances, about 20% of the physicians (with respect to both versions) answered that they would not choose drugs. More than 40% considered neuroleptics to be the drugs of choice. Benzodiazepines, antidepressants and other substances were seldom considered. No significant difference was noted in the response to the two different case histories. The results allow for the conclusion that non-drug treatments, which (at least initially) should be the treatment of choice, are mainly disregarded by the majority of the ambulatory care physicians. The reason for this seems to be a lack of education in sleep medicine and also in geriatric medicine.

[Factors influencing the prescribing of nootropic drugs. Results of a representative inquiry in Lower Saxony]

AIM OF INVESTIGATION

To discover (1) to what extent patients' wishes and the extent of any abnormality of brain performance influence the frequency with which "nootropic" drugs (those thought to affect brain activity, e.g. piracetam, pyritinol, or improve cerebral circulation, e.g. xanthine derivatives, Ginkgo biloba, secale alkaloids, calcium antagonists) are prescribed; (2) the medical practitioner's expectations of the effectiveness of such medications.

METHOD

In a personal interview, 145 family doctors and 14 neurologists in private practice in the Göttingen area of Germany (participation rate: 83.2% of those asked to participate) were questioned about fictitious cases (case 1: mild memory problem with or without expressed wish for medication; case 2: moderate dementia, of Alzheimer or multi-infarct type). The previously arranged interviews, which took place in the doctors' practice rooms, consisted of standardized open questions to the written case reports.

RESULTS

Regardless of the wish of the patient and the extent and type of the abnormal brain function about 70% of all participating doctors would prescribe those drugs, even though about 56% had doubts about their effectiveness. About 28% expected a positive effect on brain performance. A nearly equal proportion of doctors would continue an existing drug regimen as would prescribe one.

CONCLUSION

The prescription of the named group of drugs is influenced less by medical criteria than by factors which concern doctor-patient relationship.

[Panic disorder and agoraphobia: what is effective?]

The present survey of controlled studies on the treatment of panic disorder and agoraphobia (PDA) reveals that treatment with tricyclic antidepressants (e.g., imipramine and clomipramine), benzodiazepines (e.g., alprazolam), serotonin reuptake inhibitors (e.g., fluvoxamine) and the monoamine oxidase inhibitor phenelzine has been proven effective. Among psychological therapies, cognitive therapy and exposure therapy in agoraphobia have been shown to be effective. There is an insufficient number of comparisons between pharmacological and psychological treatments. From the existing studies it can be assumed that none of these treatment modalities is superior to the other. The few existing follow-up studies do not suffice to prove a longer lasting effect for the psychological therapies, compared with drug therapies. Because of the low number of investigations, it cannot be clearly stated whether it is useful or harmful do treat patients with psychopharmacological drugs during psychological therapy. It is more likely that this combination is advantageous.

Nocturnal plasma melatonin levels in patients suffering from chronic primary insomnia

Polysomnographic sleep patterns and melatonin secretion were investigated in 10 patients (age: 41.3 +/- 9.5 years) who suffered from chronic primary insomnia and complained predominantly about difficulties in maintaining sleep and in five healthy controls (age 27.2 +/- 0.7 years). Nocturnal plasma melatonin concentrations were obtained hourly, measured by direct radioimmunoassay and statistically compared between insomniacs and controls with age as a covariate. Plasma melatonin levels in the patient group tended to begin increasing earlier in the evening and were significantly (P < or = 0.01) lower during the middle of the night (peak value 82.5 +/- 26.5 pg/ml) than in the healthy controls (peak value 116.8 +/- 13.5 pg/ml). Among the patients, the most severely reduced nocturnal plasma melatonin levels were found in those patients with a history of sleep disturbance lasting for longer than five years (N = 6; age 41.8 +/- 11.7 years; duration 15.3 +/- 5.9 years; peak value 72.1 +/- 25.0 pg/ml); whereas those chronic insomniacs affected for fewer than five years had relatively higher nocturnal levels (N = 4; age 40.6 +/- 6.5 years; duration 3.8 +/- 1.5 years; peak value 98.2 +/- 23.9 pg/ml). These results show that the circadian rhythm of melatonin secretion is disturbed in patients with chronic primary insomnia, and that the nocturnal plasma melatonin secretion is increasingly more affected the longer the patients are unable to maintain a regular sleep pattern.

Reasons for prescribing cognition enhancers in primary care. Results of a representative survey in Lower Saxony, Germany

With regard either to the controversial debate about the efficacy of cognition enhancers (CEs) or to the high costs which the frequent prescription of these drugs causes the German health system's economy, we wanted to know what physicians expect from a therapy with these drugs. We performed a representative survey (response rate 83.2%) in Lower Saxony, Germany from February to July 1993. We designed two written case vignettes which described either a patient with slight memory problems or a moderately demented patient who also suffers from common systemic disorders. In a face-to-face interview 145 general practitioners and primary care internists (family physicians) and 14 community neuropsychiatrists answered the question, whether they would prescribe CEs to each of the patients described and what they would expect from this therapy. 70.4% of all physicians would prescribe a cognition enhancer to the slightly impaired patient and 63.5% to the multimorbid moderately demented patient, respectively. More than 50% of the family physicians would not expect any positive therapeutic effect in both patients, while the neuropsychiatrists did so in 57.1% in the patient with slight memory disturbances and in 35.7% in the moderately demented patient. A positive effect on cognition was expected by 28.2% of all physicians in the slight and by 18.3% in the moderately impaired patient, respectively. Other reasons mentioned were amelioration of cerebral perfusion and drive, as well as effects on disease progression. In conclusion, the results of this study clearly demonstrate that cognition enhancers are prescribed in spite of major doubts in their efficacy.

[Sleep disorders--what can be done when hypnotics no longer help? Overview and case report]

We report on the case of a 45-year old female with chronic insomnia and refractory to hypnotics, who also has a - polygraphically documented - tolerance to the imidazopyridine "zolpidem". We discuss the main differential diagnosis and demonstrate a therapeutic regimen which allows a step-by-step replacement of hypnotics by sedative antidepressants. This interval replacement treatment reduces on the one hand the risk of developing a severe withdrawal syndrome. On the other hand the replacement by sedative antidepressants improves insomnia and insomnia-associated depressive symptoms. Finally, the clinical implications and rationale of a therapeutic approach with sedative antidepressants in chronic insomnia are discussed.

[Chronification of sleep disorders. Results of a representative survey in West Germany]

In a representative selection of German citizens who were older than 13 years of age, 1,997 were asked about their sleep complaints. They were also asked how frequently a physician was consulted and how often sleeping pills were taken. According to our results sleep disturbances are an important health problem in Germany. Every fourth person suffers at least sometimes from difficulties in falling asleep and/or staying asleep, problems which are not due to external influences. Seven percent suffer frequently or always from these complaints; 15% report that they are frequently tired or that they are always tired during the day. Ten percent of all persons suffering from sleep complaints take sleeping pills daily or at least sometimes during the week. Forty-five percent of all persons who take hypnotics daily still frequently or always suffer from difficulties in falling asleep and/or staying asleep. Furthermore, sleep complaints tend to become chronic: 75% of the sleep-disturbed population are chronically ill, having had complaints for more than 2 years of since childhood. They suffer from sleep disturbances and from reduced performance during the following day. Nevertheless, it appears as though neither patients nor physicians take insomnia seriously. This might answer the question of why only 17% of the persons who do not suffer more than 2 years from sleep disturbances and only 49% of the chronically ill population consult a doctor because of their sleep disturbances. The results of this study indicate the importance of informing patients and physicians about insomnia and different ways of treating it.

Assessing the efficacy of treatments for panic disorder and agoraphobia. I. Methodological problems

An assessment of the efficacy of treatments in panic disorder and agoraphobia (PDA) is complicated by methodological problems resulting from the complexity of these disorders. In this paper, commonly used anxiety scales are discussed with regard to their relevance in the assessment of PDA. Although there are already many scales for assessing anxiety and agoraphobia, a qualified instrument for measuring the severity of PDA is still lacking. A survey of the instruments used in recent treatment studies of PDA shows that rather inhomogeneous efficacy criteria were applied. Most often, panic attack frequency was taken as a severity criterion, although this measure showed little power to differentiate between treatments. To deal with the special features of PDA, a battery of different scales was usually employed and non-standardized scales were sometimes used additionally. A new rating scale designed to overcome the methodological problems associated with the assessment of severity in PDA was introduced. The use of the psychiatrist-rated Panic and Agoraphobia (P&A) scale in patients with DSM-III-R panic disorder and/or agoraphobia (n = 235) shows that this scale has the highest correlation with the psychiatrists' clinical global impression of PDA patients (r = 0.79, p < 0.0001), compared with other commonly used observer-rated anxiety scales. The self-rating version of the P&A again had the highest correlation with a patient-rated clinical global impression (r = 0.82, p < 0.0001), whereas the other patient-rated anxiety questionnaires correlated only moderately or poorly. By means of logistic regression, it was shown that the five subscores of the scale contribute independently and almost equally to the prediction of PDA severity.