The role of sleep and wakefulness in the genesis of depression and mania

Disturbances of the sleep-wake cycle are frequently seen in affective illness and are exhibited in other psychiatric illness as well. In addition to being a useful research probe, manipulations of the sleep-wake cycle such as sleep deprivation (SD) and phase advance can cause depression to remit and thus can be used as alternative or as adjunctive to pharmacologic treatment. The antidepressant response to SD occurs whether antidepressant drugs are administered or not. However, there is some evidence that the concomitant use of antidepressants may prevent the relapses that occur after recovery sleep. Data from clinical investigations also indicate that disrupted sleep can trigger and intensify mania. Rapid cycling bipolar patients may be especially vulnerable to mania/hypomania after disrupted sleep or SD. Characteristic changes in body temperature have been recorded in sleep deprivation as well as in other antidepressant treatment modalities. Thermoregulatory physiology may therefore provide a framework for understanding the effects of sleep-wake manipulations in affective illness.

Recurrent brief depression and its relationship to seasonal affective disorder

Recurrent brief depression (RBD) and seasonal affective disorder (SAD) have been both recently described as subgroups of major depression (DSM-III-R). We have established a relationship between these two syndromes in a cohort of 42 outpatients who presented themselves to a clinic for seasonal affective disorder at the Psychiatric Department of the University of Bonn, FRG. Our preliminary data indicate that 31% of the patients who were diagnosed as suffering from either SAD or its subsyndromal form (S-SAD) can also be categorized as RBD (RBD-seasonal) in a 1-year observation period. During the time span of 1 year RBD-seasonal patients had a mean number of 20 (SD 9) episodes compared with 6 (SD 5) episodes (P less than 0.001) in the group of seasonal patients without BRD. These episodes were accentuated in fall/winter and outnumbered those in spring/summer significantly (P less than 0.001). The mean duration of each episode was 4.6 (SD 2.6) days in the RBD-seasonal group and 21.8 (SD 29) in the non-RBD-seasonal group. Patients with RBD-seasonal experienced seasonal changes as more of a problem and reported a lower percentage of first-degree relatives with a history of depression than the non-RBD-seasonal group.

Contrasts between symptoms of summer depression and winter depression

Epidemiological studies and studies of clinical populations suggest that there are primarily two opposite patterns of seasonally recurring depressions: summer depression and winter depression. In addition, there is preliminary evidence that the two seasonal types of depression may have opposite types of vegetative symptoms. In the present study, we prospectively monitored symptoms of depression in 30 patients with recurrent summer depression and 30 sex-matched patients with recurrent winter depression and compared the symptom profiles of the two groups. Consistent with predictions based on the earlier reports, we found that winter depressives were more likely to have atypical vegetative symptoms, with increased appetite, carbohydrate craving, weight gain and hypersomnia, and that summer depressives were more likely to have endogenous vegetative symptoms, with decreased appetite and insomnia. A cluster analysis performed on the patients' symptom profiles without reference to season of occurrence of their episodes separated 78% of the summer depressives and winter depressives from each other on the basis of their symptoms (chi 2 = 19.29, P less than 0.001).

Abnormal pituitary-adrenal responses to corticotropin-releasing hormone in patients with seasonal affective disorder: clinical and pathophysiological implications

CRH has been shown to produce increased locomotion, arousal, and anorexia in experimental animals. A deficiency of CRH in patients with seasonal affective disorder could contribute to the characteristic lethargy, hypersomnia, and hyperphagia characteristic of this illness. To test this hypothesis, we studied basal plasma ACTH and cortisol levels and their responses to ovine CRH in controls and depressed patients with seasonal affective disorder before and after light treatment. Untreated seasonal affective disorder patients showed normal basal plasma cortisol and ACTH levels, but their responses to CRH tended to be delayed and were significantly reduced. When patients were studied after 9 days of light treatment, a significant increase in plasma ACTH and cortisol responses to CRH was observed. Our findings in untreated patients with seasonal affective disorder are similar to those in patients with Cushing's disease 2 weeks after transsphenoidal hypophysectomy, who uniformly show sustained suppression of their CRH neuron because of long-standing hypercortisolism. This findings suggest that the CRH neuron of patients with seasonal affective disorder is hypofunctional. We postulate that the clinical symptomatology in patients with seasonal affective disorder could reflect deficient activity of this important arousal-producing system.

Therapeutic sleep deprivation and antidepressant medication in patients with major depression

Although there is a body of literature on the therapeutic efficacy of sleep deprivation (SD) there are only a few investigations in which the relevance of antidepressive medication for the clinical efficacy of SD has been studied. Based on the literature and on our own investigations with major depressed patients it seems that for the day-1 response it does not matter if and what type of antidepressive medication the patient receives. Furthermore, the results of our double blind study reveal that the day-1 response to total sleep deprivation (TSD) is not associated with a clear relationship to the outcome after 4 weeks treatment with either fluvoxamine or maprotiline. On the other hand, our data indicate that the day-2 response to TSD is significantly correlated with a beneficial outcome after subchronic treatment with maprotiline.

Immunological correlates of seasonal fluctuations in mood and behavior and their relationship to phototherapy

Immunological parameters were studied before and after phototherapy, with bright and dim light, in 38 individuals with a range of retrospectively reported seasonal changes in mood and behavior. There was a significant negative correlation between the degree of mood and behavioral difficulties in fall and winter (seasonality) and the total number of circulating natural killer cells. Changes in the numbers of circulating helper T cells correlated significantly with changes in mood following phototherapy. Moreover, mitogen-induced lymphocyte blastogenesis increased significantly after phototherapy, but there was no significant difference between the bright and dim light treatments. The results suggest that cellular immune function is associated with both seasonality and response to phototherapy.

Evaluation of seasonality in six clinical populations and two normal populations

The Seasonal Pattern Assessment Questionnaire (SPAQ) was used to evaluate retrospectively self-reported seasonal changes in mood and behavior (seasonality) of two normal and six clinical populations: patients with winter-seasonal affective disorder (SAD), summer-SAD, eating disorders, bipolar affective disorder, major depressive disorder and subsyndromal winter-SAD. The SPAQ successfully discriminated between groups expected to have high seasonality scores, such as winter-SAD, summer-SAD and subsyndromal winter-SAD, and normal controls. Bipolars and major depressives had normal seasonality scores. Patients with eating disorders had unexpectedly high scores. There was a general tendency for all groups to eat and sleep more and to gain weight in the winter. The implications of these findings are discussed.

Seasonality in major depressed inpatients

The proportion of patients with a fall-winter pattern of feeling worst comparable to that of patients with seasonal affective disorder (SAD) was 11.4% in our sample of major depressed inpatients. Since admission to psychiatric inpatient services is influenced to an unknown extent by various factors it is not possible to generalize our data to other facilities. However, based on the results of our study it seems worth while to screen depressed patients for their degree of seasonality since treatment with bright artificial light has been shown to be beneficial in SAD patients and its subsyndromal form.

Response to total sleep deprivation before and during treatment with fluvoxamine or maprotiline in patients with major depression--results of a double-blind study

To test the hypothesis that the antidepressant effects of total sleep deprivation (TSD) are linked to the serotonergic and/or noradrenergic system the authors carried out a double-blind study (fluvoxamine versus maprotiline) in 42 inpatients with endogenous depression (ICD). Patients were randomized to a four-week treatment with either fluvoxamine (100-300 mg/day) or maprotiline (100-300 mg/day). In addition, patients underwent a TSD procedure before and after one week of antidepressant medication. There was a statistically significant reduction of depression ratings (HDRS) in both the fluvoxamine and maprotiline group. The day-1 response to TSD before antidepressive medication was not associated with a clear relationship to the outcome after four weeks of treatment with either fluvoxamine or maprotiline. On the other hand, the day-2 response to TSD was significantly correlated with a good outcome to subchronic treatment with maprotiline. Furthermore, the results of the authors' data suggest that a favorable short-term outcome of TSD may be connected to antidepressants enhancing the serotonergic neurotransmission. The global comparison between fluvoxamine and maprotiline revealed that the group of patients treated with fluvoxamine had a significantly higher efficiency index (CGI) than the maprotiline group; fluvoxamine was rated to be tolerated excellently in 70% of the patients whereas this percentage was only 43% in the maprotiline group. There was also significantly more vertigo and dry mouth in the maprotiline group whereas the fluvoxamine group was rated to have significantly more sleep disturbances during the trial.

Multiple hormone responses to stimulation with dl-fenfluramine in patients with major depression before and after antidepressive treatment

The authors investigated 31 drug-free inpatients with major depression using dl-fenfluramine (dl-FEN) as a serotonin probe (fenfluramine stimulation test, FFT). The FFT was performed in the same individuals (intraindividual comparison) with and without application of dl-FEN and before and after antidepressive treatment. Blood samples were analyzed for prolactin, cortisol, thyrotropin (TSH), growth hormone (HGH), dl-FEN and its major metabolite dl-norfenfluramine. There was no difference in the conditions before and after treatment as regards peak plasma levels of dl-FEN. Compared with saline, significant (P less than 0.01) increases were detected for dl-FEN-stimulated cortisol and prolactin values. A significantly (P less than 0.01) lower increase in dl-FEN-stimulated prolactin values was found after treatment compared with the situation before treatment, a finding which was dependent on the type of medication which the patients were receiving at the time when the test procedure took place. Baseline and dl-FEN-stimulated cortisol values were significantly (P less than 0.001) lower and TSH values were significantly (P less than 0.01) higher in the condition after compared with the one before treatment. Patients' mean peak delta prolactin responses to dl-FEN before treatment were significantly (P less than 0.05) correlated with those of patients after subchronic treatment with fluvoxamine. Hormonal responses were neither associated with the severity of the illness nor with a specific psychopathological profile.

The effects of phototherapy in the general population

Patients with recurrent winter depression and its subsyndromal form have been reported to benefit from bright full-spectrum light (phototherapy). In order to determine whether this treatment (2 h in the morning) during winter is effective in a random sample of the general population we investigated the responses of 20 subjects with varying degrees of winter difficulties. A control group (n = 20) matched for the degree of seasonality, age, and sex was treated with dim light. Individuals were selected from a larger survey sample of the Montgomery County population (MD, U.S.A.) and were comparable to the latter in their degree of winter difficulties. Enhancement of environmental light does not, on the basis of the present study, appear to be indicated for the public at large, but rather for a subgroup of individuals with histories of winter difficulties.

Effects of light treatment on core body temperature in seasonal affective disorder

Abnormalities in circadian rhythms of core body temperature have been reported previously in depressed patients. In this study, we compared the temperature rhythms of 10 depressed seasonal affective disorder (SAD) patients with winter depression with those of 12 normal controls and evaluated the effects of bright light on temperature in SAD. Unlike previous studies of depressed patients, the temperature curves of the patients and normal controls during the off-light condition were nearly identical. We found a significant difference in amplitude between the patients in the untreated and light-treated conditions. Although there was no systematic difference in circadian phase across groups or treatment conditions, we present preliminary evidence that suggests that phase-typed subgroups may be present in the population distinguished by their treatment responses.

Epidemiological findings of seasonal changes in mood and behavior. A telephone survey of Montgomery County, Maryland

Patterns of seasonal changes in mood and behavior in Montgomery County, Maryland, were evaluated in randomly selected household samples by lay interviewers using a telephone version of the Seasonal Pattern Assessment Questionnaire. The method for selecting the sample unit was random-digit dialing. We found that 92% of the survey subjects noticed seasonal changes of mood and behavior to varying degrees. For 27% of the sample seasonal changes were a problem and 4.3% to 10% of subjects, depending on the case-finding definition, rated a degree of seasonal impairment equivalent to that of patients with seasonal affective disorder. The seasonal pattern of "feeling worst" exhibited a bimodal distribution with a greater winter and a substantially lower summer peak (ratio, 4.5:1). Younger women who have a problem with seasonal changes and who feel worse on short days tended to exhibit the highest seasonality scores. It is apparent from our study that seasonal affective disorder represents the extreme end of the spectrum of seasonality that affects a large percentage of the general population. The influence of environmental factors on mood disorders and mood changes in the general population might provide valuable insight into pathogenesis, treatment, and prevention of affective illness.

Phototherapy in individuals with and without subsyndromal seasonal affective disorder

Antidepressant and energizing effects of bright light exposure (phototherapy) have been widely reported to occur in patients with seasonal affective disorder. We have attempted to evaluate whether other segments of the population might benefit from phototherapy, most notably individuals with subsyndromal seasonal affective disorder, as well as healthy individuals with no winter difficulties (controls). We have studied 20 subjects in each of these two categories and have found that bright artificial light did not alter mood and behavior in controls. In contrast, individuals with subsyndromal seasonal affective disorder responded favorably to treatment with bright environmental light. A dose of 5 hours of bright light exposure, divided between morning and evening, was more effective than 2 hours of exposure. This finding may have practical implications for establishing optimal environmental lighting conditions for those individuals whose winter difficulties do not meet criteria for seasonal affective disorder.

Seasonal changes in mood and behavior: a cluster analytic approach

We report on the cluster analysis of 416 subjects from Montgomery County, Maryland, USA, who responded to lay interviewers using a telephone version of the Seasonal Pattern Assessment Questionnaire (SPAQ). Eight clusters are described, the smallest of which is consistent with a pattern comparable to that seen in patients with winter seasonal affective disorder (SAD). A larger group of individuals seems to demonstrate patterns equivalent to that of subsyndromal winter SAD patients. Furthermore, it was apparent that a large percentage of the study group seems to be affected to some degree by the characteristics of the seasons. It was observed, perhaps for the first time, that feeling worse when there is a high pollen count appears to be associated with the symptom pattern seen in winter SAD patients. There is also evidence for the existence of a group of summer subsyndromal SAD subjects.

Phototherapy in subsyndromal seasonal affective disorder (S-SAD) and "diagnosed" controls

Antidepressant and energizing effects of bright light exposure have been widely reported to occur in patients with seasonal affective disorder (SAD). In order to evaluate whether other segments of the population might also benefit from this treatment, we studied 20 normal individuals with mild SAD-like symptoms (subsyndromal SAD, S-SAD) and 20 with no reported seasonal difficulties (non-S-SAD). Whereas S-SAD individuals benefited from phototherapy, non-S-SAD normals did not. This finding raises the questions of whether a history of seasonal problems might be a marker of vulnerability to affective episodes and if S-SAD individuals might be considered as a high risk population in this regard.

Nocturnal TSH and prolactin secretion during sleep deprivation and prediction of antidepressant response in patients with major depression

In order to test the hypothesis that changes in the hypothalamic-pituitary axis during sleep deprivation are related to the antidepressant effects of this procedure, we measured thyroid-stimulating hormone (TSH) and prolactin levels in 32 depressed patients at 2:00 AM during a night before, during, and after total sleep deprivation (TSD). TSH levels increased significantly (p less than 0.05) during TSD, and prolactin levels decreased significantly (p less than 0.0001). When we divided the patients into responder and nonresponder groups based on a 30% reduction in the Hamilton Rating Scale, there was no difference between the two groups in their hormone levels on the baseline, TSD, or recovery nights. Changes in prolactin or TSH were not correlated with clinical improvement when the two groups were considered together or in the responder/nonresponder groups separately. Baseline values of both hormones were significantly (p less than 0.01) correlated with their respective levels during TSD and recovery sleep. These findings indicate that the relative levels of nocturnal TSH and prolactin are stable even within acutely depressed individuals and that changes in their levels are not related to the clinical response to sleep deprivation.

Judgement of the hypothalamic-pituitary-adrenocortical function in psychiatric patients by betamethasone-induced cortisol suppressibility

Betamethasone induced cortisol suppressibility was examined in 62 drug free consecutively admitted psychiatric inpatients. Betamethasone was choosen instead of the commonly used dexamethasone, because its double half-life compared to dexamethasone and its higher tissue availability. After a base-line evaluation with blood samples drawn at 8 a.m., 4 p.m., and 11 p.m., 0.5 mg or 1.0 mg betamethasone was given orally at 11 p.m. Postbetamethasone cortisol as well as betamethasone blood levels were then measured at the same time points as on the baseline day. In the groups receiving 1.0 mg betamethasone non-depressed patients had significantly (p less than 0.05) lower postbetamethasone cortisol levels than depressed patients for each time point measured whereas 0.5 mg betamethasone did not differentiate depressed from non-depressed patients. Patients with other depressions like schizoaffective psychosis-depressive subtype- or organic brain syndrome with depressive symptomatology demonstrated similar postbetamethasone cortisol profiles as the group of patients with major depression. Betamethasone plasma concentrations differed significantly (p less than 0.001) with respect to the oral dosage with higher values for the 1.0 mg betamethasone groups.

The CGTCA sequence motif is essential for biological activity of the vasoactive intestinal peptide gene cAMP-regulated enhancer

cAMP-regulated transcription of the human vasoactive intestinal peptide gene is dependent upon a 17-base-pair DNA element located 70 base pairs upstream from the transcriptional initiation site. This element is similar to sequences in other genes known to be regulated by cAMP and to sequences in several viral enhancers. We have demonstrated that the vasoactive intestinal peptide regulatory element is an enhancer that depends upon the integrity of two CGTCA sequence motifs for biological activity. Mutations in either of the CGTCA motifs diminish the ability of the element to respond to cAMP. Enhancers containing the CGTCA motif from the somatostatin and adenovirus genes compete for binding of nuclear proteins from C6 glioma and PC12 cells to the vasoactive intestinal peptide enhancer, suggesting that CGTCA-containing enhancers interact with similar transacting factors.

Auditory evoked potentials and total sleep deprivation in depressed patients

Cortical auditory evoked potentials (latencies N1 and P2, N1-P2 amplitude, and amplitude/stimulus intensity function) were studied before and after 1 night's total sleep deprivation in 20 drug-free depressed inpatients. Responders to sleep deprivation showed an augmenting pattern on the non-dominant hemisphere and a reducing pattern on the dominant hemisphere. The interhemispheric difference in auditory cortex was also apparent in the group of patients who failed to respond to sleep deprivation, but with values pointing in the opposite direction. The augmenting pattern shown by responders in the nondominant hemisphere may be a predictor of therapeutic response to sleep deprivation and to subsequent treatment with drugs influencing serotonergic pathways.

[Season-related forms of depression. II. Modification by phototherapy and biological results]

The efficacy of phototherapy with bright, fluorescent, full-spectrum light for treatment of seasonal affective disorders (SAD) has now been widely demonstrated in controlled studies. However, treatment with dim light did not reveal a significant therapeutic improvement. Specific parameters of light treatment are necessary or optimal for producing this response and light intensity and duration in contrast to timing and spectrum seem to be a major importance. The mechanism of action of phototherapy is closely linked to the psychobiology of SAD and has not yet been satisfactorily explained. Among the several theories which have been proposed, the melatonin hypothesis and phase shift hypothesis have been the basis for the earlier studies. Newer theories also include the function of further neuroendocrine systems, as well as neurotransmitter and immune function and electrophysiological mechanisms. Until now, the value of phototherapy in the treatment of other non-seasonal syndromes has not yet been explored thoroughly and this line of research seems worth continuing.

[Season-related forms of depression. I. Principles and clinical description of the syndrome]

Seasonal changes in behavior und physiology have been recognized in humans since ancient times. Their relevance to psychiatry was described in further detail at least as early as in the middle of the last century. However, it was only in the past six years that clinical studies were undertaken systematically to describe the profile of a syndrome that was called seasonal affective disorder (SAD) by Rosenthal et al. It emerged, that this condition is characterized by changes in affect with depressed mood, anxiety and irritability and decreased energy. In contrast to major affective disorder these patients exhibit increased appetite with carbohydrate craving, weight gain and an increased duration of sleep. Seasonality of mood and behavior appears to be a dimension affecting many different people including normal individuals and those with conditions other than SAD. In vulnerable individuals these changes may reach symptomatic levels whereas in normals they may be regarded as acceptable fluctuations.