Acupuncture increases nocturnal melatonin secretion and reduces insomnia and anxiety: a preliminary report

The response to acupuncture of 18 anxious adult subjects who complained of insomnia was assessed in an open prepost clinical trial study. Five weeks of acupuncture treatment was associated with a significant (p = 0.002) nocturnal increase in endogenous melatonin secretion (as measured in urine) and significant improvements in polysomnographic measures of sleep onset latency (p = 0.003), arousal index (p = 0.001), total sleep time (p = 0.001), and sleep efficiency (p = 0.002). Significant reductions in state (p = 0.049) and trait (p = 0.004) anxiety scores were also found. These objective findings are consistent with clinical reports of acupuncture's relaxant effects. Acupuncture treatment may be of value for some categories of anxious patients with insomnia.

Subjective and Objective Evaluation of Sleep and Performance in Daytime Versus Nighttime Sleep in Extended-Hours Shift-Workers at an Underground Mine

Extended hours of shift work has the potential for adverse consequences for workers, particularly during the nightshift, such as poorer sleep quality during the day, increased worker fatigue, and fatigue-related accidents and decreased work performance. This study examined subjective and objective measurements of sleep and performance in a group of underground miners before and after the change from a backward-rotating 8-hour to a forward-rotating 10-hour shift schedule. The purpose of this study was to evaluate the short- and long-term impact of a shift schedule change on sleep and performance. The results demonstrated improved subjective and objective measures of sleep and performance on the new 10-hour nightshift schedule. The 10-hour nightshift workers subjectively reported more refreshing sleep, fewer performance impairments and driving difficulties than 8-hour nightshift workers. The results of the objective measures of sleep and performance on the 10-hour nightshifts were overall similar or possibly better than those measured on the 10-hour dayshifts. These are some of the first data to suggest that a nightshift that does not encompass the entire night period could have significant benefits to shift-workers. We suggest that these benefits are mostly the result of the timing of the new nightshift start and end times rather than other shift-schedule factors.

Predictors of Impaired Daytime Sleep and Wakefulness in Patients With Parkinson Disease Treated With Older (Ergot) vs Newer (Nonergot) Dopamine Agonists

BACKGROUND

Patients with Parkinson disease (PD) treated with the nonergot dopamine agonists pramipexole dihydrochloride and ropinirole hydrochloride have been reported to have sleep attacks without warning.

OBJECTIVE

To perform a systematic evaluation of excessive daytime sleepiness using standard polysomnographic techniques.

DESIGN

Two overnight studies and daytime sleep tests were performed on a prospective sample. Pathologic daytime sleep latency was indexed by a mean Multiple Sleep Latency Test score of no greater than 5 minutes or a mean Maintenance of Wakefulness Test latency of no greater than 20 minutes.

PATIENTS AND SETTING

Eighty nondemented, independent PD patients treated with dopamine agonists at the Toronto Western Hospital Sleep Research Unit, Toronto, Ontario.

RESULTS

Patients treated with pramipexole dihydrochloride (n = 29), ropinirole (n = 28), or bromocriptine mesylate or pergolide mesylate (n = 23) did not differ with respect to mean Multiple Sleep Latency Test scores (overall, 12.1 minutes [SD, 5.1 minutes], F(2,77) = 0.11; P =.90) or mean Maintenance of Wakefulness Test latencies (overall, 26.7 minutes [SD, 5.4 minutes]; F(2,77) = 1.1; P =.29). Fifteen patients (18.8%) exhibited pathologic daytime sleep latencies. The main risk factor associated with pathologic daytime sleep latency was high levodopa dosage equivalents (>867.5 mg; odds ratio, 4.2; 95% confidence interval, 1.3-13.7). Subjective accounts of daytime sleep and wakefulness, as indexed by scores on the Epworth Sleepiness Scale, were not related to impaired daytime sleepiness or wakefulness (chi(2)(1) [n = 80], 0.13; P =.72).

CONCLUSIONS

Total dopaminergic drug dose rather than the specific dopamine agonist used is the best predictor of daytime sleepiness in PD patients receiving dopamine agonist therapy. Physicians concerned with daytime hypersomnolence in PD patients treated with dopamine agonists and receiving high levodopa dosage equivalents should consider polysomnographic monitoring for impaired daytime sleep latency.

Underlying sleep pathology may cause chronic high fatigue in shift-workers

About 20-25% of the population in primary healthcare settings complains of chronic fatigue but this symptom has been under-emphasized compared with sleepiness in clinical practice. Shift-workers are particularly vulnerable because of various fatigue-related personal and public morbidity and mortality. The goal of this cross-sectional study was to explore if fatigue severity could be used as an independent predictive tool to identify underlying sleep pathology. The 21 most-fatigued (study group) and 23 least-fatigued (control) miners were selected on the basis of the Fatigue Severity Scale (FSS), which was administered to 195 subjects in an underground mine in Timmins, a town in northern Ontario. The two groups were matched for age, gender, and body mass index (BMI). Mean FSS score for the most-fatigued subjects was 4.9 +/- 0.5 and the least-fatigued was 2.2 +/- 0.5 (P < 0.0001). The subjects from each group were studied polysomnographically to identify sleep disorders. The polysomnographic data in 15 of 21 (71.4%) of the most-fatigued subjects displayed significant sleep pathology compared with only three of 23 (13.0%) in the least-fatigued subjects. Based on Fisher's exact test, the difference between the two groups was highly significant (P < 0.0001). Also, in the total subject pool (n = 195), the correlation between subjective fatigue and sleepiness was not very strong (Pearson's r = 0.45), suggesting that these two symptoms can be independent phenomena. It is concluded that chronic high fatigue can be an independent manifestation of underlying sleep pathology, which warrants independent subjective and objective assessment.

Sexsomnia--a new parasomnia?

OBJECTIVE

To describe a distinct parasomnia involving sexual behaviour, which we have named sexsomnia.

METHOD

We have used a case series as a basis for the description of sexsomina.

RESULTS

Eleven patients with distinct behaviours of the sexual nature during sleep are described. The features in common with other nonrapid eye movement arousal parasomnias, such as sleepwalking are documented. Some patients had simply been referred to a tertiary sleep clinic for investigation of unrelated sleep problems. A small number had been involved in medicolegal issues. Sexsomnia has some distinct features that separate it from sleepwalking. The automatic arousal is more prominent, motor activities are relatively restricted and specific, and some form of dream mentation is often present.

CONCLUSIONS

A significant number of patients with this unusual parasomnia behaviour were identified only after specific questions were asked, suggesting that the behaviour is more common than previously thought.

Health and socioeconomic status differences among antibody hepatitis C positive and negative transfusion recipients, 1986-1990

OBJECTIVE

To characterize the socioeconomic and health status, disease symptoms of anti-HCV-positive and negative transfusion recipients.

METHODS

A cross-sectional interviewer-administered survey of subjects identified through the British Columbia Blood Recipient Program. Study subjects were 18 years and over and had to have had a transfusion between August 1, 1986 and June 30, 1990 and completed an interview of satisfactory quality. Anti-HCV-positive subjects were those seeking monetary compensation from the provincial and Canadian governments and the comparison group was randomly selected from a pool of anti-HCV-negative subjects. The study was designed to detect an assumed difference of 20% in signs and symptoms between the two groups. Statistical comparisons were conducted using bivariate and multivariate logistic regression analyses.

RESULTS

A total of 241 and 222 anti-HCV-positive and negative subjects were respectively interviewed and met the study's eligibility criteria. Results from the multivariate analysis indicated that anti-HCV-positive recipients were more likely to have two or more clinical symptoms (OR = 3.53; 95% CI: 1.44, 8.70), to be in worse health status as compared to ten years previous (OR = 1.60; 95% CI: 1.30, 1.96), to have a higher illness intrusiveness rating (OR = 1.35; 95% CI: 1.25, 1.46), and to be younger (OR = 0.97; 95% CI: 0.95, 0.98).

CONCLUSION

Our results show that persons exposed to HCV were more likely to have had two or more clinical symptoms, be male, have worse health status as compared to ten years previous, have a higher illness intrusiveness rating, and be younger in age.

Health and socioeconomic status differences among antibody hepatitis C positive and negative transfusion recipients, 1986-1990

OBJECTIVE

To characterize the socioeconomic and health status, disease symptoms of anti-HCV-positive and negative transfusion recipients.

METHODS

A cross-sectional interviewer-administered survey of subjects identified through the British Columbia Blood Recipient Program. Study subjects were 18 years and over and had to have had a transfusion between August 1, 1986 and June 30, 1990 and completed an interview of satisfactory quality. Anti-HCV-positive subjects were those seeking monetary compensation from the provincial and Canadian governments and the comparison group was randomly selected from a pool of anti-HCV-negative subjects. The study was designed to detect an assumed difference of 20% in signs and symptoms between the two groups. Statistical comparisons were conducted using bivariate and multivariate logistic regression analyses.

RESULTS

A total of 241 and 222 anti-HCV-positive and negative subjects were respectively interviewed and met the study's eligibility criteria. Results from the multivariate analysis indicated that anti-HCV-positive recipients were more likely to have two or more clinical symptoms (OR = 3.53; 95% CI: 1.44, 8.70), to be in worse health status as compared to ten years previous (OR = 1.60; 95% CI: 1.30, 1.96), to have a higher illness intrusiveness rating (OR = 1.35; 95% CI: 1.25, 1.46), and to be younger (OR = 0.97; 95% CI: 0.95, 0.98).

CONCLUSION

Our results show that persons exposed to HCV were more likely to have had two or more clinical symptoms, be male, have worse health status as compared to ten years previous, have a higher illness intrusiveness rating, and be younger in age.

Cognitive effects of long-term benzodiazepine use in older adults

This study examined the potential for cognitive morbidity associated with the long-term use of benzodiazepine (BZ) sedative-hypnotics in a sample of healthy older adults. Tests of memory, attention and processing speed were conducted prior to and 1 month after drug discontinuation for 25 BZ-users and at similar intervals for 26 healthy control subjects. After controlling for differences in affective status between BZ-users and controls, there were no significant group differences in cognitive performance. However, BZ-users showed greater gains on tests of attention and speed of processing at repeat testing compared with controls this improvement was not attributable to a change in affective status. These findings suggest that there may be subtle and reversible effects of long-term BZ use on speed-dependent tasks in older adults. However, the magnitude of these effects is quite small and may be of little clinical significance in the healthy elderly.

Are there gender differences in the prescribing of hypnotic medications for insomnia?

Gender differences in the prescribing patterns of general classes of medications for insomnia were examined. The classes of medications included: zopiclone, antidepressants, benzodiazepines, antihistamines and no medication. The sample comprised a sub-set of respondents from 2620 questionnaires of the Canadian Multicentre Sleep Database. Respondents for this database were contacted through physicians, announcements in the media and local pharmacies. The results indicated that gender alone was not associated with differential prescribing for insomnia, nor was gender associated with patterns of medication use such as frequency of taking medication, length of use, taking more or less medication than prescribed or attempts to stop taking medication. Demographic factors were included in the analysis and age and marital status were associated with different prescribing patterns for men and women with insomnia. It is possible that physicians refer to stereotypic expectations when prescribing hypnotics.

How, what, and why of sleep apnea. Perspectives for primary care physicians

OBJECTIVE

To review the need for primary care physicians to screen for patients with obstructive sleep apnea (OSA).

QUALITY OF EVIDENCE

Literature was reviewed via MEDLINE from 1993 to 2000, inclusive, using the search term "sleep apnea" combined with "epidemiology," "outcome," and "diagnosis and treatment." Citations in this review favour more recent, well controlled and randomized studies, but findings of pilot studies are included where other research is unavailable.

MAIN MESSAGE

Obstructive sleep apnea is a disorder with serious medical, socioeconomic, and psychological morbidity, yet most patients with OSA remain undetected. Primary care physicians have a vital role in screening for these patients because diagnosis can be made only through overnight (polysomnographic) studies at sleep clinics. Physicians should consider symptoms of excessive or loud snoring, complaints of daytime sleepiness or fatigue, complaints of unrefreshing sleep, and an excess of weight or body fat distribution in the neck or upper chest area as possible indications of untreated OSA.

CONCLUSION

Current research findings indicate that treating OSA patients substantially lowers morbidity and mortality rates and reduces health care costs. Primary care physicians need more information about screening for patients with OSA to ensure proper diagnosis and treatment of those with the condition.

The prevalence, cost implications, and management of sleep disorders: an overview

The International Classification of Sleep Disorders distinguishes more than 80 different disorders, which can be effectively treated. Problems with falling asleep or daytime sleepiness affect approximately 35 to 40% of the U.S. adult population annually and are a significant cause of morbidity and mortality. However, the prevalence, burden, and management of sleep disorders are often ignored or overlooked by individuals and society in general. This leads to an underappreciation and undertreatment of sleep disorders, making this group of illnesses a serious health concern. Sleep medicine is a young discipline, and as such the full implications of treating sleep disorders and the extent of sleep-related problems are not well delineated. As a result of high prevalence, severe complications, and concomitant illnesses in untreated cases, the cost implications are immense. The costs can be direct, indirect, related, and intangible. However, relatively little has been published on the economic implications of sleep disorders. Economic analysis can help evaluate available resources to set priorities and maximize management strategies for cost control without sacrificing safety, efficacy, or effectiveness. There has been considerable evidence of the cost-effectiveness of treating patients with obstructive sleep apnea, especially considering its high prevalence, morbidity, mortality, and concomitant health care consumption. We review the economic balance sheet of sleep disorders and conclude that sleep medicine education (among general population and health care professionals) and the availability of diagnostic and therapeutic facilities to treat sleep disorders will reduce the profound socioeconomic implications of untreated sleep disorders.

Development of an adjective checklist to measure five FACES of fatigue and sleepiness. Data from a national survey of insomniacs

Development and initial validation of the FACES of fatigue and sleepiness adjective checklist. An initial item pool of 65 adjectives, descriptive of fatigue, sleepiness and related deprivation states, was developed and administered to 372 individuals referred by their family physicians for psychiatric investigation and treatment of severe insomnia. Participants attended one of six Canadian university-affiliated sleep clinics where they completed a psychiatric assessment and a 766-item questionnaire, including a number of standard indices of sleep-related behavior and symptoms, medical history, sleep hygiene, psychosocial well-being and psychopathology. Principal-components and item analyses were undertaken to refine the initial 65-item pool to a smaller 50-item set, consisting of five subscales: Fatigue, Anergy, Consciousness, Energized and Sleepiness. Coefficient alpha was calculated and indicated high internal consistency reliability for all subscales. Convergent and discriminant validity were also evaluated by calculating correlations between FACES subscales and a number of independent indices. The resulting five-scale FACES questionnaire appears to offer a promising self-report instrument for the measurement of fatigue and related subjective experiences.

Sleep and daytime sleepiness in retinitis pigmentosa patients

OBJECTIVE

We examined sleep, daytime sleepiness and the ability to stay awake during the day in patients affected with retinitis pigmentosa (RP), to further delineate the role of photoreceptors in the circadian cycle.

METHODS

Twelve individuals diagnosed with RP (40 +/- 8 years) And 12 normally sighted healthy individuals (39 +/- 7 years) matched for age, body mass index (BMI) and sex were selected for the study. Participants had their sleep recorded on two consecutive nights and were monitored on the two following days. On the first day, their ability to stay awake and on the second, their sleep propensity were assessed using the Maintenance of Wakefulness Test (MWT) and the Multiple Sleep Latency Test (MSLT), respectively. Self-report measures were obtained using the Pittsburgh Sleep Quality Index (PSQI), the Epworth Sleepiness Scale (ESS), and the Toronto Hospital Alertness Test (THAT).

RESULTS

Subjective daytime sleepiness (ESS: 9 +/- 5 vs. 6 +/- 4, P=0.053) and objectively measured sleep propensity (MSLT: 10 +/- 5 vs. 17 +/- 3 min, P < 0.000) were significantly higher in RP patients than controls, whilst their alertness (THAT: 29 +/- 9 vs. 38 +/- 7, P=0.016) and ability to stay awake (MWT: 21 +/- 9 vs. 29 +/- 2 min, P=0.006) were significantly reduced. Retinitis pigmentosa participants had more disturbed nighttime sleep, with significantly more awakenings (arousal index: 14 +/- 8 vs. 8 +/- 6 h, P=0.039), and tended to have less rapid eye movement (REM) sleep (19 +/- 5 vs. 22 +/- 3%, P=0.094).

CONCLUSION

Patients with RP have increased daytime sleepiness, reduced alertness and more disturbed nighttime sleep of poorer quality than their normally sighted counterparts, suggesting an influence of photoreceptor degeneration on the circadian cycle.

Structure of lifestyle disruptions in chronic disease: a confirmatory factor analysis of the Illness Intrusiveness Ratings Scale

BACKGROUND

The Illness Intrusiveness Ratings Scale (IIRS) measures the extent to which disease or its treatment or both interfere with activities in important life domains. Before comparing IIRS scores within or across groups it is crucial to determine whether a common underlying factor structure exists across patient populations.

OBJECTIVE

To investigate the factor structure underlying the IIRS and evaluate its stability across diagnoses.

METHODS

IIRS responses from 5,671 respondents were pooled from 15 separate studies concerning quality of life in eight patient groups: rheumatoid arthritis; osteoarthritis; systemic lupus erythematosus; multiple sclerosis; end-stage renal disease (maintenance dialysis); renal transplantation; heart, liver, and lung transplantation; and insomnia. Data were gathered by different methods (eg, interview, self-administered, mail survey) and in diverse contexts (eg, individual vs. group).

RESULTS

Exploratory maximum-likelihood factor analysis identified three underlying factors in a randomly selected subset of respondents (n = 400), corresponding to "Relationships and Personal Development," "Intimacy," and "Instrumental" life domains. Confirmatory factor analysis corroborated the stability of this structure in an independent subsample (n = 2100). Complementary goodness-of-fit indices confirmed the consistency of the three-factor solution, corroborating that IIRS scores are uniquely defined across patient populations. Coefficient alpha was high for total and subscale scores.

CONCLUSIONS

IIRS scores can be compared meaningfully within and across patient groups. Both total and subscale scores can be used depending on research objectives.

Knowledge of sleep apnea in a sample grouping of primary care physicians

The purpose of this pilot study was to examine four groups of primary care physicians' knowledge of sleep apnea.

METHODS

Using a 36-item questionnaire, we investigated how cognizant primary care physicians in Ontario, Canada, were of sleep apnea and its different symptoms. The questions covered incidence, diagnosis, treatment, and medical and social ramifications of sleep apnea. Sleep apnea surveys were administered to small groups of primary care physicians attending educational conferences or were distributed by mail to physicians who had previously referred patients to the sleep clinic.

RESULTS

A total of 151 physicians responded to the survey. An overall average score of 69% was obtained on the questionnaire.

CONCLUSIONS

This score suggests that the physicians sampled in this pilot study are relatively under-informed about the clinical features and medical and social ramifications associated with sleep apnea.

Bilateral primary breast lymphoma

A primary breast lymphoma developed in a patient. After 139 months. she was diagnosed with a new primary breast lymphoma in the contralateral breast. The pathologic diagnosis in each tumor was non-Hodgkin's lymphoma, B-cell, diffuse large cell. Radiation therapy was effective in securing a clinical remission for both tumors.

A randomized, double-blind, placebo-controlled crossover study of the effect of exogenous melatonin on delayed sleep phase syndrome

OBJECTIVE

The effects of exogenous melatonin on sleep, daytime sleepiness, fatigue, and alertness were investigated in 22 patients with delayed sleep phase syndrome whose nocturnal sleep was restricted to the interval from 24:00 to 08:00 hours. This study was a randomized, double-blind, placebo-controlled crossover trial. Subjects received either placebo or melatonin (5 mg) daily for 4 weeks, underwent a 1-week washout period, and then were given the other treatment for an additional 4 weeks. Patients could take the melatonin between 19:00 and 21:00 hours, which allowed them to select the time they felt to be most beneficial for the phase-setting effects of the medication.

METHODS

Two consecutive overnight polysomnographic recordings were performed on three occasions: at baseline (before treatment), after 4 weeks of melatonin treatment, and after 4 weeks of placebo treatment.

RESULTS

In the 20 patients who completed the study, sleep onset latency was significantly reduced while subjects were taking melatonin as compared with both placebo and baseline. There was no evidence that melatonin altered total sleep time (as compared with baseline total sleep time), but there was a significant decrease in total sleep time while patients were taking placebo. Melatonin did not result in altered scores on subjective measures of sleepiness, fatigue, and alertness, which were administered at different times of the day. After an imposed conventional sleep period (from 24:00 to 08:00), subjects taking melatonin reported being less sleepy and fatigued than they did while taking placebo.

CONCLUSIONS

Melatonin ameliorated some symptoms of delayed sleep phase syndrome, as confirmed by both objective and subjective measures. No adverse effects of melatonin were noted during the 4-week treatment period.

Self-report of memory and affective dysfunction in association with medication use in a sample of individuals with chronic sleep disturbance

Benzodiazepines produce memory disturbance after acute administration. It is not clear whether chronic use of benzodiazepines is hazardous to memory processes. Epidemiological data indicate that a large proportion (10-30 per cent) of individuals with sleep dysfunction take hypnotic aids for a year or longer. The purpose of the present study was to evaluate self-reported memory dysfunction in a sample of individuals who considered their sleep disturbance sufficiently severe to seek investigation in sleep clinics. It was hypothesized that individuals taking benzodiazepines for sleep would report greater perceived everyday memory failures than individuals taking other sleep aids or no medication. Questionnaires were given to 368 individuals referred into the study by investigators in six sleep disorders clinics. All respondents completed a lengthy (700-item) questionnaire, which included scales assessing memory difficulties, affective status and sleep disturbance. Respondents also reported any medication use for sleep problems and duration of use of the current drug. Information on medication use was reported by 289 participants. Fifty-six per cent of respondents reported using some form of psychoactive medication (antidepressants, benzodiazepines, Zopiclone). Twenty-two per cent reported using no medication. Analysis of covariance showed that these medications had no detectable effect on subjective memory difficulties during chronic use, F(4,226)=1.34, p=0.25. Copyright 2000 John Wiley & Sons, Ltd.

Sleep disturbances and psychiatric disorders associated with posttraumatic stress disorder in the general population

The aim of the study was to assess sleep disturbances in subjects with posttraumatic stress disorder (PTSD) from an urban general population and to identify associated psychiatric disorders in these subjects. The study was performed with a representative sample of 1,832 respondents aged 15 to 90 years living in the Metropolitan Toronto area who were surveyed by telephone (participation rate, 72.8%). Interviewers used Sleep-EVAL, an expert system specifically designed to conduct epidemiologic studies of sleep and mental disorders in the general population. Overall, 11.6% of the sample reported having experienced a traumatic event, with no difference in the proportion of men and women. Approximately 2% (1.8%) of the entire sample were diagnosed by the system as having PTSD at the time of interview. The rate was higher for women (2.6%) than for men (0.9%), which translated into an odds ratio (OR) of 2.8 (95% confidence interval [CI], 1.3 to 6.1). PTSD was strongly associated with other mental disorders: 75.7% of respondents with PTSD received at least one other diagnosis. Most concurrent disorders (80.7%) appeared after exposure to the traumatic event. Sleep disturbances also affected about 70% of the PTSD subjects. Violent or injurious behaviors during sleep, sleep paralysis, sleep talking, and hypnagogic and hypnopompic hallucinations were more frequently reported in respondents with PTSD. Considering the relatively high prevalence of PTSD and its important comorbidity with other sleep and psychiatric disorders, an assessment of the history of traumatic events should be part of a clinician's routine inquiry in order to limit chronicity and maladjustment following a traumatic exposure. Moreover, complaints of rapid eye movement (REM)-related sleep symptoms could be an indication of an underlying problem stemming from PTSD.

Preliminary randomized double-blind placebo-controlled trial of tryptophan combined with fluoxetine to treat major depressive disorder: antidepressant and hypnotic effects

OBJECTIVE

Because the initial phase of treatment of depression with a selective serotonin reuptake inhibitor is often complicated by a delayed onset of action of the antidepressant or severe insomnia or both, we investigated whether tryptophan, an amino acid with both antidepressant-augmenting and hypnotic effects, would benefit patients with depression at the beginning of treatment with fluoxetine.

DESIGN

Randomized, double-blind, placebo-controlled trial.

PATIENTS

Thirty individuals with major depressive disorder.

INTERVENTIONS

Treatment over 8 weeks with 20 mg of fluoxetine per day and either tryptophan (2 to 4 g per day) or placebo.

OUTCOME MEASURES

Mood was assessed using the 29-item Hamilton Depression Rating Scale (HDRS-29) and the Beck Depression Inventory (BDI). Laboratory sleep studies were done at baseline and after 4 and 8 weeks of treatment using standard procedures.

RESULTS

During the first week of treatment, there was a significantly greater decrease in HDRS-29 depression scores, and a similar trend in BDI scores, in the tryptophan/fluoxetine group than in the placebo/fluoxetine group. No significant differences were noted at later time points. With respect to sleep measures, there was a significant group-by-time interaction for slow-wave sleep at week 4. Further analysis revealed a significant decrease in slow-wave sleep after 4 weeks of treatment in the placebo/fluoxetine group, but not in the tryptophan/fluoxetine group. No cases of serotonin syndrome occurred, and the combination was well tolerated, although the 4 g per day dosage of tryptophan produced daytime drowsiness.

CONCLUSIONS

Combining 20 mg of fluoxetine with 2 g of tryptophan daily at the outset of treatment for major depressive disorder appears to be a safe protocol that may have both a rapid antidepressant effect and a protective effect on slow-wave sleep. Further large-scale studies are needed to confirm these initial findings.

Interrelationships between nocturnal sleep, daytime alertness, and sleepiness: two types of alertness proposed

The authors studied daytime sleepiness and alertness (based on the Multiple Sleep Latency Test [MSLT] and Maintenance of Wakefulness Test [MWT]) and nocturnal sleep in 22 patients with depression/anxiety and in 47 nondepressed patients with sleep apnea. The patients underwent two overnight sleep studies followed by daytime tests. In depressed patients, MWT scores correlated negatively with total sleep time and stage 3. MSLT scores correlated negatively with total sleep time and with sleep efficiency. Apneic patients showed a negative correlation between MWT results and amount of stage 1 sleep. MSLT results correlated positively with sleep onset latency on the preceding overnight sleep study. Thus, in depressed patients, there is a paradox that with more disturbed sleep there is greater daytime alertness. In contrast, the more disturbed the sleep is in sleep apnea patients, the more difficult it is to maintain daytime alertness.

Differentiating DSM-IV anxiety and depressive disorders in the general population: comorbidity and treatment consequences

OBJECTIVE

To attempt, for the first time, to apply a positive and differential diagnosis process in the general population during interviews using DSM-IV classification to ascertain the profile and occurrence of concomitant mental disorders.

METHOD

A representative sample of 1832 individuals aged 15 years or older living in the metropolitan area of Toronto were interviewed by means of telephone interviews. The participation rate was 72.8%.

RESULTS

Overall, 13.2% (n = 242) of the sample had either a mood disorder (n = 127; 6.9%) or an anxiety disorder (n = 170; 9.3%) at the time of their interview. The prevalence was higher among women (16.5%) than among men (9.7%), with an odds ratio of 1.8. The comorbidity of mood and anxiety disorders was found in 3% (n = 55) of the sample. Less than one-third of respondents with a mood and/or anxiety disorder were being treated by a physician for a mental disorder. However, these individuals were greater consumers of health care services. Most of them consulted a physician an average of 5 times in the past year. Individuals on medication diagnosed with a mood and an anxiety disorder consulted a physician an average of 12 times in the past year. Only 13% of them were treated with antidepressants and under 9% with anxiolytics.

CONCLUSIONS

More than 70% of subjects with a mood disorder also complained of insomnia. With the differential process, 12% of the subjects manifesting a full-fledged anxiety disorder were diagnosed with only a mood disorder because the anxiety occurred only in the course of the mood disorder. About two-thirds of the subjects diagnosed in this study were undiagnosed and untreated by their physician.

Melatonin, sleep, and circadian rhythm disorders

In the 1970s and early 1980s, neuroendocrinology was viewed by many neuroscientists as a ""window to the brain" to an understanding of brain function." In psychiatry, many have viewed sleep physiology as a window in biological psychiatry. This is, in part, because sleep is one of the few easily quantifiable functions of interest to psychiatrists. Melatonin is a hormone with powerful effects on behavior particularly circadian and sleep behavior. In contrast with other hormones, the pathophysiology and pathology of abnormal melatonin secretion is poorly understood. In this article, we document the well-established phase-shifting and sleep-promoting effects of melatonin and discuss some implications for neuropsychiatrists when the neurophysiology of melatonin goes array. It is both striking and in some ways not surprising that the majority of patients with phase delay syndrome described in our research studies have been misdiagnosed as having depression. The reason for this is elucidated in this article and the information concerning this condition may be helpful to many who are relatively unfamiliar with this particular sleep disorder. We can anticipate that patients with specific neurological disorders may have changes in their melatonin secretion and future research, for example in patients with head injury and conditions such as retinitis pigmentosa may be the basis for reviews a few years hence.

Diagnostic values of polysomnography in forensic medicine

A man accused of a first-degree murder of a two-year-old girl claimed that he had not been conscious during the time of the alleged murder. The possibility that he may have committed the crime while "sleepwalking" was raised. The forensic psychiatrist looked to the sleep disorders facility to conduct polysomnographic investigation of the accused in order to investigate the possibility that he had a parasomnia. Overnight sleep recordings with video surveillance carried out for two consecutive nights showed no evidence of parasomnia. On the basis of the full assessment, the final report of the forensic psychiatrist did not support a legal defense of non-insane automatism and "sleepwalking" was withdrawn as a possible defense by the lawyer of the accused.

Interactions of sleep and Parkinson's disease

Sleep disruption represents an important, and clinically relevant facet of Parkinson's Disease [PD]. This review attempts to integrate the current knowledge regarding sleep alterations in PD by examining following: the nature of sleep disturbance in PD, the influence of antiparkinson medication on sleep parameters, the interaction of psychological conditions such as depression and anxiety with sleep, and possible beneficial aspects of sleep in PD. Special emphasis is placed on rapid eye movement sleep behavior disorder and the evidence of it heralding PD and related disorders.

Pseudo-narcolepsy: case report

This report describes the case of a 44-year-old woman presenting to a Sleep and Alertness clinic with symptoms of narcolepsy. The patient had clinical and polysomnographic features of narcolepsy, which disappeared after disclosure of severe psychological stress. Following a discussion of the differential diagnosis of narcolepsy, alternative diagnoses are considered. The authors suggest that the patient had a hysterical conversion disorder, or "pseudo-narcolepsy." Careful inquiry into psychological factors in unusual cases of narcolepsy may be warranted.

Nocturnal and daytime panic attacks--comparison of sleep architecture, heart rate variability, and response to sodium lactate challenge

BACKGROUND

The purpose of this study was to determine if nocturnal panic patients have greater autonomic dysregulation than patients with daytime panic.

METHODS

Three groups were studied: patients who suffer from panic attacks during sleep (n = 12), those who suffer from daytime panic attacks only (n = 12), and control subjects (n = 12). Each subject underwent 24-hour holter monitoring for heart rate variability (HRV), an overnight sleep recording, and sodium lactate challenge during wakefulness.

RESULTS

There was a marked subjective response to the sodium lactate challenge in the panic disorder (PD) patients but not in control subjects. Each group showed changes in HRV in response to sodium lactate challenge. The decrease in HRV measures was more marked in PD patients as a whole than in control subjects. During non-rapid eye movement (REM) sleep the value for total power (TP) was significantly higher in the nocturnal panic patients. The PD patients as a whole had higher values for TP and low-frequency (LF) power during REM sleep than control subjects. There were no significant differences between the two PD groups in sleep architecture. The PD patients as a whole had lower sleep efficiency and less stage 4 sleep than control subjects.

CONCLUSIONS

These findings indicate that there are substantial differences between PD and control subjects in autonomic regulation and that there are small differences between patients with daytime panic attacks and those with sleep-related panic attacks.

Motivations for sex and risky sexual behavior among adolescents and young adults: a functional perspective

The implications of a functionalist perspective for understanding sexual risk taking are explored. Key motivational dimensions thought to underlie human behavior (viz., approach vs. avoidance, autonomy vs. relatedness) were used to identify 4 broad domains of sexual motivations and to develop a measure of specific motives within each of these domains. Data from both college student and community samples are used to demonstrate the psychometric adequacy of these scales and to show that having sex for different reasons predicts distinctive patterns of sexual risk taking both cross-sectionally and longitudinally: that selection into specific types of sexual relationships partially mediates these effects; and that these needs may be differentially expressed, or even suppressed, depending on relationship context. Results provide strong support for the functionalist perspective on behavior and indicate that an adequate understanding of sexual risk-taking behavior must take into account the various needs and goals that such behavior can serve.

EEG spectral analysis of the sleep-onset period in narcoleptics and normal sleepers

The sleep-onset period of 10 drug-free patients with narcolepsy-cataplexy and 10 normals matched for age and gender was investigated using the multiple sleep latency test to elicit episodes of intentional sleep onset. Spectral analyses were calculated for delta, theta, alpha, sigma, and beta frequencies using 5-second epochs beginning at lights-out and continuing until the first 2 minutes of stage 2 or REM sleep were reached, or until 20 minutes had elapsed. The sleep-onset period was divided into quartiles, and mean root mean square (RMS) amplitude within each quartile was calculated. Mean delta amplitude was significantly higher across the sleep-onset period of narcoleptic REM naps and narcoleptic stage 2 naps compared to the sleep-onset period of normal stage 2 naps or normal stage 1 naps. Mean theta amplitude was significantly higher for narcoleptic REM naps compared to normal stage 1 naps, and tended to be higher for narcoleptic stage 2 naps compared to normal stage 1 naps. Mean alpha amplitude was significantly lower for narcoleptic REM naps and narcoleptic stage 2 naps compared to normal naps containing just stage 1. Mean sigma amplitude was significantly lower for narcoleptic REM naps compared to normal stage 1 naps, and tended to be lower for narcoleptic REM naps compared to normal stage 2 naps. Mean beta amplitude did not differ between the narcoleptic and normal sleep-onset process. These findings support the existence of electrophysiologic differences within the microstructure of the process of sleep entry in narcoleptics and normals.

Motivations for sex and risky sexual behavior among adolescents and young adults: a functional perspective

The implications of a functionalist perspective for understanding sexual risk taking are explored. Key motivational dimensions thought to underlie human behavior (viz., approach vs. avoidance, autonomy vs. relatedness) were used to identify 4 broad domains of sexual motivations and to develop a measure of specific motives within each of these domains. Data from both college student and community samples are used to demonstrate the psychometric adequacy of these scales and to show that having sex for different reasons predicts distinctive patterns of sexual risk taking both cross-sectionally and longitudinally: that selection into specific types of sexual relationships partially mediates these effects; and that these needs may be differentially expressed, or even suppressed, depending on relationship context. Results provide strong support for the functionalist perspective on behavior and indicate that an adequate understanding of sexual risk-taking behavior must take into account the various needs and goals that such behavior can serve.

Motivations for sex and risky sexual behavior among adolescents and young adults: a functional perspective

The implications of a functionalist perspective for understanding sexual risk taking are explored. Key motivational dimensions thought to underlie human behavior (viz., approach vs. avoidance, autonomy vs. relatedness) were used to identify 4 broad domains of sexual motivations and to develop a measure of specific motives within each of these domains. Data from both college student and community samples are used to demonstrate the psychometric adequacy of these scales and to show that having sex for different reasons predicts distinctive patterns of sexual risk taking both cross-sectionally and longitudinally: that selection into specific types of sexual relationships partially mediates these effects; and that these needs may be differentially expressed, or even suppressed, depending on relationship context. Results provide strong support for the functionalist perspective on behavior and indicate that an adequate understanding of sexual risk-taking behavior must take into account the various needs and goals that such behavior can serve.

The alpha attenuation test: assessing excessive daytime sleepiness in narcolepsy-cataplexy

Daytime sleep tendency was assessed in 10 drug-free patients with narcolepsy-cataplexy and 10 normals matched for age and gender. Following nocturnal polysomnography, the alpha attenuation test (AAT) and the multiple sleep latency test (MSLT) were administered during five sessions occurring at 2-hour intervals beginning at 0900 and 1000 hours, respectively. For the AAT, participants were polysomnographically recorded for 8 minutes while seated in an illuminated room with their eyes alternately opened and closed. Power spectral analyses of electroencephalograph (EEG) activity at 02-A1 (10 second epochs) were calculated using fast Fourier transformations (FFT) within the alpha frequency range (8-12 Hz) to obtain ratios of mean eyes-closed to mean eyes-open alpha power (i.e. the alpha attenuation coefficient, AAC). The narcoleptics were sleepier than the normals as indicated by a significantly smaller mean AAC and a significantly shorter mean latency to stage 1 on the MSLT. These findings suggest that the AAT may provide a quick and practical objective assessment of the excessive daytime sleepiness (EDS) associated with narcolepsy.

Prevalence of panic disorder in cardiac outpatients

OBJECTIVE

To evaluate outpatients from Toronto-area cardiology clinics for panic disorder (PD) and investigate differences between patients with and without PD.

METHOD

Participants were diagnosed using both standard DSM-IV criteria and an altered formulation that identified a more fearful panic group.

RESULTS

There was a prevalence of panic disorder (12.5%) in cardiac outpatients in keeping with previous studies. Patients with PD did not differ significantly from other patients with regard to the presence of significant heart disease. The higher prevalence of palpitations found in patients who met criteria for PD compared with those who did not reflects previous findings. PD cases did not differ significantly in family history from respondents without the disorder, but the more fearful group did (P < 0.05).

CONCLUSION

PD often presents with cardiac symptoms, especially palpitations, and is often comorbid with heart disease.

Drug-induced sleep disturbances. Focus on nonpsychotropic medications

Different medications can have significant effects on sleep quality and/or quantity. When prescribing medications it is important to be aware of these possible adverse effects of drugs. Disturbances of the sleep/wake cycle caused by medications can vary and include insomnia, daytime sleepiness, nightmares and changes in the sleep architecture. Psychotropic drugs are well known to have an effect on the sleep/wake cycle, but there is only limited information about the sleep effects of nonpsychotropic medications. Cardiovascular drugs, especially beta-blockers, which are widely used drugs, often change the sleep architecture and cause nightmares and insomnia. Both of these effects can be a potential source of noncompliance. Because of the complicated relationship between sleep, nocturnal asthma and antiasthmatic agents, the appropriate dosage and timing of medications should always be considered. Patients with Parkinson's disease often experience disrupted sleep due to their disorder and the adverse effects of anti-parkinsonian medications.