Improved Sleep Quality is Associated with Reductions in Depression and PTSD Arousal Symptoms and Increases in IGF-1 Concentrations

STUDY OBJECTIVES

One-third of deployed military personnel will be diagnosed with insomnia, placing them at high risk for comorbid depression, posttraumatic stress disorder (PTSD), and medical conditions. The disruption of trophic factors has been implicated in these comorbid conditions, which can impede postdeployment recovery. This study determined if improved sleep quality is associated with (1) reductions in depression and posttraumatic symptoms, as well as enrichments in health-related quality of life (HRQOL), and (2) changes in plasma concentrations of brain derived neurotrophic factor (BDNF) and insulin-like growth factor-1 (IGF-1).

METHODS

Forty-four military personnel diagnosed with insomnia underwent clinical evaluations and blood draws at pretreatment and at posttreatment following cognitive behavioral therapy for insomnia and automatic positive airway pressure treatment. Participants were classified as sleep improved (n = 28) or sleep declined (n = 16) based on their change in pretreatment to posttreatment Pittsburgh Sleep Quality Index (PSQI) score. Both groups were compared on outcomes of depression, PTSD, HRQOL, BDNF, and IGF-1.

RESULTS

Paired t-tests of the sleep improved group revealed significant declines in depression (p = 0.005) and posttraumatic arousal (p = 0.006) symptoms, and a significant increase in concentrations of IGF-1 (p = 0.009). The sleep declined group had no relevant change in psychiatric symptoms or trophic factors, and had further declines on five of eight dimensions of HRQOL. Between-group change score differences were significant at p < 0.05.

CONCLUSIONS

These findings suggest that interventions, which successfully improve sleep quality, are an effective means to reduce the depression and posttraumatic arousal symptoms common to military personnel, as well as increase protective trophic factors implicated in these conditions.

Determinants of psychological resistance and recovery among women exposed to assaultive trauma

INTRODUCTION

Women exposed to potentially traumatic events (PTEs) are at high risk for developing psychiatric disorders, including posttraumatic stress disorder (PTSD), general anxiety disorder (GAD), major depressive disorder (MDD), and substance-related disorders. However, this risk is not universal. Most women are resistant (i.e., remain asymptomatic), or recover following a brief symptomatic period. This study examined the psychological factors associated with resistant and recovered outcomes in a sample of high-risk women exposed to assault-related PTEs.

METHOD

One hundred and fifty-nine women completed the Life Events Checklist and were administered the Structured Clinical Interview for DSM-IV Axis I Disorders. This resulted in three groups: (1) no diagnosis (no past or current psychiatric disorder diagnosis; n = 56), (2) past diagnosis (a past psychiatric disorder diagnosis, but none currently; n = 31), and (3) current diagnosis (a current diagnosis of one or more psychiatric disorders; n = 72). Groups were compared on sociodemographics, PTE exposure, psychopathology, health-related quality of life (HRQOL), and psychological resilience-related factors.

RESULTS

The majority of respondents (79%) did not develop chronic PTSD following assault exposure, and the most common psychiatric outcome was MDD (30%). High endorsement of mastery and social support were associated with the no diagnosis group; and greater reports of mastery and posttraumatic growth were associated with recovery from a past psychiatric disorder. Furthermore, both resilient groups (i.e., no diagnosis and past diagnosis) scored higher on HRQOL measures compared with the current diagnosis group (P < 0.001).

CONCLUSION

Psychological resilience has ramifications to health and well-being, and identifying these factors has potential to inform preventive strategies and treatment interventions for assault exposed women.

A Diagnosis of Insomnia Is Associated With Differential Expression of Sleep-Regulating Genes in Military Personnel

Sleep disturbance is a common and disturbing symptom in military personnel, with many individuals progressing to the development of insomnia, which is characterized by increased arousals, wakefulness after sleep onset, and distorted sleep architecture. The molecular mechanisms underlying insomnia remain elusive, limiting future therapeutic development to address this critical issue. We examined whole gene expression profiles associated with insomnia. We compared subjects with insomnia (n = 25) to controls (n = 13) without insomnia using microarray gene expression profiles obtained from peripheral samples of whole blood obtained from military personnel. Compared to controls, participants with insomnia had differential expression of 44 transcripts from 43 identified genes. Among the identified genes, urotensin 2 was downregulated by more than 6 times in insomnia participants, and the fold-change remained significant after controlling for depression, posttraumatic stress disorder, and medication use. Urotensin 2 is involved in regulation of orexin A and B activity and rapid eye movement during sleep. These findings suggest that differential expression of these sleep-regulating genes contributes to symptoms of insomnia and, specifically, that switching between rapid eye movement and nonrapid eye movement sleep stages underlies insomnia symptoms. Future work to identify therapeutic agents that are able to regulate these pathways may provide novel treatments for insomnia.

Improved Sleep in Military Personnel is Associated with Changes in the Expression of Inflammatory Genes and Improvement in Depression Symptoms

STUDY OBJECTIVES

Sleep disturbances are common in military personnel and are associated with increased risk for psychiatric morbidity, including posttraumatic stress disorder (PTSD) and depression, as well as inflammation. Improved sleep quality is linked to reductions in inflammatory bio-markers; however, the underlying mechanisms remain elusive.

METHODS

In this study, we examine whole genome expression changes related to improved sleep in 68 military personnel diagnosed with insomnia. Subjects were classified into the following groups and then compared: improved sleep (n = 46), or non-improved sleep (n = 22) following three months of standard of care treatment for insomnia. Within subject differential expression was determined from microarray data using the Partek Genomics Suite analysis program and the ingenuity pathway analysis (IPA) was used to determine key regulators of observed expression changes. Changes in symptoms of depression and PTSD were also compared.

RESULTS

At baseline, both groups were similar in demographics, clinical characteristics, and gene-expression profiles. The microarray data revealed that 217 coding genes were differentially expressed at the follow-up-period compared to baseline in the participants with improved sleep. Expression of inflammatory cytokines were reduced including IL-1β, IL-6, IL-8, and IL-13, with fold changes ranging from -3.19 to -2.1, and there were increases in the expression of inflammatory regulatory genes including toll-like receptors 1, 4, 7, and 8 in the improved sleep group. IPA revealed six gene networks, including ubiquitin, which was a major regulator in these gene-expression changes. The improved sleep group also had a significant reduction in the severity of depressive symptoms.

CONCLUSION

Interventions that restore sleep likely reduce the expression of inflammatory genes, which relate to ubiquitin genes and relate to reductions in depressive symptoms.

Women in recovery from PTSD have similar inflammation and quality of life as non-traumatized controls

OBJECTIVE

Post-traumatic stress disorder (PTSD) is associated with greater concentrations of inflammatory biomarkers as well as substantial medical burden; however, it is not clear if these morbidity risks change following recovery from PTSD. In this study we compare women who have recovered from PTSD, to those with current PTSD, and healthy controls on their perceived health and inflammatory and metabolic biomarkers.

METHODS

We studied 3 groups of women: those with current PTSD, those who reported recovery from PTSD, and healthy non-traumatized controls, which were determined using standard diagnostic instruments. We obtained a morning blood sample and examined concentrations of inflammatory biomarkers of: interleukin 6 (IL-6) and c-reactive protein (CRP), and lipid concentrations. Lastly, we evaluated health related quality of life (HRQOL).

RESULTS

Women who had recovered from PTSD had a similar HRQOL and inflammatory biomarkers as non-traumatized controls. Their concentrations of inflammatory biomarkers were lower than women with current PTSD, and similar to non-traumatized controls.

CONCLUSION

Health perception as well as biological indicators of health significantly differ in women in recovery from PTSD, compared to those who remain symptomatic. These findings suggest that the psychological recovery is associated with normal levels of inflammatory biomarkers and HRQOL.

Dynamics of cognitive change in HIV-infected individuals commencing three different initial antiretroviral regimens: a randomized, controlled study

BACKGROUND

Improvements in neurocognitive (NC) function have been associated with commencing antiretroviral therapy in HIV-infected subjects. However, the dynamics of such improvements are poorly understood.

METHODS

We assessed changes in NC function via a validated computerized battery (CogState™, Melbourne, Victoria, Australia) at baseline and after 24 and 48 weeks in a subset of therapy-naïve neuro-asymptomatic HIV-infected subjects, randomized to commence three different antiretroviral regimens.

RESULTS

Of 28 subjects enrolled in the study, nine, eight and 11 were randomly allocated to commence tenofovir/emtricitabine with efavirenz (arm 1), atazanavir/ritonavir (arm 2) and zidovudine/abacavir (arm 3), respectively. Overall improvements in NC function were observed at week 24 and function continued to improve at week 48 (changes in z-score for overall cognitive global score of 0.16 and 0.18 at weeks 24 and 48, respectively). Within the NC speed domains, generally greater improvements were observed in arms 2 and 3, compared with arm 1 (changes in z-score for composite speed scores at weeks 24/48 of 0.16/0.16, -0.29/-0.24 and -0.15/-0.31 in arms 1, 2 and 3, respectively; P = 0.04 for change at week 48 in arm 3 versus arm 1). Finally, improvements in executive function occurred later (only observed at week 48) and were driven by improvements in arm 3 (z-score changes of 0.23, 0.06 and -0.78 in arms 1, 2 and 3, respectively; P = 0.02 for change in arm 3 versus arm 1).

CONCLUSION

Improvements in NC function continue over the first year after initiating antiretroviral therapy in neuro-asymptomatic HIV-infected subjects.

Inflammation and traumatic stress: the society to cells resiliency model to support integrative interventions

BACKGROUND

Posttraumatic stress disorder (PTSD) is a prevalent psychiatric disorder that develops following a traumatic event and has substantial health implications, including high rates of health morbidity and mortality, as well as significant health-related costs. Medical risks that are associated with PTSD often have an underlying inflammatory pathology, suggesting that inflammation contributes to these health declines.

OBJECTIVES AND DESIGN

In this critical literature review, the authors examine the medical risks associated with PTSD and the inflammatory mechanisms that likely underlie these risks.

RESULTS AND CONCLUSIONS

The authors offer a review of their "Cells to Society Resiliency Model" to motivate the development of integrative interventions that include factors of society, community, family, individual, physiological, and cellular factors to thereby reduce the health risks associated with PTSD.

Traumatic brain injury in intimate partner violence: a critical review of outcomes and mechanisms

The prevalence of intimate partner violence (IPV) is striking, as are its consequences to the lives of women. The IPV often includes physical assault, which can include injuries to the head and attempted strangulation injuries. Both types of injuries can result in traumatic brain injury (TBI). The TBI sustained during IPV often occurs over time, which can increase the risk for health declines and postconcussive syndrome (PCS). Current studies have identified sequelae of cognitive dysfunction, posttraumatic stress disorder, and depression in women experiencing IPV, yet, most fail to determine the role of TBI in the onset and propagation of these disorders. Although imaging studies indicate functional differences in neuronal activation in IPV, they also have not considered the possibility of TBI contributing to these outcomes. This review highlights the significant gaps in current findings related to neuropsychological complications and medical and psychosocial symptoms that likely result in greater morbidity, as well as the societal costs of failing to acknowledge the association of IPV and TBI in women.

Major depressive disorder in persons exposed to trauma: relationship between emotional intelligence and social support

BACKGROUND

Traumatic events are often linked to the onset of major depressive disorder (MDD) and for the increase of nonremittance of symptoms; however, psychological factors that contribute to the relationship between trauma and chronic depression are not well defined.

OBJECTIVE

The objective of this study is to determine if emotional intelligence (EI) and social support differ in traumatized depressed patients when compared with controls.

METHOD

The present study examines two psychosocial factors that may contribute to this link: EI and social support. Participants who experienced a trauma and had current MDD (n=38) were compared with nontraumatized healthy controls ( n=40).

RESULTS

Traumatized depressed participants exhibited lower total EI, because of reductions in strategic EI ability, as well as lower levels of social support compared with the control group.

CONCLUSIONS

EI and social support were significantly correlated. These findings suggest that EI may be a novel target for intervention to prevent and treat MDD.

Low early morning plasma cortisol in posttraumatic stress disorder is associated with co-morbid depression but not with enhanced glucocorticoid feedback inhibition

BACKGROUND

Co-morbid major depressive disorder (MDD) in individuals with posttraumatic stress disorder (PTSD) confers a more severe clinical course and is associated with distinct biologic abnormalities. Although dysregulation in the hypothalamic pituitary adrenal (HPA) axis has been well established in PTSD, the impact of commonly co-occuring MDD has received scant attention.

METHODS

Overnight (7p.m. to 7a.m.) plasma cortisol, adrenocorticotropic hormone (ACTH), dehydroepiandrosterone sulphate (DHEA-S) were measured at 30 min intervals in 9 participants with PTSD with MDD (PTSD+MDD), 9 with PTSD without MDD (PTSD-MDD) and 16 non-traumatized healthy controls. A low-dose dexamethasone suppression test was administered to evaluate feedback sensitivity to glucocorticoids. Linear mixed models with body mass index (BMI) and age as covariates and Bonferroni corrected post hoc tests assessed group differences.

RESULTS

Compared to healthy controls, subjects with PTSD+MDD, but not those subjects with PTSD-MDD, exhibited lower basal plasma cortisol levels between 1:30 a.m. and 3:30 a.m. and at 4:30 a.m. and 6:30 a.m. (effect size d=0.75). Despite similar plasma ACTH levels between the three groups, the ACTH/cortisol ratio was higher in PTSD+MDD patients compared to controls. We obtained similar results when the patient and control groups were re-studied 1 week later, and when men and current smokers were excluded. Basal plasma DHEA-S levels, and cortisol and ACTH response to a low-dose dexamethasone suppression test were similar in all three groups.

CONCLUSIONS

Lower early morning plasma cortisol levels and a high ACTH/cortisol ratio in subjects with PTSD and co-morbid MDD may not be due to enhanced peripheral sensitivity to glucocorticoids. A central abnormality in glucocorticoid regulation could explain HPA axis dysfunction in this subgroup.

Hepatitis C progressing to hepatocellular carcinoma: the HCV dialysis patient in dilemma

Approximately 3.2 million people in the United States have chronic hepatitis C virus (HCV) infection; the primary cause for adult liver transplantation and a significant burden on healthcare resources. The role of HCV and other risk factors in development of HCC in patients with chronic kidney disease is not well defined. We studied predictors of hepatocellular carcinoma (HCC) in dialysis patients with chronic HCV by analyzing factors associated with its development. Data were extracted from the United States Renal Database System (USRDS) using ICD-9 codes. Variables included were gender, race, duration on dialysis and co-morbidities (alcohol abuse, drug abuse, HIV, hepatitis B, diabetes and/or presence of cirrhosis). Among the 32 806 HCV infected subjects, 262 cases had HCC. HCC was 12 times more likely in subjects with cirrhosis (P < 0.001), three times more likely in subjects with alcohol abuse (P < 0.001), and 1.3 times more likely in subjects with diabetes (P = 0.04). Asians were three times more likely (P < 0.001) to have HCC. Females were less likely to have HCC compared to males (P = 0.002). The likelihood of having HCC increased with age (P =0.001). This population-based study demonstrates that among subjects with HCV on dialysis, those with cirrhosis, Asian race and history of alcohol abuse are at highest risk for development of HCC. Furthermore, these findings indicate links between HCV and HCC which are valuable in case management for identifying; monitoring, and managing dialysis patients with HCC.

PTSD is associated with an excess of inflammatory immune activities

PURPOSE. Post-traumatic stress disorder (PTSD) is associated with inflammatory-related medical conditions. This review examines studies of immune function in individuals with PTSD to determine if excessive inflammation is associated with PTSD. CONCLUSIONS. Current studies suggest an excess of inflammatory actions of the immune system in individuals with chronic PTSD. High levels of inflammatory cytokines have also been linked to PTSD vulnerability in traumatized individuals. There is also evidence that excessive inflammation is in part due to insufficient regulation by cortisol. PRACTICE IMPLICATIONS. An excess of inflammatory immune activity may contribute to health declines in individuals with PTSD, and treating PTSD symptoms may reduce these risks.

Medical conditions and symptoms associated with posttraumatic stress disorder in low-income urban women

BACKGROUND

Epidemiological studies have consistently reported rates of posttraumatic stress disorder (PTSD) in women that are twice that of men. In men and women, PTSD has been associated with comorbid medical conditions, medical symptoms and lower self-rating of health. In low-income urban women, rates of PTSD are even more elevated than in suburban women and may be related to observed health disparities.

METHODS

In this study, 250 women seeking healthcare at an urban clinic were interviewed for a PTSD diagnosis, major depressive disorder (MDD), the experience of traumatic events, the experience of current and past common medical conditions and symptoms, and subjective rating of health. A chart review was used to assess healthcare use in the past year.

RESULTS

More current (5.2 vs. 3.8, p < 0.05) and past medical conditions (4.6 vs. 3.3, p < 0.05) were reported by women with a lifetime history of PTSD than by women without this history, after controlling for demographics and current depression. Women with lifetime PTSD also had more annual clinic appointments (5.9 vs. 3.8 p < 0.03) and were 2.4 times (p < 0.05) more likely to report lower appraisal of their physical health.

CONCLUSIONS

These findings suggest that urban health-seeking women with PTSD experience health impairments that may cause increased morbidity and that healthcare providers should consider the health ramifications of PTSD when providing medical care to women.

Experiences of traumatic events and associations with PTSD and depression development in urban health care-seeking women

Posttraumatic stress disorder (PTSD) is an anxiety disorder that occurs after a traumatic event and has been linked to psychiatric and physical health declines. Rates of PTSD are far higher in individuals with low incomes and who reside in urban areas compared to the general population. In this study, 250 urban health care-seeking women were interviewed for a diagnosis of PTSD, major depressive disorder, and also the experience of traumatic events. Multivariate logistic regressions were used to determine the associations between traumatic events and PTSD development. Survival analysis was used to determine if PTSD developed from assaultive and nonassaultive events differed in symptom duration. Eighty-six percent of women reported at least one traumatic event, 14.8% of women were diagnosed with current PTSD, and 19.6% with past PTSD. More than half of women with PTSD had comorbid depression. Assaultive traumatic events were most predictive of PTSD development. More than two thirds of the women who developed PTSD developed chronic PTSD. Women who developed PTSD from assaultive events experienced PTSD for at least twice the duration of women who developed PTSD from nonassaultive events. In conclusion, PTSD was very prevalent in urban health care-seeking women. Assaultive violence was most predictive of PTSD development and also nonremittance.

Psychiatric and physical health ramifications of traumatic events in women

All individuals are at some risk of experiencing a traumatic event and developing posttraumatic stress disorder (PTSD); however some individuals are at higher risk due to individual and environmental factors. This critical literature review focuses on women, as they are twice as likely as men to develop PTSD in their lifetimes. Should a woman develop PTSD, she is then at risk of developing psychiatric and physical health comorbidities that can further impact her quality of life. The strengths and limitations of current studies regarding this topic are discussed as are directions for future research and issues for nurses treating traumatized individuals.

Deaths in yellow-eyed penguins (Megadyptes antipodes) on the Otago Peninsula during the summer of 1990

About 150 rare, adult, yellow-eyed penguins died over a short period during the summer of 1989-1990 on the Otago Peninsula. These were from a total mainland population estimated at 240 breeding pairs. Penguin chicks and non-breeding birds were not affected, but there were indications of shortages in feed supply for birds that bred successfully. Thirteen dead penguins were examined. In ten birds, the cause of death was not established. Although it was commonly found that adult birds had little or no food in their gut, none were considered to have starved to death. No consistent pathological lesions were found, nor were any viruses, Chlamydia or significant bacteria recovered from selected tissues. Toxicology tests ruled out poisoning by copper, zinc, iron, lead, arsenic, selenium, cadmium, mercury, organophosphates, organochlorines, polychlorinated biphenyls, hexachlorobenzene or the toxins of Clostridium perfringens, Clostridium botulinum and dinoflagellates. The problem did not recur during the following summer.

An outbreak of post-vaccinal suspected distemper-like encephalitis in farmed ferrets (Mustela putorius furo)

Two outbreaks of an encephalitis apparently induced by an attenuated live distemper vaccine occurred in a large ferret breeding establishment in New Zealand. Approximately 350 of 6,000 young ferrets 16-22 weeks old died. Many were found dead with no premonitory signs, others showed severe neurological signs. Some with central nervous system (C.N.S.) signs recovered. Pathological examination showed no gross abnormalities except for a few with mild conjunctivitis, rhinitis and lung emphysema. Microscopically there was a moderate to massive non-inflammatory necrosis of hippocampal nerve cell bodies. In those animals which survived for several days with CNS signs there was also a mild to moderately severe non-supportive encephalitis, and in some of these distinct neuronal intranuclear and intracytoplasmic eosinophilic inclusion bodies were seen. Some ferrets also had a bronchiolitis with intracytoplasmic eosinophilic inclusion bodies in bronchiolar epithelium. All these lesions suggest that a distemper like condition was involved. About half of the ferrets also had a mild to severe inflammatory myocardial necrosis.