Treatment of insomnia in patients with mood disorders

Effects of an internet-delivered insomnia intervention for older adults: A secondary analysis on symptoms of depression and anxiety

Objective

To test whether an Internet-delivered cognitive behavioral therapy for insomnia (CBT-I) program for older adults attenuates symptoms of depression and anxiety.

Methods

Adults aged ≥ 55 with insomnia were randomized to SHUTi-OASIS (Sleep Healthy Using the Internet for Older Adult Sufferers of Insomnia and Sleeplessness; N = 207) or Patient Education (PE; N = 104). Depression and anxiety were assessed (HADS-D and HADS-A, respectively) at baseline, post-assessment, and 6- and 12-month follow-ups.

Results

Multilevel modeling of HADS-D showed a condition by time interaction (F[3,779] = 3.23, p = .02): SHUTi-OASIS participants reported lower symptoms than PE at post-assessment. There was no such interaction effect for HADS-A (F[3,779] = 2.12, p = .10). Generalized linear modeling showed no moderation of effects by baseline symptom severity.

Conclusions

Participants randomized to Internet-delivered CBT-I showed stable depression and anxiety across time, while control participants’ depressive symptoms briefly increased. CBT-I may help prevent development or worsening of psychological distress among older adults with insomnia.

TRIAL REGISTRATION

[Registered at ClinicalTrials.gov; identifier removed for anonymity]

Chronobiologic parameter changes in patients with major depressive disorder and sleep disturbance treated with adjunctive brexpiprazole: An open-label, flexible-dose, exploratory substudy

BACKGROUND

Circadian rhythm disturbances have been reported in patients with major depressive disorder (MDD). Among these is an increased phase angle between peak cortisol concentration and dim-light melatonin onset (DLMO). The aim of this study was to evaluate changes in chronobiologic parameters of sleep in patients with MDD receiving adjunctive brexpiprazole.

METHODS

This was an interventional, multicenter, open-label, flexible-dose, exploratory study in patients with MDD and inadequate response to antidepressant treatment who were experiencing sleep disturbances. Patients received adjunctive brexpiprazole 2-3 mg/day for 8 weeks. Outcome measures included cortisol and melatonin levels, used to calculate phase angle, and the Biological Rhythms Interview of Assessment in Neuropsychiatry (BRIAN).

RESULTS

The mean (standard error) phase angle between peak cortisol and DLMO increased by 108 (61) minutes from baseline to Week 8 (n = 9). BRIAN Total score changed (improved) by -14.6 (4.6) points from baseline to Week 8 (n = 9). Change in phase angle and BRIAN Total score showed a moderate-to-high correlation (Pearson coefficient: 0.68; 95% confidence limits: 0.04, 0.93; p = 0.040).

LIMITATIONS

This study is limited by its small sample size, and its single-arm, open-label design.

CONCLUSIONS

The findings provide a preliminary indication that the phase angle between peak cortisol and DLMO is of interest as a potential biomarker for depression and therapeutic response. Adjunctive brexpiprazole may represent a strategy for correcting circadian dysfunction in patients with MDD and inadequate response to antidepressant treatment. ClinicalTrials.gov identifier: NCT01942733.

Sleep as a Therapeutic Target in the Aging Brain

Sleep is a behavioral phenomenon conserved among mammals and some invertebrates, yet the biological functions of sleep are still being elucidated. In humans, sleep time becomes shorter, more fragmented, and of poorer quality with advancing age. Epidemiologically, the development of age-related neurodegenerative diseases such as Alzheimer's and Parkinson's disease is associated with pronounced sleep disruption, whereas emerging mechanistic studies suggest that sleep disruption may be causally linked to neurodegenerative pathology, suggesting that sleep may represent a key therapeutic target in the prevention of these conditions. In this review, we discuss the physiology of sleep, the pathophysiology of neurodegenerative disease, and the current literature supporting the relationship between sleep, aging, and neurodegenerative disease.

Online insomnia treatment and the reduction of anxiety symptoms as a secondary outcome in a randomised controlled trial: The role of cognitive-behavioural factors

OBJECTIVE

Insomnia and anxiety commonly co-occur, yet the mechanisms underlying this remain unclear. The current paper describes the impact of an Internet-based intervention for insomnia on anxiety, and explores the influence of two cognitive-behavioural constructs - dysfunctional beliefs about sleep and sleep-threat monitoring.

METHODS

A large-scale, 9-week, two-arm randomised controlled trial ( N = 1149) of community-dwelling Australian adults with insomnia and elevated yet subclinical depression symptoms was conducted, comparing a cognitive behavioural therapy-based online intervention for insomnia (Sleep Healthy Using The Internet) with an attention-matched online control intervention (HealthWatch). Symptoms of anxiety were assessed at pretest, posttest, and 6-month follow-up. Dysfunctional beliefs about sleep and sleep threat monitoring were assessed only at pretest.

RESULTS

Sleep Healthy Using The Internet led to a greater reduction in anxiety symptoms at both posttest ( t_724.27 = -6.77, p < 0.001) and at 6-month follow-up ( t_700.67 = -4.27, p < 0.001) than HealthWatch. At posttest and follow-up, this effect was found to moderated by sleep-threat monitoring ( t_713.69 = -2.39, p < 0.05 and t_694.77 = -2.98, p < 0.01 respectively) but not by dysfunctional beliefs about sleep at either posttest or follow-up ( t_717.53 = -0.61, p = 0.55 and t_683.79 = 0.22, p = 0.83 respectively). Participants in the Sleep Healthy Using The Internet condition with higher levels of sleep-threat monitoring showed a greater reduction in anxiety than those with lower levels from pretest to posttest, ( t_724.27 = -6.77, p < 0.001) and through to 6-month follow-up ( t_700.67 = -4.27, p < 0.001). This result remained after controlling for baseline anxiety levels.

CONCLUSION

The findings suggest that online cognitive behavioral therapy interventions for insomnia are beneficial for reducing anxiety regardless of people's beliefs about their sleep and insomnia, and this is particularly the case for those with high sleep-threat monitoring. This study also provides further evidence for cognitive models of insomnia.

Rhesus macaques (Macaca mulatta) displaying self-injurious behavior show more sleep disruption than controls

Self-injurious behavior (SIB) is a pathology observed in both humans and animals. In humans, SIB has been linked to various mental health conditions that are also associated with significant sleep disruption. In rhesus macaques, SIB consists of self-directed biting which can range from mild skin abrasions to wounds requiring veterinary care. However, only one study suggests possible sleep disruption in macaques with SIB. We evaluated sleep disruption using a noninvasive system (infra-red camera and a video surveillance program) which created videos for every movement over the nighttime hours. Nighttime activity was examined in 13 macaques (three females) of which six were classified as having SIB (one female). Each monkey was studied for a total of 6 nights spanning a period of 4 months. Measures included total movement time (TMT), time moving in the first hour (HR1), time moving in the last hour (HR11), and number of videos <10 secs, ≥10 secs, and ≥30 secs in length. Overall, SIB monkeys had higher TMT (p < 0.01), higher HR1 (p<0.001), and generated more videos ≥10 secs (p < 0.01) and ≥30 secs (p < 0.01). Thus, SIB monkeys showed significant sleep disruption. A four-fold difference between SIB and control monkeys in the ≥30 secs videos revealed many more significant awakenings in the SIB group. Overall higher nighttime activity, in the first hour but not in the last hour, is consistent with sleep-onset insomnia in humans. Whether increased nighttime activity contributes to the SIB condition during the day or, conversely, SIB causes higher nighttime activity remains undetermined.

[Contribution of mindfulness meditation in cognitive behavioral therapy for insomnia]

INTRODUCTION

Insomnia is considered to be a serious public health issue affecting approximately 10% of adults. Chronic insomnia may increase the risk of health problem, psychological vulnerability and proneness to accidents. Cognitive behavioral therapy for insomnia (CBT-I) is recommended as the first line of treatment. Even though CBT-I is widely considered as an effective therapy, 20 to 30% of patients do not respond to this treatment. Mindfulness therapy, known to reduce rumination and stress, could be an interesting complement to enhance CBT-I. The aim of this study is to evaluate the efficacy of therapy combining mindfulness meditation and CBT-I for the treatment of chronic insomnia.

METHODS

Thirty-three patients, diagnosed with chronic insomnia, aged 18 to 75 years (51±15 years) were recruited between October 2015 and June 2016 at the Sleep Center of Marseille. The patients were then divided into two groups according to their psychotherapy method: group CBT-I alone (17 patients) or a group therapy combining CBT-I and Mindfulness (16 patients). All participants were given five sessions of standard CBT during eight weeks. The patient-reported outcome measures were sleep onset latency, wake after sleep onset (WASO), total wake time, total sleep time, time in bed, sleep efficiency and number of awakening from sleep diaries before treatment (T0) and six weeks later (T1). Assessments were done using Pittsburgh Sleep quality index (PSQI), Insomnia severity Index (ISI), the Epworth sleepiness scale, the hospital anxiety and depression scale (HAD), the dysfunctional beliefs and attitude about sleep (DBAS-16); further, the use of sleeping pills was also recorded at T0 and T1.

RESULTS

Out of the 33 participants who began the treatment, 29 completed all sessions and were included in the analyses (4 dropouts in the group CBT-I alone). The data shows that each treatment yielded significant improvements over time in sleep variables from the diary, PSQI, ISI, anxiety (P=0.004), DBAS 16, sleeping pill use and vitality measured by SF36 health survey (P=0.004). Comparing the results of the two therapy groups, the meditation associated to CBT-I shows significantly greater rates of reduction in WASO relative to CBT-I group (P=0.009).

CONCLUSIONS

This study confirms the beneficial effects of CBT for patients suffering from insomnia on sleep parameters, anxiety symptoms and quality of life. Furthermore, this study suggests, for the first time, that combining CBT and mindfulness is a superior approach compared to that of only conventional CBT-I in improving sleep.

Psychiatric Diagnoses of Patients Visiting a Sleep Disorder Clinic Due to Dyssomnias

This study analyzed the demographic characteristics and psychiatric diagnoses of 90 consecutive patients who visited a sleep disorder clinic in Taiwan with complaints of insomnia (difficulty initiating or maintaining sleep, or nonrestorative sleep) or hypersomnia (excessive sleepiness as evidenced by either prolonged sleep episodes or daytime sleep episodes that occur almost daily). All subjects were interviewed using a sleep disturbance questionnaire and the structured Mini-International Neuropsychiatric Interview supplemented by the DSM-IV criteria for psychiatric diagnoses. Among 90 patients, 79 were classified as having insomnia and 11 had hypersomnia. 53 patients also had psychiatric diagnoses other than sleep disorders. Patients with insomnia had a significantly higher rate of comorbidities with other psychiatric diagnoses (65.8%) than did subjects with hypersomnia (9.1%). These results emphasize the importance of psychiatric evaluation of patients with complaints of sleep disturbance.

The Effects of Mind-Body Interventions on Sleep Quality: A Systematic Review

Study Objectives. To evaluate the effect of mind-body interventions (MBI) on sleep. Methods. We reviewed randomized controlled MBI trials on adults (through 2013) with at least one sleep outcome measure. We searched eleven electronic databases and excluded studies on interventions not considering mind-body medicine. Studies were categorized by type of MBI, whether sleep was primary or secondary outcome measure and outcome type. Results. 1323 abstracts were screened, and 112 papers were included. Overall, 67 (60%) of studies reported a beneficial effect on at least one sleep outcome measure. Of the most common interventions, 13/23 studies using meditation, 21/30 using movement MBI, and 14/25 using relaxation reported at least some improvements in sleep. There were clear risks of bias for many studies reviewed, especially when sleep was not the main focus. Conclusions. MBI should be considered as a treatment option for patients with sleep disturbance. The benefit of MBI needs to be better documented with objective outcomes as well as the mechanism of benefit elucidated. There is some evidence that MBI have a positive benefit on sleep quality. Since sleep has a direct impact on many other health outcomes, future MBI trials should consider including sleep outcome measurements.

The GoodNight study--online CBT for insomnia for the indicated prevention of depression: study protocol for a randomised controlled trial

BACKGROUND

Cognitive Behaviour Therapy for Insomnia (CBT-I) delivered through the Internet is effective as a treatment in reducing insomnia in individuals seeking help for insomnia. CBT-I also lowers levels of depression in this group. However, it is not known if targeting insomnia using CBT-I will lower depressive symptoms, and thus reduce the risk of major depressive episode onset, in those specifically at risk for depression. Therefore, this study aims to examine whether Internet delivery of fully automated self-help CBT-I designed to reduce insomnia will prevent depression.

METHOD/DESIGN

A sample of 1,600 community-dwelling adults (aged 18-64), who screen positive for both subclinical levels of depressive symptoms and insomnia, will be recruited via various media and randomised to either a 9-week online insomnia treatment programme, Sleep Healthy Using The internet (SHUTi), or an online attention-matched control group (HealthWatch). The primary outcome variable will be depression symptom levels at the 6-month post-intervention on the Patient Heath Questionnaire-9 (PHQ-9). A secondary outcome will be onset of major depressive episodes assessed at the 6-month post-intervention using 'current' and 'time from intervention' criteria from the Mini International Neuropsychiatric Interview.

DISCUSSION

This trial is the first randomised controlled trial of an Internet-based insomnia intervention as an indicated preventative programme for depression. If effective, online provision of a depression prevention programme will facilitate dissemination.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry (ANZCTR), Registration number: ACTRN12611000121965.

Cognitive-behavioural factors that predict sleep disturbance 4 years later

OBJECTIVE

Cognitive models have identified a number of factors that maintain sleep disturbance. It is unknown whether similar factors lead to initial onset. This study tested whether three cognitive-behavioural factors: ruminative style, somatic sensitivity, and behavioural avoidance predicted sleep disturbance onset at four-year follow-up.

METHODS

Participants (n=4,042) were assessed using a) a composite measure of Somatic Sensitivity, b) the Ruminative Style Scale, c) the Behavioural Inhibition Scale of the BISBAS and d) sleep-related items from the Goldberg Depression and Anxiety Scale.

RESULTS

Sleep disturbance at 4 years was significantly predicted by all three cognitive-behavioural factors--somatic sensitivity, ruminative style and behavioural avoidance--and, in the final analysis, was independently predicted by somatic sensitivity (OR=1.427, p<0.001) and ruminative style (OR=1.035, p=0.002).

CONCLUSION

This study tested whether three cognitive-behavioural factors: ruminative style, somatic sensitivity, and behavioural avoidance were predictive of the onset of sleep disturbance after 4 years. Although all three factors were significantly associated with the onset of sleep disturbance, only ruminative style and somatic sensitivity were found to independently predict sleep disturbance, supporting these constructs as predisposing cognitive-behavioural risk factors.

A WASO sub-group analysis of a 6-month study of eszopiclone 3 mg

BACKGROUND

Insomnia marked by sleep maintenance difficulty is extremely prevalent. Yet, problems staying asleep have been relatively neglected as a research focus compared to problems falling asleep. Insomnia treatment studies typically have not required participants to have a problem specifically with sleep maintenance. It is possible that exclusion of such subjects limits the detection of treatment effects in the overall trial in general, and of effects on sleep maintenance specifically. In order to address these issues we conducted a post hoc analysis of a 6-month placebo-controlled trial in which there were no inclusion criteria that specified sleep maintenance difficulties to assess the variable effects of baseline wake time after sleep onset (WASO - the primary maintenance measure) on the efficacy of eszopiclone 3mg.

METHODS

Patients diagnosed with chronic primary insomnia were randomized to eszopiclone 3mg (n=593) or placebo (n=195) nightly for six months. The present analyses of this study consisted of: (1) determination of the distribution of baseline WASO; (2) continuous analysis of the relationship between baseline WASO severity and drug-placebo difference at month 1 and 6; and (3) categorical efficacy analyses of subgroups delimited by the following WASO thresholds: 0, 30, 45, 60, and 90 min.

RESULTS

The baseline WASO distribution was: ≤ 30=32.2%; >0 to ≤ 45=41.5%; >30 to ≤ 90=33.0%; >45 to ≤ 90=23.7%; >90=22.6%. A relationship between greater baseline WASO severity and a significantly greater drug-placebo difference in efficacy for WASO was evident in both continuous and categorical analyses. Eszopiclone was found to have significant sleep maintenance efficacy at each time point across the entire range of WASO severity studied.

CONCLUSIONS

As illustrated in this analysis, a significant proportion of chronic insomnia patients in efficacy trials that select on the basis of sleep onset latency and total sleep time criteria may have normative-range WASO. However, even in the subgroup with minimal WASO there was a significant sleep maintenance effect. The absence of any sleep maintenance effect in a drug trial may reflect the inclusion of relatively many insomnia patients with no baseline WASO abnormality. However, treatments with therapeutic effects on sleep maintenance, can still demonstrate improvement in sleep maintenance, even in a population not selected for this type of sleep problem, if adequately powered. Future clinical trials intending to examine sleep maintenance should employ WASO selection criteria that would ensure sufficient power to detect a sleep maintenance effect. Drug-placebo difference increased as a function of baseline WASO severity, suggesting that eszopiclone's clinical effectiveness for insomnia may be enhanced in patients with more severe sleep maintenance symptoms.

Is exercise an alternative treatment for chronic insomnia?

The purposes of this systematic/critical review are: 1) to identify studies on the effects of exercise on chronic insomnia and sleep complaints in middle-aged and older adults and to compare the results of exercise with those obtained with hypnotic medications and 2) to discuss potential mechanisms by which exercise could promote sleep in insomniac patients. We identified studies from 1983 through 2011 using MEDLINE, SCOPUS and Web of Science. For systematic analyses, only studies assessing the chronic effects of exercise on sleep in people with sleep complaints or chronic insomnia were considered. We used the following keywords when searching for articles: insomnia, sleep, sleep complaints, exercise and physical activity. For a critical review, studies were selected on the effects of exercise and possible mechanisms that may explain the effects of exercise on insomnia. We identified five studies that met our inclusion criteria for systematic review. Exercise training is effective at decreasing sleep complaints and insomnia. Aerobic exercise has been more extensively studied, and its effects are similar to those observed after hypnotic medication use. Mechanisms are proposed to explain the effects of exercise on insomnia. There is additional documented evidence on the antidepressant and anti-anxiety effects of exercise. Exercise is effective to decrease sleep complaints and to treat chronic insomnia. Exercise presented similar results when compared with hypnotics; however, prospective studies comparing the effects of exercise with medical and non-medical treatments are warranted before including exercise as a first-line treatment for chronic insomnia are necessary.

Wake-promoting effects of orexin: Its independent actions against the background of an impaired corticotropine-releasing hormone receptor system

It is widely accepted that orexin (hypocretin) bears wake-promoting effects. While under normal conditions the circadian rhythm of orexin release has a clear circadian distribution, the amplitude of orexin fluctuation is dampened in depression. Interestingly, clinical symptoms of depression include several sleep disturbances. In this disease, corticotropin-releasing hormone (CRH) seems to be another factor influencing sleep. As neurophysiological interactions and anatomical connections between the orexinergic and the CRH system point to mutual influences of these two neuropeptides, we examined whether a dysfunctional CRH-receptor system in two different CRH receptor knock out models alters general wake-promoting effects of orexin applied exogenously. Orexin was injected intracerebroventricularlly into CNS-restricted CRH-receptor type 1 knockout mice (CRH-R1 KO) and CRH-receptor type 2 knockout mice (CRH-R2 KO) and baseline sleep was recorded from the freely behaving mice. A third experiment included antisauvagine-30 injections (CRH-R2 antagonist) into CRH-R1 KO animals. Orexin had similar wake-promoting effects in CRH-R1KO mice, in CRH-R2 KO animals and in CRH-R1KO mice treated with antisauvagine-30. Consistent results were obtained from all corresponding control littermate experiments. According to our results we conclude that the wake-promoting effects of orexin are not influenced by a possible contribution of CRH.

The relationship between insomnia and depressive symptoms: genuine or artifact?

BACKGROUND

Somatic symptom overlap between depression and insomnia has emerged as a major concern. Self-report measures such as the Beck Depression Inventory Second Edition (BDI-II) include somatic symptoms related to depression that are also present in the research diagnostic criteria for insomnia. This study aimed firstly to examine the relationship between the cognitive and somatic factors of the BDI-II and global scores on the Pittsburgh Sleep Quality Index (PSQI) in individuals presenting for insomnia treatment and secondly to examine whether treating insomnia in depressed individuals with insomnia will lead to a reduction in their depressive symptoms and whether this reduction is related to a decrease in the somatic or cognitive factors of depressive symptoms.

METHODS

A total of 379 individuals (133 males and 246 females), with a mean (M) age of 49.95 (standard deviation [SD] = 14.15) years, were used to address the first aim. To address the second aim, a total of 64 participants (27 males and 37 females) with both insomnia and depressive symptoms were treated for their insomnia. Their ages ranged between 22 and 87 (M = 50.97, SD = 15.13) years.

RESULTS

A significant relationship was found between both the cognitive and somatic factors of the BDI-II and global scores on the PSQI. Furthermore, although results in this study are only suggestive, they lend support to the idea that the relationship between insomnia and depression is not due to somatic symptom overlap. Results may also support the hypothesis that insomnia is primary to the presentation of depressive symptoms.

CONCLUSION

Clinicians and health care providers could initially treat insomnia in individuals suffering from insomnia who also experience depressive symptoms, as this will not only remit insomnia but also abate the accompanying depressive symptoms.

Sleep and its disorders in older adults

For many older adults, aging is associated with significant changes in sleep. There are a variety of potential causes, including primary sleep disorders, circadian rhythm disturbances, insomnia, depression, medical illness, and medications. As with younger adults, the diagnosis requires a thorough sleep history and an overnight sleep recording when appropriate. Treatment should address the primary sleep problem and can result in significant improvement in quality of life and daytime functioning in older adults.

Treatment of sleep dysfunction and psychiatric disorders

Patients with neurologic disorders commonly experience sleep dysfunction and psychiatric disorders. The most common sleep dysfunction is insomnia, which is a primary symptom in 30% to 90% of psychiatric disorders. Insomnia and fatigue are prominent symptoms of anxiety disorders and major depression, including patients who are treated but have residual symptoms. Anxiety and depressive disorders account for 40% to 50% of all cases of chronic insomnia. It is also recognized that primary insomnia and other primary sleep disorders produce symptoms that are similar to those reported by patients with psychiatric disorders. A clinician must judge whether sleep deprivation causes mood disturbance or whether depressive or anxiety disorder represents the primary reason for sleep dysfunction. When insomnia is comorbid with mild to moderate depression, therapy should begin with bedtime dosing of sedating antidepressants such as mirtazapine, nefazodone, or tricyclic antidepressants, which are preferred because of their sedative effects, although side effects may limit their usefulness. Intervention for chronic insomnia is similar in nonpsychiatric and psychiatric patients. Behavioral therapies, particularly cognitive behavioral therapy, and lifestyle changes show significant long-term efficacy as treatments for chronic insomnia. Sedative hypnotic agents are the most studied agents to treat insomnia, particularly those that are active through the benzodiazepine receptor-GABA complex, such as benzodiazepines, eszopiclone, zaleplon, and zolpidem. The new melatonin-receptor agonist ramelteon has not yet been studied in psychiatric patients. Prescription of adjunctive trazodone 50 to 150 mg is a common clinical practice to treat comorbid insomnia during antidepressant therapy, but published data are surprisingly limited when considered against the frequent usage of trazodone. Although there has been insufficient research on the use of atypical antipsychotic agents in severe insomnia, psychiatrists use quetiapine, olanzapine, or other agents to lessen agitation that disrupts sleep onset or maintenance. When insomnia or hypersomnia continues even as mood, anxiety, or thought disorders improve with standard therapy, the physician should consider the potential presence of underlying sleep disorders.

Secondary insomnia in the primary care setting: review of diagnosis, treatment, and management

INTRODUCTION

Insomnia is associated with a number of medical and psychiatric disorders, including chronic pain and clinical depression. Until recently, it was assumed that effective treatment of the underlying medical condition would also correct the sleep disturbance. However, some evidence indicates that treatment of secondary or comorbid insomnia should be considered separately from, and perhaps in addition to, optimizing treatment of the primary condition.

METHODS

This article reviews the extant literature to examine the impact of secondary and comorbid insomnia on the patient, and on healthcare economics, in the primary care setting, and discusses current diagnostic and treatment approaches. A MEDLINE search was performed for literature published from 1980 to 2005, and retrieved randomized, controlled clinical trials and key review articles for the conditions most often accompanied by secondary insomnia: depression, chronic pain, and menopause/perimenopause. The search terms included those for commonly used pharmacologic treatments and behavioral therapy.

RESULTS

Due to the paucity of clinical trial data in secondary insomnia patients, physicians have had to rely on evidence derived from primary insomnia trials. These data indicate that hypnotic medications are effective in treating sleep onset insomnia. However, few of these agents are effective against the most commonly occurring insomnia symptom - poor sleep maintenance - and many are associated with problematic residual sedation. Nevertheless, the cost of not treating these insomnia symptoms is often greater than the treatment inadequacies. Physicians should thus consider treating what they perceive as secondary insomnia with one of the available forms of therapy.

CONCLUSION

Patients experiencing sleep problems associated with a potential medical or psychiatric primary condition would likely benefit from increased physician awareness of secondary insomnia and the subsequent increased attention to diagnosing and treating this prevalent condition. Recommendations for managing secondary or comorbid insomnia in the primary care setting are discussed.

Safety behaviors and dysfunctional beliefs about sleep: testing a cognitive model of the maintenance of insomnia

OBJECTIVE

Our aim was to determine if insomnia severity, dysfunctional beliefs about sleep, and depression predicted sleep-related safety behaviors.

METHOD

Standard sleep-related measures (such as the Insomnia Severity Index; the Dysfunctional Beliefs About Sleep scale; the Depression, Anxiety, and Stress Scale; and the Sleep-Related Behaviors Questionnaire) were administered. Additionally, 14 days of sleep diary (Pittsburg Sleep Diary) data and actual use of sleep-related behaviors were collected.

RESULTS

Regression analysis revealed that dysfunctional beliefs about sleep predicted sleep-related safety behaviors. Insomnia severity did not predict sleep-related safety behaviors. Depression accounted for the greatest amount of unique variance in the prediction of safety behaviors, followed by dysfunctional beliefs. Exploratory analysis revealed that participants with higher levels of depression used more sleep-related behaviors and reported greater dysfunctional beliefs about their sleep.

CONCLUSION

The findings underlie the significant influence that dysfunctional beliefs have on individuals' behaviors. Moreover, the results suggest that depression may need to be considered as an explicit component of cognitive-behavioral models of insomnia.

Pharmacological approaches to the treatment of residual symptoms

Despite the efficacy of currently available antidepressant treatment, residual symptoms are common among individuals treated for major depressive disorder and are associated with an increased risk of relapse and poor psychosocial functioning. However, distinguishing treatment-emergent side effects from residual symptoms can be challenging for clinicians. Anxiety, sleep disturbance, somnolence/fatigue, apathy and cognitive dysfunction are among the more frequent residual symptoms. Approaches to the management of residual symptoms include addressing treatment-emergent side effects and co-morbid conditions, optimizing antidepressant dosing and using augmentation therapy. Clinicians are often guided in their decisions by anecdotal impressions. Studies assessing the evaluation and treatment of residual symptoms and side effects will contribute importantly to the optimal acute and long-term management of depression.

Sleep problems in depression: how do they impact treatment and recovery?

Chronic insomnia is common, although its prevalence in the general population is quite variable, depending on definitions used and the populations surveyed. Studies indicate that as many as 85% of people with serious insomnia remain untreated. Insomnia is frequently comorbid with depression, and observational studies suggest that insomnia is a high risk factor for depression. Disturbed sleep is of particular concern in patients with depression, as it can aggravate the symptoms of depression and influence the treatment response to antidepressants. Many antidepressants, including some selective serotonin reuptake inhibitors (SSRIs), can disrupt sleep architecture, particularly in the acute phase of treatment. Although this undesirable effect may not be immediately apparent in patients with depression, because of their high level of sleep disruption at baseline, it may nevertheless contribute to reduced compliance with therapy. In some patients, persistent insomnia may be a valuable clue to treatment resistance. Thus, it is essential to monitor sleep patterns in patients being treated for depression and to adequately address any sleep problems as they arise during the whole depressive episode. Optimal therapy for depression-related insomnia has not yet been established. Co-administration of a hypnotic drug such as zolpidem may help some patients avoid the sleep-disrupting adverse effect of some antidepressants. Selection of an antidepressant with sedating effects is another alternative that may be beneficial for some patients, although daytime somnolence may limit use in some cases. New SSRIs, such as escitalopram, which may be less disruptive to sleep and possibly preserve sleep continuity without sedation, may be the preferred option for some patients.

Comparative effects of duloxetine and desipramine on sleep EEG in healthy subjects

RATIONALE

Antidepressants are known to modify human sleep patterns.

OBJECTIVES

Duloxetine is a new antidepressant with a mechanism of action involving reuptake inhibition of both serotonin (5-HT) and norepinephrine (NE). In this study, the effects of two dosing regimens of duloxetine on sleep electroencephalography (EEG) were investigated at steady-state plasma concentrations in young, healthy, male subjects.

METHODS

Placebo (n=12), desipramine (50 mg BID; n=12) and two regimens of duloxetine (80 mg QD, n=6; or 60 mg BID, n=6) were compared in a randomized, double-blind, three-period crossover study, each treatment being administered from day 1 to day 7. Sleep polygraphic recordings took place at baseline (day -1) and day 6 of each period. The Leeds sleep evaluation questionnaire (LSEQ) was also administered on the morning of day 7.

RESULTS

Both regimens of duloxetine produced a significant increase in the onset latency of REM sleep as well as a significant mean decrease in total REM sleep duration. Desipramine exhibited comparable effects. When compared to placebo, sleep continuity was significantly reduced with desipramine and duloxetine 60 mg BID whereas a significant improvement was observed with duloxetine 80 mg QD. On the LSEQ, duloxetine 80 mg QD produced a significant improvement in the "getting to sleep" subscale compared to placebo, whereas desipramine demonstrated a significant reduction (worsening) in the "quality of sleep" score versus placebo.

CONCLUSIONS

The two dose regimens of duloxetine (80 mg QD and 60 mg BID) produced a REM sleep pattern comparable to that of most antidepressant medications. Duloxetine 80 mg QD appeared to exhibit less impact upon sleep quality than duloxetine 60 mg BID in healthy subjects.

Diurnal variation of cerebrospinal fluid hypocretin-1 (Orexin-A) levels in control and depressed subjects

BACKGROUND

Hypocretins, excitatory neuropeptides at monoaminergic synapses, appear to regulate human sleep-wake cycles. Undetectable cerebrospinal fluid hypocretin-1 levels are seen in narcolepsy, which is frequently associated with secondary depression. Shortened rapid eye movement latency is observed in both narcolepsy and depression. Cerebrospinal fluid hypocretin-1 levels have not been reported in mood disorders.

METHODS

We examined hypocretin-1 levels in 14 control and 15 depressed subjects. Cerebrospinal fluid was drawn continuously in supine subjects for 24 hours with an indwelling intrathecal catheter under entrained light-dark conditions. Depressed subjects were studied before and after 5 weeks of sertraline (n=10, three nonresponders) or bupropion (n=5, two nonresponders).

RESULTS

Hypocretin-1 levels varied slightly (amplitude 10%) but significantly across the diurnal cycle in control subjects, with amplitude significantly reduced in depression (3%). Levels were lowest at midday, surprising for a hypothetically wake-promoting peptide. Mean hypocretin levels trended higher in depressive than in control subjects. Hypocretin-1 levels decreased modestly but significantly after sertraline (-14%) but not bupropion.

CONCLUSIONS

Our results are consistent with previous physiologic findings in depression indicating dampened diurnal variations in hypocretin-1. The finding that sertraline but not bupropion slightly decreased cerebrospinal fluid hypocretin-1 indicates a serotoninergic influence on hypocretin tone.

Insomnia, alcoholism and relapse

Insomnia and alcoholism are significantly associated in community surveys and patient samples. Insomnia occurs in 36-72% of alcoholic patients and may last for weeks to months after initiating abstinence from alcohol. Some correlates of insomnia in alcoholic patients are identical to those observed in non-alcoholic insomniacs, including anxiety and depression, tobacco smoking, and the use of alcohol to aid sleep. Other studies suggest that as the severity of alcoholism increases, so does the likelihood of insomnia in alcoholic patients. In the sleep laboratory, alcoholic patients who complain of insomnia have disrupted sleep continuity when compared to alcoholic patients without insomnia complaints. Recently sober alcoholics are also more likely than non-alcoholics to have sleep-disordered breathing and increased periodic leg movements, which might contribute to insomnia in some alcoholic patients. The co-occurrence of insomnia and alcoholism is clinically significant because alcoholism can exacerbate the adverse consequences of insomnia (e.g. mood changes and performance decrements) and because insomnia among patients entering treatment for alcoholism has been significantly associated with subsequent alcoholic relapse. Baseline polysomnographic correlates of subsequent relapse include prolonged sleep latency, decreased sleep efficiency and total sleep time, increased rapid eye movement sleep pressure, and decreased slow wave sleep. Whether treatment of insomnia in alcoholic patients reduces relapse rates is unknown, but preliminary treatment guidelines that accommodate the special characteristics of alcoholic patients are provided, with a goal to reduce daytime impairment and psychological distress.