Quantifying subjective assessment of sleep and life-quality in antidepressant-treated depressed patients

Depressive symptoms' trajectories since adolescence and sleep quality in early adulthood: results from the EPITeen cohort

OBJECTIVES

We aimed to estimate the association between depressive symptoms' trajectories during adolescence and young adulthood and sleep quality in early adulthood.

METHODS

Data from 802 participants of the EPITeen study, evaluated at 13, 17 and 21 years of age, were analysed. Depressive symptoms were assessed using the Beck Depression Inventory-II and three trajectory classes from adolescence to adulthood were previously identified (High, Moderate, Low). The prevalences of poor sleep quality, overall (score>5) and in its specific dimensions: subjective sleep quality, sleep latency, sleep duration, sleep efficiency, sleep disturbance, use of sleep drugs and daytime dysfunction (score≥2), at 21 years of age were evaluated using the Pittsburgh Sleep Quality Index. Associations were estimated using adjusted odds ratio (OR) and the respective 95 % confidence intervals (CI).

RESULTS

At 21 years of age, 29.8 % young adults presented poor sleep quality, which was significantly different between those in the Low and High depressive trajectories (14.3 and 53.1 %, respectively, p<0.001). Compared with participants in the Low trajectory, those in the High trajectory were more likely to present poorer sleep quality at 21 years of age (OR=6.34 95 % CI: 3.94-10.21), particularly worse levels of sleep disturbance (OR=5.89 95 % CI: 2.84-12.21), daytime dysfunction (OR=7.63 95 % CI: 3.63-16.06) and subjective sleep quality (OR=6.61 95 % CI: 3.69-11.85).

CONCLUSIONS

Poor sleep quality in early adulthood was more frequent among individuals who had high levels of depressive symptoms since adolescence. Monitoring depression until adulthood may help to identify those at higher risk of sleep problems which, in turn, can lead to worse health outcomes over time.

Major depressive disorder

Major depressive disorder (MDD) is characterized by persistent depressed mood, loss of interest or pleasure in previously enjoyable activities, recurrent thoughts of death, and physical and cognitive symptoms. People with MDD can have reduced quality of life owing to the disorder itself as well as related medical comorbidities, social factors, and impaired functional outcomes. MDD is a complex disorder that cannot be fully explained by any one single established biological or environmental pathway. Instead, MDD seems to be caused by a combination of genetic, environmental, psychological and biological factors. Treatment for MDD commonly involves pharmacological therapy with antidepressant medications, psychotherapy or a combination of both. In people with severe and/or treatment-resistant MDD, other biological therapies, such as electroconvulsive therapy, may also be offered.

Clinical guidelines for the use of lifestyle-based mental health care in major depressive disorder: World Federation of Societies for Biological Psychiatry (WFSBP) and Australasian Society of Lifestyle Medicine (ASLM) taskforce

OBJECTIVES

The primary objectives of these international guidelines were to provide a global audience of clinicians with (a) a series of evidence-based recommendations for the provision of lifestyle-based mental health care in clinical practice for adults with Major Depressive Disorder (MDD) and (b) a series of implementation considerations that may be applicable across a range of settings.

METHODS

Recommendations and associated evidence-based gradings were based on a series of systematic literature searches of published research as well as the clinical expertise of taskforce members. The focus of the guidelines was eight lifestyle domains: physical activity and exercise, smoking cessation, work-directed interventions, mindfulness-based and stress management therapies, diet, sleep, loneliness and social support, and green space interaction. The following electronic bibliographic databases were searched for articles published prior to June 2020: PubMed, EMBASE, The Cochrane Library (Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials (CENTRAL), Cochrane Methodology Register), CINAHL, PsycINFO. Evidence grading was based on the level of evidence specific to MDD and risk of bias, in accordance with the World Federation of Societies for Biological Psychiatry criteria.

RESULTS

Nine recommendations were formed. The recommendations with the highest ratings to improve MDD were the use of physical activity and exercise, relaxation techniques, work-directed interventions, sleep, and mindfulness-based therapies (Grade 2). Interventions related to diet and green space were recommended, but with a lower strength of evidence (Grade 3). Recommendations regarding smoking cessation and loneliness and social support were based on expert opinion. Key implementation considerations included the need for input from allied health professionals and support networks to implement this type of approach, the importance of partnering such recommendations with behaviour change support, and the need to deliver interventions using a biopsychosocial-cultural framework.

CONCLUSIONS

Lifestyle-based interventions are recommended as a foundational component of mental health care in clinical practice for adults with Major Depressive Disorder, where other evidence-based therapies can be added or used in combination. The findings and recommendations of these guidelines support the need for further research to address existing gaps in efficacy and implementation research, especially for emerging lifestyle-based approaches (e.g. green space, loneliness and social support interventions) where data are limited. Further work is also needed to develop innovative approaches for delivery and models of care, and to support the training of health professionals regarding lifestyle-based mental health care.

Sleep disturbances and the association with attenuated psychotic symptoms in individuals at ultra high-risk of psychosis

Sleep disturbances are common in individuals at ultra high-risk (UHR) of psychosis and have proven to play a causal role in the occurrence of psychotic symptoms in healthy individuals. Only a few studies have systematically investigated sleep disturbances in UHR individuals. The help-seeking UHR individuals were 18-40 years old, and we included 72 UHR individuals according to the Comprehensive Assessment of At-Risk Mental State criteria (CAARMS) and 36 healthy controls. Sleep was measured with a modified version of the Karolinska Sleep Questionnaire and actigraphy for one night, and melatonin was measured at awakening and bedtime. We compared subjective rated sleep and actigraphy between healthy and UHR individuals (t-test and chi-square test) and examined the association between a CAARMS-composite score (linear regression). UHR individuals subjectively experienced poor sleep, categorised as disturbed sleep- and awakening index compared with healthy controls. We found no differences in actigraphy variables or morning/evening melatonin between UHR and healthy controls (t-test and chi-square). A high CAARMS-composite score was associated with high morning melatonin (B = 0.15, CI 0.02 to 0.27, p = 0.024) and high awakening index (B = 1.86, CI 0.58 to 3.14, p = 0.004) in UHR individuals. The results suggest that UHR individuals with high CAARMS scores have a delayed sleep phase; they have difficulties waking up and feel exhausted at awakening. It might be necessary to evaluate how UHR individuals sleep, and it would be of great interest to follow these patients over time according to the development of psychosis.

Factors Associated with Quality of Life of Clinical Nurses: A Cross-Sectional Survey

Nurses often have a heavy workload and struggle to maintain a good quality of life (QOL). The aim of this study was to explore the relationship between perceived stresses and sleep disturbance, and quality of life among Korean clinical nurses. A cross-sectional design was used to examine these relationships among 200 clinical nurses at three hospitals in South Korea. Standardized instruments were used, including the Perceived Stress Scale (PSS), Insomnia Severity Index (ISI), Eating Behavior Questionnaire (DEBQ), and the WHOQoL-BREF questionnaire. The data were analyzed using descriptive statistics, the t-test, ANOVA, the Scheffe test, Pearson's correlation coefficient, and multiple regression analysis using SPSS/WIN 24.0 program. Multiple regression analysis showed that clinical nurses who had a subjective health status (β = 0.29, p = 0.001), perceived stress (β = -0.32, p < 0.001), and sleep disturbance (β = -0.21, p = 0.001) were more likely to have a higher quality of life. The explanatory power of the regression model was statistically significant at 36.7%. Multiple regression analysis showed that clinical nurses who had better subjective health status, lower perceived stress, and fewer sleep disturbances were more likely to have a higher quality of life.

Healthy Sleep Every Day Keeps the Doctor Away

When one considers the big picture of their health, sufficient sleep may often go overlooked as a keystone element in this picture. Insufficient sleep in either quality or duration is a growing problem for our modern society. It is essential to look at what this means for our health because insufficient sleep increases our risks of innumerable lifechanging diseases. Beyond increasing the risk of developing these diseases, it also makes the symptoms and pathogenesis of many diseases worse. Additionally, consistent quality sleep can not only improve our physical health but has also been shown to improve mental health and overall quality of life. Substandard sleep health could be a root cause for numerous issues individuals may be facing in their lives. It is essential that physicians take the time to learn about how to educate their patients on sleep health and try to work with them on an individual level to help motivate lifestyle changes. Facilitating access to sleep education for their patients is one way in which physicians can help provide patients with the tools to improve their sleep health. Throughout this paper, we will review the mechanisms behind the relationship between insufficient sleep health and chronic disease and what the science says about how inadequate sleep health negatively impacts the overall health and the quality of our lives. We will also explain the lifechanging effects of sufficient sleep and how we can help patients get there.

Slow Wave Sleep Deficits in the Flinders Sensitive Line Rodent Model of Depression: Effects of Medial Forebrain Bundle Deep-Brain Stimulation

Major Depressive Disorder (MDD) is an affective disorder typically accompanied by sleep disturbances. Deep brain stimulation (DBS) of the medial forebrain bundle (MFB) is an emerging intervention for treatment-resistant depression, but its effect on sleep has not been closely examined. Here we aimed to characterise sleep deficits in the Flinders sensitive line, an established rodent model of depression, and investigate the consequences of MFB stimulation on sleep-related phenotypes. Rats were implanted with bilateral stimulation electrodes in the MFB, surface electrodes to record electrocorticography and electromyography for sleep scoring and electrodes within the prelimbic cortex, nucleus accumbens (NAc) and dorsal hippocampus. Recordings of sleep and oscillatory activity were conducted prior to and following twenty-four hours of MFB stimulation. Behavioural anti-depressant effects were monitored using the forced swim test. Previously unreported abnormalities in the Flinders sensitive line rats were observed during slow wave sleep, including decreased circadian amplitude of its rhythm, a reduction in slow wave activity and elevated gamma band oscillations. Previously established rapid eye movement sleep deficits were replicated. MFB stimulation had anti-depressant effects on behavioural phenotype, but did not significantly impact sleep architecture; it suppressed elevated gamma activity during slow wave sleep in the electrocorticogram and prelimbic cortex signals. Diverse abnormalities in Flinders sensitive line rats emphasise slow wave sleep as a state of dysfunction in affective disorders. MFB stimulation is able to affect behaviour and sleep physiology without influencing sleep architecture. Gamma modulation may represent a component of antidepressant mechanism.

The relationship between the HDRS insomnia items and polysomnographic (PSG) measures in individuals with treatment-resistant depression

The Hamilton Depression Rating Scale (HDRS), which includes several insomnia-related items, is potentially valuable in evaluating both depressive and sleep symptoms. However, the HDRS insomnia items have not been fully assessed by objective measures. This study compared the three HDRS insomnia items (Early, Middle, and Late) with the corresponding objective polysomnography (PSG) measures of Sleep Latency (SL), middle wakefulness, and late wakefulness. The study used HDRS and PSG data from 130 baseline nights, drawn from 80 participants enrolled in clinical trials for treatment-resistant depression (TRD). Mixed models evaluated the relationship between the HDRS and PSG, and primary analyses examined the Early, Middle, and Late Insomnia HDRS items and the PSG variables SL and Waking After Sleep Onset (WASO). To approximate the Middle and Late HDRS Insomnia items more closely, WASO was divided into WASO before 4:00 a.m. (waking between Sleep Onset and 0400 h) and WASO after 4:00 a.m. (waking between 0400 h and 0700 h). Secondary analyses included summed HDRS Global Insomnia score. HDRS Early and Late Insomnia items predicted objective PSG measures of early and late wakefulness. For Early Insomnia, each additional point in severity was associated with 61% [95%CI: 35%, 93%] longer SL. For Late Insomnia, each additional point was associated with a 35% [95% CI: 13%, 63%] increase in WASO after 4:00 a.m. Middle Insomnia was marginally related to WASO before 4:00 a.m. HDRS Early and Late Insomnia items may thus provide an index of wakefulness in TRD and help monitor treatment response when objective measures such as PSG are not feasible. CLINICAL TRIALS IDENTIFIER: www.clinicaltrials.gov (NCT01204918, NCT00054704, NCT00088699).

Rotating between day and night shifts: Factors influencing sleep patterns of hospital nurses

AIMS AND OBJECTIVES

This study aimed to investigate sleep patterns of hospital nurses using a wearable electronic device and determine the influence of rotating day and night shifts and lifestyle factors on their sleep efficiency.

BACKGROUND

Nurses working in shifts are vulnerable to sleep disturbances. However, little is known about the influence of rotating day and night shift schedules and healthy lifestyle on nurses' daily sleep patterns.

DESIGN

Descriptive correlational design.

METHODS

Thirty-two hospital nurses working in shifts and 32 hospital nurses not working in shifts participated in data collection. Their sleep patterns were measured for six consecutive days using Fitbit Charge 3^™ , and information on alcohol consumption, exercise, and eating habits were assessed using a questionnaire. Data were analysed using repeated measures analysis of variance with post hoc Scheffe's test and hierarchical multiple regression analysis. The study was conducted in accordance with the STROBE guideline.

RESULTS

Overall, nurses working on rotating day and night shifts had significantly shorter total sleep time, longer sleep onset latency, and lower sleep efficiency than those not working in shifts. In particular, nurses working for 3 or 4 consecutive night shifts had significantly shorter total sleep time, lower sleep efficiency and longer sleep onset latency than those working for 0-2 consecutive night shifts. Rotating day and night shifts and alcohol consumption significantly influenced sleep efficiency.

CONCLUSIONS

A work schedule of ≥3 consecutive night shifts and the habit of alcohol consumption before bed time influence nurses' sleep efficiency.

RELEVANCE TO CLINICAL PRACTICE

Given the poor sleep pattern among nurses working in shifts, particularly those working on ≥2 consecutive night shifts, it is necessary to develop an optimal shift schedule and a program to promote healthy lifestyle among hospital nurses.

The Effect Of Fluvoxamine On Sleep Architecture Of Depressed Patients With Insomnia: An 8-Week, Open-Label, Baseline-Controlled Study

BACKGROUND AND AIMS

Fluvoxamine can markedly increase the serum melatonin level, which regulates human circadian rhythm. However, only limited research has evaluated the effects of fluvoxamine on sleep architecture. Thus, the current study aims to investigate the effect of fluvoxamine on PSG characteristics and the impact of persistent insomnia on the prognosis of depression in the depressed individual with insomnia over the course of 8 weeks.

METHODS

Thirty-one clinically depressed patients with insomnia were enrolled in this 8-week, open-label, baseline-controlled study, and 23 patients completed the study. All participants were assigned to receive fluvoxamine for 8 weeks. They were assessed by the PSG, Hamilton Rating Scale for Depression (17 items) (HRSD-17), Clinical Global Index, Pittsburgh Sleep Quality Index, and Epworth Sleepiness Scale at baseline and the following visits, which were at day 14, day 28, and day 56. A patient with an ≥4 HRSD-17 sleep disturbance factor score at both baseline and endpoint (day 56) was defined as a patient with persistent insomnia.

RESULTS

Compared with baseline, the percentage of stage 3 sleep had significantly (F=11.630, P=0.001) increased in all 3 visits. Moreover, the percentage of rapid eye movement sleep was reduced during the study, with only a significant difference (F=3.991, P=0.027) between baseline and day 14. Finally, 47.8% (11/23) of the participants were in remission, and 60.9% (14/23) of them did not report insomnia. The clinical remission ratio of the persistent insomnia group (11.1% [1/9]) (χ² =8.811, P=0.004) was significantly lower than that of the non-insomnia group (71.4% [10/14]) at the endpoint. Additionally, during the first clinical evaluation (day 14), patients without insomnia had significantly higher final remission ratios than patients with insomnia (80% [8/10] versus 30.8% [4/13]; χ² =5.79; P=0.016).

CONCLUSION

Fluvoxamine improved PSG parameters and ameliorated complaints of insomnia simultaneously during this 8-week study. Moreover, depressed individuals who reported persistent insomnia were at higher risk of remaining depressed by the end of the trial, which might be forecasted by the sleep status on day 14.

TRIAL REGISTRATION

The Effect of Fluvoxamine on Polysomnogram in Depressed Patients with Insomnia; https://clinicaltrials.gov/ct2/show/NCT02442713. Registry identifier: NCT02442713. Registry date: May 13, 2015.

A practical approach to perioperative management of cardiac implantable electronic devices

With the increased use of cardiac implantable electronic devices (CIEDs), it is increasingly important to recognise the unique challenges involved in the management of patients with CIEDs who are undergoing surgery. Practice advisories and consensus statements have been issued by the American Society of Anesthesiologists and the Heart Rhythm Society, advocating a multidisciplinary approach. This review discusses and presents a practical approach to perioperative CIED management in the Singapore context.

The Relationship between Sleep Quality and Social Intimacy, and Academic Burn-Out in Students of Medical Sciences

Introduction:

Academic burnout leads to creation of a series of negative and scattered thoughts, loss of hope and emotional and physical exhaustion in carrying out activities. Two factors that affect academic burnout are sleep quality and social intimacy. This study was conducted in order to investigate the relationship between sleep quality and social intimacy, and academic burn-out in the students of Tabriz University of Medical Sciences

Materials & Methods:

This study was descriptive and correlational. The population of this study consisted of the students in Tabriz University of Medical Sciences and 196 medical students were selected. They completed Berso et al. Academic Burnout Questionnaire, Pittsburgh Sleep Quality Index (PSQI) and Miller Social Intimacy Scale (MSIS). The validity of the questionnaires confirmed by experts’ views. Their reliability were obtained as 77%, 64% and 85% for academic burnout, sleep quality and social intimacy questionnaires respectively by calculating the internal consistency (Cronbach’s alpha). For data analysis, descriptive statistics and Pearson correlation test, Regression, cluster analysis and t-test were used.

Results:

The results showed that there was a positive and significant relationship between sleep quality and academic burnout at the level p<0.05 (r=0.38). There was a negative and significant relationship between social intimacy and academic burnout at the level p<0.05 (r=-0.40). Also, the regression results showed that sleep quality and social intimacy were able to predict 37% and 39% of academic burnout respectively. Moreover, the students were divided into two clusters of individuals with high social intimacy and individuals with low social intimacy. No significant difference was found between the two types in terms of the variable of academic burn-out.

Conclusion:

Based on the research results, it can be stated that the variables of sleep quality and social intimacy are the predictor factors of academic burn-out.

Propofol versus flunitrazepam for inducing and maintaining sleep in postoperative ICU patients

Context:

Sleep deprivation is a common problem on intensive care units (ICUs) influencing not only cognition, but also cellular functions. An appropriate sleep-wake cycle should therefore be maintained to improve patients’ outcome. Multiple disruptive factors on ICUs necessitate the administration of sedating and sleep-promoting drugs for patients who are not analgo-sedated.

Aims:

The objective of the present study was to evaluate sleep quantity and sleep quality in ICU patients receiving either propofol or flunitrazepam.

Settings and Design:

Monocentric, randomized, double-blinded trial.

Materials and Methods:

A total of 66 ICU patients were enrolled in the study (flunitrazepam n = 32, propofol n = 34). Propofol was injected continuously (2 mg/kg/h), flunitrazepam as a bolus dose (0.015 mg/kg). Differences between groups were evaluated using a standardized sleep diary and the bispectral index (BIS).

Statistical Analysis Used:

Group comparisons were performed by Mann-Whitney U-Test. P < 0.05 was considered to be statistically significant.

Results:

Sleep quality and the frequency of awakenings were significantly better in the propofol group (Pg). In the same group lower BIS values were recorded (median BIS propofol 74.05, flunitrazepam 78.7 [P = 0.016]). BIS values had to be classified predominantly to slow-wave sleep under propofol and light sleep after administration of flunitrazepam. Sleep quality improved in the Pg with decreasing frequency of awakenings and in the flunitrazepam group with increasing sleep duration.

Conclusions:

Continuous low-dose injection of propofol for promoting and maintaining night sleep in ICU patients who are not analgo-sedated was superior to flunitrazepam regarding sleep quality and sleep structure.

Nonrestorative sleep: symptom or unique diagnostic entity?

Nonrestorative sleep (NRS) refers to the subjective experience of sleep as insufficiently refreshing, often despite the appearance of normal sleep according to traditionally assessed objective parameters. This has led researchers to pursue alternative physiological markers of nonrestorative or unrefreshing sleep, though much of this research remains controversial and inconclusive. This review summarizes the recent findings on NRS in the literature and discusses some of the issues inherent in current efforts to define and measure NRS. We offer a summary of recommended clinical approaches to NRS and discuss a new potential paradigm for the assessment of NRS-an approach modelled on current diagnosis of insomnia.

Barriers to achieving treatment goals: a focus on sleep disturbance and sexual dysfunction

BACKGROUND

Patients who meet the criteria for a major depressive episode experience a constellation of symptoms, and different symptom configurations may reflect distinct underlying neurological disturbances. Similarly, the differing receptor profiles of the various antidepressants may explain relatively low remission rates and persistent symptoms even after remission. In particular, depressed patients frequently display altered circadian rhythms, sleep disturbances, and diurnal mood variation. Exploring treatments that can restore mood while having a positive impact on circadian rhythms and sleep would greatly improve the ability to treat this core features of depression.

METHODS

The mechanisms of action of the various classes of antidepressants, their effects on sleep and issues beyond sleep, including sexual dysfunction, are explored, along with questions relating to adherence.

RESULTS

Unfortunately, persistent sleep problems are among the most difficult-to-treat residual symptoms of depression. Many of the currently available antidepressants have adverse effects on circadian processes, including sleep, and may actually worsen sleep problems. Tolerability is also an enduring issue; SSRI and SNRI antidepressants are associated with central nervous sysytem and gastrointestinal effects, sexual side effects and suicidality. Improved drug tolerability would not only minimize distressing adverse effects, but would also improve adherence, thus maximizing the chances of successful treatment.

CONCLUSIONS

The complexity of managing a major depressive episode is well illustrated by sleep disturbance and sexual dysfunction, two core symptoms of MDD that may also be caused or exacerbated by antidepressant therapy. Future antidepressants should alleviate symptoms without adversely affecting sleep or sexual function.

Subjective sleep, depression and anxiety: inter-relationships in a non-clinical sample

OBJECTIVES

Previous research confirms the interdependent relationship between poor sleep and depression, but has often focused on objective measures of sleep and overlooked the importance of subjective factors. Insomnia may be maintained by anxiety and perceptions of poor sleep timing, and depression is associated with poor sleep satisfaction, regardless of perceived sleep timing.

METHODS

This study explored the contribution of current depression and anxiety to sleep perceptions. Participants (n = 98) completed the Hospital Anxiety and Depression scale, and questionnaires were used to evaluate current and previous psychiatric illness, sleep disorders and prescribed psychotropic medication.

RESULTS

A series of ANOVAs and regression analyses indicated that variance in sleep timing perceptions was more likely to be explained by symptoms of anxiety than depression; explained variance (adj. R(2)) 25%, t = 2.361; p = 0.023. The analyses also showed that sleep satisfaction perceptions (adj. R(2) = 20%, t = 3.085; p = 0.004), and those relating to overall quality of life (adj. R(2) = 37%, t = -2.763; p = 0.013), were more likely to be explained by symptoms of depression.

CONCLUSIONS

These findings support the observation that anxiety appears related to poorer sleep timing perceptions, while depression appears associated with poor sleep satisfaction. Further research is needed to explore the factors that might maintain poor sleep satisfaction in depression.

Sleep disorders as core symptoms of depression

Links between sleep and depression are strong. About three quarters of depressed patients have insomnia symptoms, and hypersomnia is present in about 40% of young depressed adults and 10% of older patients, with a preponderance in females. The symptoms cause huge distress, have a major impact on quality of life, and are a strong risk factor for suicide. As well as the subjective experience of sleep symptoms, there are well-documented changes in objective sleep architecture in depression. Mechanisms of sleep regulation and how they might be disturbed in depression are discussed. The sleep symptoms are often unresolved by treatment, and confer a greater risk of relapse and recurrence. Epidemiological studies have pointed out that insomnia in nondepressed subjects is a risk factor for later development of depression. There is therefore a need for more successful management of sleep disturbance in depression, in order to improve quality of life in these patients and reduce an important factor in depressive relapse and recurrence.

Quetiapine monotherapy in the treatment of depressive episodes of bipolar I and II disorder: Improvements in quality of life and quality of sleep

INTRODUCTION

The depressive symptoms of bipolar disorder impact health-related quality of life, quality of sleep and functioning. The BOLDER I and II trials demonstrated that quetiapine significantly improves depressive symptoms in patients with acute bipolar depression. Post-hoc analysis of the BOLDER I and II data permits a detailed investigation of the effects of quetiapine on these other measures in this patient population.

METHODS

Secondary analysis was performed on data from BOLDER I and II, which were two 8-week, double-blind, randomized, placebo-controlled studies of quetiapine at fixed doses (300 or 600 mg/day) in a total of 1051 patients with acute depressive episodes of bipolar I or II disorder. Measures included the Short-Form Quality of Life Enjoyment and Satisfaction Questionnaire (Q-LES-Q SF) in BOLDER I and II, the Pittsburgh Sleep Quality Index (PSQI) in BOLDER I, and the Sheehan Disability Scale (SDS) in BOLDER II. Analyses of Q-LES-Q SF score changes were based on data from the combined BOLDER I and II populations, and analyses of PSQI and SDS score changes were based on BOLDER I and BOLDER II populations, respectively.

RESULTS

Assessments at day 57 by mixed-model repeated measures analysis demonstrated that quetiapine relative to placebo provided significant or numerical improvements in rating scale score on the Q-LES-Q SF (10.89 with 300 mg/day and 12.14 with 600 mg/day vs. 7.79 with placebo; p<0.001 for each quetiapine dose), PSQI (-5.34 and -6.00 vs. -3.35; p<0.001, each dose), and SDS (-7.78 and -8.25 vs. -6.49; p=0.156 and 0.054, respectively). Effect sizes at day 57 with quetiapine 300 and 600 mg/day, respectively, were 0.34 and 0.46 for Q-LES-Q SF, 0.59 and 0.79 for PSQI, and 0.17 and 0.23 for SDS. Improvements were evident at first post-baseline assessment on day 29 and were consistent over the majority of rating scale domains. Quetiapine was generally well tolerated and most adverse events were of mild to moderate intensity.

CONCLUSIONS

Quetiapine monotherapy is effective in improving impairment in important aspects of life that accompany improvements in depressive symptoms in patients with acute bipolar depression.

Limitations of current medical treatments for depression: disturbed circadian rhythms as a possible therapeutic target

The proportion of diagnosed depressives prescribed antidepressants has increased markedly over the last 20 years, mainly following the introduction of the selective serotonin reuptake inhibitors. However, currently available antidepressants have notable limitations, relating to their only moderate efficacy relative to placebo, relatively slow onset of action, possible withdrawal symptoms, and problems of compliance. Sleep disturbances are often used to identify newly presenting depressive patients, and may be part of a more general alteration of bodily rhythms. There are links between pharmacological treatments and circadian rhythms in depression, which might represent another, new option for the development of a therapeutic approach to depression treatment. Many antidepressants affect sleep, some are sedative, and others have been used specifically in severely insomniac depressives. Disturbances in circadian rhythms may be an integral part of depressive mechanisms, and normalising them via an innovative mechanism of antidepressant action may be a fruitful avenue in the search for improved antidepressant agents.

Qualidade subjetiva do sono em pacientes com transtorno depressivo

O objetivo deste estudo foi avaliar a qualidade subjetiva do sono em pacientes com transtorno depressivo. Setenta pacientes (44 mulheres e 26 homens) ambulatoriais com diagnóstico de transtorno depressivo foram entrevistados e responderam ao Índice de Qualidade de Sono de Pittsburgh (IQSP), ao Questionário de Hábitos do Sono e ao Inventário de Depressão de Beck (BDI). As médias das pontuações globais do IQSP e BDI foram respectivamente 12,80 ± 3,77 e 35,83 ± 8,85, e a correlação foi positiva e significativa entre essas escalas (r = 0,70; p < 0,05). As pontuações globais do IQSP em pacientes com insônia (16,61 ± 4,21) e hipersonia (8,82 ± 2,71) apresentaram diferenças marcantes (p < 0,05). Os resultados da análise multivariada indicaram que apenas a insônia foi significativamente associada à qualidade subjetiva do sono (RC = 4,1; 95% IC = 2,0-4,2). Os resultados sugerem que os pacientes da amostra apresentaram percepção inferior da qualidade subjetiva do sono, principalmente na insônia.

Development of the sleep quality scale

Sleep quality affects health and the overall quality of life. As the factors that influence sleep quality and their relative importance vary among individuals, a self-report method is essential. Although various questionnaires have been used to assess sleep quality, few all-inclusive assessment scales have been developed. Therefore, the purpose of this study was to develop an instrument for measuring sleep quality and to study its validity and reliability. A Sleep Quality Scale (SQS) was developed using item analysis and factor analysis on items with content validity. SQS, composed of 28 items and six factors, accounted for 62.6% of the total variance. The difference of SQS score between insomniacs and normal subjects confirmed the construct validity (t = -13.8, P = 0.000). Concurrent validity was identified by the significant correlation of SQS with the Pittsburgh Sleep Quality Index (r = 0.72, P = 0.000). The Cronbach's alpha coefficient was 0.92 for internal consistency and the correlation coefficient was 0.81 for test-retest reliability at a 2-week interval. The developed SQS was therefore confirmed to be a valid and reliable instrument for the comprehensive assessment of sleep quality.

Sleep in mood disorders

Sleep disturbances are among the most common symptoms in patients who have acute episodes of mood disorders, and patients who have mood disorders exhibit higher rates of sleep disturbances than the general population, even during periods of remission. Insomnia and hypersomnia are associated with an increased risk for the development or recurrence of mood disorders and increased severity of psychiatric symptoms. Sleep electroencephalogram recordings have identified objective abnormalities associated with mood disorders, providing insight into the neurobiologic relationships between mood and sleep. Future studies will continue to investigate this association and potentially improve treatment of sleep and mood disorders.

The relationship between sleep disturbance and depression

This paper focuses on several aspects of the relationship between sleep and depression, with particular attention to objective factors and subjective perceptions. It does not address the effect that antidepressants have on sleep, nor does it explore the wider implications of the types and course of depression, age, or other psychiatric conditions. "Normal sleep" is explored, examining typical sleep architecture in individuals without sleep disorders, psychiatric conditions or physical illness. Sleep disorders are reviewed and examined to present the nature of the disturbance and the role that they may play in depression, with particular attention paid to insomnia. Studies have identified a sub-group of insomnia patients (highly distressed poor sleepers), who appear to be less satisfied with their sleep quality than "low distressed poor sleepers", even though they did not differ on sleep timing perceptions. Recent work has shown that depressed individuals to be less satisfied with sleep quality than healthy controls, even though they did not differ on sleep timing perceptions. The evidence presented here supports the view that subjective sleep perceptions play an important role in depression. Poor subjective perceptions of sleep in depression may be associated with faulty cognitions. This has been found extensively in insomnia, but is under-researched in depression.

Antidepressants and sleep: a qualitative review of the literature

Most antidepressants change sleep; in particular, they alter the physiological patterns of sleep stages recorded overnight with EEG and other physiological measures. These effects are greatest and most consistent on rapid eye movement (REM) sleep, and tend to be in the opposite direction to the sleep abnormalities found in major depression, but are usually of greater degree. Reductions in the amount of REM sleep and increases in REM sleep onset latency are seen after taking antidepressants, both in healthy volunteers and in depressed patients. Antidepressants that increase serotonin function by blocking reuptake or by inhibiting metabolism have the greatest effect on REM sleep. The decrease in amount of REM sleep appears to be greatest early in treatment, and gradually diminishes during long-term treatment, except after monoamine oxidase inhibitors when REM sleep is often absent for many months. Sleep initiation and maintenance are also affected by antidepressants, but the effects are much less consistent between drugs. Some antidepressants such as clomipramine and the selective serotonin receptor inhibitors (SSRIs), particularly fluoxetine, are sleep-disturbing early in treatment and some others such as amitriptyline and the newer serotonin 5-HT2-receptor antagonists are sleep promoting. However, these effects are fairly short-lived and there are very few significant differences between drugs after a few weeks of treatment. In general, the objectively measured sleep of depressed patients improves during 3-4 weeks of effective antidepressant treatment with most agents, as does their subjective impression of their sleep. Sleep improvement earlier in treatment may be an important clinical goal in some patients, perhaps when insomnia is particularly distressing, or to ensure compliance. In these patients, the choice of a safely used and effective antidepressant which improves sleep in short term is indicated. Patients with other sleep disorders such as restless legs syndrome and REM sleep behaviour disorder should be identified before choosing a treatment, as some antidepressants worsen these conditions. Conversely, there is evidence that some antidepressants may be useful in the treatment of sleep disorders such as night terrors.

Effects of socio-demographic variables on health-related quality of life determined by the quality of life index--German version

STUDY OBJECTIVE

The purpose of this study was to determine subjective health-related quality of life (HRQoL) in a sample of the Austrian population over 14 years of age in order to evaluate the effect of socio-demographic variables on HRQoL.

DESIGN/SETTING

HRQoL was determined by means of the quality of life index-German version (QLI-Ge). The influence of socio-demographic variables on HRQoL was assessed by statistical analysis using the Kruskal-Wallis test and an analysis of variance.

PARTICIPANTS

A random-quota procedure was used to get balanced representation from regions and demographic groups of the Austrian population. The sample consisted of 1049 participants, 493 men and 556 women.

MAIN RESULTS

Age was found to influence the QLI-Ge total score (index score) and most individual items, with increasing age resulting in a decrease in HRQoL. Differences between the sexes were observed in three dimensions: males scored higher in 'physical well-being', 'psychological well-being' and 'occupational functioning'. Marital status impacted most items with married persons showing better values than divorced persons or singles. Profession had only a minor effect on HRQoL, the level of education showed no influence at all.

CONCLUSIONS

The socio-demographic variables age, sex and objective living conditions had a major influence on subjectively rated HRQoL, whereas profession and education were found to play a minor role in this context. It is recommended that in the interpretation of studies assessing HRQoL the above-mentioned objective factors be considered. This will be of particular importance when determining the effect of a pharmacotherapy on HRQoL in patients.

A systematic review of patient-reported outcome instruments measuring sleep dysfunction in adults

Sleep dysfunction can manifest in several ways, ranging from insomnia to somnolence, and from disrupted sleep to lack of restful sleep. Measuring sleep dysfunction is an area of active research and there exist a number of patient-reported outcome instruments that measure various aspects of sleep dysfunction. However, these instruments have not been evaluated systematically. We used a conceptual model of sleep that included four physical domains of general interest to patients and investigators, and cover the breadth of this disorder: sleep initiation; sleep maintenance; sleep adequacy; and somnolence. We next considered the additional health-related quality-of-life (HR-QOL) domains of psychological and social functioning, progressing along the continuum to include health perceptions and opportunity. We then conducted a literature review to identify instruments and, using criteria developed by the Medical Outcomes Trust Scientific Advisory Committee, evaluated these instruments for their potential use in measuring sleep dysfunction. Twenty-two instruments were identified. Six instruments were found to include the four physical domains defined a priori (Basic Nordic Sleep Questionnaire, Leeds Sleep Evaluation Questionnaire, Medical Outcomes Study - Sleep Problems Measures, Pittsburgh Sleep Diary, Pittsburgh Sleep Quality Index, Self-Rated Sleep Questionnaire and the Sleep Dissatisfaction Questionnaire). Several additional instruments addressed at least some of the domains and thus may be useful for specific purposes. A few instruments addressed overall HR-QOL, but did not include all four domains of interest (Functional Outcomes of Sleep Questionnaire, Quality of Life in Insomniacs and the Sleep-Wake Activity Inventory). Two instruments had undergone extensive psychometric evaluation (Medical Outcomes Study - Sleep Problems Measures and Pittsburgh Sleep Quality Index), with only the latter reporting information about interpretability. Our review indicates that measuring sleep dysfunction in adults is an area of active research and that much work still needs to be completed, specifically the study of interpretability and the application of patient preferences or item response theory. The specific research focus should dictate instrument selection.

Correlation of subjective and objective sleep measurements at different stages of the treatment of depression

Studies of the correlation of subjective and objective sleep measures in depressed patients have produced mixed results so far. Further, they were carried out in sleep laboratories and tended to obtain one-off assessments, thus not taking into account the effect of treatment. We investigated forty (40) patients over the course of 8-week treatment of depression with either paroxetine or nefazodone. We used home polysomnography at baseline, nights 3 and 10, and week 8 of treatment, with extensive assessments of subjective sleep, the morning after each sleep recording. The patients were able to judge accurately their total sleep time and sleep onset latency, both before and during treatment. However, they were inaccurate in estimating the number of times they woke up during the night. Sleep satisfaction correlated negatively with Stage 1 sleep at baseline. Sleep quality was represented by a combination of subjective parameters measuring the ease of initiation and maintenance of sleep, and it appeared to derive from slow wave sleep and sleep continuity as seen in polysomnography. The partial discrepancy between subjective and objective measures suggests that a cognitive element is combined with the biological element to produce the sleep problems reported by depressed patients.

Assessing subjective sleep reports in the first-degree relatives of antidepressant-treated depressed outpatients

This study sought to investigate whether first-degree relatives of depressed patients report, and react to, sleep perceptions in the same way as the depressed group. Our previous research suggested that depressed individuals may experience greater sleep 'distress' than healthy individuals; we wished to explore whether this was also apparent in their nearest relatives. A sample was recruited of 18 antidepressant-treated patients with a current DSM-IV diagnosis of major depressive disorder, 18 healthy controls, and a group of 10 first-degree relatives for each study group. In accordance with previous findings, poorer sleep perceptions corresponded with poorer life-quality and mood perceptions, and depressed individuals reported poorer sleep perceptions and poorer life-quality/mood perceptions than controls. Additionally, there was evidence of similar sleep reporting between depressed patients and their relatives, and for a difference between these relatives and other non-depressed groups. There was a non-significant trend for depressed patients, and their relatives, to report total sleep time in the same manner as each other, and differently to other non-depressed groups. Reports of poor sleep may be associated with reports of poor mood in depression, but in non-depressed individuals the association may be with a feeling of weariness.