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Antila H, Lilius TO, Palada V, Lohela T, Bell RF, Porkka-Heiskanen T, Kalso E. Effects of commonly used analgesics on sleep architecture-A topical review. Pain 2024; 165:00006396-990000000-00539. [PMID: 38442410 PMCID: PMC11247456 DOI: 10.1097/j.pain.0000000000003201] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Revised: 01/11/2024] [Accepted: 01/15/2024] [Indexed: 03/07/2024]
Affiliation(s)
- Hanna Antila
- Neuroscience Center, Helsinki Institute of Life Science, University of Helsinki, Finland
- SleepWell Research Program Unit, Faculty of Medicine, University of Helsinki, Finland
- Individualized Drug Therapy Research Program Unit, Faculty of Medicine, University of Helsinki, Finland
| | - Tuomas O. Lilius
- Individualized Drug Therapy Research Program Unit, Faculty of Medicine, University of Helsinki, Finland
- Department of Pharmacology, Faculty of Medicine, University of Helsinki, Finland
- Department of Emergency Medicine and Services, Helsinki University Hospital and University of Helsinki, Finland
| | - Vinko Palada
- SleepWell Research Program Unit, Faculty of Medicine, University of Helsinki, Finland
- Department of Physiology, Faculty of Medicine, University of Helsinki, Finland
| | - Terhi Lohela
- Individualized Drug Therapy Research Program Unit, Faculty of Medicine, University of Helsinki, Finland
- Department of Anaesthesiology, Intensive Care and Pain Medicine, Helsinki University Hospital and University of Helsinki, Finland
| | - Rae F. Bell
- Regional Centre of Excellence in Palliative Care, Haukeland University Hospital, Bergen, Norway
| | | | - Eija Kalso
- SleepWell Research Program Unit, Faculty of Medicine, University of Helsinki, Finland
- Department of Pharmacology, Faculty of Medicine, University of Helsinki, Finland
- Department of Anaesthesiology, Intensive Care and Pain Medicine, Helsinki University Hospital and University of Helsinki, Finland
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Ellis CA, Sendi MSE, Zhang R, Carbajal DA, Wang MD, Miller RL, Calhoun VD. Novel methods for elucidating modality importance in multimodal electrophysiology classifiers. Front Neuroinform 2023; 17:1123376. [PMID: 37006636 PMCID: PMC10050434 DOI: 10.3389/fninf.2023.1123376] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Accepted: 03/01/2023] [Indexed: 03/17/2023] Open
Abstract
IntroductionMultimodal classification is increasingly common in electrophysiology studies. Many studies use deep learning classifiers with raw time-series data, which makes explainability difficult, and has resulted in relatively few studies applying explainability methods. This is concerning because explainability is vital to the development and implementation of clinical classifiers. As such, new multimodal explainability methods are needed.MethodsIn this study, we train a convolutional neural network for automated sleep stage classification with electroencephalogram (EEG), electrooculogram, and electromyogram data. We then present a global explainability approach that is uniquely adapted for electrophysiology analysis and compare it to an existing approach. We present the first two local multimodal explainability approaches. We look for subject-level differences in the local explanations that are obscured by global methods and look for relationships between the explanations and clinical and demographic variables in a novel analysis.ResultsWe find a high level of agreement between methods. We find that EEG is globally the most important modality for most sleep stages and that subject-level differences in importance arise in local explanations that are not captured in global explanations. We further show that sex, followed by medication and age, had significant effects upon the patterns learned by the classifier.DiscussionOur novel methods enhance explainability for the growing field of multimodal electrophysiology classification, provide avenues for the advancement of personalized medicine, yield unique insights into the effects of demographic and clinical variables upon classifiers, and help pave the way for the implementation of multimodal electrophysiology clinical classifiers.
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Affiliation(s)
- Charles A. Ellis
- The Wallace H. Coulter Department of Biomedical Engineering, Georgia Institute of Technology, Emory University, Atlanta, GA, United States
- Tri-Institutional Center for Translational Research in Neuroimaging and Data Science, Georgia State University, Georgia Institute of Technology, Emory University, Atlanta, GA, United States
- *Correspondence: Charles A. Ellis,
| | - Mohammad S. E. Sendi
- Tri-Institutional Center for Translational Research in Neuroimaging and Data Science, Georgia State University, Georgia Institute of Technology, Emory University, Atlanta, GA, United States
- McLean Hospital and Harvard Medical School, Boston, MA, United States
| | - Rongen Zhang
- Hankamer School of Business, Baylor University, Waco, TX, United States
| | - Darwin A. Carbajal
- The Wallace H. Coulter Department of Biomedical Engineering, Georgia Institute of Technology, Atlanta, GA, United States
| | - May D. Wang
- The Wallace H. Coulter Department of Biomedical Engineering, Georgia Institute of Technology, Emory University, Atlanta, GA, United States
| | - Robyn L. Miller
- Tri-Institutional Center for Translational Research in Neuroimaging and Data Science, Georgia State University, Georgia Institute of Technology, Emory University, Atlanta, GA, United States
- Department of Computer Science, Georgia State University, Atlanta, GA, United States
| | - Vince D. Calhoun
- The Wallace H. Coulter Department of Biomedical Engineering, Georgia Institute of Technology, Emory University, Atlanta, GA, United States
- Tri-Institutional Center for Translational Research in Neuroimaging and Data Science, Georgia State University, Georgia Institute of Technology, Emory University, Atlanta, GA, United States
- Department of Computer Science, Georgia State University, Atlanta, GA, United States
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Pain and Analgesic related insomnia. Pain Manag Nurs 2022; 24:254-264. [DOI: 10.1016/j.pmn.2022.11.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2021] [Revised: 10/11/2022] [Accepted: 11/15/2022] [Indexed: 12/23/2022]
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Krahn LE, Arand DL, Avidan AY, Davila DG, DeBassio WA, Ruoff CM, Harrod CG. Recommended protocols for the Multiple Sleep Latency Test and Maintenance of Wakefulness Test in adults: guidance from the American Academy of Sleep Medicine. J Clin Sleep Med 2021; 17:2489-2498. [PMID: 34423768 DOI: 10.5664/jcsm.9620] [Citation(s) in RCA: 39] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
This article updates the American Academy of Sleep Medicine protocols for the administration of the Multiple Sleep Latency Test and the Maintenance of Wakefulness Test. The American Academy of Sleep Medicine commissioned a task force of clinical experts in sleep medicine to review published literature on the performance of these tests since the publication of the 2005 American Academy of Sleep Medicine practice parameter paper. Although no evidence-based changes to the protocols were warranted, the task force made several changes based on consensus. These changes included guidance on patient preparation, medication and substance use, sleep before testing, test scheduling, optimum test conditions, and documentation. This article provides guidance to providers who order and administer the Multiple Sleep Latency Test and the Maintenance of Wakefulness Test. CITATION Krahn LE, Arand DL, Avidan AY, et al. Recommended protocols for the Multiple Sleep Latency Test and the Maintenance of Wakefulness Test in adults: guidance from the American Academy of Sleep Medicine. J Clin Sleep Med. 2021;17(12):2489-2498.
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Affiliation(s)
| | - Donna L Arand
- Wright State University Boonshoft School of Medicine, Dayton, Ohio
| | - Alon Y Avidan
- David Geffen School of Medicine at UCLA, University of California, Los Angeles, Los Angeles, California
| | - David G Davila
- Central Arkansas Veterans Healthcare System, Little Rock, Arkansas
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Raymond JS, Rehn S, Hoyos CM, Bowen MT. The influence of oxytocin-based interventions on sleep-wake and sleep-related behaviour and neurobiology: A systematic review of preclinical and clinical studies. Neurosci Biobehav Rev 2021; 131:1005-1026. [PMID: 34673110 DOI: 10.1016/j.neubiorev.2021.10.016] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2021] [Revised: 10/13/2021] [Accepted: 10/14/2021] [Indexed: 12/26/2022]
Abstract
The oxytocin (OXT) system has garnered considerable interest due to its influence on diverse behaviours. However, scant research has considered the influence of oxytocin on sleep-wake and sleep-related behaviour and neurobiology. Consequently, the objective of this systematic review was to assess the extant preclinical and clinical evidence for the influence of oxytocin-based interventions on sleep-wake outcomes. The primary search was conducted on 22/7/2020 using six electronic databases; 30 studies (19 preclinical, 11 clinical) were included based on inclusion criteria. Studies were evaluated for risk of bias using the SYRCLE tool and the Cochrane risk of bias tools for preclinical and clinical studies, respectively. Results indicated manipulation of the OXT system can influence sleep-wake outcomes. Preclinical evidence suggests a wake-promoting influence of OXT system activation whereas the clinical evidence suggests little or no sleep-promoting influence of OXT. OXT dose was identified as a likely modulatory factor of OXT-induced effects on sleep-wake behaviour. Future studies are necessary to validate and strengthen these tentative conclusions about the influence of OXT on sleep-wake behaviour.
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Affiliation(s)
- Joel S Raymond
- The University of Sydney, Faculty of Science, School of Psychology, Camperdown, NSW, Australia; The University of Sydney, Brain and Mind Centre, Camperdown, NSW, Australia
| | - Simone Rehn
- The University of Sydney, Faculty of Science, School of Psychology, Camperdown, NSW, Australia
| | - Camilla M Hoyos
- The University of Sydney, Faculty of Science, School of Psychology, Camperdown, NSW, Australia; The University of Sydney, Brain and Mind Centre, Camperdown, NSW, Australia; The University of Sydney, Woolcock Institute of Medical Research, Centre for Sleep and Chronobiology, Camperdown, NSW, Australia
| | - Michael T Bowen
- The University of Sydney, Faculty of Science, School of Psychology, Camperdown, NSW, Australia; The University of Sydney, Brain and Mind Centre, Camperdown, NSW, Australia.
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Iacovides S, Kamerman P, Baker FC, Mitchell D. Why It Is Important to Consider the Effects of Analgesics on Sleep: A Critical Review. Compr Physiol 2021; 11:2589-2619. [PMID: 34558668 DOI: 10.1002/cphy.c210006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
We review the known physiological mechanisms underpinning all of pain processing, sleep regulation, and pharmacology of analgesics prescribed for chronic pain. In particular, we describe how commonly prescribed analgesics act in sleep-wake neural pathways, with potential unintended impact on sleep and/or wake function. Sleep disruption, whether pain- or drug-induced, negatively impacts quality of life, mental and physical health. In the context of chronic pain, poor sleep quality heightens pain sensitivity and may affect analgesic function, potentially resulting in further analgesic need. Clinicians already have to consider factors including efficacy, abuse potential, and likely side effects when making analgesic prescribing choices. We propose that analgesic-related sleep disruption should also be considered. The neurochemical mechanisms underlying the reciprocal relationship between pain and sleep are poorly understood, and studies investigating sleep in those with specific chronic pain conditions (including those with comorbidities) are lacking. We emphasize the importance of further work to clarify the effects (intended and unintended) of each analgesic class to inform personalized treatment decisions in patients with chronic pain. © 2021 American Physiological Society. Compr Physiol 11:1-31, 2021.
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Affiliation(s)
- Stella Iacovides
- Brain Function Research Group, School of Physiology, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Peter Kamerman
- Brain Function Research Group, School of Physiology, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Fiona C Baker
- Brain Function Research Group, School of Physiology, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.,Human Sleep Research Program, SRI International, Menlo Park, California, USA
| | - Duncan Mitchell
- Brain Function Research Group, School of Physiology, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
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7
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Association of Sleep Architecture and Physiology with Depressive Disorder and Antidepressants Treatment. Int J Mol Sci 2021; 22:ijms22031333. [PMID: 33572767 PMCID: PMC7866255 DOI: 10.3390/ijms22031333] [Citation(s) in RCA: 31] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2021] [Revised: 01/25/2021] [Accepted: 01/27/2021] [Indexed: 01/27/2023] Open
Abstract
Sleep problems are frequently associated with the principal diagnostic criteria for many mental disorders. Alterations in the sleep of depressive patients are of high clinical significance because continuous sleep problems raise the chance of relapse, recurrence, or suicide, as well as the need for augmenting medications. Most antidepressants have been proven to influence the sleep architecture. While some classes of antidepressants improve sleep, others may cause sleep impairment. The successful treatment of depressive disorder also requires an understanding of the effects of antidepressants on sleep. This article briefly reviews the physiology of sleep and the typical alterations in the sleep architecture in depressive patients and updates the different effects of the majority of antidepressants including novel drugs in clinical practice on sleep. The summary of the updated scientific findings of the relationship between depression and sleep disturbances could be clinically beneficial in choosing the best medication for depressive patients with concurrent sleep disorders.
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Herrero Babiloni A, Beetz G, Bruneau A, Martel MO, Cistulli PA, Nixdorf DR, Conway JM, Lavigne GJ. Multitargeting the sleep-pain interaction with pharmacological approaches: A narrative review with suggestions on new avenues of investigation. Sleep Med Rev 2021; 59:101459. [PMID: 33601274 DOI: 10.1016/j.smrv.2021.101459] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2020] [Revised: 01/18/2021] [Accepted: 01/19/2021] [Indexed: 12/21/2022]
Abstract
The multimorbidity formed by sleep disturbances and pain conditions is highly prevalent and has a significant impact in global health and in the socioeconomic system. Although different approaches have been directed toward its management, evidence regarding an optimal treatment is lacking, and pharmacological options are often preferred. Health professionals (e.g., pain and sleep clinicians) tend to focus on their respective expertise, targeting a single symptom with a single drug. This may increase polypharmacy and the risk of drug interactions, adverse events, and mortality. Hence, the use of medications that can directly or indirectly improve sleep, pain, and other possible accompanying conditions without exacerbating them becomes especially relevant. The objectives of this comprehensive review are to: a) describe the beneficial or deleterious effects that some commonly used medications to manage pain have on sleep and sleep disorders; and b) describe the beneficial or deleterious effects that frequently prescribed medications for sleep may have on pain. Moreover, medications targeting some specific sleep-pain interactions will be suggested and future directions for improving sleep and alleviating pain of these patients will be provided with clinical and research perspectives.
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Affiliation(s)
- Alberto Herrero Babiloni
- Division of Experimental Medicine, McGill University, Montreal, Québec, Canada; Center for Advanced Research in Sleep Medicine, Research Centre, Hôpital du Sacré-Coeur de Montréal (CIUSSS du Nord de-l'Île-de-Montréal), Québec, Canada; Faculty of Dental Medicine, Université de Montréal, Québec, Canada.
| | - Gabrielle Beetz
- Center for Advanced Research in Sleep Medicine, Research Centre, Hôpital du Sacré-Coeur de Montréal (CIUSSS du Nord de-l'Île-de-Montréal), Québec, Canada
| | - Alice Bruneau
- Division of Experimental Medicine, McGill University, Montreal, Québec, Canada
| | - Marc O Martel
- Division of Experimental Medicine, McGill University, Montreal, Québec, Canada; Faculty of Dentistry & Department of Anesthesia, McGill University, Canada
| | - Peter A Cistulli
- Sleep Research Group, Charles Perkins Centre, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia; Centre for Sleep Health and Research, Department of Respiratory and Sleep Medicine, Royal North Shore Hospital, Sydney, New South Wales, Australia
| | - Donald R Nixdorf
- Division of TMD and Orofacial Pain, Department of Diagnostic and Biological Sciences, School of Dentistry, University of Minnesota, Minneapolis, MN, USA; Department of Neurology, Medical School, University of Minnesota, Minneapolis, MN, USA; HealthPartners Institute for Education and Research, Bloomington, MN, USA
| | | | - Gilles J Lavigne
- Division of Experimental Medicine, McGill University, Montreal, Québec, Canada; Center for Advanced Research in Sleep Medicine, Research Centre, Hôpital du Sacré-Coeur de Montréal (CIUSSS du Nord de-l'Île-de-Montréal), Québec, Canada; Faculty of Dental Medicine, Université de Montréal, Québec, Canada
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9
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Abstract
There is a complex interplay between sleep disturbance and patients in pain. There is an increasing appreciation of the direct effects of analgesic drugs and sleep quality. This review provides an overview of the effects of different analgesic drugs and their effects on phases of sleep. The effects of different pain conditions and their direct effects on sleep physiology are also discussed. A structured search of the scientific literature using MEDLINE and PubMed databases. Original human and animal studies were included. A multi-search term strategy was employed. An appreciation of the physiological effects of these drugs will allow a more considered prescription of them to better manage sleep disturbance.
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Affiliation(s)
- Adam Woo
- Consultant Anaesthetist & Pain Physician, King's College Hospital, London, UK
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10
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Onton JA, Matthews SC, Kang DY, Coleman TP. In-Home Sleep Recordings in Military Veterans With Posttraumatic Stress Disorder Reveal Less REM and Deep Sleep <1 Hz. Front Hum Neurosci 2018; 12:196. [PMID: 29867419 PMCID: PMC5958207 DOI: 10.3389/fnhum.2018.00196] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2018] [Accepted: 04/23/2018] [Indexed: 11/13/2022] Open
Abstract
Veterans with posttraumatic stress disorder (PTSD) often report suboptimal sleep quality, often described as lack of restfulness for unknown reasons. These experiences are sometimes difficult to objectively quantify in sleep lab assessments. Here, we used a streamlined sleep assessment tool to record in-home 2-channel electroencephalogram (EEG) with concurrent collection of electrodermal activity (EDA) and acceleration. Data from a single forehead channel were transformed into a whole-night spectrogram, and sleep stages were classified using a fully automated algorithm. For this study, 71 control subjects and 60 military-related PTSD subjects were analyzed for percentage of time spent in Light, Hi Deep (1-3 Hz), Lo Deep (<1 Hz), and rapid eye movement (REM) sleep stages, as well as sleep efficiency and fragmentation. The results showed a significant tendency for PTSD sleepers to spend a smaller percentage of the night in REM (p < 0.0001) and Lo Deep (p = 0.001) sleep, while spending a larger percentage of the night in Hi Deep (p < 0.0001) sleep. The percentage of combined Hi+Lo Deep sleep did not differ between groups. All sleepers usually showed EDA peaks during Lo, but not Hi, Deep sleep; however, PTSD sleepers were more likely to lack EDA peaks altogether, which usually coincided with a lack of Lo Deep sleep. Linear regressions with all subjects showed that a decreased percentage of REM sleep in PTSD sleepers was accounted for by age, prazosin, SSRIs and SNRIs (p < 0.02), while decreased Lo Deep and increased Hi Deep in the PTSD group could not be accounted for by any factor in this study (p < 0.005). Linear regression models with only the PTSD group showed that decreased REM correlated with self-reported depression, as measured with the Depression, Anxiety, and Stress Scales (DASS; p < 0.00001). DASS anxiety was associated with increased REM time (p < 0.0001). This study shows altered sleep patterns in sleepers with PTSD that can be partially accounted for by age and medication use; however, differences in deep sleep related to PTSD could not be linked to any known factor. With several medications [prazosin, selective serotonin reuptake inhibitors (SSRIs), serotonin-norepinephrine reuptake inhibitors (SNRIs); p < 0.03], as well as SSRIs were associated with less sleep efficiency (b = -3.3 ± 0.95; p = 0.0005) and more sleep fragmentation (b = -1.7 ± 0.51; p = 0.0009). Anti-psychotics were associated with less sleep efficiency (b = -4.9 ± 1.4; p = 0.0004). Sleep efficiency was negatively impacted by SSRIs, antipsychotic medications, and depression (p < 0.008). Increased sleep fragmentation was associated with SSRIs, SNRIs, and anxiety (p < 0.009), while prazosin and antipsychotic medications correlated with decreased sleep fragmentation (p < 0.05).
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Affiliation(s)
- Julie A. Onton
- Institute for Neural Computation, University of California, San Diego, La Jolla, CA, United States
- Warfighter Performance, Naval Health Research Center, San Diego, CA, United States
| | - Scott C. Matthews
- Psychiatry, VA San Diego Healthcare System, San Diego, CA, United States
- Department of Psychiatry, University of California, San Diego, La Jolla, CA, United States
| | - Dae Y. Kang
- Department of Bioengineering, University of California, San Diego, La Jolla, CA, United States
| | - Todd P. Coleman
- Department of Bioengineering, University of California, San Diego, La Jolla, CA, United States
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Treatment of cognitive dysfunction in major depressive disorder—a review of the preclinical evidence for efficacy of selective serotonin reuptake inhibitors, serotonin–norepinephrine reuptake inhibitors and the multimodal-acting antidepressant vortioxetine. Eur J Pharmacol 2015; 753:19-31. [DOI: 10.1016/j.ejphar.2014.07.044] [Citation(s) in RCA: 62] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2014] [Revised: 06/06/2014] [Accepted: 07/24/2014] [Indexed: 02/02/2023]
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Decreased delta sleep ratio and elevated alpha power predict vulnerability to depression during interferon-alpha treatment. Acta Neuropsychiatr 2015; 27:14-24. [PMID: 25434651 DOI: 10.1017/neu.2014.30] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
OBJECTIVE Although poor sleep accompanies depression, it is unknown which specific sleep abnormalities precede depression. This is similarly the case for depression developing during interferon-α (IFN-α) therapy. Because vulnerability becomes evident in those who slept poorly before IFN-α, we prospectively determined which specific aspect of sleep could predict subsequent depression. METHODS Two nights of polysomnography with quantitative electroencephalogram (EEG) were obtained in 24 adult, euthymic subjects--all subsequently treated with IFN-α for hepatitis C. Every 2 weeks, a Beck Depression Inventory-II (BDI-II) score was obtained, and the maximal increase in BDI-II from pre-treatment baseline--excluding the sleep question--was determined. RESULTS The delta sleep ratio (DSR; an index of early-night restorative delta power) was inversely associated with BDI-II increases (p<0.01), as was elevated alpha power (8-12 Hz; p<0.001). Both delta (0.5-4 Hz) and alpha power exhibited high between-night correlations (r=0.83 and 0.92, respectively). In mixed-effect repeated-measure analyses, there was an interaction between alpha power and DSR (p<0.001)--subjects with low alpha power and elevated DSR were resilient to developing depression. Most other sleep parameters--including total sleep time and percentage of time in slow wave sleep--were not associated with subsequent changes in depression. CONCLUSIONS Both high DSR and low alpha power may be specific indices of resilience. As most other aspects of sleep were not associated with resilience or vulnerability, sleep interventions to prevent depression may need to specifically target these specific sleep parameters.
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Dhillon S. Duloxetine: a review of its use in the management of major depressive disorder in older adults. Drugs Aging 2014; 30:59-79. [PMID: 23239363 DOI: 10.1007/s40266-012-0040-1] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Duloxetine (Cymbalta(®)) is a selective serotonin norepinephrine reuptake inhibitor indicated for the treatment of major depressive disorder (MDD). This article reviews the therapeutic efficacy and tolerability of duloxetine in older adults with MDD and summarizes its pharmacological properties. Treatment with duloxetine significantly improved several measures of cognition, depression, anxiety, pain and health-related quality-of-life (HR-QOL) in older adults with MDD in two 8-week, double-blind, placebo-controlled trials. However, no significant improvements in measures of depression were observed at week 12 (primary endpoint) of a 24-week, double-blind trial, although symptoms of depression did improve significantly at earlier timepoints. Benefit of treatment was also observed during continued therapy in the 24-week study (i.e. after the 12-week primary endpoint) and in an open-label, 52-week study, with improvements being observed in some measures of depression, pain and HR-QOL. Duloxetine was generally well tolerated in these studies, with nausea, dizziness and adverse events reflecting noradrenergic activity (e.g. dry mouth, constipation) being the most common treatment-emergent adverse events during treatment for up to 52 weeks. Duloxetine therapy had little effect on cardiovascular parameters and bodyweight. Although further well designed and long-term studies in this patient population are required to confirm the efficacy of duloxetine and to compare it with that of other antidepressants, current evidence suggests that treatment with duloxetine may be beneficial in older adults with MDD.
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Affiliation(s)
- Sohita Dhillon
- Adis, 41 Centorian Drive, Mairangi Bay, Private Bag 65901, North Shore, Auckland, New Zealand.
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Boyle J, Eriksson MEV, Gribble L, Gouni R, Johnsen S, Coppini DV, Kerr D. Randomized, placebo-controlled comparison of amitriptyline, duloxetine, and pregabalin in patients with chronic diabetic peripheral neuropathic pain: impact on pain, polysomnographic sleep, daytime functioning, and quality of life. Diabetes Care 2012; 35:2451-8. [PMID: 22991449 PMCID: PMC3507552 DOI: 10.2337/dc12-0656] [Citation(s) in RCA: 141] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE Chronic diabetic peripheral neuropathic pain (DPNP) is difficult to treat, with treatment regimens often inadequate at controlling pain and limited by side effects and drug tolerance. Secondary parameters, such as quality of sleep and mood, may also be important for successful DPNP management. The objectives of this study were to compare the analgesic efficacy of pregabalin, amitriptyline, and duloxetine, and their effect on polysomnographic sleep, daytime functioning, and quality of life in patients with DPNP. RESEARCH DESIGN AND METHODS This was a double-blind, randomized, parallel group investigation of type 1 and 2 diabetic subjects with DPNP. Each treatment group had a single-blind, 8-day, placebo run-in followed by 14 days of lower-dose and 14 days of higher-dose medication. At the end of each dose titration period, subjective pain, sleep, and daytime functioning were assessed during a 2-day residential period. RESULTS All medications reduced pain when compared with placebo, but no one treatment was superior to any other. For sleep, pregabalin improved sleep continuity (P < 0.001), whereas duloxetine increased wake and reduced total sleep time (P < 0.01 and P < 0.001). Despite negative effects on sleep, duloxetine enhanced central nervous system arousal and performance on sensory motor tasks. There were no significant safety findings; however, there was a significantly higher number of adverse events in the pregabalin treatment group. CONCLUSIONS There was no significant difference in analgesic efficacy between amitriptyline, duloxetine, and pregabalin. However, there were significant differences in the secondary parameters, which may be of relevance when deciding the optimal treatment for DPNP.
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Affiliation(s)
- Julia Boyle
- Surrey Clinical Research Centre, Institute of Biosciences and Medicine, Faculty of Health and Medical Sciences, University of Surrey, Guildford, Surrey, UK
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15
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Michel MC, Oelke M. Duloxetine in the treatment of stress urinary incontinence. ACTA ACUST UNITED AC 2012; 1:345-58. [PMID: 19803876 DOI: 10.2217/17455057.1.3.345] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
This manuscript reviews the pharmacodynamics and pharmacokinetics of duloxetine and its efficacy and safety in women with stress urinary incontinence. Duloxetine is a selective inhibitor of neuronal serotonin and norepinephrine uptake which increases urethral striated muscle activity and bladder capacity. Duloxetine is readily absorbed and extensively metabolized; cytochrome P450 1A2 (CYP1A2) inhibiting drugs can markedly increase duloxetine exposure. The clinical efficacy of duloxetine has consistently been demonstrated in several randomized, double-blind studies in women with moderate-to-severe stress urinary incontinence, but the additional benefit relative to placebo was moderate. Duloxetine treatment is frequently associated with adverse events such as nausea, dry mouth, fatigue, insomnia and constipation, but serious adverse events are rare. Therefore, duloxetine appears suitable for the treatment of stress urinary incontinence.
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Affiliation(s)
- Martin C Michel
- Dept. Pharmacology & Pharmacotherapy, Academic Medical Center,University of Amsterdam,Meibergdreef 15,1105 AZ Amsterdam, Netherlands.
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Henry NL, Banerjee M, Wicha M, Van Poznak C, Smerage JB, Schott AF, Griggs JJ, Hayes DF. Pilot study of duloxetine for treatment of aromatase inhibitor-associated musculoskeletal symptoms. Cancer 2011; 117:5469-75. [DOI: 10.1002/cncr.26230] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2011] [Revised: 03/24/2011] [Accepted: 04/11/2011] [Indexed: 11/06/2022]
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Conroy DA, Brower KJ. Alcohol, toxins, and medications as a cause of sleep dysfunction. HANDBOOK OF CLINICAL NEUROLOGY 2011; 98:587-612. [PMID: 21056213 DOI: 10.1016/b978-0-444-52006-7.00038-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Affiliation(s)
- Deirdre A Conroy
- University of Michigan Addiction Resarch Center, Ann Arbor, MI 48109-2700, USA
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Affiliation(s)
- Andrew D. Krystal
- Director, Insomnia and Sleep Research Program, Professor of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Box 3309, Duke University Medical Center, Durham, NC, 27710, Phone: 919-681-8742, FAX: 919-681-8744
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20
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Fell MJ, Witkin JM, Falcone JF, Katner JS, Perry KW, Hart J, Rorick-Kehn L, Overshiner CD, Rasmussen K, Chaney SF, Benvenga MJ, Li X, Marlow DL, Thompson LK, Luecke SK, Wafford KA, Seidel WF, Edgar DM, Quets AT, Felder CC, Wang X, Heinz BA, Nikolayev A, Kuo MS, Mayhugh D, Khilevich A, Zhang D, Ebert PJ, Eckstein JA, Ackermann BL, Swanson SP, Catlow JT, Dean RA, Jackson K, Tauscher-Wisniewski S, Marek GJ, Schkeryantz JM, Svensson KA. N-(4-((2-(trifluoromethyl)-3-hydroxy-4-(isobutyryl)phenoxy)methyl)benzyl)-1-methyl-1H-imidazole-4-carboxamide (THIIC), a Novel Metabotropic Glutamate 2 Potentiator with Potential Anxiolytic/Antidepressant Properties: In Vivo Profiling Suggests a Link between Behavioral and Central Nervous System Neurochemical Changes. J Pharmacol Exp Ther 2010; 336:165-77. [DOI: 10.1124/jpet.110.172957] [Citation(s) in RCA: 88] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
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Morillas-Arques P, Rodriguez-Lopez CM, Molina-Barea R, Rico-Villademoros F, Calandre EP. Trazodone for the treatment of fibromyalgia: an open-label, 12-week study. BMC Musculoskelet Disord 2010; 11:204. [PMID: 20831796 PMCID: PMC2945951 DOI: 10.1186/1471-2474-11-204] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2010] [Accepted: 09/10/2010] [Indexed: 11/22/2022] Open
Abstract
Background Despite its frequent use as a hypnotic, trazodone has not been systematically assessed in fibromyalgia patients. In the present study have we evaluated the potential effectiveness and tolerability of trazodone in the treatment of fibromyalgia. Methods A flexible dose of trazodone (50-300 mg/day), was administered to 66 fibromyalgia patients for 12 weeks. The primary outcome measure was the Pittsburgh Sleep Quality Index (PSQI). Secondary outcome measures included the Fibromyalgia Impact Questionnaire (FIQ), the Beck Depression Inventory (BDI), the Hospital Anxiety and Depression Scale (HADS), the Brief Pain Inventory (BPI), the Short-Form Health Survey (SF-36), and the Patients' Global Improvement Scale (PGI). Trazodone's emergent adverse reactions were recorded. Data were analyzed with repeated measures one-way ANOVA and paired Student's t test. Results Trazodone markedly improved sleep quality, with large effect sizes in total PSQI score as well on sleep quality, sleep duration and sleep efficiency. Significant improvement, although with moderate effect sizes, were also observed in total FIQ scores, anxiety and depression scores (both HADS and BDI), and pain interference with daily activities. Unexpectedly, the most frequent and severe side effect associated with trazodone in our sample was tachycardia, which was reported by 14 (21.2%) patients. Conclusions In doses higher than those usually prescribed as hypnotic, the utility of trazodone in fibromyalgia management surpasses its hypnotic activity. However, the emergence of tachycardia should be closely monitored. Trial registration This trial has been registered with ClinicalTrials.gov number NCT-00791739.
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Affiliation(s)
- Piedad Morillas-Arques
- Instituto de Neurociencias y Centro de Investigaciones Biomédicas, Universidad de Granada, Granada, Spain.
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22
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Abstract
The almost ubiquitous sleep disturbances in patients with depression commonly, but not always, subside with the remission of depression. Evidence linking insomnia with the risk of relapses in recurrent depression, as well as suicide, makes optimization of the treatment of insomnia associated with depression a priority. However, most antidepressant agents do not adequately address the sleep complaints in depression: their effects on sleep range from sizeable improvement to equally significant worsening. One approach to the management of insomnia associated with depression is to choose a sedating antidepressant agent such as trazodone, mirtazapine or agomelatine. A second approach is to start with a non-sedating antidepressant (e.g. the selective serotonin reuptake inhibitors, bupropion, venlafaxine or duloxetine); those with a persistent or treatment-emergent insomnia can be switched to a more sedating antidepressant, or offered a hypnotic or cognitive-behavioural therapy as adjunctive treatment. The review discusses the advantages and disadvantages of all treatment options, pharmacological and otherwise.
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Affiliation(s)
- Ripu D Jindal
- University of Ottawa School of Medicine, Ottawa, Ontario, Canada.
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23
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Abstract
PURPOSE Insomnia is one of the most common symptoms seen in both primary and psychiatric care. Sleep hypnotics and benzodiazepines are the drugs of choice for insomnia but are not appropriate for all patients. CONCLUSION The sedating tricyclics, the serotonin-2A receptor antagonist/serotonin-reuptake inhibitor antidepressants, and the atypical antidepressants can improve sleep and return sleep architecture to its restorative function. The serotonin/norepinephrine reuptake inhibitors and selective serotonin-reuptake inhibitors, with the possible exception of escitalopram, derange sleep architecture and decrease restorative sleep. PRACTICE IMPLICATIONS Although most antidepressants cause sedation, not all antidepressants are equal in their effects on producing restorative sleep.
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Affiliation(s)
- Joseph M Holshoe
- University of South Alabama College of Nursing, Mobile, AL, USA.
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24
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Moldofsky H. The Significance of Dysfunctions of the Sleeping/Waking Brain to the Pathogenesis and Treatment of Fibromyalgia Syndrome. Rheum Dis Clin North Am 2009; 35:275-83. [DOI: 10.1016/j.rdc.2009.05.008] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Izzi F, Placidi F, Marciani MG, Zannino S, Torelli F, Corte F, Pisani LR, Romigi A. Effective treatment of narcolepsy–cataplexy with duloxetine: A report of three cases. Sleep Med 2009; 10:153-4. [PMID: 18226953 DOI: 10.1016/j.sleep.2007.11.014] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2007] [Accepted: 11/15/2007] [Indexed: 11/26/2022]
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Abstract
The objective of this study was to conduct a meta-analysis of the clinical impact of duloxetine treatment on sleep in adults with major depressive disorder. Data were pooled from 11 placebo-controlled, double-blind studies of duloxetine treatment (8-9 weeks acute therapy, modal dose 60 mg/day). Sleep outcome was assessed by the Hamilton Depression Rating Scale-17 (HAMD(17)) sleep items (onset latency, middle awakening, and early awakening) and their sum (insomnia subscale) and by occurrence of sleep-related treatment-emergent adverse events (TEAEs). Efficacy was measured by HAMD(17) Maier subscale scores. Adult outpatients (mean age: 45.4 years; 65.8% women) were assigned randomly to duloxetine (N=1760) or placebo (N=1159). Duloxetine-treated patients improved more on the HAMD(17) sleep subscale compared with placebo-treated patients (mean=-1.2 vs. -1.1, P< or =0.05). Sleep-related TEAEs that occurred more frequently for patients treated with duloxetine, compared with placebo, were insomnia (8.9 vs. 5.9%, P< or =0.001), middle insomnia (1.4 vs. 0.3%, P=0.001), and hypersomnia (1.0 vs. 0.3%, P< or =0.01). Patients with sleep-related TEAEs demonstrated similar mean improvement in Maier subscale score as patients without sleep-related TEAEs (P=0.223). Compared with placebo, duloxetine treatment was associated with a positive, but negligible, benefit on clinical ratings of insomnia and with more frequent sleep-related TEAEs that did not negatively impact overall efficacy for major depressive disorder.
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Kluge M, Schüssler P, Steiger A. Duloxetine increases stage 3 sleep and suppresses rapid eye movement (REM) sleep in patients with major depression. Eur Neuropsychopharmacol 2007; 17:527-31. [PMID: 17337164 DOI: 10.1016/j.euroneuro.2007.01.006] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2006] [Revised: 01/29/2007] [Accepted: 01/31/2007] [Indexed: 10/23/2022]
Abstract
Sleep studies in patients with major depression receiving the new selective norepinephrine and serotonin reuptake inhibitor (SNRI) duloxetine are lacking. Therefore, polysomnography in 10 patients with major depression (7 males, 39.9+/-7.6 years, HAMD-21 score: 23.6+/-5.6) was recorded twice, before and after 7-14 days of treatment with duloxetine. Stage 3 sleep significantly (P<0.01) increased from 21.0+/-10.7 to 37.4+/-20.1 min. Rapid eye movement (REM) latency significantly (P<0.005) increased from 58.5+/-31.1 to 193.6+/-72.6 min. REM sleep significantly (P<0.005) decreased from 94.8+/-34.5 to 51.5+/-42.5 min. These results partly differ from those in healthy subjects receiving duloxetine.
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Affiliation(s)
- Michael Kluge
- Max-Planck Institute of Psychiatry, Munich, Germany.
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Laloux C, Derambure P, Jacquesson JM, Bordet R, Destée A, Monaca C. The effects of serotoninergic, noradrenergic, cholinergic and dopaminergic drugs on vigilance states in MPTP-treated mice. Brain Res 2007; 1161:79-87. [PMID: 17586479 DOI: 10.1016/j.brainres.2007.05.039] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2007] [Revised: 05/26/2007] [Accepted: 05/30/2007] [Indexed: 11/30/2022]
Abstract
Sleep/wakefulness disorders are frequent in Parkinson's disease. Although the causes have yet to be established, it is known that dopaminergic neuronal lesions modulate paradoxical sleep (PS) regulation structures containing serotonin, noradrenaline and acetylcholine. Our previous vigilance state studies have revealed an increase in the amount of PS over the nyctohemeral period in the MPTP-treated mouse model of Parkinson's disease. The aim of the present work was to compare the effect of drugs modulating serotonin (citalopram), noradrenaline (desipramine), acetylcholine (arecoline) and dopamine (GBR 12909) neurotransmission on sleep/wakefulness patterns in MPTP mice and control mice. Citalopram reduced the amount of PS in MPTP and control mice to the same extent. Desipramine also induced a PS reduction, which was less pronounced in MPTP mice than in control mice. Arecoline increased the amount of PS in MPTP mice but not in controls. GBR 12909 induced a PS reduction (for the highest dose) more pronounced in MPTP mice than in control animals. Given that the responsiveness of MPTP mice differs markedly from that of controls, our study suggests that MPTP can alter sleep/wakefulness neurotransmission systems. Dysfunction of the latter may be responsible for PS disorders in MPTP mice.
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Affiliation(s)
- Charlotte Laloux
- Laboratoire de Physiologie, EA2683, Institut Fédératif de Recherche 114, Faculté de Médecine Henri Warembourg, Pôle recherche, 1 place de Verdun, F-59045 Lille cedex, France
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Abstract
The diagnosis and treatment of neuropathic pain may be complicated by comorbid conditions such as sleep disturbances, depression, and anxiety. The interrelationship between the index neuropathic pain state and these comorbidities is complex: comorbid conditions exacerbate pain, and in turn, pain exacerbates the comorbid conditions. Because comorbidities can negatively impact response to pain treatment, healthcare providers should assess comorbidities as part of the diagnostic work-up, and management strategies should be designed to treat the whole patient, not just the pain. Theoretically, therapies that not only reduce pain, but also improve sleep and reduce anxiety and depression can provide multiple benefits without the risk of increased side effects inherent in combination therapy. Anticonvulsants and antidepressants have demonstrated efficacy in improving neuropathic pain and positively impacting comorbid sleep and mood disturbances. Novel anticonvulsants that can address one or more comorbidities in addition to pain may represent viable treatment options for patients with neuropathic pain.
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Affiliation(s)
- Charles E Argoff
- Cohn Pain Management Center, North Shore-LIJ Health System, NY, USA.
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Culpepper L. Secondary insomnia in the primary care setting: review of diagnosis, treatment, and management. Curr Med Res Opin 2006; 22:1257-68. [PMID: 16834824 DOI: 10.1185/030079906x112589] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
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.
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Affiliation(s)
- Larry Culpepper
- Family Medicine, Boston University Medical Center, Boston, MA 02118, USA.
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Oelke M, Roovers JPWR, Michel MC. Safety and tolerability of duloxetine in women with stress urinary incontinence. BJOG 2006; 113 Suppl 1:22-6. [PMID: 16529566 DOI: 10.1111/j.1471-0528.2006.00880.x] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND The serotonin/noradrenaline uptake inhibitor duloxetine has been shown to be effective in the medical treatment of stress urinary incontinence (SUI) in women. AIM To review the safety and tolerability of duloxetine with SUI. METHODS A systematic Medline search for the key word "duloxetine" was performed, and abstracts from recent international gynaecological and urological meetings were also considered. RESULTS Various unpleasant adverse effects exist, among which nausea is the most frequent, but is mild to moderate and transient in most cases. Dose escalation upon initiation of treatment improves the tolerability of duloxetine. The use of duloxetine appears safe as it lacks the cardiovascular adverse effects of older amine reuptake inhibitors. CONCLUSIONS Duloxetine has an acceptable safety profile. Dose escalation combined with patient counselling on the intensity and transient nature of adverse effects may help to further improve the benefit/tolerability ratio of duloxetine in the treatment of SUI.
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Affiliation(s)
- M Oelke
- Department of Urology, Academic Medical Centre, University of Amsterdam, Meibergdreef 15, 1105 AZ Amsterdam, The Netherlands
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Abstract
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.
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Affiliation(s)
- Sue Wilson
- Psychopharmacology Unit, University of Bristol, Bristol, UK.
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