Treatment of sleep dysfunction and psychiatric disorders

The Psychiatric Symptomology of Visual Snow Syndrome

Objective: To characterise the psychiatric symptoms of visual snow syndrome (VSS), and determine their relationship to quality of life and severity of visual symptoms. Methods: One hundred twenty-five patients with VSS completed a battery of questionnaires assessing depression/anxiety, dissociative experiences (depersonalisation), sleep quality, fatigue, and quality of life, as well as a structured clinical interview about their visual and sensory symptoms. Results: VSS patients showed high rates of anxiety and depression, depersonalisation, fatigue, and poor sleep, which significantly impacted quality of life. Further, psychiatric symptoms, particularly depersonalisation, were related to increased severity of visual symptoms. The severity/frequency of psychiatric symptoms did not differ significantly due to the presence of migraine, patient sex, or timing of VSS onset (lifelong vs. later onset). Conclusion: Psychiatric symptoms are highly prevalent in patients with VSS and are associated with increased visual symptom severity and reduced quality of life. Importantly, patients with lifelong VSS reported lower levels of distress and milder self-ratings of visual symptoms compared to patients with a later onset, while being equally likely to experience psychiatric symptoms. This suggests that the psychiatric symptoms of VSS are not solely due to distress caused by visual symptoms. While no consistently effective treatments are available for the visual symptomology of VSS, psychiatric symptoms offer an avenue of treatment that is likely to significantly improve patient quality of life and ability to cope with visual symptoms.

Major depressive disorder: mechanism-based prescribing for personalized medicine

Individual patients with depression present with unique symptom clusters - before, during, and even after treatment. The prevalence of persistent, unresolved symptoms and their contribution to patient functioning and disease progression emphasize the importance of finding the right treatment choice at the onset and the utility of switching medications based on suboptimal responses. Our primary goal as clinicians is to improve patient function and quality of life. In fact, feelings of well-being and the return to premorbid levels of functioning are frequently rated by patients as being more important than symptom relief. However, functional improvements often lag behind resolution of mood, attributed in large part to persistent and functionally impairing symptoms - namely, fatigue, sleep/wake disturbance, and cognitive dysfunction. Thus, patient outcomes can be optimized by deconstructing each patient's depressive profile to its component symptoms and specifically targeting those domains that differentially limit patient function. This article will provide an evidence-based framework within which clinicians may tailor pharmacotherapy to patient symptomatology for improved treatment outcomes.

Electroencephalographic power spectral density profile of the orexin receptor antagonist suvorexant in patients with primary insomnia and healthy subjects

STUDY OBJECTIVES

Suvorexant, an orexin receptor antagonist, improves sleep in healthy subjects (HS) and patients with insomnia. We compared the electroencephalographic (EEG) power spectral density (PSD) profile of suvorexant with placebo using data from a phase 2 trial in patients with insomnia. We also compared suvorexant's PSD profile with the profiles of other insomnia treatments using data from 3 HS studies.

DESIGN

Phase 2 trial--randomized, double-blind, two-period (4 w per period) crossover. HS studies--randomized, double-blind, crossover.

SETTING

Sleep laboratories.

PARTICIPANTS

Insomnia patients (n = 229) or HS (n = 124).

INTERVENTIONS

Phase 2 trial--suvorexant 10 mg, 20 mg, 40 mg, 80 mg, placebo; HS study 1--suvorexant 10 mg, 50 mg, placebo; HS study 2--gaboxadol 15 mg, zolpidem 10 mg, placebo; HS study 3--trazodone 150 mg, placebo.

MEASUREMENTS AND RESULTS

The PSD of the EEG signal at 1-32 Hz of each PSG recording during nonrapid eye movement (NREM) and rapid eye movement (REM) sleep were calculated. The day 1 and day 28 PSD profiles of suvorexant at all four doses during NREM and REM sleep in patients with insomnia were generally flat and close to 1.0 (placebo) at all frequencies. The day 1 PSD profile of suvorexant in HS was similar to that in insomnia patients. In contrast, the other three drugs had distinct PSD profiles in HS that differed from each other.

CONCLUSIONS

Suvorexant at clinically effective doses had limited effects on power spectral density compared with placebo in healthy subjects and in patients with insomnia, in contrast to the three comparison insomnia treatments. These findings suggest the possibility that antagonism of the orexin pathway might lead to improvements in sleep without major changes in the patient's neurophysiology as assessed by electroencephalographic.

Update of sleep alterations in depression

Sleep disturbances in depression are up to 70%. Patients frequently have difficulty in falling asleep, frequent awakenings during the night and non-restorative sleep. Sleep abnormalities in depression are mainly characterized by increased rapid eye movement (REM) sleep and reduced slow wave sleep. Among the mechanisms of sleep disturbances in depression are hyperactivation of the hypothalamic-pituitary-adrenal axis, CLOCK gene polymorphism and primary sleep disorders. The habenula is a structure regulating the activities of monoaminergic neurons in the brain. The hyperactivation of the habenula has also been implicated, together with sleep disturbances, in depression. The presence of depression in primary sleep disorders is common. Sleep disturbances treatment include pharmacotherapy or Cognitive Behavioral Therapy.

Associations of regional GABA and glutamate with intrinsic and extrinsic neural activity in humans—a review of multimodal imaging studies

The integration of multiple imaging modalities is becoming an increasingly well used research strategy for studying the human brain. The neurotransmitters glutamate and GABA particularly lend themselves towards such studies. This is because these transmitters are ubiquitous throughout the cortex, where they are the key constituents of the inhibition/excitation balance, and because they can be easily measured in vivo through magnetic resonance spectroscopy, as well as with select positron emission tomography approaches. How these transmitters underly functional responses measured with techniques such as fMRI and EEG remains unclear though, and was the target of this review. Consistently shown in the literature was a negative correlation between GABA concentrations and stimulus-induced activity within the measured region. Also consistently found was a positive correlation between glutamate concentrations and inter-regional activity relationships, both during tasks and rest. These findings are outlined along with results from populations with mental disorders to give an overview of what brain imaging has suggested to date about the biochemical underpinnings of functional activity in health and disease. We conclude that the combination of functional and biochemical imaging in humans is an increasingly informative approach that does however require a number of key methodological and interpretive issues be addressed before can meet its potential.

Health behaviors predict higher interleukin-6 levels among patients newly diagnosed with head and neck squamous cell carcinoma

BACKGROUND

Health behaviors have been shown to be associated with recurrence risk and survival rates in patients with cancer and are also associated with interleukin-6 (IL-6) levels, but few epidemiologic studies have investigated the relationship of health behaviors and IL-6 among cancer populations. The purpose of the study is to look at the relationship between five health behaviors, viz.: smoking, alcohol problems, body mass index (BMI; a marker of nutritional status), physical activity, and sleep and pretreatment IL-6 levels in persons with head and neck cancer.

METHODS

Patients (N = 409) were recruited in otolaryngology clinic waiting rooms and invited to complete written surveys. A medical record audit was also conducted. Descriptive statistics and multivariate analyses were conducted to determine which health behaviors were associated with higher IL-6 levels controlling for demographic and clinical variables among patients with newly diagnosed head and neck cancer.

RESULTS

While smoking, alcohol problems, BMI, physical activity, and sleep were associated with IL-6 levels in bivariate analysis, only smoking (current and former) and decreased sleep were independent predictors of higher IL-6 levels in multivariate regression analysis. Covariates associated with higher IL-6 levels were age and higher tumor stage, whereas comorbidities were marginally significant.

CONCLUSION

Health behaviors, particularly smoking and sleep disturbances, are associated with higher IL-6 levels among patients with head and neck cancer.

IMPACT

Treating health behavior problems, especially smoking and sleep disturbances, may be beneficial to decreasing IL-6 levels, which could have a beneficial effect on overall cancer treatment outcomes.

Role of IL-6 in the etiology of hyperexcitable neuropsychiatric conditions: experimental evidence and therapeutic implications

Many neuropsychiatric conditions are primed or triggered by different types of stressors. The mechanisms through which stress induces neuropsychiatric disease are complex and incompletely understood. A ‘double hit’ hypothesis of neuropsychiatric disease postulates that stress induces maladaptive behavior in two phases separated by a dormant period. Recent research shows that the pleiotropic cytokine IL-6 is released centrally and peripherally following physical and psychological stress. In this article, we analyze evidence from clinics and animal models suggesting that stress-induced elevation in the levels of IL-6 may play a key role in the etiology of a heterogeneous family of hyperexcitable central conditions including epilepsy, schizophrenic psychoses, anxiety and disorders of the autistic spectrum. The cellular mechanism leading to hyperexcitable conditions might be a decrease in inhibitory/excitatory synaptic balance in either or both temporal phases of the conditions. Following these observations, we discuss how they may have important implications for optimal prophylactic and therapeutic pharmacological treatment.

Antidepressant use, depressive symptoms, and incident frailty in women aged 65 and older from the Women's Health Initiative Observational Study

OBJECTIVES

To examine the associations between depressive symptoms, antidepressant use, and duration of use with incident frailty 3 years later in nonfrail women aged 65 and older.

DESIGN

Secondary analysis of the Women's Health Initiative Observational Study (WHI-OS), a prospective cohort study.

SETTING

WHI-OS was conducted in 40 U.S. clinical centers.

PARTICIPANTS

Women aged 65 to 79, not frail at baseline.

MEASUREMENTS

Antidepressant use was assessed through medication container inspection at baseline. Four groups were created according to baseline use and Burnam depression screen (range 0-1, 0.06 cutoff): antidepressant nonusers without depressive symptoms (reference group), antidepressant nonusers with depressive symptoms, antidepressant users without depressive symptoms, and antidepressant users with depressive symptoms. Frailty components included slowness or weakness, exhaustion, low physical activity, and unintended weight loss, ascertained through self-report and physical measurements at baseline and Year 3.

RESULTS

Of 27,652 women at baseline, 1,350 (4.9%) were antidepressant users and 1,794 (6.5%) were categorized as depressed. At Year 3, 4,125 (14.9%) were frail. All groups had a greater risk of incident frailty than the reference group. Odds ratios (ORs) ranged from 1.73 (95% confidence interval (CI) = 1.41-2.12) in antidepressant users who were not depressed to 3.63 in antidepressant users who were depressed (95% CI = 2.37-5.55). All durations of use were associated with incident frailty (<1 year OR = 1.95, 95% CI = 1.41-2.68; 1-3 years OR = 1.99, 95% CI = 1.45-2.74; >3 years OR = 1.60, 95% CI = 1.20-2.14).

CONCLUSION

In older adult women, depressive symptoms and antidepressant use were associated with frailty after 3 years of follow-up.

Reconsidering GHB: orphan drug or new model antidepressant?

For six decades, the principal mode of action of antidepressant drugs is the inhibition of monoamine re-uptake from the synaptic cleft. Tricyclic antidepressants, selective serotonin re-uptake inhibitors (SSRIs) and the new generation of dual antidepressants all exert their antidepressant effects by this mechanism. In the early days of the monoaminergic era, other efforts have been made to ameliorate the symptoms of depression by pharmacological means. The gamma-aminobutyric acid (GABA) system was and possibly still is one of the main alternative drug targets. Gammahydroxybutyrate (GHB) was developed as an orally active GABA analogue. It was tested in animal models of depression and human studies. The effects on sleep, agitation, anhedonia and depression were promising. However, the rise of benzodiazepines and tricyclic antidepressants brought GHB out of the scope of possible treatment alternatives. GHB is a GABA(B) and GHB receptor agonist with a unique spectrum of behavioural, neuroendocrine and sleep effects, and improves daytime sleepiness in various disorders such as narcolepsy, Parkinson's disease and fibromyalgia. Although it was banned from the US market at the end of the 1990s because of its abuse and overdose potential, it later was approved for the treatment of narcolepsy. New research methods and an extended view on other neurotransmitter systems as possible treatment targets of antidepressant treatment brought GHB back to the scene. This article discusses the unique neurobiological effects of GHB, its misuse potential and possible role as a model substance for the development of novel pharmacological treatment strategies in depressive disorders.

Sleep America: managing the crisis of adult chronic insomnia and associated conditions

INTRODUCTION

Chronic insomnia, a public health crisis affecting 10-15% of the U.S. population and costing billions of dollars annually, typically presents with one or more comorbid psychiatric or organic conditions. Historical classification of chronic insomnia as "secondary" to a presenting comorbid condition has resulted in under-recognition and under-treatment of both the insomnia and comorbid condition(s). Though critical in any model of comorbid disease management, chronic insomnia receives little, if any, public policy attention.

METHOD

We conducted a systematic review of recent empirical studies, review papers, books, government documents, press releases, advertisements, and articles pertaining to the classification, epidemiology, treatment, and physiology of sleep, insomnia, and comorbid conditions. Data were located primarily through MEDLINE, PsycINFO, SCOPUS, and PUBMED databases.

OBJECTIVE AND RESULTS

Our goal was to provide an overview of the systems for classifying insomnia and available epidemiological data, and to review theoretical models regarding the etiology and maintaining factors of chronic insomnia along with research on the complex, bidirectional associations between chronic insomnia and various affective (and other) conditions.

CONCLUSIONS

After thorough review of the literature, we propose several public policy measures as an initial step in managing chronic insomnia in the United States. These include introducing a nation-wide multi-modal educational and awareness campaign titled "Sleep America;" increasing the availability and demand for behavioral sleep medicine - the initially preferred treatment approach; and increasing the use of monitoring and enforcement activities by regulatory authorities to curtail false and misleading claims by sponsors of supplements or treatments for insomnia. Through the adoption of such measures, we hope to galvanize a national interest in healthy sleep and the evidence-based treatment of chronic insomnia.

Mapping of the Insomnia Severity Index and other sleep measures to EuroQol EQ-5D health state utilities

BACKGROUND

This study sought to map the Insomnia Severity Index (ISI) and symptom variables onto the EQ-5D.

METHODS

A cross-sectional survey was conducted among adult US residents with self-reported sleep problems. Respondents provided demographic, comorbidity, and sleep-related information and had completed the ISI and the EQ-5D profile. Respondents were classified into ISI categories indicating no, threshold, moderate, or severe insomnia. Generalized linear models (GLM) were used to map the ISI's 7 items (Model I), summary scores (Model II), clinical categories (Model III), and insomnia symptoms (Model IV), onto the EQ-5D. We used 50% of the sample for estimation and 50% for prediction. Prediction accuracy was assessed by mean squared errors (MSEs) and mean absolute errors (MAEs).

RESULTS

Mean (standard deviation) sleep duration for respondents (N = 2,842) was 7.8 (1.9) hours, and mean ISI score was 14.1 (4.8). Mean predicted EQ-5D utility was 0.765 (0.08) from Models I-III, which overlapped with observed utilities 0.765 (0.18). Predicted utility using insomnia symptoms was higher (0.771(0.07)). Based on Model I, predicted utilities increased linearly with improving ISI (0.493 if ISI = 28 vs. 1.00 if ISI = 0, p < 0.01). From Model II, each unit decrease in ISI summary score was associated with a 0.022 (p < 0.001) increase in utility. Predicted utilities were 0.868, 0.809, 0.722, and 0.579, respectively, for the 4 clinical categories, suggesting that lower utility was related to greater insomnia severity. The symptom model (Model IV) indicated a concave sleep-duration function of the EQ-5D; thus, utilities diminished after an optimal amount of sleep. The MSEs/MAEs were substantially lower when predicting EQ-5D > 0.40, and results were comparable in all models.

CONCLUSIONS

Findings suggest that mapping relationships between the EQ-5D and insomnia measures could be established. These relationships may be used to estimate insomnia-related treatment effects on health state utilities.

Sleep interventions for the treatment of depression

Sleep disturbances are common in depressed patients. Insomnia may predate the onset of major depression, increases the likelihood of a depressive relapse, and is associated with an impaired response to treatment. Benzodiazepine drugs may have inherent antidepressant effects; thus, these and other sedative-hypnotic drugs can be beneficial for treating insomnia in depressed patients and may enhance the overall effectiveness of antidepressant drugs. Sedating antidepressant drugs are used for treating primary insomnia, but their sleep-promoting effects have been demonstrated primarily in depressed patients. Several second-generation antipsychotic drugs are used in low doses to promote sleep, but they also have inherent antidepressant effects. Cognitive-behavioral therapy targeting insomnia can effectively enhance the response to antidepressant medication. Sleep deprivation, which is also associated with a transient antidepressant effect, is difficult to use in routine clinical practice but might be an appropriate strategy for treatment-resistant forms of depression.

Hypersomnolence and sleep disorders in a rheumatic disease patient population

OBJECTIVES

There is increasing awareness of the importance of sleep in health maintenance. Our primary objective was to evaluate prevalence of excess daytime sleepiness in a rheumatic disease patient population. Secondary objectives included evaluation of prevalence of abnormal sleep quality and primary sleep disorders.

METHODS

Consecutive Rheumatology clinic patients were invited to participate in a self-administered questionnaire study. Included were measures for pain, fatigue, and global functioning, modified Health Assessment Questionnaire, Epworth Sleepiness Score (ESS), Pittsburgh Sleep Quality Index (PSQI), Berlin Score, diagnostic criteria for restless legs syndrome (RLS), Centre for Epidemiologic Studies Depression score (CES-D), stress scores, and the short form-36 quality of life instrument.

RESULTS

Of 507 consecutive patients invited to participate, 423 agreed. Mean age was 52.1 years; 26% were male. Prevalence of excessive sleepiness (ESS >10) was 25.7%, abnormal sleep quality (PSQI >5) was 67.3%, high risk for obstructive sleep apnea Berlin scores were present in 35.2% and 24% of participants met criteria for RLS. Significantly worse pain, fatigue, global function, short form-36 summary scores, modified Health Assessment Questionnaire, depression, and stress scores were present in patients with higher ESS and PSQI scores. No significant differences in sleep assessment scores were observed between specific rheumatic disease groups.

CONCLUSIONS

Our findings suggest a high prevalence of unrecognized hypersomnolence, poor sleep quality, and primary sleep disorders in rheumatology patients. We suggest evaluation of sleep health be incorporated into standard clinical assessments of all rheumatology patients. We would recommend this evaluation include the ESS and the criteria for RLS.

Therapeutic armamentarium for treating depression

Depressive disorders are highly prevalent and are a leading cause of disability, morbidity, and mortality worldwide; however, they often remain undertreated or untreated. This article provides a broad overview of the many strategies for treating depression. More than 24 antidepressant medications and depression-focused psychotherapies are available as first-choice options for treating depression. When patients have not had a satisfactory treatment response, the 2 main strategies are switching to an alternative antidepressant therapy or adding a second antidepressant therapy. A large number of medication combinations have been reported in the literature, and some have been shown to be effective in controlled studies. Nonstandard alternatives to conventional antidepressant treatments include exercise, light therapy, sleep deprivation, and various complementary and alternative therapies. For more chronic and refractory forms of depression, various neuromodulation therapies are available or are being investigated. Because depressive disorders are common in primary care and other medical settings, medical practitioners should be aware of the therapeutic armamentarium available for treating depression.

Beyond fatigue: Assessing variables associated with sleep problems and use of sleep medications in multiple sclerosis

Background:

Recent research indicates that sleep disturbances are common in persons with multiple sclerosis (MS), though research to date has primarily focused on the relationship between fatigue and sleep. In order to improve treatment of sleep disorders in MS, a better understanding of other factors that contribute to MS sleep disturbance and use of sleep medications in this population is needed.

Methods:

Individuals with MS (N = 473) involved in an ongoing self-report survey study were asked to report on use of over-the-counter and prescription sleep medications. Participants completed the Medical Outcomes Study Sleep (MOSS) scale and other common self-report symptom measures. Multiple regression was used to evaluate factors associated with sleep problems and descriptive statistics were generated to examine use of sleep medications.

Results:

The mean score on the MOSS scale was 35.9 (standard deviation, 20.2) and 46.8% of the sample had moderate or severe sleep problems. The majority of participants did not use over-the-counter (78%) or prescription (70%) sleep medications. In a regression model variables statistically significantly associated with sleep problems included depression, nighttime leg cramps, younger age, pain, female sex, fatigue, shorter duration of MS, and nocturia. The model explained 45% of the variance in sleep problems. Of the variance explained, depression accounted for the majority of variance in sleep problems (33%), with other variables explaining significantly less variance.

Conclusions:

Regression results indicate that fatigue may play a minor role in sleep disturbance in MS and that clinicians should consider the interrelationship between depression and sleep problems when treating either symptom in this population. More research is needed to explore the possibility of under-treatment of sleep disorders in MS and examine the potential effectiveness of nonpharmaceutical treatment options.

Defining and measuring functional recovery from depression

Depression is associated with significant functional impairment and reduced quality of life. Disruptions occur both globally as well as in specific functional areas such as work, interpersonal relationships and cognitive function. From both a clinical and research perspective, much focus has been given to the resolution of symptoms associated with depression, while relatively little attention has been given to functional improvements. Definitions of remission in depression are most frequently based on achieving a cut-off score on clinical rating scales of depressive symptoms. Research in this area has sparsely included psychosocial function or health-related quality of life as a primary outcome measure in clinical trials. However, the need to fully understand the impact of depression and its treatments on functioning is great, given the existing evidence of the profound effect that depression has on function. Even mild depressive symptoms and subsyndromal depression result in functional impairment and reduced quality of life, and untreated residual depressive symptomatology can result in an increased likelihood for relapse of the fully symptomatic disorder (i.e. major depressive disorder). Therefore, clinicians and researchers alike need to broaden the focus of treatment to encompass not only the specific symptoms of depression, but the functional consequences as well. Many tools have been developed to assess function and quality of life, both globally as well as within specific domains. In addition, the effect of residual symptoms associated with functional impairment (i.e. insomnia, fatigue, pain [somatic] symptoms and cognition) in depression, even independently of depressive symptoms, warrants evaluation and monitoring. Recommendations for evaluating functional outcomes include: (i) adequately assessing functional impairment; (ii) identifying and/or developing treatment plans that will target symptoms associated with functional impairments; and (iii) monitoring functional impairments and associated symptoms throughout the course of treatment. The development of treatments that specifically target improvements in functional impairments is needed, and may require the use of novel treatment strategies.