Fluvoxamine versus desipramine: comparative polysomnographic effects

Association of Sleep Architecture and Physiology with Depressive Disorder and Antidepressants Treatment

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.

The effects of antidepressant treatment on sleep disturbances in depression

Sleep problems are classical complaints in depressed patients. Polygraphie recordings performed in drug free depressed patients during an acute episode of the illness have allowed description of sleep continuity, architecture and REM sleep disturbances. While the specificity of these abnormalities is not fully established, these perturbations appear to be core symptoms of the depressive episode. Antidepressants drugs, whatever their pharmacological profile have been shown to suppress or at least to reduce REM sleep. However, the effects of these drugs on sleep continuity and architecture seem to be related to their specific pharmacological action.

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.

Antisuicidal Response Following Ketamine Infusion Is Associated With Decreased Nighttime Wakefulness in Major Depressive Disorder and Bipolar Disorder

OBJECTIVE

Insomnia and disrupted sleep are associated with increased risk of suicide. The N-methyl-d-aspartate antagonist ketamine has been associated with reduced suicidal thoughts, but the mechanism of action is unknown. This study sought to evaluate differences in nocturnal wakefulness in depressed individuals who did and did not have an antisuicidal response to ketamine.

METHODS

Thirty-four participants with baseline suicidal ideation diagnosed with either DSM-IV major depressive disorder (n = 23) or bipolar depression (n = 11) between 2006 and 2013 completed nighttime electroencephalography (EEG) the night before and the night after a single ketamine infusion (0.5 mg/kg over 40 minutes). Suicidal ideation was assessed at baseline and the morning after ketamine infusion via several measures, including the Hamilton Depression Rating Scale suicide item, the suicide item of the Montgomery-Asberg Depression Rating Scale, and the first 5 items of the Scale for Suicide Ideation. A generalized linear mixed model evaluated differences in nocturnal wakefulness, as verified by EEG, between those who had an antisuicidal response to ketamine and those who did not, controlling for baseline nocturnal wakefulness. Results were also compared to the sleep of healthy controls (n = 22).

RESULTS

After analyses adjusted for baseline sleep, participants with an antisuicidal response to ketamine showed significantly reduced nocturnal wakefulness the night after ketamine infusion compared to those without an antisuicidal response (F₁,₂₂ = 5.04, P = .04). Level of nocturnal wakefulness after antisuicidal response to ketamine did not differ significantly from nocturnal wakefulness in the control sample but did differ at a trend level (F₁,₄₀ = 3.15, P = .08).

CONCLUSIONS

Reductions in wakefulness following ketamine may point to a biological mechanism underlying the effect of ketamine on suicidal ideation.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT00088699.

Adverse Effects of Psychotropic Medications on Sleep

Psychotropic medications such as antidepressants, antipsychotics, stimulants, and benzodiazepines are widely prescribed. Most of these medications are thought to exert their effects through modulation of various monoamines as well as interactions with receptors such as histamine and muscarinic cholinergic receptors. Through these interactions, psychotropics can also have a significant impact on sleep physiology, resulting in both beneficial and adverse effects on sleep.

Empirically Supported Use of Psychiatric Medications in Adolescents and Adults with IBD

BACKGROUND

The use of psychotropic medications, particularly antidepressants, is common in patients with inflammatory bowel disease (IBD) in spite of a lack of their robust efficacy in this population. This review provides an overview of the use trends of different classes of antidepressant and anti-anxiety medication and their effects on mood, nervous system function, gastrointestinal physiology and immunity drawing from the literature available in the general population, other medical conditions, and when available, patients with IBD. It also covers the evidence base for the actions, efficacy, and potential complications of antidepressants organized by different classes.

METHODS

We conducted a PubMed search of articles relating the different drug classes probed to the terms above in different populations of interest. All types of articles were accepted including case reports and series, open and randomized trials, reviews, and expert opinion. We also examined the reference lists of the publications found.

RESULTS

Selective serotonin reuptake inhibitors (SSRIs) and tricyclic antidepressants (TCAs) are the most commonly prescribed agents for anxiety and depression in patients with IBD, though their efficacy for these conditions in the general population are mild to moderate at best. SSRIs are generally well tolerated, though at higher doses, they, like most antidepressant classes, can be associated with activation, serotonergic syndrome, and increased suicidal ideation. TCAs have many more serious side effects but have some shown efficacy for functional GI symptoms. A newer class, the serotonin noradrenergic reuptake inhibitors (SNRIs), can be effective for refractory depression, anxiety and chronic pain syndromes with a side effect profile similar to both SSRIs and more mild manifestations of TCAs. Mirtazapine has moderate efficacy for depression if sedation and weight gain side effects are tolerated and some small support for use in nausea and vomiting. Bupropion targets dopamine and noradrenaline reuptake and has moderate efficacy for depression, and some small support for use in fatigue and smoking cessation. Buspirone has an indication for generalized anxiety disorder though studies show only a minimal benefit. It has some growing evidence for use in functional dyspepsia. Most of these agents have physiological effects on the brain, immune system, and gastrointestinal tract (with the exception of bupropion) hence their therapeutic and side effects manifested in these systems.

CONCLUSION

Antidepressant medications are frequently prescribed for depression, anxiety disorders, and chronic pain syndromes, but overall support for their efficacy is modest at best. Psychological interventions have growing support for having much more robust effects without the side effects of antidepressants and should be considered first-line treatment or at least an adjunct to psychotropic medications for these conditions.

Fluvoxamine versus other anti-depressive agents for depression

BACKGROUND

Fluvoxamine, one of the oldest selective serotonin reuptake inhibitors (SSRIs), is prescribed to patients with major depression in many countries. Several studies have previously reviewed the efficacy and tolerability of fluvoxamine for the treatment of major depression. However, these reviews are now outdated.

OBJECTIVES

Our objective is to evaluate the effectiveness, tolerability and side effect profile of fluvoxamine for major depression in comparison with other anti-depressive agents, including tricyclics (TCAs), heterocyclics, other SSRIs, SNRIs, other newer agents and other conventional psychotropic drugs.

SEARCH STRATEGY

We searched the Cochrane Collaboration Depression, Anxiety and Neurosis Controlled Trials Register. Trial databases and ongoing trial registers in North America, Europe, Japan and Australia, were handsearched for randomised controlled trials. We checked reference lists of the articles included in the review, previous systematic reviews and major textbooks of affective disorder for published reports and citations of unpublished research. The date of last search was 31 August 2008.

SELECTION CRITERIA

We included all randomised controlled trials, published in any language, that compared fluvoxamine with any other active antidepressants in the acute phase treatment of major depression.

DATA COLLECTION AND ANALYSIS

Two independent review authors inspected citations and abstracts, obtained papers, extracted data and assessed the risk of bias of included studies. We analysed dichotomous data using odds ratios (ORs) and continuous data using the standardised mean difference (SMD). A random effects model was used to combine studies.

MAIN RESULTS

A total of 54 randomised controlled trials (n = 5122) were included. No strong evidence was found to indicate that fluvoxamine was either superior or inferior to other antidepressants regarding response, remission and tolerability. However, differing side effect profiles were evident, especially with regard to gastrointestinal side effects of fluvoxamine when compared to other antidepressants. For example, fluvoxamine was generally associated with a higher incidence of vomiting/nausea (versus imipramine, OR 2.23, CI 1.59 to 3.14; versus clomipramine, OR 2.13, CI 1.06 to 4.27; versus amitriptyline, OR 2.86, CI 1.31 to 2.63).

AUTHORS' CONCLUSIONS

We found no strong evidence that fluvoxamine was either superior or inferior to any other antidepressants in terms of efficacy and tolerability in the acute phase treatment of depression. However, differing side effect profiles were evident. Based on these findings, we conclude that clinicians should focus on practical or clinically relevant considerations, including these differences in side effect profiles.

Duloxetine increases stage 3 sleep and suppresses rapid eye movement (REM) sleep in patients with major depression

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.

Contribution of sleep research to the development of new antidepressants

Several sleep anomalies are known to accompany depression and other psychiatric disorders, and to be partially modified by drugs efficient on clinical symptoms. Many puzzling theoretical questions remain, even after 30 years of research, because these drugs do not act in a uniform way: some reduce slow-wave sleep while others increase it; some prolong rapid-eye movement sleep latency while others do not. The relationship between insomnia and depression is likely to be a close one, since a large majority of patients with depression suffer insomnia, and that insomnia can predate depression by a few years. However, questions remain here, too, since sleep deprivation is also an effective means to combat depression, and some patients present with hypersomnia rather than insomnia. This review details the action of all current classes of antidepressants on sleep. It examines the predictive value of baseline electronencephalographic sleep symptoms or early modifications due to treatment for eventual clinical efficiency. We will also discuss the two main theories on the relationship between sleep and depression. The action on sleep of all new drugs- and antidepressants in particular - is carefully examined during development, for insomnia is currently considered to be a major health concern in industrialized countries.

Antidepressants and their effect on sleep

Given the relationship between sleep and depression, there is inevitably going to be an effect of antidepressants on sleep. Current evidence suggests that this effect depends on the class of antidepressant used and the dosage. The extent of variation between the effects of antidepressants and sleep may relate to their mechanism of action. This systematic review examines randomised-controlled trials (RCTs) that have reported the effect that antidepressants appear to have on sleep. RCTs are not restricted to depressed populations, since several studies provide useful information about the effects on sleep in other groups. Nevertheless, the distinction is made between those studies because the participant's health may influence the baseline sleep profiles and the effect of the antidepressant. Insomnia is often seen with monoamine oxidase inhibitors (MAOIs), with all tricyclic antidepressants (TCAs) except amitriptyline, and all selective serotonin reuptake inhibitors (SSRIs) with venlafaxine and moclobemide as well. Sedation has been reported with all TCAs except desipramine, with mirtazapine and nefazodone, the TCA-related maprotiline, trazodone and mianserin, and with all MAOIs. REM sleep suppression has been observed with all TCAs except trimipramine, but especially clomipramine, with all MAOIs and SSRIs and with venlafaxine, trazodone and bupropion. However, the effect on sleep varies between compounds within antidepressant classes, differences relating to the amount of sedative or alerting (insomnia) effects, changes to baseline sleep parameters, differences relating to REM sleep, and the degree of sleep-related side effects.

Sleep disturbances in depression and the effects of antidepressants

Depressed patients often report sleep problems, which usually include difficulties with initiation and maintenance of sleep, as well as poor subjective quality of sleep. Such reports are confirmed by objective analysis of depressed patients' sleep through polysomnography, although there is no exact correspondence between subjective and objective measurements. In the present paper, we discuss some methodological problems related to the subjective estimates of sleep. Further, we review the differential effects of the various classes of antidepressants on subjective sleep parameters, as well as on sleep onset latency, continuity of sleep, sleep efficiency and rapid eye movement (REM) sleep verified with sleep recordings. Finally, we discuss the attempts to use these and other indices, such as delta sleep ratio (DSR), as signposts of the course of the illness, and predictors of response to treatment.

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.

Sleep laboratory study on single and repeated dose effects of paroxetine, alprazolam and their combination in healthy young volunteers

AIMS

To evaluate the potential interaction of 20 mg paroxetine and 1 mg alprazolam (early morning once-daily administration) on polysomnographic (PSG) sleep and subjective sleep and awakening quality, both after a single intake and after reaching a steady-state concentration.

METHODS

Twenty-two (11 for the PSG) healthy young volunteers of both sexes with no history of sleep disturbances (Pittsburgh Sleep Quality Index <5) participated in a double-blind, double-dummy, placebo-controlled, repeated-dose, 4-period, cross-over study. All volunteers received all 4 treatment sequences: paroxetine-alprazolam placebo (PAP); paroxetine placebo-alprazolam (PPA); paroxetine-alprazolam (PA), and paroxetine placebo-alprazolam placebo (PLA), in a randomized order. Each treatment was administered over 15 consecutive days, with a treatment-free interval of 7 days prior to the subsequent study period. In each experimental period, one PSG sleep study was performed on the 1st night (single-dose effects) and another study was performed on the 15th night (repeated-dose effects). Additionally, two other PSG studies were assessed: an adaptation recording, and a control night recording. All-night PSG recordings were obtained following standard procedures. Each 30-second period was scored according to the criteria of Rechtschaffen and Kales by means of an automatic sleep analysis system: Somnolyzer 24x7. A self-rating scale for sleep and awakening quality and early morning behavior was completed no later than 15 min after awakening over the 15 days of each experimental intervention. General lineal models (treatment/time) were applied separately to each variable.

RESULTS

(1) No significant effects were observed in any sleep variables when control nights were compared with the 1st night with PLA. (2) Sleep continuity: After PAP a clear awakening effect was seen both in the first and second evaluations, mainly in wake time, movement time, number of awakenings and stage-1 duration. After PPA an evident hypnotic effect was observed on night 1. This effect was mainly observed in maintenance variables and slightly in sleep initiation variables; it had decreased by night 15. After PA an intermediate behavior in the variables related to sleep continuity was seen, highlighting the absence of the tolerance phenomenon observed when PPA was administered alone. (3) Sleep architecture: The most important effects in REM sleep were observed after PAP; an increase in REM latency and decreases in REM sleep. PAP also induced decreases in the number of non-REM and REM periods and increases in the average duration of non-REM periods and sleep cycles. PA presented a similar pattern to PAP, and PPA similar to PLA. In relation to non-REM sleep, PA showed more stage-2 and less slow-wave sleep (SWS). (4) Subjective perception: No significant differences were observed between treatments while they were being taken, but impairments in subjective sleep quality, awaking quality, latency and efficiency were seen, mainly after PA but also after PPA discontinuations.

CONCLUSION

The combination of PAP and PPA presented an intermediate pattern in relation to sleep continuity, with less awaking effect than PAP alone and less hypnotic effect than PPA alone, and without developing tolerance. The PAP and PPA combination also showed a similar effect to PAP on REM sleep and was the treatment with the longest stage 2 and shortest SWS. No subjective sleep and awakening effects were seen during drug intake but subjective withdrawal reports were seen after abrupt interruption. The high agreement rate for the epoch-by-epoch comparison between automatic and human scoring confirms the validity of the Somnolyzer 24x7 and thus facilitates sleep studies in neuropsychopharmacological research.

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

RATIONALE

Antidepressants are known to modify human sleep patterns.

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Effects of sertraline on sleep architecture in patients with depression

Previous studies indicate that selective serotonin reuptake inhibitors (SSRIs), including fluoxetine, fluvoxamine, citalopram and paroxetine, suppress rapid eye movement sleep, and increased nocturnal arousals. There has been no published report of the impact of sertraline on the sleep of depressed patients. This study examines such effects. Forty-seven patients with major depressive disorder, randomized to double-blind treatment with sertraline or placebo, completed sleep studies before and after 12 weeks of pharmacotherapy. Groups were compared using multivariate analyses of covariance and/or analyses of covariance to examine 4 empirically defined sets of sleep measures. Compared to the placebo-treated group, patients who received sertraline experienced an increase in delta wave sleep in the first sleep cycle and prolonged rapid eye movement (REM) sleep latency. Although, sertraline therapy decreased the average number of REM periods (from 3.86 to 2.40), the activity of both REM period 1 and REM period 2 was significantly increased. Aside from an increase in sleep latency, sertraline therapy was not associated with a worsening of measures of sleep continuity. There was also no significant difference between the groups on a measure of subjective sleepiness. These findings are both similar and different from those observed in previous studies of other SSRIs. The increase in delta sleep ratio and consolidation of REM sleep may have some other clinical implications. However, the generalizability of these findings is limited because of a number of reasons. Further studies are needed to examine the effects of SSRIs in acute treatment of depressed patients with severe insomnia, and the relationship of acute changes and relapse prevention of recurrent depression.

The neurobiology of depression: perspectives from animal and human sleep studies

This article reviews human and animal studies in the neurobiology of depression. The etiology of the illness, associated neurotransmitter dysregulation, sex steroids, the role of stress, and sleep regulation are discussed. It is suggested that the genesis of depression is related to homeostatic maladaptation that is sexually dimorphic. The authors propose that depressed females are hyperresponsive to stress, whereas depressed males are hyporesponsive to stress. This divergence reflects the exaggeration of naturally occurring differences between males and females, which are most obvious under challenge conditions. The authors conclude that future work in this area should fully evaluate sexual dimorphism, neural plasticity, critical periods, and individual differences in vulnerability.

Effects of trazodone and imipramine on the biological rhythm: an analysis of sleep EEG and body core temperature

Depression commonly involves abnormalities of the sleep-wake rhythm, the temperature rhythm, and other biological rhythms. The changes of these biological rhythms are caused in remission by medications. However, it has yet to be clarified whether the biological rhythms are changed as a result of recovery from depression or from the direct pharmacological effects of the antidepressants. Therefore, we have undertaken a study on the direct effects of the antidepressants trazodone and imipramine on the biological rhythms of healthy volunteers. The study involved 12 healthy male volunteers (ages 21 approximately 28 years, mean age 23.9+/-1.7 years) who had given written informed consent. Placebo, trazodone, and imipramine were each administered in a single blind manner four times a day, during the three-day study period. The total daily dosage of trazodone was 100 mg (50 mg in one subject), and of imipramine 40 mg (20 mg in one subject). Subjects were submitted to polysomnography (PSG) and body core temperature (rectal temperature) measurements during the study period. We compared the data concerning the antidepressants to those of the placebo. The results show that, with regard to the sleep rhythm, trazodone significantly increased slow wave sleep (SWS), but no changes were observed in REM (rapid eye movement) sleep. Imipramine significantly decreased REM sleep and prolonged the REM cycle. With regard to the temperature rhythm, trazodone showed a tendency to advance the appearance time of the minimal temperature. Imipramine significantly lowered the maximal temperature and decreased the difference between the maximal and the minimal temperature, but no changes in the phases were observed. Neither antidepressant had any effect on the temperature cycle. Trazodone and imipramine showed different effects on PSG. Furthermore, they had different effects on the temperature rhythm. The changes of the sleep-wake rhythm were greater than those of the temperature rhythm. Although the two antidepressants had different mechanisms of action, it is worthy of note that both directly influenced the biological rhythms of healthy volunteers.

Depression, sleep physiology, and antidepressant drugs

This review summarizes current findings regarding effects of antidepressant compounds on sleep architecture and interprets their clinical relevance. Effects of the major classes of antidepressant drugs on sleep properties are presented, with the antidepressant compounds organized into categories based primarily on their putative mechanism of action. The majority of antidepressant compounds, across several different categories, exhibit robust suppression of REM sleep. Others, such as bupropion and nefazodone, lack REM suppressant effects. Such findings support the idea that critical neurochemical mechanisms involved in the regulation of discrete sleep stages can be elucidated by means of polysomnographic investigations utilizing pharmacologically targeted agents. Clinicians have appreciated the importance of antidepressant drug effects on sleep when considering therapeutic options for patients. While such decisions in the past were based on empirical observations, an increasing amount of information regarding specific effects of different antidepressant drugs on sleep continuity and sleep architecture is available. Thus, clinicians may choose to consider profiles of sleep effects for different antidepressant drugs in the initial selection of an antidepressant compound.

Fluvoxamine and sleep disturbances in posttraumatic stress disorder

This study assesses the efficacy of fluvoxamine treatment on different domains of subjective sleep quality in Vietnam combat veterans with chronic posttraumatic stress disorder (PTSD). Medically healthy male Vietnam theater combat veterans (N = 21) completed a 10-week open label trial. Fluvoxamine treatment led to improvements in PTSD symptoms and all domains of subjective sleep quality. The largest effect was for dreams linked to the traumatic experience in combat. In contrast, generic unpleasant dreams showed only a modest response to treatment. Sleep maintenance insomnia and the item "troubled sleep" showed a large treatment response, whereas sleep onset insomnia improved less substantially. These therapeutic benefits contrast with published reports that have found activating effects of Selective Serotonin Reuptake Inhibitors on the sleep electroencephalogram.

REM sleep - by default?

Elements of three old, overlapping theories of REM sleep (REM) function, the Ontogenetic, Homeostatic and Phylogenetic hypotheses, together still provide a plausible framework - that REM (i) is directed towards early cortical development, (ii) "tones up" the sleeping cortex, (iii) can substitute for wakefulness, (iv) has a calming effect. This framework is developed in the light of recent findings. It is argued that the "primitiveness" of REM and its similarity to wakefulness liken it to a default state of "non-wakefulness" or a waking antagonist, anteceding "true" (non-REM) sleep. The "toning up" is reflected by inhibition of motor, sensory and (importantly) emotional systems, together pointing to integrated "flight or fight" activity, that preoccupies/distracts the organism when non-REM is absent and wakefulness unnecessary. Dreaming facilitates this distraction. In rodents, REM can provide stress coping and calming, but REM deprivation procedures incorporating immobility may further enhance stress and confound outcomes. REM "pressure" (e.g. REM rebounds) may be a default from a loss of inhibition of REM by non-REM. REM can be reduced and/or replaced by wakefulness, without adverse effects. REM has little advantage over wakefulness in providing positive cerebral recovery or memory consolidation.

The effects of antidepressants on sleep in patients with depression

This paper reviews sleep disturbances in patients with major depressive disorders and the effects of different classes of antidepressants on sleep. It is clear from the studies reviewed that not all antidepressants improve sleep, and, indeed, some worsen sleep disturbances in patients with depression. Whether sleep is improved or further disrupted is of high clinical significance, because persistent sleep problems elevate the risk of relapse, recurrence, or suicide, as well as the need for augmenting medications.

Effects of selective serotonin reuptake inhibitors on objective and subjective sleep quality

The purpose of this paper is to review the effects of selective serotonin (5-HT) reuptake inhibitors on objective and subjective sleep and awakening quality measures. Polysomnography (PSG) demonstrated in both healthy volunteers and depressed patients a decrease in sleep efficiency and total sleep time, a lengthening of sleep latency and a deterioration in sleep continuity, including an increase in the number of awakenings and wake time during the total sleep period. Sleep architecture mostly showed an increase in S1 and S2 and a decrease in S3, S4 and REM sleep as well as a lengthening of REM latency. Objective awakening quality, if measured at all by psychometry, generally showed no decrements. Concerning subjective sleep and awakening quality, normals demonstrated either no changes or a tendency towards a deterioration, while in patients some improvement was observed. Reasons for this discrepancy will be discussed. Novel 5-HT reuptake inhibitors with additional modes of action such as 5-HT2 antagonism (e.g. trazodone, nefazodone) are more likely to improve objective and subjective sleep quality, although some shortcomings may be inherent in regard to comorbidity (e.g. sleep-related breathing disorders). Thus, PSG seems to be a necessity for diagnosis and treatment of complex sleep disorders.

The acute effects of the noradrenaline reuptake inhibitor Org 4428 on EEG sleep in healthy volunteers

Drug-induced improvement of depression may be mediated by changes in sleep physiology. In earlier studies on sleep EEG changes during treatment with antidepressants in depressed patients it could not be excluded that sleep disruptions and changes in the amount and distribution of REM sleep play a role in the changes in the sleep EEG. Therefore knowledge of the effects of antidepressants on the sleep EEG in healthy subjects with non-disturbed baseline sleep is necessary. In a three-way cross-over study in 12 healthy volunteers two single doses of Org 4428 (a highly specific noradrenaline reuptake inhibitor), 25 and 100 mg, were compared with placebo. Sleep EEGs were visually analysed and EEG power of non-REM sleep was measured. The results indicate that sole noradrenaline reuptake inhibiting activity is a potent mechanism to affect sleep polygraphic variables in an antidepressant-like way, i.e. REM sleep suppression and lengthening of REM latency. Despite the increase in the duration of non-REM sleep, i.e. stage 2, no significant changes in EEG power in the range 1-15 Hz were found. Therefore, the acute REM sleep suppression of Org 4428 did not result in a simultaneous reduction of EEG power during non-REM sleep. To date, these and earlier results indicate that most drugs with antidepressant properties affect REM sleep variables consistently, whereas their effect on both sleep polygraphic and EEG power variables in non-REM sleep is unpredictable.

Effects of drugs on sleep

Many commonly prescribed medications and substances of abuse can have significant effects on sleep and wakefulness. Chronic use or abuse of certain drugs may lead to the development of substance-related sleep disorders. Primary sleep disorders, such as apnea, periodic movement disorders, and parasomnias, may be exacerbated by various drugs. This article summarizes the effects of widely used medications and recreational drugs on sleep.

The effects of nefazodone on sleep in depressed patients and healthy controls

This paper briefly reviews the effects of antidepressants on sleep, and highlights recent studies on the effects of nefazodone on sleep in healthy adults and those with major depressive disorders. Studies indicate significant improvement in sleep quality, decreased light sleep, and a reduction in nocturnal awakenings on nefazodone with minimal effect on REM sleep. The clinical relevance of these sleep findings is also discussed.

The link between sleep and depression: the effects of antidepressants on EEG sleep

The assumption that sleep dysregulation is more than a mere epiphenomenon of depression is based on several observations: sleep disturbances are strongly associated with the depressive state; a number of sleep manipulations can alleviate symptoms of depression in some patients; and the majority of antidepressants bring about remarkable changes in sleep polygraphic variables. An obvious question is whether changes in sleep physiological processes are intimately involved in the pathogenesis and recovery from depression. One way to elucidate the link between sleep and depression is to examine whether the influence of antidepressants on sleep is related to clinical improvements in depressives. For that purpose, the effects of antidepressants on EEG sleep and their importance for the treatment of depression are summarized against the background of two existing hypotheses concerning the link between sleep and depression: one hypothesis concerning the role of REM; the other concerning the role of non-REM sleep. EEG sleep studies on the use of antidepressants in depressives have not produced clear evidence of the involvement of REM sleep or non-REM sleep in the mechanisms underlying clinical change. Furthermore, the role of sleep physiological mechanisms during treatment with antidepressants is still unclear. To interpret the effects of antidepressants on EEG sleep in terms of sleep physiological processes more fundamental sleep research is necessary. Also, more comparative studies of antidepressants with similar therapeutic effects but different pharmacological profiles are needed in both healthy and depressed subjects to further quantify the impact of EEG sleep modification in the recovery from depression and to differentiate between pharmacological and sleep-related aspects.

Effects of drugs on sleep

Many commonly prescribed medications and substances of abuse can have significant effects on sleep and wakefulness. Chronic use or abuse of certain drugs may lead to the development of substance-related sleep disorders. Primary sleep disorders, such as apnea, periodic movement disorders, and parasomnias, may be exacerbated by various drugs. This article summarizes the effects of widely used medications and recreational drugs on sleep.

The effects of paroxetine and nefazodone on sleep: a placebo controlled trial

We studied the effect of acute (1 day) and subacute (16 days) administration of the new antidepressant, nefazodone (400 mg daily), and the selective serotonin re-uptake inhibitor (SSRI), paroxetine (30 mg daily), on the sleep polysomnogram of 37 healthy volunteers using a random allocation, double-blind, placebo-controlled design. Compared to placebo, paroxetine lowered rapid eye movement (REM) sleep and increased REM latency. In addition, paroxetine increased awakenings and reduced Actual Sleep Time and Sleep Efficiency. In contrast, nefazodone did not alter REM sleep and had little effect on measures of sleep continuity. We conclude that in contrast to typical SSRIs, nefazodone administration has little effect on sleep architecture in healthy volunteers.

Estimation of the time course of slow-wave sleep over the night in depressed patients: effects of clomipramine and clinical response

The distribution of slow-wave activity during sleep has been analyzed using a method related to the two-process model of sleep regulation. This method is applied to the analyses of data collected from 21 inpatients with unipolar depression who received the antidepressant clomipramine (CMI) in a pulse-loading protocol. CMI infusion was found to redistribute slow-wave activity, producing more concentration in the early part of the night, and also significantly reduced the fluctuation in slow-wave power as a function of time. These measures also distinguished clinical responders from the nonresponders. Drug responders had a significant redistribution of slow-wave activity to the earlier part of the night as compared to nonresponders. This suggests that measures of the distribution of slow-wave activity over the night may represent a good measure of clinical response to antidepressant therapy and have implications for the interpretation of the two-process model and sleep in depression.

Circadian rhythms and the pharmacology of affective illness

The chronic effects of antidepressant drugs (ADs) on circadian rhythms of behavior, physiology and endocrinology are reviewed. The timekeeping properties of several classes of ADs, including tricyclic antidepressants, selective serotonin reuptake inhibitors, monoamine oxidase inhibitors, serotonin agonists and antagonists, benzodiazepines, and melatonin are reviewed. Pharmacological effects on the circadian amplitude and phase, as well as effects on day-night measurements of motor activity, sleep-wake, body temperature (Tb), 3-methoxy-4-hydroxyphenylglycol, cortisol, thyroid hormone, prolactin, growth hormone and melatonin are examined. ADs often lower nocturnal Tb and affect the homeostatic regulation of sleep. ADs often advance the timing and decrease the amount of slow wave sleep, reduce rapid eye movement sleep and increase or decrease arousal. Together, AD effects on nocturnal Tb and sleep may be related to their therapeutic properties. ADs sometimes delay nocturnal cortisol timing and increase nocturnal melatonin, thyroid hormone and prolactin levels; these effects often vary with diagnosis, and clinical state. The effects of ADs on the coupling of the central circadian pacemaker to photic and nonphotic zeitgebers are discussed.

Effect of pharmacologic treatments on the sleep of depressed patients

Antidepressant drugs produce striking effects on sleep architecture that are best understood in terms of their interactions with the monoamine pathways controlling sleep and wakefulness. Many different antidepressant drugs, including tricyclic antidepressants (TCAs), monoamine oxidase inhibitors (MAOIs), and selective 5-hydroxytryptamine (5-HT; serotonin) reuptake inhibitors (SSRIs), decrease rapid eye movement (REM) sleep. The reduction in REM sleep produced by antidepressants may be an important part of their mechanism of action; however, the ability of new antidepressant compounds, such as nefazodone and moclobemide, to increase REM sleep throws doubt on this suggestion. The effects of antidepressants on slow-wave sleep (SWS) are quite diverse; in general, antidepressants having significant 5-HT2A/2C receptor antagonist properties increase SWS, whereas other drugs, such as SSRIs or MAOIs, either lower SWS or produce no change. Sleep continuity is improved acutely following administration of antidepressants with sedating properties such as certain TCAs, trazodone, and mianserin. Some nonsedating drugs (ritanserin and nefazodone) also improve sleep continuity measures, possibly through 5-HT2A/2C receptor blockade.

Effect of pulse loading with clomipramine on EEG sleep

Two different initial dosing regimens with clomipramine (CMI) were used to compare early response indicators and dose strategies. Thirty-two inpatients with major depressive disorder were randomized in a double-blind protocol. The pulse-loading group received 150 and 200 mg of CMI on 2 consecutive evenings and then received a placebo for 8 days. The traditional dosing group began at 50 mg of CMI followed by gradual increases every second day until 200 mg was reached. After 10 days, both groups were placed on an adjustable dosing schedule of CMI, initially set at 200 mg, for an additional 2 weeks. Significant drug effects were noted on several sleep parameters demonstrating suppression of rapid eye movement (REM) sleep. In the pulse-loading group, drug responders were found to have a significantly faster and more robust rebound in REM sleep than nonresponders. Both measures of REM activity and REM sleep time showed a significant difference between the groups. In addition, a significant correlation was found between falling levels of the desmethylclomipramine metabolite of CMI and REM sleep activity during the rebound phase. The clinical and theoretical implications of these findings are discussed.

Shortened REM latency PostECT is associated with rapid recurrence of depressive symptomatology

Electroconvulsive therapy (ECT) is highly effective in the treatment of major depressive disorder (MDD). The 1-year relapse rates are reported to be high and in the 30%-60% range, however. To test whether polysomnography (PS) can identify patients with a propensity for relapse we studied 20 patients, responders to a course of ECT, with PS studies. All patients met baseline diagnostic criteria for MDD, were treated with ECT following standardized protocols, had PS studies performed after the course of ECT in a medication-free state, received maintenance antidepressants postECT, and were followed periodically with phone interviews. The recurrence of depressive symptoms was determined at 3 months and 6 months after discharge. Fifty-five percent of the patients were symptomatic when evaluated 6 months after the ECT. Sleep Onset rapid eye movement (REM) periods were identified in 55% of the patients. As a group, patients who had experienced a recurrence of depressive symptoms by 6 months after discharge, had significantly shorter REM latencies after the course of ECT. A shorter REM latency after ECT identified patients who at six months demonstrated significant depressive symptomatology. Shortened REM latency after ECT in patients with MDD appears to be a correlate of vulnerability for relapse.

Persistent effects of antidepressants: EEG sleep studies in depressed patients during maintenance treatment

Electroencephalographic (EEG) sleep studies represent a research tool that can be used to examine depressed patients over different phases of their illness. We examined the long-term effects of imipramine on EEG sleep in 27 subjects who completed 3 years of maintenance treatment on imipramine without experiencing a recurrence. The analyses were performed on EEG sleep data collected prior to acute treatment, after 3 months in maintenance, and every 3 months thereafter. The major aim was to examine specific changes in rapid eye movement (REM) and slow-wave sleep (SWS) as they unfolded over the course of illness and recovery during long-term drug maintenance. The acute changes in the sleep profile produced by antidepressants remained essentially the same throughout the entire period of drug administration. The REM sleep parameters, which were affected immediately, remained essentially unchanged thereafter, even as long as 3 years into maintenance treatment. A rapid redistribution of slow-wave sleep in the first part of the night was also observed without an increase in the total amount of slow-wave sleep throughout the night. The application of spectral analysis confirmed that the sleep changes following drug administration remained stable throughout all phases of drug treatment. Thus, it appears that sustained clinical improvement is accompanied by persistent sleep alterations on tricyclic antidepressant medication.

Sleep patterns in depression and anxiety: theory and pharmacological effects

Sleep is invariably disrupted in patients who have depression and in patients with anxiety disorders. Depression and anxiety frequently coexist and are associated with disturbances in various neurotransmitters. The authors explore the relationship between sleep and the two disorders as well as the effects of antidepressants and anxiolytics on sleep architecture. The effects on sleep of various neurotransmitter systems implicated in depression and anxiety are outlined. Lastly, various theoretical models are proposed to account for the above mentioned phenomena and further directions for research are suggested.

Sleep Electroencephalographic Studies After ECT: Age and Clinical Response

Forty-one patients with major depressive disorder were treated with electroconvulsive therapy (ECT). Sleep polysomnography studies (SPSs) were performed after the course of ECT. The hypotheses tested were that age is a significant factor in post-ECT SPS results and that some SPS parameters are correlates of outcome of ECT. An interaction between age and response to ECT could not be identified; however, older patients demon strated significantly disrupted sleep post-ECT. Response to ECT was associated with lower REM activity and lower REM density. Sleep-onset REM periods post-ECT were observed in almost 50% of the patients regardless of age. The SPS monitoring of recovery after a course of ECT may identify sleep correlates of response to ECT and variables associated with poorer longitudinal outcome.

[Sleep and biological rhythms in depression. Changes caused by antidepressants]

Sleep in depression is characterized by an increase in the number and duration of awakenings, sleep instability, and SWS decrease. REM sleep occurs earlier. REMs density during the 1st REM period is higher than in normal controls matched in age. Accordingly, sleep in depression is similar to sleep in normal aging. Endogenous depression cannot be distinguished from other types of depression by means of polygraphic criteria. Sleep recordings at the beginning of tricyclic compound treatment could be predictive of clinical response to treatment. Sleep modifications induced by antidepressive drugs are reviewed. Sleep recordings enabled us to formulate several physiopathological hypotheses of depression mechanisms: cholinergic-aminergic hypothesis, phase advance, deficiency of process S. Other hypotheses are reviewed: flattening of a hypothetical circadian rhythm of arousal, depressogenic property of sleep in itself (or only of SWS) or timing delay for the start of sleep. A significant phase advance of biological rhythms (temperature, cortisol) is rarely found. A reduction in the amplitude of rhythms (temperature, TSH, melatonine) is more frequent.

Immediate effects of intravenous clomipramine on sleep and sleep-related secretion in depressed patients

An i.v. challenge dose of clomipramine (12.5 mg) was given to eight outpatients with major depression. The procedure facilitated the examination of all-night sleep and sleep-related neuroendocrine changes (cortisol, growth hormone, and prolactin). In comparison to baseline saline nights, the patients experienced a profound suppression of rapid eye movement (REM) sleep throughout the night with no rebound recovery in the second half of the night. Furthermore, REM-suppressing effects were noted on the following no-drug night. In contrast, little effect on delta wave sleep was found, except for increased consolidation of delta waves within stage 3 and 4 sleep. Delta sleep measures were significantly correlated with levels of cortisol and growth hormone.