Focusing on insomnia symptoms to better understand depression: A STAR*D report

Insomnia and Alexithymia in Chinese Adolescents with Major Depressive Disorder: A Cross-Sectional Study of Sex Differences and Associations

Purpose

Insomnia is related to alexithymia in adults, but the relationship between insomnia and alexithymia in adolescents with major depressive disorder remains unclear. This study aimed to investigate the sex differences and the association between insomnia and alexithymia in adolescents with major depressive disorder.

Patients and Methods

From October 2020 to April 2022, adolescent patients with major depressive disorder were recruited from psychiatric departments of seven hospitals in Anhui Province, China. Their general demographic and clinical information were collected. The 20-item Toronto Alexithymia Scale, the Center for Epidemiologic Studies of Depression Scale, and the Insomnia Severity Index Scale were used to assess their alexithymia, depression, and insomnia symptoms, respectively. The analysis of variance (ANOVA), Student's t-test and Mann-Whitney U-test were used for continuous variables and chi-square tests for categorical variables. Pearson's correlation analysis and Spearman correlation analysis were used to examine the correlation between ISI and demographic and clinical variables. Multiple binary logistic regression analyses with the "Enter" method were carried out to explore the correlations of insomnia.

Results

The prevalence of insomnia in female adolescent patients was similar to that of male patients (χ2=1.84, p = 0.175). Compared with those without insomnia, patients with insomnia had worse family relationships (F = 7.71, p = 0.021), perceived heavier academic stress (F = 6.32, p = 0.012), more likely to take sedative-hypnotics (F = 5.51, p = 0.019), had higher levels of depression (F = 81.57, p < 0.001) and alexithymia (F = 28.57, p < 0.001). Correlation analysis showed that alexithymia was significantly associated with insomnia in adolescent patients (r = 0.360, p < 0.01). Binary logistic regression analyses showed that, alexithymia was significantly associated with insomnia in female patients (OR = 1.050, p < 0.05) but not male patients.

Conclusion

In female adolescent patients, alexithymia is a risk factor of insomnia, which is of great importance in the understanding of the psychopathological mechanisms, treatments and psychological interventions of insomnia in adolescents with major depressive disorder.

The Relationship between Insomnia and the Pathophysiology of Major Depressive Disorder: An Evaluation of a Broad Selection of Serum and Urine Biomarkers

Insomnia exhibits a clinically relevant relationship with major depressive disorder (MDD). Increasing evidence suggests that insomnia is associated with neurobiological alterations that resemble the pathophysiology of MDD. However, research in a clinical population is limited. The present study, therefore, aimed to investigate the relationship between insomnia and the main pathophysiological mechanisms of MDD in a clinical sample of individuals with MDD. Data were extracted from three cohorts (N = 227) and included an evaluation of depression severity (Quick Inventory of Depressive Symptomatology, QIDS-SR₁₆) and insomnia severity (QIDS-SR₁₆ insomnia items) as well as serum and urine assessments of 24 immunologic (e.g., tumour necrosis factor α receptor 2 and calprotectin), neurotrophic (e.g., brain-derived neurotrophic factor and epidermal growth factor), neuroendocrine (e.g., cortisol and aldosterone), neuropeptide (i.e., substance P), and metabolic (e.g., leptin and acetyl-L-carnitine) biomarkers. Linear regression analyses evaluating the association between insomnia severity and biomarker levels were conducted with and without controlling for depression severity (M = 17.32), antidepressant use (18.9%), gender (59.0% female; 40.5% male), age (M = 42.04), and the cohort of origin. The results demonstrated no significant associations between insomnia severity and biomarker levels. In conclusion, for the included biomarkers, current findings reveal no contribution of insomnia to the clinical pathophysiology of MDD.

The course of insomnia symptoms during the acute treatment of major depressive disorder: A CAN-BIND-1 report

Despite considerable efforts to study the relationship between insomnia and depression, there is minimal research investigating whether insomnia symptoms change over time during a course of antidepressant pharmacotherapy. This study investigated the course of insomnia symptoms during the acute treatment of major depressive disorder (MDD) using a secondary analysis of data from MDD patients (N = 180) who were treated with open-label escitalopram (10-20 mg/day) for 8-weeks. Montgomery-Asberg Depression Rating Scale without sleep item (modified-MADRS) assessed depression and Self-reported Quick Inventory Depressive Scale (QIDS-SR) measured subjective sleep-onset, mid-nocturnal, and early-morning insomnia throughout 8-weeks of treatment. Pittsburgh Sleep Quality Index (PSQI) was used to assess subjective sleep quality, duration, onset latency, and efficiency throughout 8-weeks of treatment. Remission of depression was defined as modified-MADRS ≤10 at week-8. Mixed model repeated measures (MMRMs) were conducted with remission status as an independent variable and each sleep variable as a dependent variable. MMRMs demonstrated that remitters had significantly lower QIDS-SR sleep-onset and mid-nocturnal insomnia scores as well as a significantly lower PSQI sleep quality score than non-remitters throughout 8-weeks of treatment. Monitoring subjective sleep-onset and mid-nocturnal insomnia during the course of treatment with serotonergic antidepressants may be useful for predicting acute remission of depression.

The relationship between childhood trauma and insomnia among college students with major depressive disorder: Mediation by the role of negative life events and dysfunctional attitudes

BACKGROUND

Insomnia is a common problem among patients with major depressive disorder (MDD). According to previous studies, the development and severity of Insomnia are influenced by childhood trauma experience. Furthermore, negative life events and dysfunctional attitudes may also mediate the impact. So, this study aimed to examine the association between childhood trauma, negative life events, dysfunctional attitudes and insomnia and investigate how negative life events and dysfunctional attitudes mediate the relationship between childhood trauma and insomnia in MDD.

METHOD

This cross-sectional study recruited 621 college students with MDD. The Childhood Trauma Questionnaire (CTQ), Life Event Scale (LES), Dysfunctional Attitude Scale (DAS), Insomnia Severity Index (ISI), and Hamilton Depression Scale-17 (HAMD-17) were used to assess participants' psychosocial factors. Descriptive analysis, Chi-square test, t-test, Pearson correlations, and serial mediation analyses were used in data analysis. In order to eliminate the influence of the severity of depression symptoms, severity of depression symptoms was used as a control variable in this study.

RESULTS

There were 166 (26.7%) participants having clinical insomnia (ISI score > 14). After controlling for the effect of severity of depression symptoms, results of serial mediation analyses determined that childhood trauma has a direct (Estimate = 0.109, 95%CI: 0.023,0.190) and indirect (Estimate = 0.090, 95%CI: 0.054,0.137) impact to insomnia. The indirect impact of childhood trauma on insomnia through the pathways of negative life events alone (Estimate = 0.050, 95%CI: 0.024,0.093), dysfunctional attitudes alone (Estimate = 0.027, 95%CI: 0.008,0.050), and negative life events to dysfunctional attitudes (Estimate = 0.013, 95%CI: 0.006,0.024) were significant.

CONCLUSIONS

This study demonstrates that screening for childhood trauma should be considered when treating insomnia in college students with MDD. Managing negative life events and dysfunctional attitudes may mitigate the negative impact of childhood trauma on insomnia in college students with MDD.

Psychometric properties of Concise Associated Symptom Tracking (CAST) scale in youths and young adults: Findings from the Texas youth depression and suicide research network (TX-YDSRN)

Symptoms of irritability, anxiety, panic, and insomnia are common in patients with depression, and their worsening after antidepressant treatment initiation is associated with poorer long-term outcomes. The Concise Associated Symptom Tracking (CAST) scale was developed to measure these symptoms in adults with major depressive disorder (MDD). Here, we evaluate the psychometric properties of CAST in an ongoing community-based observational study involving children, adolescents, and young adults. Individuals from the ongoing Texas Youth Depression and Suicide Research Network (TX-YDSRN; N = 952) with CAST data available were included. Fit statistics [Goodness of Fit Index (GFI), Comparative Fit Index (CFI), and Root Mean Square Error of Approximation (RMSEA)] from confirmatory factor analyses were used to evaluate the five- and four-domain structure of CAST. Item response theory (IRT) analyses were also used. Individuals were grouped based on age (in years) as youths (8-17) and young adults (18-20). Correlations with other clinical measures were used to inform construct validity. Four-domain (irritability, anxiety, panic, and insomnia) 12-item structure of CAST (CAST-12) was optimal for youths (N = 709, GFI = 0.906, CFI = 0.919, RMSEA = 0.095) and young adults (N = 243, GFI = 0.921, CFI = 0.938, RMSEA = 0.0797) with Cronbach's alpha of 0.87 and 0.88, respectively. Slope of each item exceeded 1.0 on IRT analyses suggesting adequate discrimination for each item. Scores on irritability, anxiety, panic, and insomnia were significantly correlated with similar items on other scales. Together these findings suggest that CAST-12 is a valid self-report measure of irritability, anxiety, insomnia, and panic in youths and young adults.

Hypnotic Medications as an Adjunct Treatment to Cognitive Behavioral Therapy for Insomnia

Cognitive behavioral therapy for insomnia (CBT-I) is the universally recommended treatment of choice for insomnia disorder based on its safety and posttreatment durability of benefit. However, CBT-I does not help all patients achieve remission. The second most evidence-based treatment, hypnotic pharmacotherapy (PCT), does not resolve perpetuating factors of insomnia, resulting in potential waning of benefit and dependence. This article presents a rationale that supports consideration of hypnotic augmentation of CBT-I (COMB), along with a review of select randomized controlled trials relevant to clinical decision-making.

Risk of resistant hypertension associated with insomnia in patients with obstructive sleep apnea

OBJECTIVES

Patients with obstructive sleep apnea (OSA) have a high prevalence of hypertension but vary in blood pressure (BP) control, which may be partially explained by comorbid insomnia. We investigated the association of insomnia symptoms with uncontrolled BP and resistant hypertension (RH) in OSA patients.

METHODS

Between 2018 and 2021, hypertensive patients with OSA were enrolled. Information on demographic characteristics, insomnia symptoms, class of antihypertensive medications, BP control and sleep study data were collected. Controlled BP was defined as systolic BP < 140 mm Hg and diastolic BP < 90 mm Hg (BP standard); uncontrolled BP as above BP standard with use of 1-2 classes of antihypertensive medication; and RH as above BP standard with the use of ≥3 classes of antihypertensive medication (including a diuretic). Multinomial logistic regression models were fit to determine the association between insomnia symptoms and uncontrolled BP or RH (versus controlled BP) after multivariable adjustment.

RESULTS

Among the analytic sample (n = 326), 64.1% of participants had uncontrolled BP and 15.6% had RH. OSA severity was associated with a higher odds of RH (OR, 2.92; 95% CI, 1.71-4.99). After adjustment for confounders including demographic characteristics, sedative hypnotics usage, sleepiness, OSA severity and quality of life, participants experiencing insomnia symptoms had a 3.0 times higher odds of RH. Insomnia was not associated with uncontrolled BP.

CONCLUSIONS

Experiencing insomnia was associated with increased odds of RH in OSA patients. These results suggest that comorbid insomnia may contribute to inadequate BP control in OSA patients.

Effect of insomnia in the major depressive disorder

Background

People with sleep problems are more likely to have mental disorders. This study aimed to assess the effect of insomnia on the prognosis of patients with major depressive disorder (MDD).

Methods

We divided the patients into three groups according to the Insomnia Severity Index (ISI) scores. In addition, we compared the results of the Hamilton Depression Scale (HAMD) and Symptom Checklist-90 (SCL-90) scores. We evaluated the effect of insomnia at the 2nd, 4th, and 8th-week follow-up on the prognosis of MDD.

Results

Fifty-five patients between 19 and 58 years old, with a diagnosis of MDD via the Structured Clinical Interview for the Diagnostic and Statistical Manual-5 (DSM-5). The ISI scores of the moderate and severe group decreased significantly (P < 0.05) in the 2nd week compared to the baseline. The HAMD scores in all groups improved significantly in the 2nd week.

Conclusions

This study was inspired to assess insomnia as a comorbid disorder for patients with MDD, which may bring poor treatment consequences.

Recent advances in the utilization of tea active ingredients to regulate sleep through neuroendocrine pathway, immune system and intestinal microbiota

Sleep disorders have received widespread attention nowadays, which have been promoted by the accelerated pace of life, unhealthy diets and lack of exercise in modern society. The chemical medications to improve sleep has shown serious side effects and risks with high costs. Therefore, it is urgent to develop efficient nutraceuticals from natural sources to ensure sleep quality as a sustainable strategy. As the second most consumed beverage worldwide, the health-promoting effects of tea have long been widely recognized. However, the modulatory effect of teas on sleep disorders has received much less attention. Tea contains various natural sleep-modulating active ingredients such as L-theanine (LTA), caffeine, tea polyphenols (TPP), tea pigments, tea polysaccharides (TPS) and γ-aminobutyric acid (GABA). This review focuses on the potential influence and main regulating mechanisms of different tea active ingredients on sleep, including being absorbed by the small intestine and then cross the blood-brain barrier to act on neurons in the brain as neurotransmitters, manipulating the immune system and further affect sleep-wake cycle by regulating the levels of cytokines, and controlling the gut microbes to maintain the homeostasis of circadian rhythm. Current research progress and limitations are summarized and several future development directions are also proposed. This review hopes to provide new insights into the future elucidation of the sleep-regulating mechanisms of different teas and their natural active ingredients and the development of tea-based functional foods for alleviating sleep disorders. HighlightsNatural sleep-modulating active ingredients in tea have been summarized.Influences of drinking tea or tea active ingredients on sleep are reviewed.Three main regulating mechanisms of tea active ingredients on sleep are explained.The associations among nervous system, immune system and intestinal microbiota are investigated.The potential of developing delivery carriers for tea active ingredients is proposed.

The acute effects of aerobic exercise on sleep in patients with unipolar depression: a randomized controlled trial

STUDY OBJECTIVES

Insomnia increases the risk of negative disease trajectory, relapse, and suicide in patients with depression. We aimed at investigating the effects of a single bout of aerobic exercise, performed after 02:00 pm, on the subsequent night's sleep in patients with depression.

METHODS

The study was designed as a two-arm parallel-group, randomized, outcome assessor-blinded, controlled, superiority trial. Patients between 18 and 65 years of age with a primary diagnosis of unipolar depression were included. The intervention was a single 30-minute bout of moderate aerobic exercise. The control group sat and read for 30 minutes. The primary outcome was sleep efficiency measured by polysomnography. Secondary outcomes were other polysomnographic variables, subjective sleep quality, daytime sleepiness, mood states, and adverse events.

RESULTS

Ninety-two patients were randomized to the exercise (N = 46) or control group (N = 46). There were no clinically relevant differences at baseline. Intent-to-treat analysis ANCOVA of follow-up sleep efficiency, adjusted for baseline levels and minimization factors, did not detect a significant effect of the allocation (β = -0.93, p = 0.59). There was no evidence for significant differences between both groups in any other objective or subjective sleep outcomes, daytime sleepiness, or adverse events. The intervention had an immediate positive effect on mood states, including depressiveness (β = -0.40, p = 0.003).

CONCLUSIONS

This is the first trial to study the effects of a single bout of aerobic exercise on sleep in patients with depression to the best of our knowledge. Aerobic exercise had no effect on sleep efficiency but had a strong beneficial effect on mood and did not increase adverse outcomes. These results add to the growing body of evidence that, contrary to sleep hygiene recommendations, exercise after 02:00 pm is not detrimental for sleep.

CLINICAL TRIAL REGISTRATION

Clinicaltrials.gov, https://clinicaltrials.gov/ct2/show/NCT03673397. Protocol registered on September 17, 2018.

The Acute Effects of Aerobic Exercise on Nocturnal and Pre-Sleep Arousal in Patients with Unipolar Depression: Preplanned Secondary Analysis of a Randomized Controlled Trial

Unipolar depression is associated with insomnia and autonomic arousal. The aim of this study was to quantify the effect of a single bout of aerobic exercise on nocturnal heart rate variability and pre-sleep arousal in patients with depression. This study was designed as a two-arm, parallel-group, randomized, outcome assessor-blinded, controlled, superiority trial. Patients with a primary diagnosis of unipolar depression aged 18-65 years were included. The intervention consisted of a single 30 min moderate-intensity aerobic exercise bout. The control group sat and read for 30 min. The primary outcome of interest was RMSSD during the sleep period assessed with polysomnography. Secondary outcomes were additional heart rate variability outcomes during the sleep and pre-sleep period as well as subjective pre-sleep arousal. A total of 92 patients were randomized to either the exercise (N = 46) or the control (N = 46) group. Intent-to-treat analysis ANCOVA of follow-up sleep period RMSSD, adjusted for baseline levels and minimization factors, did not detect a significant effect of the allocation (β = 0.12, p = 0.94). There was no evidence for significant differences between both groups in any other heart rate variability measure nor in measures of cognitive or somatic pre-sleep arousal. As this is the first trial of its kind in this population, the findings need to be confirmed in further studies. Patients with depression should be encouraged to exercise regularly in order to profit from the known benefits on sleep and depressive symptoms, which are supported by extensive literature.

Predictors and moderators of quality of life in patients with major depressive disorder: An AGTs-MDD study report

Effective and targeted interventions for improving quality of life (QOL) in addition to achieving 'clinical remission' are imperatives for patients with major depressive disorder (MDD). This study aimed to examine potential predictors and moderators of QOL in depression. Data were obtained from the Algorithm Guided Treatment Strategies for Major Depressive Disorder (AGTs-MDD) study, a multisite, randomized controlled trial composed of 980 depressed patients. Mixed Model Repeated Measures (MMRM) analyses were conducted to identify baseline characteristics associated with QOL overall (predictors) and their interaction effects (moderators). Severe core depressive, anxiety and pain symptoms were found to be independently associated with poor QOL over the 12-week acute phase treatment. Severe depression, severe anxiety or pain symptoms, or severe suicidal ideation predicted a larger improvement of QOL during acute phase treatment, whereas males showed less improvement. None of the putative moderators were identified except for the educational level. Patients with lower educational level showed a larger improvement of QOL in the AGT started with escitalopram (AGT-E) group and AGT started with mirtazapine (AGT-M) group compared to the treatment as usual (TAU) group. These findings may help to instruct informed decision-making for heterogeneous patients with MDD in the view of full recovery.

The effects of exercise on sleep in unipolar depression: A systematic review and network meta-analysis

Insomnia predicts the onset, course, and reoccurrence of unipolar depression. However, systematic reviews of treatment options for insomnia in unipolar depression are lacking. After screening 7725 records, 17 trials comprising 1645 patients randomized to 13 treatments were included for quantitative synthesis. Network meta-analysis showed that compared to a passive control condition, all exercise interventions except moderate aerobic exercise alone resulted in significantly better sleep outcomes. Compared with treatment as usual, mind-body exercise plus treatment as usual (SMD: -0.46; 95% CI: -0.80, -0.12) and vigorous strength exercise (SMD: -0.61; 95% CI: -1.12, -0.10) were significantly more effective. Pairwise meta-analyses showed that mind-body exercise (SMD: -0.54; 95% CI: -0.85, -0.23) had beneficial effects compared to passive control. The network meta-analysis is statistically very robust with low heterogeneity, incoherence, and indirectness. However, confidence in the findings was moderate to very low, primarily due to within-study bias. This is the first network meta-analysis to assess exercise's efficacy to improve sleep quality in patients with depression. The findings confirm the benefits of exercise as an add-on treatment for depression. This consolidation of the current state of evidence can help clinicians make evidence-based decisions.

Potential Genetic Overlap Between Insomnia and Sleep Symptoms in Major Depressive Disorder: A Polygenic Risk Score Analysis

Background: The prevalence of insomnia and hypersomnia in depressed individuals is substantially higher than that found in the general population. Unfortunately, these concurrent sleep problems can have profound effects on the disease course. Although the full biology of sleep remains to be elucidated, a recent genome-wide association (GWAS) of insomnia, and other sleep traits in over 1 million individuals was recently published and provides many promising hits for genetics of insomnia in a population-based sample. Methods: Using data from the largest available GWAS of insomnia and other sleep traits, we sought to test if sleep variable PRS scores derived from population-based studies predicted sleep variables in samples of depressed cases [Psychiatric Genomics Consortium - Major Depressive Disorder subjects (PGC MDD)]. A leave-one-out analysis was performed to determine the effects that each individual study had on our results. Results: The only significant finding was for insomnia, where p-value threshold, p = 0.05 was associated with insomnia in our PGC MDD sample (R ² = 1.75^-3, p = 0.006). Conclusion: Our results reveal that <1% of variance is explained by the variants that cover the two significant p-value thresholds, which is in line with the fact that depression and insomnia are both polygenic disorders. To the best of our knowledge, this is the first study to investigate genetic overlap between the general population and a depression sample for insomnia, which has important treatment implications, such as leading to novel drug targets in future research efforts.

Prevalence of Depression in Older Nursing Home Residents in High and Low Altitude Regions: A Comparative Study

Objective: Depressive symptoms (depression hereafter) is common in older adults, and closely associated with environmental factors. This study compared the prevalence of depression in older adults living in high-altitude and low-altitude regions, and their association with quality of life (QOL). Method: A total of 632 older nursing home residents were included, with 425 participants living in low-altitude and 207 participants living in high-altitude regions. Depression and QOL were assessed using standardized instruments. Results: The prevalence of depression was 26.9% (95% CI: 23.43-30.37%) in the whole sample of older nursing home residents, with 11.1% (95% CI: 8.01-14.05%) in those living in low-altitude and 59.4% (95% CI: 52.68-66.17%) in those living in high-altitude regions. Multiple logistic regression analysis revealed that living in low-altitude region (P < 0.001, OR = 0.07, 95% CI: 0.04-0.12) was associated with lower risk of depression, while perception of poor health status (P < 0.001, OR = 3.86, 95% CI: 1.98-7.54) and having insomnia (P < 0.001, OR = 4.76, 95% CI: 2.99-7.56) were associated with higher risk of depression. QOL was significantly lower in physical (F _(1,632) = 35.421, P < 0.001), psychological (F _(1,632) = 20.777, P < 0.001), social (F _(1,632) = 8.169, P < 0.001) and environmental domains (F _(1,632) = 11.861, P < 0.001) in those with depression. Conclusion: Depression was common in older nursing home residents especially those living in the high-altitude region. Considering the negative impact of depression on QOL and functional outcomes, routine screening and timely treatment of depression should be implemented in this population.

Effect of Sleep Disturbance on Efficacy of Esketamine in Treatment-Resistant Depression: Findings from Randomized Controlled Trials

PURPOSE

To evaluate the relationship of sleep disturbance to the antidepressant effects of esketamine.

MATERIALS AND METHODS

Two double-blind, 4-week studies randomized adults with treatment-resistant depression (TRD) to placebo or esketamine nasal spray, each with newly initiated antidepressant. Sleep was assessed using Montgomery-Åsberg Depression Rating Scale (MADRS) item 4. Change in response (≥50% decrease in MADRS total score) and remission (total MADRS score ≤12) at day 28 was examined by presence/absence of baseline sleep disturbance using logistic regression models. Impact on reported sleep disturbance (MADRS item 4 score) was examined using ANCOVA models.

RESULTS

At baseline, most patients reported disturbed sleep - moderate/severe (65.3%, 369/565), mild (25.3%, 143/565), or none/slightly (9.4%, 53/565) - with similar distribution between treatment groups. A higher proportion of esketamine-treated patients achieved response (OR = 2.05; 95% CI: 1.40-3.02; P < 0.001) and remission (OR = 1.81; 95% CI: 1.23-2.66; P = 0.003) at day 28 compared to antidepressant plus placebo, regardless of presence/severity of sleep disturbance. Consistent with this, sleep (MADRS item 4 score) improved in both groups after the first dose, more so with esketamine by day 8 (between-group difference: P ≤ 0.02 at all time points). Across both treatment groups, 1-point improvement in sleep at day 8 increased the probability of antidepressant response on day 28 by 26% (OR = 1.26, 95% CI: 1.12-1.42; P < 0.001), and remission by 28% (OR = 1.28, 95% CI: 1.14-1.43; P < 0.001).

CONCLUSION

Antidepressant efficacy of esketamine was demonstrated in patients with TRD, regardless of the presence of sleep disturbance. After 8 days of treatment and thereafter, significantly more esketamine-treated patients reported improvement in sleep versus antidepressant plus placebo.