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Biscarini F, Barateau L, Pizza F, Plazzi G, Dauvilliers Y. Narcolepsy and rapid eye movement sleep. J Sleep Res 2024:e14277. [PMID: 38955433 DOI: 10.1111/jsr.14277] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2024] [Revised: 06/06/2024] [Accepted: 06/09/2024] [Indexed: 07/04/2024]
Abstract
Since the first description of narcolepsy at the end of the 19th Century, great progress has been made. The disease is nowadays distinguished as narcolepsy type 1 and type 2. In the 1960s, the discovery of rapid eye movement sleep at sleep onset led to improved understanding of core sleep-related disease symptoms of the disease (excessive daytime sleepiness with early occurrence of rapid eye movement sleep, sleep-related hallucinations, sleep paralysis, rapid eye movement parasomnia), as possible dysregulation of rapid eye movement sleep, and cataplexy resembling an intrusion of rapid eye movement atonia during wake. The relevance of non-sleep-related symptoms, such as obesity, precocious puberty, psychiatric and cardiovascular morbidities, has subsequently been recognized. The diagnostic tools have been improved, but sleep-onset rapid eye movement periods on polysomnography and Multiple Sleep Latency Test remain key criteria. The pathogenic mechanisms of narcolepsy type 1 have been partly elucidated after the discovery of strong HLA class II association and orexin/hypocretin deficiency, a neurotransmitter that is involved in altered rapid eye movement sleep regulation. Conversely, the causes of narcolepsy type 2, where cataplexy and orexin deficiency are absent, remain unknown. Symptomatic medications to treat patients with narcolepsy have been developed, and management has been codified with guidelines, until the recent promising orexin-receptor agonists. The present review retraces the steps of the research on narcolepsy that linked the features of the disease with rapid eye movement sleep abnormality, and those that do not appear associated with rapid eye movement sleep.
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Affiliation(s)
- Francesco Biscarini
- Department of Biomedical and Neuromotor Sciences (DIBINEM), University of Bologna, Bologna, Italy
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy
| | - Lucie Barateau
- Sleep-Wake Disorders Unit, Department of Neurology, Gui-de-Chauliac Hospital, CHU Montpellier, Montpellier, France
- National Reference Centre for Orphan Diseases, Narcolepsy, Idiopathic Hypersomnia, and Kleine-Levin Syndrome, Montpellier, France
- Institute for Neurosciences of Montpellier, University of Montpellier, INSERM, Montpellier, France
| | - Fabio Pizza
- Department of Biomedical and Neuromotor Sciences (DIBINEM), University of Bologna, Bologna, Italy
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy
| | - Giuseppe Plazzi
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy
- Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio-Emilia, Modena, Italy
| | - Yves Dauvilliers
- Sleep-Wake Disorders Unit, Department of Neurology, Gui-de-Chauliac Hospital, CHU Montpellier, Montpellier, France
- National Reference Centre for Orphan Diseases, Narcolepsy, Idiopathic Hypersomnia, and Kleine-Levin Syndrome, Montpellier, France
- Institute for Neurosciences of Montpellier, University of Montpellier, INSERM, Montpellier, France
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2
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Silvestri R. Addressing the challenges and gaps in understanding pediatric periodic limb movement disorder. Sleep Med Rev 2024; 76:101973. [PMID: 38959696 DOI: 10.1016/j.smrv.2024.101973] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2024] [Accepted: 06/27/2024] [Indexed: 07/05/2024]
Affiliation(s)
- Rosalia Silvestri
- Sleep Medicine Center, Neurophysiopathology and Movement Disorders Unit, Department of Clinical and Experimental Medicine, University of Messina, Azienda Ospedaliera Universitaria Gaetano Martino, Centro Disturbi del Sonno - Pad. H, Via Consolare Valeria, 1, 98124, Messina, Italy.
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3
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Raggi A, Serretti A, Ferri R. A comprehensive overview of post-stroke depression treatment options. Int Clin Psychopharmacol 2024; 39:127-138. [PMID: 38170802 DOI: 10.1097/yic.0000000000000532] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2024]
Abstract
Nearly one-third of all stroke patients develop depression at any time after a stroke, and its presence is associated with unfavorable outcomes. This narrative review aims to provide a synopsis of possible pharmacological and non-pharmacological treatment modalities for post-stroke depression (PSD). Several studies have demonstrated the efficacy and safety of selective serotonin reuptake inhibitors in treating the symptoms of this clinical condition. The treatment of PSD has been recently enhanced by innovative approaches, such as cognitive-behavioral therapy, virtual reality, telehealth, repetitive transcranial magnetic stimulation, and non-conventional therapies, which might improve depression treatment in stroke survivors. Future high-quality randomized controlled trials are necessary to confirm this hypothesis.
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Affiliation(s)
- Alberto Raggi
- Unit of Neurology, G.B. Morgagni - L. Pierantoni Civic Hospital, Forlì
| | | | - Raffaele Ferri
- Department of Neurology, Oasi Research Institute - IRCCS, Troina, Italy
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4
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Bergmann M, Stefani A, Ibrahim A, Anselmi V, Brandauer E, Högl B, Cesari M. A 24% prevalence of excessive fragmentary myoclonus in 500 consecutive sleep laboratory patients. J Sleep Res 2024; 33:e14074. [PMID: 37922734 DOI: 10.1111/jsr.14074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Revised: 09/30/2023] [Accepted: 10/06/2023] [Indexed: 11/07/2023]
Abstract
Excessive fragmentary myoclonus (EFM) is a frequent finding during routine video-polysomnography (VPSG). We aimed to automatically measure the prevalence of EFM according to current American Academy of Sleep Medicine (AASM) criteria, and the fragmentary myoclonus index (FMI) in sleep stage N1, N2, N3, rapid eye movement (REM) sleep and wake in a large patient population. A total of 500 VPSG recordings of patients admitted to the Sleep Laboratory, Department of Neurology, Medical University of Innsbruck, Austria, between May 1, 2022 and February 28, 2023, were included. EFM according to AASM criteria and FMI were computed by applying a previously validated algorithm. EFM was automatically detected in 121 of the 500 Sleep Laboratory patients (24.2%, 95% confidence interval 20.1%-28.9%). FMI increased with age, male gender, apnea-hypopnea-index (AHI), oxygen desaturation index (ODI), and periodic leg movements of sleep (PLMS) index. FMI was highest in REM sleep behaviour disorder (RBD), followed by neurodegenerative and internal medicine diseases, but the increase in the FMI was not explained by the disease itself but rather by the age and sex of the patients. Almost a quarter of our patient population had EFM. However, the prevalence of EFM does not allow the drawing of any conclusions about the pathophysiology of EFM or even the determination of a pathological FMI cut-off value. Associations of the FMI with age, sex, AHI, ODI and PLMS are in line with previous studies, but the FMI needs to be evaluated in different disease entities to learn more about its pathophysiology.
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Affiliation(s)
- Melanie Bergmann
- Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Ambra Stefani
- Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Abubaker Ibrahim
- Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Victoria Anselmi
- Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Elisabeth Brandauer
- Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Birgit Högl
- Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Matteo Cesari
- Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
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Mogavero MP, Salemi M, Lanza G, Rinaldi A, Marchese G, Ravo M, Salluzzo MG, Antoci A, DelRosso LM, Bruni O, Ferini-Strambi L, Ferri R. Unveiling the pathophysiology of restless legs syndrome through transcriptome analysis. iScience 2024; 27:109568. [PMID: 38617564 PMCID: PMC11015462 DOI: 10.1016/j.isci.2024.109568] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2023] [Revised: 01/22/2024] [Accepted: 03/22/2024] [Indexed: 04/16/2024] Open
Abstract
The aim of this study was to analyze signaling pathways associated with differentially expressed messenger RNAs in people with restless legs syndrome (RLS). Seventeen RLS patients and 18 controls were enrolled. Coding RNA expression profiling of 12,857 gene transcripts by next-generation sequencing was performed. Enrichment analysis by pathfindR tool was carried-out, with p-adjusted ≤0.001 and fold-change ≥2.5. Nine main different network groups were significantly dysregulated in RLS: infections, inflammation, immunology, neurodegeneration, cancer, neurotransmission and biological, blood and metabolic mechanisms. Genetic predisposition plays a key role in RLS and evidence indicates its inflammatory nature; the high involvement of mainly neurotropic viruses and the TORCH complex might trigger inflammatory/immune reactions in genetically predisposed subjects and activate a series of biological pathways-especially IL-17, receptor potential channels, nuclear factor kappa-light-chain-enhancer of activated B cells, NOD-like receptor, mitogen-activated protein kinase, p53, mitophagy, and ferroptosis-involved in neurotransmitter mechanisms, synaptic plasticity, axon guidance, neurodegeneration, carcinogenesis, and metabolism.
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Affiliation(s)
- Maria P. Mogavero
- Vita-Salute San Raffaele University, 20132 Milan, Italy
- San Raffaele Scientific Institute, Division of Neuroscience, Sleep Disorders Center, 20127 Milan, Italy
| | | | - Giuseppe Lanza
- Oasi Research Institute-IRCCS, 94018 Troina, Italy
- University of Catania, Department of Surgery and Medical-Surgical Specialties, 95123 Catania, Italy
| | - Antonio Rinaldi
- Genomix4Life Srl, 84081 Baronissi, Italy
- Genome Research Center for Health-CRGS, 84081 Baronissi, Italy
| | - Giovanna Marchese
- Genomix4Life Srl, 84081 Baronissi, Italy
- Genome Research Center for Health-CRGS, 84081 Baronissi, Italy
| | - Maria Ravo
- Genomix4Life Srl, 84081 Baronissi, Italy
- Genome Research Center for Health-CRGS, 84081 Baronissi, Italy
| | | | | | | | - Oliviero Bruni
- Sapienza University of Rome, Developmental and Social Psychology, 00185 Rome, Italy
| | - Luigi Ferini-Strambi
- Vita-Salute San Raffaele University, 20132 Milan, Italy
- San Raffaele Scientific Institute, Division of Neuroscience, Sleep Disorders Center, 20127 Milan, Italy
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DelRosso LM, Picchietti DL, Sharon D, Spruyt K, Owens JA, Walters AS, Zucconi M, Ferri R. Periodic limb movement disorder in children: A systematic review. Sleep Med Rev 2024; 76:101935. [PMID: 38652932 DOI: 10.1016/j.smrv.2024.101935] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2024] [Revised: 03/09/2024] [Accepted: 04/07/2024] [Indexed: 04/25/2024]
Abstract
This systematic review evaluates the scientific literature on pediatric periodic limb movement disorder (PLMD), adhering to PRISMA guidelines and utilizing PICOS criteria. The search across PubMed, EMBASE, and Scopus yielded 331 articles, with 17 meeting inclusion criteria. Diagnostic criteria evolved, with polysomnography and PLMS index ≥5 required since 2003. Also, PLMD diagnosis mandates clinical consequences like insomnia, hypersomnia, and fatigue, excluding comorbidities causing sleep disruption. Prevalence in children is low (0.3%), emphasizing the need for meticulous investigation. Comorbidities, particularly the bidirectional relationship with ADHD, were explored. Challenges in diagnosis and understanding arise from overlapping conditions such as sleep disordered breathing, psychotropic medication, and criteria non-adherence. Despite generally good study quality, weaknesses include sample size justification and biases. The periodic leg movement index shows high sensitivity but low specificity, underscoring strict diagnostic criteria adherence. Diverse metrics for symptoms necessitate standardized approaches. Family history of RLS in children with PLMD suggests unexplored aspects. Treatment, mainly iron supplementation, lacks standardized assessment metrics. The review emphasizes diagnostic and treatment challenges, recommending unbiased studies with precise techniques. Comprehensive research, quantifying PLMS and objectively assessing sleep parameters, is crucial for advancing understanding in pediatric PLMD. PROSPERO REGISTRATION NUMBER: CRD42021251406.
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Affiliation(s)
| | - Daniel L Picchietti
- University of Illinois School of Medicine, Carle Illinois College of Medicine, and Carle Health, Urbana, IL, USA.
| | - Denise Sharon
- Pomona Valley Hospital and Medical Center, Claremont, CA, USA.
| | - Karen Spruyt
- Université de Paris, NeuroDiderot, INSERM, Paris, 75019, France.
| | - Judith A Owens
- Division of Neurology, Boston Children's Hospital, Harvard Medical School, Waltham, MA, USA.
| | - Arthur S Walters
- Division of Sleep Medicine, Vanderbilt University School of Medicine, Nashville, TN, USA.
| | - Marco Zucconi
- Sleep Disorders Center, Department of Neurology, Scientific Institute and University Ospedale San Raffaele, Vita-Salute University, Institute and Ospedale San Raffaele, Milan, Italy.
| | - Raffaele Ferri
- Sleep Research Centre, Oasi Research Institute - IRCCS, Troina, Italy.
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Maski KP, Amos LB, Carter JC, Koch EE, Kazmi U, Rosen CL. Recommended protocols for the Multiple Sleep Latency Test and Maintenance of Wakefulness Test in children: guidance from the American Academy of Sleep Medicine. J Clin Sleep Med 2024; 20:631-641. [PMID: 38149645 PMCID: PMC10985297 DOI: 10.5664/jcsm.10974] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2023] [Accepted: 12/26/2023] [Indexed: 12/28/2023]
Abstract
The American Academy of Sleep Medicine commissioned a task force of clinical experts in pediatric sleep medicine to review published literature on performing the Multiple Sleep Latency Test (MSLT) and Maintenance of Wakefulness Test for diagnosis and management of central disorders of hypersomnolence among children and adolescents. This paper follows a format similar to that of the paper "Recommended protocols for the Multiple Sleep Latency Test and Maintenance of Wakefulness Test in adults: guidance from the American Academy of Sleep Medicine" that was published in 2021. Since there is insufficient evidence to specify a recommended protocol for the Maintenance of Wakefulness Test in children and adolescents, this paper focuses only on the MSLT protocol. This protocol paper provides guidance to health care providers who order, sleep specialists who interpret, and technical staff who administer the MSLT to pediatric patients. Similar to the adult protocol paper, this document provides guidance based on pediatric expert consensus and evidence-based data when available. Topics include patient preparation, evaluation of medication and substance use, sleep needs before testing, scheduling considerations, optimal test conditions for youth, and documentation. Specific changes recommended for pediatric MSLT protocols include (1) provision of a minimum of 7 hours of sleep (with a minimum 8-hour recording time) on polysomnography the night before the MSLT, ideally meeting age-based needs; (2) use of clinical judgment to guide the need for sleep-disordered breathing treatments before polysomnography-MSLT testing; and (3) shared patient-health care provider decision-making regarding modifications in the protocol for children and adolescents with neurodevelopmental/neurological disorders, young age, and/or delayed sleep phase. CITATION Maski KP, Amos LB, Carter JC, Koch EE, Kazmi U, Rosen CL. Recommended protocols for the Multiple Sleep Latency Test and Maintenance of Wakefulness Test in children: guidance from the American Academy of Sleep Medicine. J Clin Sleep Med. 2024;20(4):631-641.
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Affiliation(s)
- Kiran P. Maski
- Department of Neurology, Boston Children’s Hospital, Boston, Massachusetts
- Department of Neurology, Harvard Medical School, Boston, Massachusetts
| | - Louella B. Amos
- Pediatric Pulmonology and Sleep Medicine, Children’s Wisconsin, Milwaukee, Wisconsin
- Department of Pediatrics, Division of Pulmonary and Sleep Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - John C. Carter
- Department of Medicine, MetroHealth Medical Center, Cleveland, Ohio
- Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Ellen E. Koch
- American Academy of Sleep Medicine, Darien, Illinois
| | - Uzma Kazmi
- American Academy of Sleep Medicine, Darien, Illinois
| | - Carol L. Rosen
- Case Western Reserve University School of Medicine, Cleveland, Ohio
- American Academy of Sleep Medicine, Darien, Illinois
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Boersma GJ, Mijnster T, Vantyghem P, Kerkhof GA, Lancel M. Shift work is associated with extensively disordered sleep, especially when working nights. Front Psychiatry 2023; 14:1233640. [PMID: 38161719 PMCID: PMC10755475 DOI: 10.3389/fpsyt.2023.1233640] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Accepted: 10/17/2023] [Indexed: 01/03/2024] Open
Abstract
Background Shift work is generally associated with working and sleeping out of phase with the endogenous, circadian sleep-wake cycle. This exerts detrimental effects on sleep health. The present study aimed at evaluating the presence of short and long sleep as well as sleep disorders within a broad range of shift work schedules and elucidating the role of sociodemographic factors therein. Methods A large dataset containing information on sleep was collected through advertisement in a Belgium newspaper (De Standaard). Adult, working individuals were selected (n = 37,662) and categorized based on their work schedule (regular day, early morning, evening, night, and rotating shift). In this cross-sectional study, prevalence rates of short sleep (≤6 h), long sleep (≥9 h) and sleep disorders (screened with Holland Sleep Disorders Questionnaire), and associations between these sleep variables and sociodemographics (age, sex, education, living companion(s)) were analyzed using binominal logistic regression analyses. Results In the total sample all sociodemographic factors affected prevalences of short, long and disordered sleep, consistent with previous studies. Compared to day workers, shift workers more frequently reported short sleep, most prominently night workers (26 vs. 50%) (p < 0.001). Furthermore, all sleep disorders as well as sleep disorder comorbidity were more common in shift workers, again most pronounced in night workers (all p < 0.05). In night shift workers the level of education had the strongest associations with disturbed sleep with a two-fold higher prevalence of short and disordered sleep in low relative to academic educated groups (all p < 0.02). Conclusion Shift work is related not only to curtailed sleep and shift work disorder, but also to a plethora of sleep disorders, including insomnia, sleep-related breathing disorders and sleep-related movement disorders. Our findings imply that education on coping strategies may be especially important for young and/or lower educated shift workers.
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Affiliation(s)
- G. J. Boersma
- Forensic Psychiatric Hospital, GGZ Drenthe Mental Health Institute, Assen, Netherlands
| | - T. Mijnster
- Centre of Expertise on Sleep and Psychiatry, GGZ Drenthe Mental Health Institute, Assen, Netherlands
- Department of Clinical Psychology and Experimental Psychopathology, University of Groningen, Groningen, Netherlands
| | - P. Vantyghem
- De Standaard (Daily Newspaper), Mediahuis, Brussels, Belgium
| | - G. A. Kerkhof
- Department of Psychology, University of Amsterdam, Amsterdam, Netherlands
- Sleep Disorders Center, Haaglanden Medical Center (HMC), The Hague, Netherlands
| | - Marike Lancel
- Forensic Psychiatric Hospital, GGZ Drenthe Mental Health Institute, Assen, Netherlands
- Centre of Expertise on Sleep and Psychiatry, GGZ Drenthe Mental Health Institute, Assen, Netherlands
- Department of Clinical Psychology and Experimental Psychopathology, University of Groningen, Groningen, Netherlands
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Dama M, Wu M, Tassone VK, Demchenko I, Frey BN, Milev RV, Ravindran AV, Parikh SV, Rotzinger S, Lou W, Lam RW, Kennedy SH, Bhat V. The course of insomnia symptoms during the acute treatment of major depressive disorder: A CAN-BIND-1 report. Psychiatry Res 2023; 325:115222. [PMID: 37163883 DOI: 10.1016/j.psychres.2023.115222] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2022] [Revised: 04/17/2023] [Accepted: 04/23/2023] [Indexed: 05/12/2023]
Abstract
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.
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Affiliation(s)
- Manish Dama
- School of Medicine, Trinity College Dublin, The University of Dublin, Dublin, Ireland; Interventional Psychiatry Program and Centre for Depression & Suicide Studies, St. Michael's Hospital, Toronto, Ontario, Canada
| | - Michelle Wu
- Interventional Psychiatry Program and Centre for Depression & Suicide Studies, St. Michael's Hospital, Toronto, Ontario, Canada
| | - Vanessa K Tassone
- Interventional Psychiatry Program and Centre for Depression & Suicide Studies, St. Michael's Hospital, Toronto, Ontario, Canada
| | - Ilya Demchenko
- Interventional Psychiatry Program and Centre for Depression & Suicide Studies, St. Michael's Hospital, Toronto, Ontario, Canada; Institute of Medical Science, University of Toronto, Toronto, Ontario, Canada
| | - Benicio N Frey
- Department of Psychiatry and Behavioural Neurosciences, McMaster University, Hamilton, Ontario, Canada; Mood Disorders Program, St. Joseph's Healthcare Hamilton, Ontario, Canada
| | - Roumen V Milev
- Department of Psychiatry, Queen's University, Kingston, Ontario, Canada
| | - Arun V Ravindran
- Institute of Medical Science, University of Toronto, Toronto, Ontario, Canada; Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada
| | - Sagar V Parikh
- Department of Psychiatry, University of Michigan, Ann Arbor, Michigan, United States
| | - Susan Rotzinger
- Interventional Psychiatry Program and Centre for Depression & Suicide Studies, St. Michael's Hospital, Toronto, Ontario, Canada
| | - Wendy Lou
- Dalla Lana School of Public Health, University of Toronto, Ontario, Canada
| | - Raymond W Lam
- Department of Psychiatry, University of British Columbia, Vancouver, British Columbia, Canada
| | - Sidney H Kennedy
- Interventional Psychiatry Program and Centre for Depression & Suicide Studies, St. Michael's Hospital, Toronto, Ontario, Canada; Institute of Medical Science, University of Toronto, Toronto, Ontario, Canada; Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada; Li Ka Shing Knowledge Institute & Krembil Research Institute, Toronto, Ontario, Canada
| | - Venkat Bhat
- Interventional Psychiatry Program and Centre for Depression & Suicide Studies, St. Michael's Hospital, Toronto, Ontario, Canada; Institute of Medical Science, University of Toronto, Toronto, Ontario, Canada; Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada; Li Ka Shing Knowledge Institute & Krembil Research Institute, Toronto, Ontario, Canada.
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