1
|
Yousefzadehfard Y, Wechsler B, DeLorenzo C. Human circadian rhythm studies: Practical guidelines for inclusion/exclusion criteria and protocol. Neurobiol Sleep Circadian Rhythms 2022; 13:100080. [PMID: 35989718 PMCID: PMC9382328 DOI: 10.1016/j.nbscr.2022.100080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2022] [Revised: 08/01/2022] [Accepted: 08/02/2022] [Indexed: 11/03/2022] Open
Abstract
As interest in circadian rhythms and their effects continues to grow, there is an increasing need to perform circadian studies in humans. Although the constant routine is the gold standard for these studies, there are advantages to performing more naturalistic studies. Here, a review of protocols for such studies is provided along with sample inclusion and exclusion criteria. Sleep routines, drug use, shift work, and menstrual cycle are addressed as screening considerations. Regarding protocol, best practices for measuring melatonin, including light settings, posture, exercise, and dietary habits are described. The inclusion/exclusion recommendations and protocol guidelines are intended to reduce confounding variables in studies that do not involve the constant routine. Given practical limitations, a range of recommendations is provided from stringent to lenient. The scientific rationale behind these recommendations is discussed. However, where the science is equivocal, recommendations are based on empirical decisions made in previous studies. While not all of the recommendations listed may be practical in all research settings and with limited potential participants, the goal is to allow investigators to make well informed decisions about their screening procedures and protocol techniques and to improve rigor and reproducibility, in line with the objectives of the National Institutes of Health.
Collapse
Affiliation(s)
- Yashar Yousefzadehfard
- Center for Understanding Biology Using Imaging Technology, Department of Psychiatry, Stony Brook University, Stony Brook, NY, USA.,Department of Psychiatry, Texas Tech University Health Science Center, Midland, TX, USA
| | - Bennett Wechsler
- Department of Psychiatry, University of Massachusetts Medical School, Worcester, MA, USA
| | - Christine DeLorenzo
- Center for Understanding Biology Using Imaging Technology, Department of Psychiatry, Stony Brook University, Stony Brook, NY, USA
| |
Collapse
|
2
|
Morera-Fumero AL, Fernandez-Lopez L, Abreu-Gonzalez P. Melatonin and melatonin agonists as treatments for benzodiazepines and hypnotics withdrawal in patients with primary insomnia. A systematic review. Drug Alcohol Depend 2020; 212:107994. [PMID: 32409111 DOI: 10.1016/j.drugalcdep.2020.107994] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2019] [Revised: 02/29/2020] [Accepted: 03/26/2020] [Indexed: 12/18/2022]
Abstract
BACKGROUND Hypnotics (HYP) and benzodiazepines (BZD) are medicines prescribed for the insomnia treatment. Many patients present difficulties in discontinuing the treatment once established. Melatonin (MLT) has been prescribed as a treatment for BZD/HYP detoxification. AIMS The primary objective of this systematic review is to assess the efficacy of MLT and MLT agonists (melatoninergics) in improving the rate of BZD and/or HYP discontinuation among adults with primary insomnia attempting to discontinue BZD and/or HYP. The secondary objective is to evaluate the partial efficacy of melatoninergic drugs in the discontinuation of BZD and/or HYP consumption in subjects that could not stop their consumption. METHOD A search on Web of Science and Scopus was carried out from database inception to July 1st, 2019. RESULTS Three hundred and forty-nine articles were identified but only four were included in the final review. Two were cohort prospective, one placebo-control double blind and one double blind placebo-control cross-over designed study. Total withdrawal (TW) ranged from 0% to 25% in the placebo arm and from 64.3% to 77.8% in the MLT arm. In cohort studies TW figures ranged from 30.8% to 65%. Partial withdrawal ranged between 20% and 30.8% of patients that did not achieve TW with reduction figures of diazepam equivalent dose ranging from 25% to 75%. CONCLUSION MLT has a place in the physician armamentarium to treat the suspension/reduction of BZD/HYP consumption in patients with primary insomnia.
Collapse
Affiliation(s)
- Armando L Morera-Fumero
- Departamento de Medicina Interna, Dermatología y Psiquiatría. Facultad de Ciencias de la Salud, Universidad de La Laguna, La Laguna, Santa Cruz de Tenerife, Spain; Consultoría Psiquiátrica SC, Santa Cruz de Tenerife, Spain.
| | - Lourdes Fernandez-Lopez
- Departamento de Medicina Interna, Dermatología y Psiquiatría. Facultad de Ciencias de la Salud, Universidad de La Laguna, La Laguna, Santa Cruz de Tenerife, Spain; Sociedad para la Investigación y Asistencia en Salud Mental, Santa Cruz de Tenerife, Spain
| | - Pedro Abreu-Gonzalez
- Departamento de Ciencias Médicas Básicas: Unidad de Fisiología. Facultad de Ciencias de la Salud. Universidad de la Laguna, la Laguna, Santa Cruz de Tenerife, Spain
| |
Collapse
|
3
|
Schüssler P, Kluge M, Adamczyk M, Beitinger ME, Beitinger P, Bleifuss A, Cordeiro S, Mattern C, Uhr M, Wetter TC, Yassouridis A, Rupprecht R, Friess E, Steiger A. Sleep after intranasal progesterone vs. zolpidem and placebo in postmenopausal women - A randomized, double-blind cross over study. Psychoneuroendocrinology 2018; 92:81-86. [PMID: 29649764 DOI: 10.1016/j.psyneuen.2018.04.001] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2017] [Revised: 03/04/2018] [Accepted: 04/02/2018] [Indexed: 11/16/2022]
Abstract
CONTEXT The loss of progesterone during menopause is linked to sleep complaints of the affected women. Previously we demonstrated sleep promoting effects of oral progesterone replacement in postmenopausal women. The oral administration of progesterone, however, is compromised by individual differences in bioavailability and metabolism of the steroid. OBJECTIVE We compared the sleep-endocrine effects after intranasal progesterone (MPP22), zolpidem and placebo in healthy postmenopausal women. DESIGN This was a randomized double-blind cross-over study. SETTING German monocentric study PARTICIPANTS: Participants were 12 healthy postmenopausal women. INTERVENTIONS Subjects received in randomized order four treatments, 2 doses of intranasal progesterone (4.5 mg and 9 mg of MPP22), 10 mg of zolpidem and placebo. OUTCOME MEASURES Main outcome were conventional and quantitative sleep-EEG variables. Secondary outcomes were the subjective sleep variables and the sleep related concentrations of cortisol, growth hormone (GH), melatonin and progesterone. RESULTS Sleep promoting effects were found after the higher dosage of MPP22 and after zolpidem. Zolpidem prompted benzodiazepine-like effects on quantitative sleep EEG as expected, whereas no such changes were found after the two dosages of MP22. Nocturnal progesterone levels increased after 9.0 mg MPP22. No other changes of hormone secretion were found. CONCLUSIONS Our study shows sleep promoting effects after intranasal progesterone. The spectral signature of intranasal progesterone did not resemble the sleep-EEG alterations induced by GABA active compounds. Progesterone levels were elevated after 9.0 mg MPP22. No other endocrine effects were observed.
Collapse
Affiliation(s)
- P Schüssler
- Max Planck Institute of Psychiatry, Kraepelinstrasse 2-10, 80804 Munich, Germany; Department of Psychiatry, University of Regensburg, Regensburg, Germany
| | - M Kluge
- Max Planck Institute of Psychiatry, Kraepelinstrasse 2-10, 80804 Munich, Germany; Department of Psychiatry, University of Leipzig, Leipzig, Germany
| | - M Adamczyk
- Max Planck Institute of Psychiatry, Kraepelinstrasse 2-10, 80804 Munich, Germany
| | - M E Beitinger
- Max Planck Institute of Psychiatry, Kraepelinstrasse 2-10, 80804 Munich, Germany
| | - P Beitinger
- Max Planck Institute of Psychiatry, Kraepelinstrasse 2-10, 80804 Munich, Germany
| | - A Bleifuss
- Max Planck Institute of Psychiatry, Kraepelinstrasse 2-10, 80804 Munich, Germany
| | - S Cordeiro
- Max Planck Institute of Psychiatry, Kraepelinstrasse 2-10, 80804 Munich, Germany
| | - C Mattern
- M et P Pharma AG, 6376 Emmetten, Switzerland
| | - M Uhr
- Max Planck Institute of Psychiatry, Kraepelinstrasse 2-10, 80804 Munich, Germany
| | - T C Wetter
- Department of Psychiatry, University of Regensburg, Regensburg, Germany
| | - A Yassouridis
- Max Planck Institute of Psychiatry, Kraepelinstrasse 2-10, 80804 Munich, Germany
| | - R Rupprecht
- Department of Psychiatry, University of Regensburg, Regensburg, Germany
| | - E Friess
- Max Planck Institute of Psychiatry, Kraepelinstrasse 2-10, 80804 Munich, Germany
| | - A Steiger
- Max Planck Institute of Psychiatry, Kraepelinstrasse 2-10, 80804 Munich, Germany.
| |
Collapse
|
4
|
McKenna HT, Reiss IK, Martin DS. The significance of circadian rhythms and dysrhythmias in critical illness. J Intensive Care Soc 2017; 18:121-129. [PMID: 28979558 DOI: 10.1177/1751143717692603] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Many physiological and cellular processes cycle with time, with the period between one peak and the next being roughly equal to 24 h. These circadian rhythms underlie 'permissive homeostasis', whereby anticipation of periods of increased energy demand or stress may enhance the function of individual cells, organ systems or whole organisms. Many physiological variables related to survival during critical illness have a circadian rhythm, including the sleep/wake cycle, haemodynamic and respiratory indices, immunity and coagulation, but their clinical significance remains underappreciated. Critically ill patients suffer from circadian dysrhythmia, manifesting overtly as sleep disturbance and delirium, but with widespread covert effects on cellular and organ function. Environmental and pharmacological strategies that ameliorate or prevent circadian dysrhythmia have demonstrated clinical benefit. Harnessing these important biological phenomena to match metabolic supply to demand and bolster cell defenses at the apposite time may be a future therapeutic strategy in the intensive care unit.
Collapse
Affiliation(s)
- Helen T McKenna
- University College London Centre for Altitude Space and Extreme Environment Medicine, UCLH NIHR Biomedical Research Centre, Institute of Sport and Exercise Health, London, UK.,Critical Care Unit, The London Clinic, London, UK.,Intensive Care Unit, Royal Free Hospital, London, UK
| | - Irwin Km Reiss
- Division of Neonatology, Department of Paediatrics, Erasmus University Hospital, Rotterdam, the Netherlands
| | - Daniel S Martin
- University College London Centre for Altitude Space and Extreme Environment Medicine, UCLH NIHR Biomedical Research Centre, Institute of Sport and Exercise Health, London, UK.,Intensive Care Unit, Royal Free Hospital, London, UK.,University College London Division of Surgery and Interventional Science, Royal Free Hospital, London, UK
| |
Collapse
|
5
|
Abstract
OBJECTIVES Circadian rhythms are severely disrupted among the critically ill. These circadian arrhythmias impair mentation, immunity, autonomic function, endocrine activity, hormonal signaling, and ultimately healing. In this review, we present a modern model of circadian disruption among the critically ill, discuss causes of these circadian arrhythmias, review observational and intervention studies of the effects of circadian-rhythm-restoring factors on medical outcomes, and identify needed key trials of circadian interventions in the critically ill. DATA SOURCES MEDLINE, EMBASE, PsychINFO, Google Scholar through December 2014. STUDY SELECTION Articles relevant to circadian rhythms, melatonin, and light in the critically ill were selected. DATA EXTRACTION AND DATA SYNTHESIS Articles were synthesized for this review of circadian arrhythmia and the use of circadian-rhythm-restoring interventions among the critically ill. CONCLUSIONS Circadian disruption often demonstrates serial degradation: initially, the amplitude attenuates along with delayed circadian phase. With increasing acuity of illness, circadian rhythmicity may be lost entirely. Causes of chronodisruption may be environmental or internal to the patient. In particular, inadequate daytime illumination and nocturnal light pollution disrupt healthy circadian periodicity. Internal causes of circadian arrhythmia include critical illness itself and subjective experience of distress and pain. Observational studies of windowed rooms and real-time ambient lighting have found that physiologic light-dark patterns may support recovery from critical illness. Studies of early morning bright light or evening melatonin agonists have found improved rates of delirium, enhanced sleep, and lower arrhythmia prevalence. The current evidence base emphasizes that lighting and melatoninergic interventions deserve to be tested in full-scale trials.
Collapse
|
6
|
Abstract
Because of proven efficacy, reduced side effects, and less concern about addiction, non-benzodiazepine receptor agonists (non-BzRA) have become the most commonly prescribed hypnotic agents to treat onset and maintenance insomnia. First-line treatment is cognitive-behavioral therapy. When pharmacologic treatment is indicated, non-BzRA are first-line agents for the short-term and long-term management of transient and chronic insomnia related to adjustment, psychophysiologic, primary, and secondary causation. In this article, the benefits and risks of non-BzRA are reviewed, and the selection of a hypnotic agent is defined, based on efficacy, pharmacologic profile, and adverse events.
Collapse
Affiliation(s)
- Philip M Becker
- Department of Psychiatry, University of Texas Southwestern Medical Center at Dallas, Dallas, TX, USA; Sleep Medicine Associates of Texas, 5477 Glen Lakes Drive, Suite 100, Dallas, TX 75231, USA.
| | - Manya Somiah
- Sleep Medicine Associates of Texas, 5477 Glen Lakes Drive, Suite 100, Dallas, TX 75231, USA
| |
Collapse
|
7
|
Abstract
Benzodiazepine sedative-hypnotic drugs are widely used for the treatment of insomnia. Nevertheless, their adverse effects, such as next-day hangover, dependence and impairment of memory, make them unsuitable for long-term treatment. Melatonin has been used for improving sleep in patients with insomnia mainly because it does not cause hangover or show any addictive potential. However, there is a lack of consistency on its therapeutic value (partly because of its short half-life and the small quantities of melatonin employed). Thus, attention has been focused either on the development of more potent melatonin analogs with prolonged effects or on the design of slow release melatonin preparations. The MT(1) and MT(2) melatonergic receptor ramelteon was effective in increasing total sleep time and sleep efficiency, as well as in reducing sleep latency, in insomnia patients. The melatonergic antidepressant agomelatine, displaying potent MT(1) and MT(2) melatonergic agonism and relatively weak serotonin 5HT(2C) receptor antagonism, was found effective in the treatment of depressed patients. However, long-term safety studies are lacking for both melatonin agonists, particularly considering the pharmacological activity of their metabolites. In view of the higher binding affinities, longest half-life and relative higher potencies of the different melatonin agonists, studies using 2 or 3mg/day of melatonin are probably unsuitable to give appropriate comparison of the effects of the natural compound. Hence, clinical trials employing melatonin doses in the range of 50-100mg/day are warranted before the relative merits of the melatonin analogs versus melatonin can be settled.
Collapse
Affiliation(s)
- Daniel P Cardinali
- Departmento de Docencia e Investigación, Facultad de Ciencias Médicas, Pontificia Universidad Católica Argentina, Buenos Aires, Argentina.
| | | | | | | |
Collapse
|
8
|
Srinivasan V, Brzezinski A, Pandi-Perumal SR, Spence DW, Cardinali DP, Brown GM. Melatonin agonists in primary insomnia and depression-associated insomnia: are they superior to sedative-hypnotics? Prog Neuropsychopharmacol Biol Psychiatry 2011; 35:913-23. [PMID: 21453740 DOI: 10.1016/j.pnpbp.2011.03.013] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2010] [Revised: 03/22/2011] [Accepted: 03/22/2011] [Indexed: 01/20/2023]
Abstract
Current pharmacological treatment of insomnia involves the use of sedative-hypnotic benzodiazepine and non-benzodiazepine drugs. Although benzodiazepines improve sleep, their multiple adverse effects hamper their application. Adverse effects include impairment of memory and cognitive functions, next-day hangover and dependence. Non-benzodiazepines are effective for initiating sleep but are not as effective as benzodiazepines for improving sleep quality or efficiency. Furthermore, their prolonged use produces adverse effects similar to those observed with benzodiazepines. Inasmuch as insomnia may be associated with decreased nocturnal melatonin, administration of melatonin is a strategy that has been increasingly used for treating insomnia. Melatonin can be effective for improving sleep quality without the adverse effects associated with hypnotic-sedatives. Ramelteon, a synthetic analog of melatonin which has a longer half life and a stronger affinity for MT1 and MT2 melatonergic receptors, has been reportedly effective for initiating and improving sleep in both adult and elderly insomniacs without showing hangover, dependence, or cognitive impairment. Insomnia is also a major complaint among patients suffering from depressive disorders and is often aggravated by conventional antidepressants especially the specific serotonin reuptake inhibitors. The novel antidepressant agomelatine, a dual action agent with affinity for melatonin MT1 and MT2 receptors and 5-HT2c antagonistic properties, constitutes a new approach to the treatment of major depressive disorders. Agomelatine ameliorates the symptoms of depression and improves the quality and efficiency of sleep. Taken together, the evidence indicates that MT1/MT2 receptor agonists like ramelteon or agomelatine may be valuable pharmacological tools for insomnia and for depression-associated insomnia.
Collapse
Affiliation(s)
- Venkatramanujan Srinivasan
- Sri Sathya Sai Medical Educational and Research Foundation, Prsanthi Nilayam, Plot-40 Kovai Thirunagar, Coimbatore-641014, India
| | | | | | | | | | | |
Collapse
|