Effects of drugs on sleep

Comparative study of sleep and circadian rhythms in patients presenting unipolar or bipolar major depressive episodes

Currently, there is a major challenge in distinguishing between unipolar and bipolar major depressive episode. A significant body of research has been dedicated to identifying biomarkers that can aid in this differentiation due to its crucial implications, particularly for therapeutic and prognostic purposes. Among the biomarkers of interest, markers related to sleep and circadian rhythms show promise and could potentially aid in making this distinction. Nevertheless, no study has simultaneously examined sleep-wake disorders, circadian rhythms, and seasonal patterns using both subjective and objective measures. This study aims to characterize and compare the sleep-wake and rhythm disorders including patients with unipolar major depressive episode (n = 72) and with bipolar major depressive episode (n = 43) using both subjective markers (using self-report questionnaires and sleep complaints) and objective markers (using actigraphy). Patients with unipolar major depressive episode seem to experience significantly poorer quality of sleep, more symptoms of insomnia and lower sleep efficiency compared to patients with bipolar major depressive episode. On the other hand, patients with bipolar major depressive episode exhibit significantly more symptoms of motor retardation and hypersomnia compared to patients with unipolar disorder. These results hold significant implications for identifying individuals with unipolar major depressive episode or bipolar major depressive episode using sleep and circadian markers, and for developing recommended and personalized therapeutic strategies.

The relationship between sleep and appetitive conditioning: A systematic review and meta-analysis

This systematic review and meta-analysis (PROSPERO registration animal/human studies: CRD42021234793/CRD42021234790) examined the relationship between sleep and appetitive conditioning. Inclusion criteria included: a) appetitive conditioning paradigm; b) measure of conditioning; c) sleep measurement and/or sleep loss; d) human and/etor non-human animal samples; and e) written in English. Searches of seven databases returned 3777 publications. The final sample consisted of 42 studies using primarily animal samples and involving food- and drug-related conditioning tasks. We found sleep loss disrupted appetitive conditioning of food rewards (p < 0.001) but potentiated appetitive conditioning of drug rewards (p < 0.001). Furthermore, sleep loss negatively impacted extinction learning irrespective of the reward type. Post-learning sleep was associated with increases in REM sleep (p = 0.02). Findings suggest sleep loss potentiates the impact of psychoactive substances in a manner likely to produce an increased risk of problematic substance use. In obese/overweight populations, sleep loss may be associated with deficits in the conditioning and extinction of reward-related behaviours. Further research should assess the relationship between sleep and appetitive conditioning in humans.

Sleep and the Pharmacotherapy of Alcohol Use Disorder: Unfortunate Bedfellows. A Systematic Review With Meta-Analysis

Background: Sleep disorders are commonly associated with acute and chronic use of alcohol and with abstinence. To date, there are four approved drugs to treat alcohol use disorder (AUD): disulfiram, acamprosate, naltrexone, and nalmefene. These AUD therapies reduce the craving and risk of relapse into heavy drinking, but little is known about their effect on sleep. As recent evidences indicate a crucial role of sleep disorders in AUD, claiming that sleep problems may trigger alcohol abuse and relapses, it is fundamental to clarify the impact of those drugs on the sleep quality of AUD patients. This systematic review aims to answer the question: how does the pharmacotherapy for AUD affect sleep? Methods: We searched PubMed, Embase, CINAHL Plus, Cochrane, and Scopus using sleep- and AUD pharmacotherapy-related keywords. The articles included were appraised using the CASP checklists, and the risk of bias was assessed following the Cochrane risk-of-bias assessment tool. Finally, we pooled sleep outcomes in a meta-analysis to measure the overall effect. Results and Conclusion: We included 26 studies: only three studies focused on sleep as a main outcome, two with polysomnography (objective measurement), and one with subjective self-reported sleep, while all the other studies reported sleep problems among the adverse effects (subjective report). The only study available on disulfiram showed reduced REM sleep. Acamprosate showed no/little effect on self-reported sleep but improved sleep continuity and architecture measured by polysomnography. The two opioidergic drugs naltrexone and nalmefene had mainly detrimental effect on sleep, giving increased insomnia and/or somnolence compared with placebo, although not always significant. The meta-analysis confirmed significantly increased somnolence and insomnia in the naltrexone group, compared with the placebo. Overall, the currently available evidences show more sleep problems with the opioidergic drugs (especially naltrexone), while acamprosate seems to be well tolerated or even beneficial. Acamprosate might be a more suitable choice when patients with AUD report sleep problems. Due to the paucity of information available, and with the majority of results being subjective, more research on this topic is needed to further inform the clinical practice, ideally with more objective measurements such as polysomnography.

Evaluation of the Sleepy Patient: Differential Diagnosis

Excessive daytime sleepiness is defined as the inability to maintain wakefulness during waking hours, resulting in unintended lapses into sleep. It is important to distinguish sleepiness from fatigue. The evaluation of a sleep patient begins with a careful clinical assessment that includes a detailed sleep history, medical and psychiatric history, a review of medications, as well as a social and family history. Physical examination should include a general medical examination with careful attention to the upper airway and the neurologic examination. Appropriate objective testing with a polysomnogram and a multiple sleep latency test if needed will help confirm the diagnosis and direct the appropriate treatment plan.

Influence of lithium on sleep and chronotypes in remitted patients with bipolar disorder

BACKGROUND

Lithium (Li) is the first-line treatment for bipolar disorder (BD), but its mechanisms of action remain unknown. Although the chronobiological action of Li is well documented in animals, its effects on sleep and chronotypes in remitted BD patients have never been investigated.

METHODS

OPTHYMUM is a multicenter, cross-sectional, observational study conducted in France. We compared the sleep (Pittsburgh Sleep Quality Index, PSQI) and chronotypes (Composite Scale of Morningness, CSM) of 525 euthymic adult bipolar outpatients with (n=149) and without (n=376) current Li treatment. We used a general linear mixed-effects Poisson model to correct for age, gender, BD subtype, and mood symptoms.

RESULTS

In patients with BD type I, women taking Li had significantly lower PSQI (-23% [-37; -7]), but men did not (-4% [-20; +16]). Patients with BD I taking Li had better sleep efficiency (-40% [-61; -7]) and tended to better sleep duration scores (-42% [-68; +3]). A Li effect exists in women for both sleep duration and the use of night sedation (resp. -70% [-90; -10] and -37% [-60; +0.01]) but not in men (resp. -12% [-63;+113] and +9% [-31;+72]). No such associations were observed for BD II. No lithium effect was detected in the CSM score.

LIMITATIONS

No controls for other medications but no between-group differences for sedative or antidepressant intakes.

CONCLUSIONS

Euthymic BD I patients with Li have better sleep efficiency and longer sleep duration than those without Li. Women with Li have better sleep quality, longer sleep duration and less frequent use of night sedation.

Insomnia and its associations in patients with recurrent glial neoplasms

Background

Patient with neurological disorders and cancer can develop sleep disturbance, in particular insomnia. Etiology of insomnia is multi-factorial in primary brain tumour patients with possible causes including corticosteroids, psychoactive medications, co-morbid psychiatric/medical conditions, and damage to neuronal tissue.

Findings

To understand better insomnia in recurrent glioma patients, a single-center retrospective analysis was performed looking at recurrent glioma patients from January 2004 to May 2009. Data was extracted and included demographics, clinical factors, psychoactive medications, and co-morbid symptoms. Presence and absence of insomnia complaints was evaluated with other co-morbidities using Chi square and Wilcoxon analyses. Records from 340 recurrent glioma patients were evaluated and 46.8 % (n = 159) indicated presence of insomnia with 20 % (n = 66) actively using medications for sleep. Use of corticosteroids were significantly associated with insomnia (p = 0.0003). Age, gender, tumour location, use of stimulants, antipsychotics, and antidepressants were not significantly associated with insomnia in recurrent glioma patients. There was a trend towards a possible significant association with insomnia to fatigue complaints and use of anti-epileptics, p-values of 0.0501 and 0.0725 respectively.

Conclusions

In conclusion, insomnia is commonly encountered in patients with recurrent glial tumors. Corticosteroid use is associated with insomnia in this population. In light of the frequency of insomnia and its associations, future analysis is warranted into sleep complaints in recurrent glioma patients and its impact on quality of life.

Guidelines for the recording and evaluation of pharmaco-sleep studies in man: the International Pharmaco-EEG Society (IPEG)

The International Pharmaco-EEG Society (IPEG) presents guidelines summarising the requirements for the recording and computerised evaluation of pharmaco-sleep data in man. Over the past years, technical and data-processing methods have advanced steadily, thus enhancing data quality and expanding the palette of sleep assessment tools that can be used to investigate the activity of drugs on the central nervous system (CNS), determine the time course of effects and pharmacodynamic properties of novel therapeutics, hence enabling the study of the pharmacokinetic/pharmacodynamic relationship, and evaluate the CNS penetration or toxicity of compounds. However, despite the presence of robust guidelines on the scoring of polysomnography -recordings, a review of the literature reveals inconsistent -aspects in the operating procedures from one study to another. While this fact does not invalidate results, the lack of standardisation constitutes a regrettable shortcoming, especially in the context of drug development programmes. The present guidelines are intended to assist investigators, who are using pharmaco-sleep measures in clinical research, in an effort to provide clear and concise recommendations and thereby to standardise methodology and facilitate comparability of data across laboratories.

Divided dosing reduces prednisolone-induced hyperglycaemia and glycaemic variability: a randomized trial after kidney transplantation

BACKGROUND

Prednisolone is a major risk factor for hyperglycaemia and new-onset diabetes after transplantation. Uncontrolled observational data suggest that divided dosing may reduce requirements for hypoglycaemic agents. This study aims to compare the glycaemic effects of divided twice daily (BD) and once daily (QD) prednisolone.

METHODS

Twenty-two kidney transplant recipients without diabetes were randomized to BD or QD prednisolone. Three weeks post-transplant, a continuous glucose monitor (iPro2(®) Medtronic) was applied for 5 days with subjects continuing their initial prednisolone regimen (Days 1-2) before crossover to the alternative regimen. Mean glucose, peak glucose, nadir glucose, exposure to hyperglycaemia (glucose ≥7.8 mmol/L) and glycaemic variability were assessed.

RESULTS

The mean ± standard deviation (SD) age of subjects was 50 ± 10 years and 77% were male. Median (interquartile range) daily prednisolone dose was 25 (20, 25) mg. BD prednisolone was associated with decreased mean glucose (mean 7.9 ± 1.7 versus 8.1 ± 2.3 mmol/L, P < 0.001), peak glucose [median 10.4 (9.5, 11.4) versus 11.4 (10.3, 13.4) mmol/L, P< 0.001] and exposure to hyperglycaemia [median 25.5 (14.6, 30.3) versus 40.4 (33.2, 51.2) mmol/L/h, P = 0.003]. Median glucose peaked between 14:55-15.05 h with BD and 15:25-15:30 h with QD. Median glycaemic variability scores were decreased with BD: SD (1.1 versus 1.9, P < 0.001), mean amplitude of glycaemic excursion (1.5 versus 2.2, P = 0.001), continuous overlapping net glycaemic action-1 (CONGA-1; 1.0 versus 1.2, P = 0.039), CONGA-2 (1.2 versus 1.4, P = 0.008) and J-index (25 versus 31, P = 0.003).

CONCLUSIONS

Split prednisolone dosing reduces glycaemic variability and hyperglycaemia early post-kidney transplant.

'Ecstasy' and the use of sleep medications in a general community sample: a 4-year follow-up

AIMS

Animal models show that a single dose of 3,4-methylenedioxymethamhetamine (MDMA; 'ecstasy') can result in long-term disruption of sleep. We evaluated the relationship between ecstasy consumption and the use of sleep medications in humans after controlling for key factors.

DESIGN

The Personality and Total Health Through Life project uses a longitudinal cohort with follow-up every 4 years. This study reports data from waves 2 and 3.

SETTING

Participants were recruited from the electoral roll in the Australian Capital Territory and Queanbeyan, New South Wales, Australia.

PARTICIPANTS

Participants were aged 20-24 years at wave 1 (1999-2000).

MEASURES

The study collected self-reported data on ecstasy, meth/amphetamine, cannabis, alcohol, tobacco and use of sleeping medications (pharmaceutical or other substances). Depression was categorized using the Brief Patient Health Questionnaire (BPHQ). Other psychosocial measures included life-time traumas. We used generalized estimating equations to model outcomes.

FINDINGS

Ecstasy data were available from 2128 people at wave 2 and 1977 at wave 3: sleeping medication use was reported by 227 (10.7%) respondents at wave 2 and 239 (12.1%) at wave 3. Increased odds ratios (OR) for sleeping medication use was found for those with depression [OR = 1.88, 95% confidence interval (CI): 1.39, 2.53], women (OR = 1.44, 95% CI: 1.13, 1.84), and increased by 19% for each life-time trauma. Ecstasy use was not a significant predictor, but ≥monthly versus never meth/amphetamine use increased the odds (OR = 3.03, 95% CI 1.30, 7.03).

CONCLUSION

The use of ecstasy appears to be associated with the use of sleeping medications but this association can be accounted for by other factors.

Obstructive sleep apnea and severe mental illness: evolution and consequences

Sleep complaints are commonly encountered in psychiatric clinics. Underlying medical disorders or sleep disorders need to be identified and treated to optimize treatment of the mental illness. Excessive daytime sleepiness, which is the main symptom of obstructive sleep apnea (OSA), overlaps with those of many severe mental illnesses. Medication side effects or the disorder itself maybe account for daytime sleepiness but comorbid OSA is a possibility that should not be overlooked. The diagnosis of OSA is straightforward but treatment compliance is problematic in psychiatric patients. This article summarizes studies concerning comorbid OSA in patients with severe mental illness and includes suggestions for future investigations.

Dilemmas in chronic/persistent pain management

The burden of chronic/persistent pain is substantial for the patient and society as a whole. Although a variety of pharmacologic treatments are available, chronic/persistent pain remains inadequately treated. Many pharmacologic treatment options provide analgesic efficacy for 4 to 6 hours, requiring multiple doses for continuous pain relief. The inconvenience of multiple doses may prevent many patients from achieving adequate pain relief. Other limitations to the current pharmacologic treatment options include gastrointestinal effects, cardiovascular effects, and organ toxicity, as well as fear of abuse or addiction. The purpose of this review is to highlight the burden of chronic/persistent pain in today's society and discuss the limitations of short-acting pharmacologic therapies used in the treatment of chronic/persistent pain.

Dilemmas in chronic/persistent pain management

The burden of chronic/persistent pain is substantial for the patient and society as a whole. Although a variety of pharmacologic treatments are available, chronic/persistent pain remains inadequately treated. Many pharmacologic treatment options provide analgesic efficacy for 4 to 6 hours, requiring multiple doses for continuous pain relief. The inconvenience of multiple doses may prevent many patients from achieving adequate pain relief. Other limitations to the current pharmacologic treatment options include gastrointestinal effects, cardiovascular effects, and organ toxicity, as well as fear of abuse or addiction. The purpose of this review is to highlight the burden of chronic/persistent pain in today's society and discuss the limitations of short-acting pharmacologic therapies used in the treatment of chronic/persistent pain.

Insomnia in the elderly: cause, approach, and treatment

Insomnia is a prevalent problem in late life. Sleep problems in the elderly are often mistakenly considered a normal part of aging. Insomnia, the most common sleep disorder, is a subjective report of insufficient or nonrestorative sleep despite adequate opportunity to sleep. Despite the fact that more than 50% of elderly people have insomnia, it is typically undertreated, and nonpharmacologic interventions are underused by health care practitioners. This article will review the causes of insomnia in the elderly, the approach to patient evaluation, and the nonpharmacologic and pharmacologic treatment of insomnia.

Eszopiclone, a Nonbenzodiazepine Sedative-Hypnotic Agent for the Treatment of Transient and Chronic Insomnia

OBJECTIVE

This paper reviews the pharmacologic and pharmacokinetic properties, clinical efficacy, and safety profile of the nonbenzodiazepine cyclopyrrolone agent eszopiclone in the management of adult patients with insomnia.

METHODS

Recent studies, abstracts, reviews, and consensus statements published in English were identified through searches of MEDLINE (1966-December 2005), International Pharmaceutical Abstracts (1970 December 2005), and PharmaProjects (1990-December 2005) using the search terms eszopiclone, cyclopyrrolone, insomnia, nonbenzodiazepine, and zopiclone enantiomer. Selected information provided by the manufacturer of eszopiclone was included, as were all pertinent clinical trials.

RESULTS

Eszopiclone is rapidly absorbed after oral administration, with Tmax achieved within approximately 1 hour and a terminal-phase elimination half-life of approximately 6 hours. Approximately 52% to 59% of a dose is weakly bound to plasma protein. Eszopiclone is extensively metabolized by oxidation and demethylation. In vitro studies have indicated that the cytochrome P450 (CYP) isozymes CYP3A4 and CYP2E1 are involved in the biotransformation of eszopiclone; therefore, drugs that induce or inhibit these CYP isozymes may affect the metabolism of eszopiclone. Eszopiclone is excreted in the urine as racemic zopiclone at <10% of the orally administered dose. Six Phase III clinical trials were identified that evaluated the safety profile and efficacy of eszopiclone, 1 in healthy subjects with transient insomnia and 5 in patients with primary chronic insomnia (3 in younger adults and 2 in the elderly). In the trials in younger adults, eszopiclone significantly improved sleep efficiency, sleep latency, wake time after sleep onset, number of awakenings, number of nights awakened weekly, total sleep time, and quality and depth of sleep compared with placebo (P<0.05). In the trials in elderly patients, who received eszopiclone 2 mg or placebo for 2 weeks, eszopiclone was associated with significantly shorter sleep latency compared with placebo (P<0.004), as well as a significant decrease in the cumulative number of naps (P<0.05). The most commonly reported drug-related, dose-responsive adverse event in clinical trials of eszopiclone 2 and 3 mg was bitter taste (17% and 34%, respectively), followed by dizziness (5% and 7%) and dry mouth (5% and 7%). Somnolence occurred at an incidence of 4% to 9% with both doses. Tolerance or rebound insomnia was not reported.

CONCLUSIONS

Eszopiclone represents an effective and well-tolerated option for the treatment of insomnia. In the absence of published studies comparing eszopiclone with similar hypnotic agents (eg, zolpidem, zaleplon, zopiclone), it is not yet possible to evaluate its efficacy relative to other agents used for insomnia.

Sleep and sedation in the pediatric intensive care unit

Sleep is an important and necessary function of the human body. Somatic growth and cellular repair occur during sleep. Critically ill children have disturbed sleep while in the pediatric intensive care unit related both to the illness itself and to light, noise, and caregiver activities disrupting an environment conducive to sleep. Medications administered in the pediatric intensive care unit can also disrupt sleep. This article reviews what is known about sleep in the pediatric intensive care unit and the effects of common sedation medications on sleep.

Long-term treatment of sleep breathing disorder in a patient with Huntington's disease

Huntington's disease (HD) is an autosomal dominant neurodegenerative disorder. An association with sleep breathing disorder has not previously been established in the literature. We report the case of a 45-year-old woman with HD, presenting with snoring and observed apnea. Polysomnography showed obstructive sleep apnea with an apnea-hypopnea index (AHI) of 6.6 per hour including events up to 57 s long during rapid eye movement (REM) sleep. A trial of continuous positive airway pressure (CPAP) resulted in significant improvement in sleep structure, nocturnal respiration, daytime alertness, and subjective memory. Snoring, apneas, and respiratory arousals were abolished on CPAP. HD patients may suffer from sleep breathing disorder, and in spite of potential chorea, CPAP is feasible and may significantly improve their quality of life.

Somnambulism (sleepwalking)

Somnambulism is an arousal parasomnia consisting of a series of complex behaviours that result in large movements in bed or walking during sleep. It occurs in 2-14% of children and 1.6-2.4% of adults. Occasional benign episodes are managed conservatively. However, recurrent sleepwalking with a risk of injury to self or others mandates immediate treatment with pharmacotherapy while awaiting work-up. The most commonly used medications are benzodiazepines, particularly clonazepam, with tricyclic antidepressants and serotonin selective re-uptake inhibitors also administered. Treatment of underlying causes such as obstructive sleep apnoea, upper airway resistance syndrome, restless legs syndrome and periodic limb movements, is currently the best approach and usually eliminates somnambulism in children and adults.

Sleep monitoring in children during neuromuscular blockade in the pediatric intensive care unit: a pilot study

BACKGROUND

Sleep is an important physiologic process that is known to be disrupted in the intensive care unit. Nevertheless, there is little information on how intensive care unit admission affects sleep in children. Because laryngotracheoplasty is elective but entails 5-7 days of neuromuscular blockade following surgery, children undergoing this procedure present a unique opportunity to analyze sleep during neuromuscular blockade apart from confounding variables resulting from critical illness.

OBJECTIVE

To determine the feasibility of using polysomnography to assess sleep patterns in children during neuromuscular blockade.

METHODS

Polysomnography recordings were obtained continuously for 4 days (96 hrs) in two children following laryngotracheoplasty. Medication administration (neuromuscular blockades, sedatives) and time of suctioning were also recorded.

RESULTS

Both subjects had documented sleep. However, the proportion of time in each stage was markedly different from developmental norms, and a greater proportion of sleep occurred during the day. Furthermore, there was substantial day-night and day-to-day variability. Some rebound of consolidated sleep appeared by day 4. Sedative use varied considerably. However, neither bolus sedation administration nor endotracheal suctioning appeared to affect sleep. Few monitoring difficulties were encountered.

CONCLUSIONS

Sleep can be monitored with minimal difficulty in children undergoing neuromuscular blockade in the pediatric intensive care unit. Sleep occurred throughout the day, and there was considerable fragmentation. To fully assess sleep in the intensive care unit, monitoring needs to be continuous over several days, rather than only at night or for < or =24 hrs. Further research is needed in the area to determine typical sleep patterns in children undergoing neuromuscular blockade.

Valerian Use for Sleep Disturbances Related to Rheumatoid Arthritis

Complementary therapies are becoming increasingly popular, particularly for symptoms such as sleep disturbance. The herb valerian may be useful as a mild sleep aid in clinical populations, such as persons with rheumatoid arthritis. This article reviews valerian to inform healthcare providers of potential uses and safety considerations.

Analyzing Sleep Abnormalities in HIV‐Infected Patients Treated with Efavirenz

Ambulatory electroencephalogram monitoring was performed for 18 HIV-infected subjects treated with efavirenz with and without insomnia and for 13 healthy control subjects. All patients receiving efavirenz had longer sleep latencies and shorter duration of deep sleep, although poor sleepers also showed reduced sleep efficiency and shorter duration of rapid eye movement sleep. Efavirenz plasma levels were higher in patients with insomnia and/or reduced sleep efficiency.

Effects of antiepileptic drugs on sleep structure : are all drugs equal?

Good-quality sleep is an important and frequently overlooked component of general health, but it is particularly essential to patients with epilepsy. Their sleep can be affected by seizures, concurrent sleep disorders and seizure treatment. Worsening sleep can result not only in poor daytime functioning but also potentially in worsening epilepsy. The effects of antiepileptic drugs (AEDs) on sleep are of particular concern. Some agents have detrimental effects on sleep, particularly benzodiazepines and barbiturates but also phenytoin and, possibly, carbamazepine. Others, especially gabapentin, seem to actually improve sleep quality. Much research in this area is confounded by the effects of seizures and concurrent conditions on sleep, making it difficult to isolate the direct effects of AEDs on sleep. But because AEDs have independent effects on sleep quality, the choice of an appropriate agent not only determines whether seizures are completely controlled but also whether the patient performs optimally on a daily basis.

Comprehensive assessment of insomnia in recovering alcoholics using daily sleep diaries and ambulatory monitoring

BACKGROUND

Many alcoholics continue to experience disrupted sleep after quitting drinking. Previous studies with recovering alcoholics have relied on retrospective questionnaires and a single night of polysomnography to document sleep problems. In the present study, sleep was assessed at home over the course of a week using both subjective and objective sleep measures.

METHODS

A mixed gender group of alcoholics in recovery (n = 63) experiencing insomnia underwent a multimodal sleep assessment including a structured interview, daily sleep diaries, questionnaires, and ambulatory sleep monitoring. Alcoholics with short-term (<12 months) and long-term (>12 months) abstinence had their sleep monitored prospectively and were compared.

RESULTS

Over half of the participants reported sleep problems that predated the onset of alcohol dependence. Alcoholics with short- and long-term abstinence had similarly disturbed sleep. Overall, problems with getting to sleep were worse than sleep maintenance difficulties. Severity of insomnia was unrelated to drinking history and modestly correlated with the current level of depressive symptoms. Poor sleep hygiene was evident in the sample.

CONCLUSIONS

Alcoholics can experience sleep problems for many months after quitting drinking. Implications for sleep interventions with this population are discussed.

REM sleep effects as a biomarker for the effects of antidepressants in healthy volunteers

The potential use of rapid eye movement (REM) sleep effects as a biomarker for the therapeutic effects of antidepressants in healthy volunteers is reviewed. A literature search was performed to select studies investigating the effects of antidepressants on REM sleep. To assess the specificity of REM sleep effects as a biomarker, the effects of other central nervous system drugs on REM sleep were also investigated. A significant REM sleep reduction was shown for 16 of 21 investigated antidepressants after single-dose (mean reduction 34.1%) and for 11/13 drugs after multiple-dose administration (mean reduction 29.2%). The median increase in REM latency was approximatety 60% after single- or multiple-dose administration. REM sleep effects were linearly normalized to therapeutic doses, by dividing the REM sleep effect by the investigated dose and multiplying by the therapeutic dose. Normalized REM sleep effects were highly variable (range -27.0% to 81.8% for REM sleep; range -17.0% to 266.3% for REM latency) and demonstrated no relationship with relevant pharmacological properties of the investigated drugs. No quantifiable dose-response relationship could be constructed after single and multiple dose administration. REM sleep effects were not specific for antidepressants. Benzodiazepines, for example, caused an average dose normalized REM sleep reduction of 8.7% and a median 8.6% increase of REM latency. This review demonstrates that although REM sleep effects occur with most of the antidepressants, it is by itself of limited value as a biomarker for antidepressant action. The specificity for antidepressants is limited, and it does not show a quantitative dose-response relationship to antidepressant agents. This is at least partly due to the complex relationships between drug pharmacokinetics and the variable time course of REM and other sleep stages throughout the night. Models that take these complex relationships into account may provide more comprehensive and quantifiable results.

Gender differences in excessive daytime sleepiness among Japanese workers

Excessive daytime sleepiness (EDS) is serious concern in the workplace with respect to errors, accidents, absenteeism, reduced productivity and impaired personal or professional life. Previous community studies found a female preponderance of EDS, however, there is little research on EDS and gender in occupational settings. We examined the gender differences in prevalence and risk factors of EDS among employees working at a telecommunications company in the Tokyo metropolitan area. Our outcome measure of EDS was the Epworth Sleepiness Scale (ESS). A self-administered questionnaire on health and sleep including ESS was distributed to 5,571 workers between December 1999 and January 2000, and 5,072 responses were returned (91.0%). A total of 4,722 full-time, non-manual and non-shift employees aged 20-59 were used for analysis (3,909 men and 813 women). Chi-squared tests and multiple logistic regression analyses were applied for examining the gender differences in the prevalence and risk factors of EDS. The prevalence rates of EDS were 13.3% for women and 7.2% for men (P<0.001). We identified that deprived nocturnal sleep, an irregular sleep-wake schedule and depression were the risk factors of EDS for both genders, and being married worked as a protective factor against EDS for men alone. It is obvious that a ban on overtime work and a provision of mental health hygiene are the general strategies for reducing EDS at worksites. In the case of women, we suggest the formation of effective strategies for improving women's status at home and in the workplace must also be a solution for the prevention of EDS (e.g. promoting gender equality in the division of labor at home and strengthening family care policies for working women).

Enhancement of REM sleep during extraocular light exposure in humans

This study examined the effects on sleep of light administered to an extraocular site. A 3-h photic stimulus was applied to the popliteal region during sleep in 14 human subjects. Each subject also underwent a control stimulus condition during a separate laboratory session. The proportion of rapid eye movement (REM) sleep during the 3-h light administration session increased by an average of 31% relative to the control condition. The frequency but not the duration of REM episodes was altered during light exposure, thereby shortening the REM/non-REM (NREM) cycle length. No other sleep stages were significantly affected during light administration nor was sleep architecture altered after the light-exposure interval. These results confirm that extraocular light is transduced into a signal that is received and processed by the human central nervous system. In addition, they expand to a novel sensory modality previous findings that REM sleep can be enhanced by sensory stimulation.

The Importance of Residual Effects When Choosing a Hypnotic: The Unique Profile of Zaleplon

BACKGROUND: Insomnia is a prevalent medical disorder that has significant effects on occupational performance, health, and quality of life. Insomnia places an enormous burden on society through increased visits to physicians, loss of productivity in the workplace, and an increased rate of accidents. An estimated sum of $100 million is spent each year on direct treatment of unresolved insomnia. Physicians need to initiate early effective treatment to prevent development of chronic insomnia and its associated morbidity. Institution of good sleep hygiene practices may be useful in some patients but may not be adequate for resolution of all sleep problems. Behavioral treatments, while effective and durable, are time consuming and not widely utilized in clinical practice. Pharmacotherapy includes benzodiazepine hypnotics, but concerns regarding adverse effects (e.g., residual sedation) prompted the search for safer options. DATA SOURCES: Published and presented studies containing clinical data on zaleplon, a new nonbenzodiazepine sleep medication, were identified via MEDLINE, Current Contents (ISI database), bibliographic reviews, and consultation with sleep specialists. RESULTS: Zaleplon effectively shortens sleep onset time and improves the quality of sleep in patients with insomnia. Whether administered at bedtime or later at night, zaleplon is devoid of residual sedative effects that impair next-day functioning. Follow-up studies evaluating the long-term efficacy and safety of zaleplon showed that decreased time to sleep onset was maintained during therapy lasting up to 52 weeks, without a withdrawal syndrome after discontinuation. CONCLUSION: Insomnia is recurrent and unpredictable in nature. Despite the long-term morbidity of this sleep disorder, research evidence and practice guidelines have not explored long-term use of hypnotics. Many patients could benefit from long-term drug therapy with a sleep medication that is devoid of residual effects and can be taken at bedtime or later as symptoms occur, rather than nightly in anticipation of a sleep problem.

Interactions between sleep and epilepsy

Sleep is one of the best-documented factors influencing the expression of seizures and interictal discharges. Janz studied the relation between seizures and the sleep/wake cycle and divided the epilepsies into three categories: nocturnal, awakening, and diffuse. Since then, the effect of sleep on the ictal and interictal manifestations of epilepsy has been studied extensively. Many seizures are activated by sleep or arousal from sleep. Interictal discharges are also seen more commonly during sleep, with the greatest activation seen during nonrapid eye movement sleep. Sleep not only increases the frequency of epileptiform abnormalities, but also may alter their morphology and distribution. Sleep deprivation also facilitates both epileptiform abnormalities and seizures. Seizures, on the other hand, also impact sleep. Epileptic patients demonstrate multiple sleep abnormalities, including an increased sleep latency, fragmented sleep, increased awakenings and stage shifts, and an increase in stages 1 and 2 of nonrapid eye movement sleep. These disturbances may in turn be modulated by antiepileptic treatment. This review summarizes the interactions between sleep and epilepsy, including the timing of seizures during the sleep/wake cycle, the influence of sleep on various seizure disorders, the effects of sleep deprivation, and the changes in sleep patterns caused by seizures and their treatment.

Depressive symptoms and cigarette smoking predict development and persistence of sleep problems in US adolescents

OBJECTIVE

To evaluate factors related to the development and persistence of adolescent sleep problems.

METHODS

In this longitudinal, population-based study, the Teenage Attitudes and Practices Survey was administered by telephone to 7960 adolescents (3921 girls and 4039 boys) 12 to 18 years old in 1989 and at follow-up in 1993. Sleep problems at both time points were assessed using a single item on the Teenage Attitudes and Practices Survey. Those who responded that they "often or sometimes" had trouble going to sleep or staying asleep during the past 12 months were categorized as reporting sleep problems, whereas those who responded "often" were categorized as having frequent sleep problems. Multiple logistic regression analyses were used to identify baseline characteristics predictive of the development and persistence of sleep problems or frequent sleep problems, respectively, from baseline to follow-up.

RESULTS

Of the 4866 adolescents without sleep problems at baseline, 28% developed sleep problems by 1993, and 9% developed frequent sleep problems. Of the 3094 adolescents who reported sleep problems at baseline, 52% reported sleep problems in 1993, and 21% reported frequent sleep problems. Female sex and notable depressive symptoms were associated with the development and persistence of sleep problems and frequent sleep problems at follow-up. Cigarette smoking status showed a dose-response relationship with development of sleep problems and frequent sleep problems, and with persistence of frequent sleep problems at follow-up.

CONCLUSION

The reduction of depressive symptoms and cigarette smoking among adolescents are important factors to consider in prevention and treatment efforts focused on adolescent sleep problems.

What is causing excessive daytime sleepiness? Evaluation to distinguish sleep deprivation from sleep disorders

Many people have a temporary spell, often in early afternoon, when they feel drowsy. This passing desire for a quick nap is completely different from excessive daytime sleepiness, which is a much more significant problem. Considering the potentially dire personal and economic consequences of falling asleep unintentionally or at inappropriate times, excessive daytime sleepiness must be taken very seriously. A thorough evaluation, as described by Dr. Mahowald, virtually always leads to a specific underlying cause, allowing effective treatment recommendations.

Management of insomnia

OBJECTIVE

To review current issues in the pharmacologic and nonpharmacologic management of insomnia.

DATA SOURCES

Controlled trials and case studies identified via MEDLINE for 1990 through April 1999 under the search terms insomnia, hypnotics, flurazepam, quazepam, estazolam, temazepam, triazolam, zolpidem, zaleplon, L-846, CL-284,846, melatonin, and valerian.

DATA SYNTHESIS

Insomnia is a common, undertreated disorder. Nonpharmacologic management strategies (e.g., stimulus control, relaxation therapy, sleep hygiene) are therapeutic options that, compared with medication use, provide more sustained effects. The benzodiazepines and zolpidem are the most commonly prescribed hypnotic agents, but their use is associated with tolerance and central nervous system adverse effects. A new nonbenzodiazepine hypnotic agent, zaleplon, was very recently approved in the United States. Because of its short half-life, zaleplon will be useful in patients experiencing difficulty in falling asleep and in those who wake up at night and have trouble falling back to sleep. Antidepressants, antihistamines, and alternative medications are other treatment options. To avoid complications of therapy, hypnotic agents should be used at their lowest possible doses and for limited treatment durations.

CONCLUSION

Pharmacotherapy is currently the most common treatment modality for insomnia, but long-term use of hypnotic agents can become complicated by drug tolerance, dependence, or rebound insomnia. Nonpharmacologic options--including combinations of behavioral interventions, sleep-restriction therapy, and patient education--provide longer-lasting benefits.

Adjuncts to analgesia. Sedation and neuromuscular blockade

This article provides an overview of some of the current issues involved in sedation and anxiolysis in the intensive care unit. The problems involved in trying to monitor sedation levels are discussed, as are some of the newer options available for physiologic monitoring of the central nervous system. The problem of abnormal mental states in the intensive care unit and the range of antidepressant therapy now available are also covered. The importance of sleep deprivation and the properties of the neuromuscular blockers are also discussed.

Sleep disorders presenting as psychiatric disorders

In summary, disordered sleep can present in a complex and atypical fashion in which the primary sleep-related component may not be immediately apparent. A high index of suspicion serves the clinician well in these cases. A careful and systematic evaluation of sleep often proves to be rewarding in terms of diagnostic accuracy and improved treatment outcome.