Human circadian melatonin rhythm phase delay during a fixed sleep-wake schedule interspersed with nights of sleep deprivation

The dark side of apnea: altered 24-hour melatonin secretion in obstructive sleep apnea (OSAS) is disease severity dependent

PURPOSE

Melatonin aids in the synchronization of the circadian rhythm to the external environment. Few studies have tried to elucidate the relationship between melatonin and obstructive sleep apnea syndrome (OSAS). These often include few patients, do not differentiate between OSAS severity and/or do not analyse a 24-h melatonin profile. This study set out to investigate disease severity dependent differences in 24-h salivary melatonin secretion of OSAS patients compared to a reference population in a retrospective design.

METHODS

24-h salivary melatonin profiles of 169 OSAS patients were analysed (55 light, 66 moderate, 48 severe) as well as 91 reference patients. Several aspects of the melatonin curve were analysed and stratified according to OSAS severity. Parameters included: dim light melatonin onset (DLMO), time of returning below DLMO (DLMOoff), peak melatonin concentration and time, and total melatonin exposure.

RESULTS

Significant effects were corrected for confounding by age and sex using linear regression. Our analysis shows that, compared to reference and in a disease dependent manner, OSAS patients have a significantly lower 24-h melatonin curve, lower melatonin peak concentration, lower total melatonin exposure and a smaller proportion of patients reach DLMO. The differences in peak melatonin production and total melatonin exposure were resistant to confounding by age and/or sex.

CONCLUSION

This study describes clear OSAS severity dependent abnormalities in melatonin production in OSAS patients, independent of sex and/or age. Future research should indicate whether oral melatonin supplementation has beneficial effects in OSAS patients with attenuated endogenous melatonin production.

Relationship between Circadian Phase Delay without Morning Light and Phase Advance by Bright Light Exposure the Following Morning

Humans have a circadian rhythm for which the period varies among individuals. In the present study, we investigated the amount of natural phase delay of circadian rhythms after spending a day under dim light (Day 1 to Day 2) and the amount of phase advance due to light exposure (8000 lx, 4100 K) the following morning (Day 2 to Day 3). The relationships of the phase shifts with the circadian phase, chronotype and sleep habits were also investigated. Dim light melatonin onset (DLMO) was investigated as a circadian phase marker on each day. In the 27 individuals used for the analysis, DLMO was delayed significantly (-0.24 ± 0.33 h, p < 0.01) from Day 1 to Day 2 and DLMO was advanced significantly (0.18 ± 0.36 h, p < 0.05) from Day 2 to Day 3. There was a significant correlation between phase shifts, with subjects who had a greater phase delay in the dim environment having a greater phase advance by light exposure (r = -0.43, p < 0.05). However, no significant correlations with circadian phase, chronotype or sleep habits were found. These phase shifts may reflect the stability of the phase, but do not account for an individual's chronotype-related indicators.

Sleep and circadian phenotype in people without cone-mediated vision: a case series of five CNGB3 and two CNGA3 patients

Light exposure entrains the circadian clock through the intrinsically photosensitive retinal ganglion cells, which sense light in addition to the cone and rod photoreceptors. In congenital achromatopsia (prevalence 1:30-50 000), the cone system is non-functional, resulting in severe light avoidance and photophobia at daytime light levels. How this condition affects circadian and neuroendocrine responses to light is not known. In this case series of genetically confirmed congenital achromatopsia patients (n = 7; age 30-72 years; 6 women, 1 male), we examined survey-assessed sleep/circadian phenotype, self-reported visual function, sensitivity to light and use of spectral filters that modify chronic light exposure. In all but one patient, we measured rest-activity cycles using actigraphy over 3 weeks and measured the melatonin phase angle of entrainment using the dim-light melatonin onset. Owing to their light sensitivity, congenital achromatopsia patients used filters to reduce retinal illumination. Thus, congenital achromatopsia patients experienced severely attenuated light exposure. In aggregate, we found a tendency to a late chronotype. We found regular rest-activity patterns in all patients and normal phase angles of entrainment in participants with a measurable dim-light melatonin onset. Our results reveal that a functional cone system and exposure to daytime light intensities are not necessary for regular behavioural and hormonal entrainment, even when survey-assessed sleep and circadian phenotype indicated a tendency for a late chronotype and sleep problems in our congenital achromatopsia cohort.

Seasonal variation in neurohormones, mood and sleep in patients with primary open angle glaucoma - implications of the ipRGC-system

Primary open angle glaucoma is associated with an increased risk of mood and sleep disorders. These adversities have been suggested to relate to a disrupted function of the intrinsically photosensitive retinal ganglion cells (ipRGCs). The ipRGCs are key components in the nonvisual photoreceptive system that mediates light effects on mood, sleep and circadian rhythm. We assessed the diurnal hormone levels, pupillary responses and mood and sleep under seasons with different photoperiods in 24 patients with glaucoma and 24 age- and sex-matched healthy controls to investigate responses to naturalistic seasonal changes in daylight. The patients had moderate-to-advanced glaucoma with substantial visual field defects and reductions in the ipRGC-mediated pupillary responses (p < .001). In winter, compared with summer, patients with glaucoma had higher daytime melatonin concentration (p < .001) and lower nighttime cortisol (p = .002). In winter, the daytime melatonin level was inversely correlated with the ipRGC-mediated pupillary responses in the control group (p = .04). In the control group, there were no significant changes in hormone levels between seasons or any correlations between neurohormone levels and the ipRGC-mediated responses. The two groups showed a similar response to season with lower depression scores in summer compared with winter. In between-group comparison, the nocturnal melatonin level (area under curve from 20:00 h to 08:00 h) in summer was lower in glaucoma compared with controls (p = .03). In winter, nocturnal cortisol (at 04:00 h) was lower (p = .004) and daytime cortisol (12:00 h and 16:00 h) was higher (p = .007) in glaucoma compared with controls. In conclusion, we found that patients with glaucoma displayed a seasonal variation in diurnal hormone levels that was not present in healthy controls. Such neurohormonal changes may contribute to the increased risk of mood and sleep disorders seen in patients with glaucoma.

Distinct feedback actions of behavioural arousal to the master circadian clock in nocturnal and diurnal mammals

The master clock in the suprachiasmatic nucleus (SCN) of the hypothalamus provides a temporal pattern of sleep and wake that - like many other behavioural and physiological rhythms - is oppositely phased in nocturnal and diurnal animals. The SCN primarily uses environmental light, perceived through the retina, to synchronize its endogenous circadian rhythms with the exact 24 h light/dark cycle of the outside world. The light responsiveness of the SCN is maximal during the night in both nocturnal and diurnal species. Behavioural arousal during the resting period not only perturbs sleep homeostasis, but also acts as a potent non-photic synchronizing cue. The feedback action of arousal on the SCN is mediated by processes involving several brain nuclei and neurotransmitters, which ultimately change the molecular functions of SCN pacemaker cells. Arousing stimuli during the sleeping period differentially affect the circadian system of nocturnal and diurnal species, as evidenced by the different circadian windows of sensitivity to behavioural arousal. In addition, arousing stimuli reduce and increase light resetting in nocturnal and diurnal species, respectively. It is important to address further question of circadian impairments associated with shift work and trans-meridian travel not only in the standard nocturnal laboratory animals but also in diurnal animal models.

Chronotherapies for Parkinson's disease

Parkinson's disease (PD) is the second-most common progressive neurodegenerative disorder. Although the clinical diagnosis of PD is still based on its cardinal motor dysfunctions, several non-motor symptoms (NMS) have been established as integral part of the disease. Unlike motor disorders, development of therapies against NMS are still challenging and remain a critical unmet clinical need. During the last decade, several studies have characterised the molecular, physiological and behavioural alterations of the circadian system in PD patients. As a consequence, and given the ubiquitous nature of circadian rhythms in the entire organism, the biological clock has emerged as a potential therapeutic target to ease suffering from both motor and NMS in PD patients. Here we discuss the emerging field of using bright light, physical exercise and melatonin as chronotherapeutic tools to alleviate motor disorders, sleep/wake alterations, anxiety and depression in PD patients. We also highlight the potential of these readily available therapies to improve the general quality of life and wellbeing of PD patients. Finally, we provide specific data- and mechanisms-driven recommendations that might help improve the therapeutic benefit of light and physical exercise in PD patients.

The influence of intermittent fasting on the circadian pattern of melatonin while controlling for caloric intake, energy expenditure, light exposure, and sleep schedules: A preliminary report

AIMS:

We hypothesized that if we control for food composition, caloric intake, light exposure, sleep schedule, and exercise, intermittent fasting would not influence the circadian pattern of melatonin. Therefore, we designed this study to assess the effect of intermittent fasting on the circadian pattern of melatonin.

METHODS:

Eight healthy volunteers with a mean age of 26.6 ± 4.9 years and body mass index of 23.7 ± 3.5 kg/m² reported to the Sleep Disorders Center (the laboratory) on four occasions: (1) adaptation, (2) 4 weeks before Ramadan while performing Islamic intermittent fasting for 1 week (fasting outside Ramadan [FOR]), (3) 1 week before Ramadan (nonfasting baseline [BL]), and (4) during the 2^nd week of Ramadan while fasting (Ramadan). The plasma levels of melatonin were measured using enzyme-linked immunoassays at 22:00, 02:00, 04:00, 06:00, and 11:00 h. The light exposure, meal composition, energy expenditure, and sleep schedules remained the same while the participants stayed at the laboratory.

RESULTS:

The melatonin levels followed the same circadian pattern during the three monitoring periods (BL, FOR, and Ramadan). The peak melatonin level was at 02:00 h and the trough level was at 11:00 h in all studied periods. Lower melatonin levels at 22:00 h were found during fasting compared to BL. Cosinor analysis revealed no significant changes in the acrophase of melatonin levels.

CONCLUSIONS:

In this preliminary report, under controlled conditions of light exposure, meal composition, energy expenditure, and sleep-wake schedules, intermittent fasting has no significant influence on the circadian pattern of melatonin.

Sleep-Wake Regulation and Its Impact on Working Memory Performance: The Role of Adenosine

The sleep-wake cycle is regulated by a fine-tuned interplay between sleep-homeostatic and circadian mechanisms. Compelling evidence suggests that adenosine plays an important role in mediating the increase of homeostatic sleep pressure during time spent awake and its decrease during sleep. Here, we summarize evidence that adenosinergic mechanisms regulate not only the dynamic of sleep pressure, but are also implicated in the interaction of homeostatic and circadian processes. We review how this interaction becomes evident at several levels, including electrophysiological data, neuroimaging studies and behavioral observations. Regarding complex human behavior, we particularly focus on sleep-wake regulatory influences on working memory performance and underlying brain activity, with a specific emphasis on the role of adenosine in this interplay. We conclude that a change in adenosinergic mechanisms, whether exogenous or endogenous, does not only impact on sleep-homeostatic processes, but also interferes with the circadian timing system.

How sleep and wakefulness influence circadian rhythmicity: effects of insufficient and mistimed sleep on the animal and human transcriptome

The mammalian circadian system is a multi-oscillator, hierarchically organised system where a central pacemaker synchronises behavioural, physiological and gene expression rhythms in peripheral tissues. Epidemiological studies show that disruption of this internal synchronisation by short sleep and shift work is associated with adverse health outcomes through mechanisms that remain to be elucidated. Here, we review recent animal and human studies demonstrating the profound effects of insufficient and mistimed sleep on the rhythms of gene expression in central and peripheral tissues. In mice, sleep restriction leads to an ~80% reduction in circadian transcripts in the brain and profound disruption of the liver transcriptome. In humans, sleep restriction leads to a 1.9% reduction in circadian transcripts in whole blood, and when sleep is displaced to the daytime, 97% of rhythmic genes become arrhythmic and one-third of all genes show changes in temporal expression profiles. These changes in mice and humans include a significant reduction in the circadian regulation of transcription and translation and core clock genes in the periphery, while at the same time rhythms within the suprachiasmatic nucleus are not disrupted. Although the physiological mediators of these sleep disruption effects on the transcriptome have not been established, altered food intake, changes in hormones such as cortisol, and changes in body and brain temperature may play important roles. Processes and molecular pathways associated with these disruptions include metabolism, immune function, inflammatory and stress responses, and point to the molecular mechanisms underlying the established adverse health outcomes associated with short sleep duration and shift work, such as metabolic syndrome and cancer.

Melatonin regulates the rhythmic migration of neutrophils in live zebrafish

The circadian clock plays a vital role in physiology and behavior such as the sleep-wake cycle and blood pressure and hormone levels. Immune responses also display circadian rhythmicity and particularly pineal melatonin contributes to immunological processes. Little attention, however, is given to mechanisms underlying rhythmic neutrophil responses to the injury. Here, we used a transgenic Tg(lyz:EGFP) zebrafish tail fin transection model to investigate whether the recruitment of neutrophils toward the injured site is regulated by the circadian clock. We found that migrating neutrophils display robust rhythmicity, peaking at darkness. Melatonin positively regulates rhythmic neutrophil migration, as evidenced that treatment with melatonin at low dosage can significantly enhance neutrophil recruitment toward the injured site, which is attenuated by luzindole treatment and in pinealectomized fish. Furthermore, using a transgenic zebrafish eyeball model, we observed that melatonin enhances secretion of two cytokines, TNF-α and IL-8, both of which markedly enhance neutrophil migration. Taken together, these results highlight a positive role of melatonin in rhythmic neutrophil migration and help obtain a better understanding of circadian regulation in immunology.

Validating and extending the three process model of alertness in airline operations

Sleepiness and fatigue are important risk factors in the transport sector and bio-mathematical sleepiness, sleep and fatigue modeling is increasingly becoming a valuable tool for assessing safety of work schedules and rosters in Fatigue Risk Management Systems (FRMS). The present study sought to validate the inner workings of one such model, Three Process Model (TPM), on aircrews and extend the model with functions to model jetlag and to directly assess the risk of any sleepiness level in any shift schedule or roster with and without knowledge of sleep timings. We collected sleep and sleepiness data from 136 aircrews in a real life situation by means of an application running on a handheld touch screen computer device (iPhone, iPod or iPad) and used the TPM to predict sleepiness with varying level of complexity of model equations and data. The results based on multilevel linear and non-linear mixed effects models showed that the TPM predictions correlated with observed ratings of sleepiness, but explorative analyses suggest that the default model can be improved and reduced to include only two-processes (S+C), with adjusted phases of the circadian process based on a single question of circadian type. We also extended the model with a function to model jetlag acclimatization and with estimates of individual differences including reference limits accounting for 50%, 75% and 90% of the population as well as functions for predicting the probability of any level of sleepiness for ecological assessment of absolute and relative risk of sleepiness in shift systems for safety applications.

Melatonin ameliorates cognitive impairment induced by sleep deprivation in rats: role of oxidative stress, BDNF and CaMKII

Sleep deprivation (SD) has been shown to induce oxidative stress which causes cognitive impairment. Melatonin, an endogenous potent antioxidant, protects neurons from oxidative stress in many disease models. The present study investigated the effect of melatonin against SD-induced cognitive impairment and attempted to define the possible mechanisms involved. SD was induced in rats using modified multiple platform model. Melatonin (15 mg/kg) was administered to the rats via intraperitoneal injection. The open field test and Morris water maze were used to evaluate cognitive ability. The cerebral cortex (CC) and hippocampus were dissected and homogenized. Nitric oxide (NO) and malondialdehyde (MDA) levels and the superoxide dismutase (SOD) enzyme activity of hippocampal and cortical tissues (10% wet weight per volume) were performed to determine the level of oxidative stress. The expression of brain-derived neurotrophic factor (BDNF) and calcium-calmodulin dependent kinase II (CaMKII) proteins in CC and hippocampus was assayed by means of immunohistochemistry. The results revealed that SD impairs cognitive ability, while melatonin treatment prevented these changes. In addition, melatonin reversed SD-induced changes in NO, MDA and SOD in both of the CC and hippocampus. The results of immunoreactivity showed that SD decreased gray values of BDNF and CaMKII in CC and hippocamal CA1, CA3 and dentate gyrus regions, whereas melatonin improved the gray values. In conclusion, our results suggest that melatonin prevents cognitive impairment induced by SD. The possible mechanism may be attributed to its ability to reduce oxidative stress and increase the levels of CaMKII and BDNF in CC and hippocampus.

Effect of sleep deprivation on rhythms of clock gene expression and melatonin in humans

This study investigated the impact of sleep deprivation on the human circadian system. Plasma melatonin and cortisol levels and leukocyte expression levels of 12 genes were examined over 48 h (sleep vs. no-sleep nights) in 12 young males (mean±SD: 23±5 yrs). During one night of total sleep deprivation, BMAL1 expression was suppressed, the heat shock gene HSPA1B expression was induced, and the amplitude of the melatonin rhythm increased, whereas other high-amplitude clock gene rhythms (e.g., PER1-3, REV-ERBα) remained unaffected. These data suggest that the core clock mechanism in peripheral oscillators is compromised during acute sleep deprivation.

Melatonin and its analogs in insomnia and depression

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.

Amplitude reduction and phase shifts of melatonin, cortisol and other circadian rhythms after a gradual advance of sleep and light exposure in humans

BACKGROUND

The phase and amplitude of rhythms in physiology and behavior are generated by circadian oscillators and entrained to the 24-h day by exposure to the light-dark cycle and feedback from the sleep-wake cycle. The extent to which the phase and amplitude of multiple rhythms are similarly affected during altered timing of light exposure and the sleep-wake cycle has not been fully characterized.

METHODOLOGY/PRINCIPAL FINDINGS

We assessed the phase and amplitude of the rhythms of melatonin, core body temperature, cortisol, alertness, performance and sleep after a perturbation of entrainment by a gradual advance of the sleep-wake schedule (10 h in 5 days) and associated light-dark cycle in 14 healthy men. The light-dark cycle consisted either of moderate intensity 'room' light (∼90-150 lux) or moderate light supplemented with bright light (∼10,000 lux) for 5 to 8 hours following sleep. After the advance of the sleep-wake schedule in moderate light, no significant advance of the melatonin rhythm was observed whereas, after bright light supplementation the phase advance was 8.1 h (SEM 0.7 h). Individual differences in phase shifts correlated across variables. The amplitude of the melatonin rhythm assessed under constant conditions was reduced after moderate light by 54% (17-94%) and after bright light by 52% (range 12-84%), as compared to the amplitude at baseline in the presence of a sleep-wake cycle. Individual differences in amplitude reduction of the melatonin rhythm correlated with the amplitude of body temperature, cortisol and alertness.

CONCLUSIONS/SIGNIFICANCE

Alterations in the timing of the sleep-wake cycle and associated bright or moderate light exposure can lead to changes in phase and reduction of circadian amplitude which are consistent across multiple variables but differ between individuals. These data have implications for our understanding of circadian organization and the negative health outcomes associated with shift-work, jet-lag and exposure to artificial light.

Relationship of morningness-eveningness questionnaire score to melatonin and sleep timing, body mass index and atypical depressive symptoms in peri- and post-menopausal women

Previous work shows a relationship between measures of morning or evening preference (e.g., morningness-eveningness questionnaire (MEQ) scores) and melatonin and sleep timing, body mass index (BMI) and mood. This study explores the relationship of these factors to atypical depression (ATD) symptoms, particularly increased appetite and hypersomnia, in depressed and non-depressed peri- and post-menopausal women. Participants were 19 normal control subjects and 10 depressed patients, 46-72 years of age. In a university hospital setting, we administered the MEQ and Structured Interview Guide for the Hamilton Depression Rating Scale, Seasonal Affective Disorders (SIGH-SAD version), which includes a measure of ATD, 3-5 weeks before obtaining nighttime polysomnography and overnight plasma melatonin in dim light (<30lx). Scores on SIGH-SAD appetite-related items were significantly correlated with MEQ, dim light melatonin onset (DLMO) time and midsleep time (MST); BMI was related to MST, sleep end time, phase-angle differences between sleep and melatonin timing, and appetite measures. Results suggest that relative to women with earlier DLMOs and MSTs, depressed peri- and post-menopausal women whose DLMOs and MSTs are phase-delayed may experience increases in appetite, hypersomnia, and BMI. These symptoms might be relieved by sleep or light manipulations that advance melatonin and sleep timing parameters.

Adaptation rate of 6-sulfatoxymelatonin and cognitive performance in offshore fleet shift workers: a field study

PURPOSE

To determine the total phase delay and adaptation rate of 6-sulfatoxymelatonin (aMT6s) on subjective and objective sleep quality and cognitive performance after 7 days of working night shifts (1800-0600 hours). The subjects studied were offshore fleet workers (N = 7).

METHODS

Seven days of urine samples were collected to determine the total phase delay and adaptation rate of aMT6s. Subjective and objective sleep quality was registered with sleep diaries and actigraphy on a daily basis. Cognitive performance, as measured by vigilance and reaction time, was measured with the Vienna test system on days 1 and 7. Light exposure was measured in the vessel compartments daily.

RESULTS

The rhythm of aMT6s shifted significantly from 4.78 +/- 0.94 h on day 1 to 8.84 +/- 1.76 h on day 7. Rate of adaptation was 0.84 h per day. Subjective sleep quality showed significant time effects on four variables, but objective sleep quality did not show any significant time effects. Vigilance and reaction time improved significantly from days 1 to 7. Light exposure intensities varied between 3 and 243 lux.

CONCLUSIONS

This field study showed that offshore fleet workers are able to adapt to the imposed regimen of 12-h night shifts. The adaptation is slower compared to other branches of the offshore industry, which most likely is due to lower light exposure. Subjective sleep quality improved to some extent, but the results were not conclusive. No significant effects were observed in the objective measures. Cognitive performance improved significantly, which was likely to be caused by the extended working hours on day 1 and an entrainment of the suprachiasmatic nuclei (SCN).

Phase angle of entrainment in morning- and evening-types under naturalistic conditions

Differences in morningness-eveningness among humans are commonly ascribed to circadian parameters, such as circadian period and responsivity to environmental time cues, as well as homeostatic sleep drive. Light is the primary synchronizer of the human biological clock, and if circadian differences exist between morning and evening types, they should have different phase angles of entrainment to the light/dark cycle; that is, morning and evening types should have different patterns of light exposure relative to endogenous circadian phase (ECP). When phase angle of entrainment is strictly defined as the relationship between a marker of ECP and the timing of light exposure, such differences have been demonstrated in the laboratory under controlled light/dark cycles and have recently been shown under conditions of spring and summer light exposure outside the laboratory, taking into account the variable intensity of light. Here, we report similar results from a large (n=66), diverse cohort of morning and evening types across the age span studied at all different times of the year. Differences between morning and evening types in light exposure relative to ECP, indicative of a difference in the phase angle of entrainment to the external light/dark cycle, were found. Specifically, evening types, compared to morning types, had a higher ratio of phase advancing to phase delaying by light. We interpret this as indicating a longer circadian period (tau) in evening types.

Melatonin Entrains Free‐running Blind People According to a Physiological Dose‐response Curve

The specific circadian role proposed for endogenous melatonin production was based on a study of sighted people who took low pharmacological doses (500 microg) of this chemical signal for the "biological night": the magnitude and direction of the induced phase shifts were dependent on what time of day exogenous melatonin was administered and were described by a phase-response curve that turned out to be the opposite of that for light. We now report that lower (physiological) doses of up to 300 microg can entrain (synchronize) free-running circadian rhythms of 10 totally blind subjects that would otherwise drift later each day. The resulting log-linear dose-response curve in the physiological range adds support for a circadian function of endogenous melatonin in humans. Efficacy of exogenous doses in the physiological range are of clinical significance for totally blind people who will need to take melatonin daily over their entire lifetimes in order to remain entrained to the 24 h day. Left untreated, their free-running endocrine, metabolic, behavioral, and sleep/wake cycles can be almost as burdensome as not having vision.

Ramelteon: a review of its therapeutic potential in sleep disorders

Ramelteon is a tricyclic synthetic analog of melatonin that acts specifically on MT(1) and MT(2) melatonin receptors. Ramelteon's half-life is longer than that of melatonin, being metabolized in the body to four main metabolites, M-I, M-II, M-III, and M-IV. M-II has an affinity to MT(1) and MT(2) of about one-tenth of the parent compound, but its concentration in the circulation exceeds that of ramelteon by more than an order of magnitude. Ramelteon is effective in decreasing latency to persistent sleep and increasing total sleep time in freely moving monkeys. A number of clinical studies have been undertaken to study the efficacy of ramelteon in subjects with chronic insomnia. In almost all of these studies, ramelteon, in various doses of 4, 8, or 16 mg most commonly, significantly reduced sleep latency and increased sleep duration. Its primary action in sleep promotion is not a generalized gamma-aminobutyric (GABA)-ergic central nervous system depression, but rather it acts as a melatonergic agonist in the suprachiasmatic nucleus (and at other central nervous system sites), from where downstream processes, including GABA-ergic effects, are controlled via the hypothalamic sleep switch. Unlike other commonly prescribed hypnotic drugs, ramelteon is not associated with next morning hangover effects or reductions in alertness, nor has it been shown to cause withdrawal symptoms. The adverse symptoms reported with ramelteon are mild. All long-term investigations that have been carried out support the conclusion that ramelteon is a well tolerated and effective drug for the treatment of insomnia.

Late, but not early, wake therapy reduces morning plasma melatonin: relationship to mood in Premenstrual Dysphoric Disorder

Wake therapy improves mood in Premenstrual Dysphoric Disorder (PMDD), a depressive disorder in DSM-IV. We tested the hypothesis that the therapeutic effect of wake therapy in PMDD is mediated by altering sleep phase with melatonin secretion. We measured plasma melatonin every 30 min (18:00-09:00 h) in 19 PMDD and 18 normal control (NC) women during mid-follicular (MF) and late luteal (LL) menstrual cycle phases, and during LL interventions with early wake therapy (EWT) (sleep 03:00-07:00 h)(control condition) vs. late wake therapy (LWT) (sleep 21:00-01:00 h)(active condition). Melatonin offset was delayed and duration was longer in the symptomatic LL vs. asymptomatic MF phase in both NC and PMDD subjects. LWT, but not EWT, advanced offset and shortened duration vs. the LL baseline, although they improved mood equally. Later baseline LL morning melatonin offset was associated with more depressed mood in PMDD patients, and longer melatonin duration in the MF phase predicted greater mood improvement following LWT. That LWT, but not EWT, advanced melatonin offset and shortened duration while they were equally effective in improving mood suggests that decreasing morning melatonin secretion is not necessary for the therapeutic effects of wake therapy in PMDD.

Melatonin reduces arousal and startle responsiveness without influencing startle habituation or affective startle modulation in young women

Melatonin has been suggested to affect human emotion, but conflicting evidence exists. Therefore, we tested the effect of a single dose of a 4 mg prolonged release formulation of melatonin on a biologically based model of emotional processing. Affective modulation of acoustic white noise startle (103 dB) by emotional slides selected from the International Affective Picture System (IAPS) was assessed in 16 healthy young women twice, in a double-blind, placebo-controlled, balanced cross-over design. Melatonin significantly reduced startle responsiveness, but did not impact affective startle modulation, nor startle habituation. Melatonin significantly reduced arousal ratings and induced a parasympathetically dominated heart rate variability pattern indicative of a non-aroused state. We conclude that melatonin reduces arousal and startle responsiveness. However, no evidence for a direct emotion-modulating effect of melatonin was found in this healthy cohort.

Plasma melatonin rhythms in young and older humans during sleep, sleep deprivation, and wake

STUDY OBJECTIVES

To determine the effects of sleep and sleep deprivation on plasma melatonin concentrations in humans and whether these effects are age-dependent.

DESIGN

At least 2 weeks of regular at-home, sleep/wake schedule followed by 3 baseline days in the laboratory and at least one constant routine (sleep deprivation).

SETTING

General Clinical Research Center (GCRC), Brigham and Women's Hospital, Boston, MA.

PARTICIPANTS

In Study 1, one group (<10 lux when awake) of 19 young men (18-30 y) plus a second group (<2 lux when awake) of 15 young men (20-28 y) and 10 young women (19-27 y); in Study 2, 90 young men (18-30 y), 18 older women (65-81 y), and 11 older men (64-75 y). All participants were in good health, as determined by medical and psychological screening.

INTERVENTIONS

One to three constant routines with interspersed inversion of the sleep/wake cycle in those with multiple constant routines.

MEASUREMENTS AND RESULTS

Examination of plasma melatonin concentrations and core body temperature. Study 1. There was a small, but significant effect of sleep deprivation of up to 50 hours on melatonin concentrations (increase of 9.81 +/- 3.73%, P <0.05, compared to normally timed melatonin). There was also an effect of circadian phase angle with the prior sleep episode, such that if melatonin onset occurred <8 hours after wake time, the amplitude was significantly lower (22.4% +/- 4.79%, P <0.001). Study 2. In comparing melatonin concentrations during sleep to the same hours during constant wakefulness, in young men, melatonin amplitude was 6.7% +/- 2.1% higher(P <0.001) during the sleep episode. In older men, melatonin amplitude was 37.0% +/- 12.5% lower (P <0.05) during the sleep episode and in older women, melatonin amplitude was non-significantly 10.9% +/- 8.38% lower (P = 0.13) during the sleep episode.

CONCLUSIONS

Both sleep and sleep deprivation likely influence melatonin amplitude, and the effect of sleep on melatonin appears to be age dependent.

Addition of a non-photic component to a light-based mathematical model of the human circadian pacemaker

Mathematical models have become vital to the study of many biological processes in humans due to the complexity of the physiological mechanisms underlying these processes and systems. While our current mathematical representation of the human circadian pacemaker has proven useful in many experimental situations, it uses as input only a direct effect of light on the circadian pacemaker. Although light (a photic stimulus) has been shown to be the primary synchronizer of the circadian pacemaker across a number of species, studies in both animals and humans have confirmed the existence of non-photic effects that also contribute to phase shifting and entrainment. We modified our light-based circadian mathematical model to reflect evidence from these studies that the sleep-wake cycle and/or associated behaviors have a non-photic effect on the circadian pacemaker. In our representation, the sleep-wake cycle and its associated behaviors provides a non-photic drive on the circadian pacemaker that acts both independently and concomitantly with light stimuli. Further experiments are required to validate fully our model and to understand the exact effect of the sleep-wake cycle as a non-photic stimulus for the human circadian pacemaker.

Melatonin and human chronobiology

With the development of accurate and sensitive assays for measuring melatonin in plasma and saliva, it has been possible to advance our understanding of human chronobiology. In particular, the dim light melatonin onset (DLMO) is expected to have an increasingly important role in the diagnosis of circadian phase disorders and their treatment with appropriately timed bright light exposure and/or low-dose melatonin administration. The phase angle difference (PAD) between DLMO and mid-sleep can be used as a marker for internal circadian alignment and may also be used to differentiate individuals who are phase advanced from those who are phase delayed (a long interval indicates the former and a short interval indicates the latter). To provide a corrective phase delay, light exposure should be scheduled in the evening and melatonin should be administered in the morning. To provide a corrective phase advance, light exposure should be scheduled in the morning and melatonin should be administered in the afternoon/evening. The study of patients with seasonal affective disorder (SAD), as well as individuals who are totally blind, has resulted in several findings of interest to basic scientists, as well as psychiatrists and sleep specialists.

Circadian uses of melatonin in humans

Melatonin in humans can be an independent or dependent variable. Measurement of endogenous melatonin levels under dim-light conditions, particularly the dim-light melatonin onset (DLMO), has received increasing attention among researchers, and for clinicians it may soon become a convenient test that can be done at home using saliva collections in the evening, without interfering with sleep. Melatonin, even at low physiological doses, can cause advances (shifts to an earlier time) or delays (shifts to a later time) depending on when it is administered on its phase-response curve (in most sighted people, these times are approximately in the p.m. and in the a.m., respectively). Although both bright light and melatonin can be used separately or together in the treatment of circadian phase disorders in sighted people-such as advanced and delayed sleep phase syndromes, jet lag, shift-work maladaptation, and winter depression (seasonal affective disorder, or SAD)-melatonin is the treatment of choice in totally blind people. These people provide a unique opportunity to study the human circadian system without the overwhelming effects of ocularly mediated light, thus permitting us to establish that all blind free-runners (BFRs) studied under high resolution appear to have phase-advancing and phase-delaying responses to as yet unidentified zeitgebers (time givers) that are usually too weak to result in entrainment.

Timing and consolidation of human sleep, wakefulness, and performance by a symphony of oscillators

Daily rhythms in sleep and waking performance are generated by the interplay of multiple external and internal oscillators. These include the light-dark and social cycles, a circadian hypothalamic oscillator oscillating virtually independently of behavior, and a homeostatic oscillator driven primarily by sleep-wake behavior. Both internal oscillators contribute to variation in many aspects of sleep and wakefulness (e.g., sleep timing and duration, REM sleep, non-REM sleep, REM density, sleep spindles, slow-wave sleep, electroencephalographic oscillations during wakefulness and sleep, and performance parameters, including attention and memory). The relative contribution of the oscillators varies greatly between these variables. Sleep and performance cannot be predicted by either oscillator independently but critically depend on their phase relationship and amplitude. The homeostatic oscillator feeds back onto the central pacemaker or its outputs. Thus, the amplitude of observed circadian variation in sleep and performance depends on how long we have been asleep or awake. During entrainment to external 24-h cycles, the opposing interplay between circadian and homeostatic changes in sleep propensity consolidates sleep and wakefulness. Some physiological correlates and mediators of both the circadian process (e.g., melatonin and hypocretin rhythms) and the homeostat (e.g., EEG, slow-wave activity, and adenosine release) have been established, offering targets for the development of countermeasures for circadian sleep and performance disorders. Interindividual differences in sleep timing, duration, and morning or evening preference are associated with changes of circadian or sleep homeostatic processes or both. Molecular genetic correlates, including polymorphisms in clock genes, of some of these interindividual differences are emerging.

Sleep deprivation

The occurrence of chronic sleep deprivation in the population is commonplace. Both duration and quality of sleep are important to assess when evaluating a patient who has sleep complaints. Excessive sleepiness and decreased psychomotor performance have been demonstrated after sleep deprivation. Sleep loss may impact mood, autonomic function, and the immune system. Sleep-deprived adults may have impaired job performance and are prone to motor vehicle accidents. Simple interventions to ensure adequate sleep can help avoid these hazards.

Circadian phase determined from melatonin profiles is reproducible after 1 wk in subjects who sleep later on weekends

The aim of this study was to determine whether circadian phase from salivary melatonin profiles is the same when measured in phase assessments 1 wk apart. Eleven healthy young men and women maintained a fixed, home sleep-wake schedule, in bed, in the dark 23:00-07:00 hr on weekdays. On Friday and Saturday nights they were permitted to wake up and go to bed up to 1 hr later, and on Saturdays and Sundays they could nap between 13:30 and 16:30 hr. The study was run in the summer. Subjects wore sunglasses when outside during the day, and went outside for at least 15 min between 08:00 and 09:00 hr each morning. They maintained this schedule for 15 days before the first assessment and the 6 days in between the two assessments. During the assessments subjects remained awake overnight in <5 lux and gave saliva samples every 30 min. A recovery nap (13:00-17:00 hr) followed the first session. The dim light melatonin onset (DLMO), offset (DLMOff) and midpoint were used as phase markers. There was minimal change in their timing between the two phase assessments. The average absolute change in midpoint (the change in phase regardless of direction) was 20 min. There was a small, 30 min delay in the DLMO. Thus, circadian phase can be measured a week in advance of any phase shifting intervention and, as long as the prescribed sleep and morning light schedule is maintained, the phase at the start of treatment can be confidently estimated.