Variations of rest – activity rhythm and sleep – wake in schizophrenic patients versus healthy subjects: An actigraphic comparative study

Interaction of the Melatonin/Ca2+-CaM Complex with Calmodulin Kinase II: Physiological Importance

Melatonin N-acetyl-5-methoxytriptamine is an ancient molecule which synchronizes the internal biologic activity with the environmental photoperiod. It is synthesized by the pineal gland during the night and released to the general circulation, where it reaches nanomolar concentrations. The indolamine acts through melatonin receptors and binds to different proteins such as calmodulin: a phylogenetically conserved protein which is the main transductor of the calcium signaling. In this review, we will describe evidence supporting that melatonin binds to calmodulin in presence of calcium, and we discuss the effects of this indolamine on the activity of calmodulin kinase II as an inhibitor and as stimulator of calmodulin-dependent protein kinase II activity. We also provide a literature review supporting the relevance of melatonin binding to calmodulin in the regulation of circadian rhythms in unicellular organisms, as well as in neuronal development in mammals as an ancient, conserved mechanism. Finally, we highlight the importance of antioxidant effects of melatonin on calmodulin preservation. SIGNIFICANCE STATEMENT: This review compiled evidence supporting that melatonin binds to calmodulin. We discuss the dual effect of melatonin on the activity of calmodulin kinase II, the possible mechanisms involved, and the relevance on regulation of circadian rhythms and neurodevelopment. Finally, we describe evidence supporting that the binding of melatonin to calmodulin hydrophobic pockets may prevent the oxidation of methionine species with a shielding effect that preserves the functionality of calmodulin.

The circadian system: A neglected player in neurodevelopmental disorders

Patients with neurodevelopmental disorders, such as autism spectrum disorder, often display abnormal circadian rhythms. The role of the circadian system in these disorders has gained considerable attention over the last decades. Yet, it remains largely unknown how these disruptions occur and to what extent they contribute to the disorders' development. In this review, we examine circadian system dysregulation as observed in patients and animal models of neurodevelopmental disorders. Second, we explore whether circadian rhythm disruptions constitute a risk factor for neurodevelopmental disorders from studies in humans and model organisms. Lastly, we focus on the impact of psychiatric medications on circadian rhythms and the potential benefits of chronotherapy. The literature reveals that patients with neurodevelopmental disorders display altered sleep-wake cycles and melatonin rhythms/levels in a heterogeneous manner, and model organisms used to study these disorders appear to support that circadian dysfunction may be an inherent characteristic of neurodevelopmental disorders. Furthermore, the pre-clinical and clinical evidence indicates that circadian disruption at the environmental and genetic levels may contribute to the behavioural changes observed in these disorders. Finally, studies suggest that psychiatric medications, particularly those prescribed for attention-deficit/hyperactivity disorder and schizophrenia, can have direct effects on the circadian system and that chronotherapy may be leveraged to offset some of these side effects. This review highlights that circadian system dysfunction is likely a core pathological feature of neurodevelopmental disorders and that further research is required to elucidate this relationship.

Shared and distinct abnormalities in sleep-wake patterns and their relationship with the negative symptoms of Schizophrenia Spectrum Disorder patients

Sleep and rest-activity-rhythm (RAR) abnormalities are commonly reported in schizophrenia spectrum disorder (SSD) patients. However, an in-depth characterization of sleep/RAR alterations in SSD, including patients in different treatment settings, and the relationship between these alterations and SSD clinical features (e.g., negative symptoms) is lacking. SSD (N = 137 altogether, N = 79 residential and N = 58 outpatients) and healthy control (HC) subjects (N = 113) were recruited for the DiAPAson project. Participants wore an ActiGraph for seven consecutive days to monitor habitual sleep-RAR patterns. Sleep/rest duration, activity (i.e., M10, calculated on the 10 most active hours), rhythm fragmentation within days (i.e., intra-daily variability, IV; beta, steepness of rest-active changes), and rhythm regularity across days (i.e., inter-daily stability, IS) were computed in each study participant. Negative symptoms were assessed in SSD patients with the Brief Negative Symptom Scale (BNSS). Both SSD groups showed lower M10 and longer sleep/rest duration vs. HC, while only residential patients had more fragmented and irregular rhythms than HC. Compared to outpatients, residential patients had lower M10 and higher beta, IV and IS. Furthermore, residential patients had worse BNSS scores relative to outpatients, and higher IS contributed to between-group differences in BNSS score severity. Altogether, residentials and outpatients SSD had both shared and unique abnormalities in Sleep/RAR measures vs. HC and relative to one another, which also contributed to the patients' negative symptom severity. Future work will help establish whether improving some of these measures may ameliorate the quality of life and clinical symptoms of SSD patients.

Effects of antipsychotics on circadian rhythms in humans: a systematic review and meta-analysis

Antipsychotics are widely used to treat psychiatric illness and insomnia. However, the etiology of insomnia is multifactorial, including disrupted circadian rhythms. Several studies show that antipsychotics might modulate even healthy circadian rhythms. The purpose of this systematic review is to integrate current knowledge about the effects of antipsychotics on the circadian rhythms in humans, and to conduct a meta- analysis with the available data. Nine electronic databases were searched. We followed the PRISMA guidelines and included randomized controlled trials (RCTs), non-RCTs, case-control studies, case series, and case reports. Of 7,217 articles, 70 were included. The available data was mainly from healthy individuals, or patients having schizophrenia, but the findings showed a transdiagnostic impact on circadian parameters. This was consistently seen as decreased amplitude of cortisol, melatonin, and body temperature. Particularly, a meta-analysis of 16 RCTs measuring cortisol rhythm showed that antipsychotics, especially atypical antipsychotics, decreased the cortisol area under the curve and morning cortisol level, compared to placebo. The data with melatonin or actigraphy was limited. Overall, this evidence about the circadian effect of antipsychotics showed a need for longitudinal, real-time monitoring of specific circadian markers to differentiate a change in amplitude from a shift in phasing, and for knowledge about optimal timing of administration of antipsychotics, according to individual baseline circadian parameters. Standardizing selection criteria and outcome methods could facilitate good quality intervention studies and evidence-based treatment guidelines. This is relevant considering the accumulating evidence of the high prevalence and unfavorable impact of disrupted circadian rhythms in psychiatric disorders.

Sleep and Circadian Rhythm Disturbance in Remitted Schizophrenia and Bipolar Disorder: A Systematic Review and Meta-analysis

BACKGROUND

Sleep and circadian rhythm disturbances in schizophrenia are common, but incompletely characterized. We aimed to describe and compare the magnitude and heterogeneity of sleep-circadian alterations in remitted schizophrenia and compare them with those in interepisode bipolar disorder.

METHODS

EMBASE, Medline, and PsycINFO were searched for case-control studies reporting actigraphic parameters in remitted schizophrenia or bipolar disorder. Standardized and absolute mean differences between patients and controls were quantified using Hedges' g, and patient-control differences in variability were quantified using the mean-scaled coefficient of variation ratio (CVR). A wald-type test compared effect sizes between disorders.

RESULTS

Thirty studies reporting on 967 patients and 803 controls were included. Compared with controls, both schizophrenia and bipolar groups had significantly longer total sleep time (mean difference [minutes] [95% confidence interval {CI}] = 99.9 [66.8, 133.1] and 31.1 [19.3, 42.9], respectively), time in bed (mean difference = 77.8 [13.7, 142.0] and 50.3 [20.3, 80.3]), but also greater sleep latency (16.5 [6.1, 27.0] and 2.6 [0.5, 4.6]) and reduced motor activity (standardized mean difference [95% CI] = -0.86 [-1.22, -0.51] and -0.75 [-1.20, -0.29]). Effect sizes were significantly greater in schizophrenia compared with the bipolar disorder group for total sleep time, sleep latency, and wake after sleep onset. CVR was significantly elevated in both diagnoses for total sleep time, time in bed, and relative amplitude.

CONCLUSIONS

In both disorders, longer overall sleep duration, but also disturbed initiation, continuity, and reduced motor activity were found. Common, modifiable factors may be associated with these sleep-circadian phenotypes and advocate for further development of transdiagnostic interventions that target them.

Risperidone Provides Better Improvement of Sleep Disturbances Than Haloperidol Therapy in Schizophrenia Patients With Cannabis-Positive Urinalysis

A high percentage of persons with Schizophrenia also uses Cannabis and this may potentially alter the therapeutic benefits of the antipsychotic medications prescribed. The aim of this study was to assess the impact of Cannabis usage on antipsychotic therapy of sleep disturbances in schizophrenia subjects. Male subjects, ≥18 years, admitted to the University Hospital of the West Indies psychiatric ward between October 2015 and October 2016, and diagnosed with schizophrenia were recruited for the study. Following written informed consent to the study, subjects were prescribed either risperidone monotherapy or haloperidol monotherapy orally for 14 days and classified as Cannabis users (CU) or non-users (non-CU), with presence/absence of Cannabis metabolite in urine samples. After 1 week of admission, subjects wore the Actiwatch-2 device, to record sleep data for 7 consecutive nights. Inferential statistical analysis involved non-parametric tests, expressed as median and inter-quartile ranges (IQR), with p<0.05 considered statistically significant. Fifty subjects were assessed, with a median (IQR) age of 28 (14) years. Majority (30; 60%) were CU, displaying longer sleep latency (SL) than non-CU when receiving haloperidol; but equivalent SL when receiving risperidone. In comparison to non-CU, the CU also displayed longer time in bed, but shorter durations asleep, awoke more frequently during the nights and for longer durations, whether receiving haloperidol or risperidone. This resulted in lower sleep efficiency for the CU (<85%) compared to the non-CU (≥85%). Over the study period, sleep efficiency was significantly improved for non-CU receiving either risperidone (p = 0.032) or haloperidol (p = 0.010); but was only significantly improved with risperidone for the CU (p = 0.045). It is apparent that the presence of Cannabis may be impacting the therapeutic benefits of antipsychotic drugs on sleep. In schizophrenia subjects with concomitant Cannabis use, risperidone is more beneficial than haloperidol in improving sleep efficiency.

A review of physiological and behavioral monitoring with digital sensors for neuropsychiatric illnesses

Physiological, behavioral, and psychological changes associated with neuropsychiatric illness are reflected in several related signals, including actigraphy, location, word sentiment, voice tone, social activity, heart rate, and responses to standardized questionnaires. These signals can be passively monitored using sensors in smartphones, wearable accelerometers, Holter monitors, and multimodal sensing approaches that fuse multiple data types. Connection of these devices to the internet has made large scale studies feasible and is enabling a revolution in neuropsychiatric monitoring. Currently, evaluation and diagnosis of neuropsychiatric disorders relies on clinical visits, which are infrequent and out of the context of a patient's home environment. Moreover, the demand for clinical care far exceeds the supply of providers. The growing prevalence of context-aware and physiologically relevant digital sensors in consumer technology could help address these challenges, enable objective indexing of patient severity, and inform rapid adjustment of treatment in real-time. Here we review recent studies utilizing such sensors in the context of neuropsychiatric illnesses including stress and depression, bipolar disorder, schizophrenia, post traumatic stress disorder, Alzheimer's disease, and Parkinson's disease.

Quantification of free-living activity patterns using accelerometry in adults with mental illness

Physical activity is disrupted in many psychiatric disorders. Advances in everyday technologies - such as accelerometers in smart phones - opens exciting possibilities for non-intrusive acquisition of activity data. Successful exploitation of this opportunity requires the validation of analytical methods that can capture the full movement spectrum. The study aim was to demonstrate an analytical approach to characterise accelerometer-derived activity patterns. Here, we use statistical methods to characterize accelerometer-derived activity patterns from a heterogeneous sample of 99 community-based adults with mental illnesses. Diagnoses were screened using the Mini International Neuropsychiatric Interview, and participants wore accelerometers for one week. We studied the relative ability of simple (exponential), complex (heavy-tailed), and composite models to explain patterns of activity and inactivity. Activity during wakefulness was a composite of brief random (exponential) movements and complex (heavy-tailed) processes, whereas movement during sleep lacked the heavy-tailed component. In contrast, inactivity followed a heavy-tailed process, lacking the random component. Activity patterns differed in nature between those with a diagnosis of bipolar disorder and a primary psychotic disorder. These results show the potential of complex models to quantify the rich nature of human movement captured by accelerometry during wake and sleep, and the interaction with diagnosis and health.

Clinical application of actigraphy in psychotic disorders: a systematic review

Actigraphy has become increasingly recognized as a useful method to study sleep/wake patterns and activity monitoring. It is a reliable tool for confirming a diagnosis and evaluating the effect of treatments for sleep problems in patients with primary psychiatric diagnoses such as schizophrenia. In addition, actigraphy is an objective measure that circumvents the lack of insight and often unreliable self-reporting of mental health related problems. However, the literature regarding the use of actigraphy in research and clinical applications related to severe psychiatric populations is scarce. Amalgamation of the evidence is needed to advance the use of actigraphy in psychiatry. We summarized the literature to date related to the use of actigraphy in patients with psychotic disorders, specifically schizophrenia. We conducted a systematic review of journal databases. Sixty-six studies emerged from the search of the electronic search engines, 14 were RCTs/case-control studies and 14 were review/guideline papers and others were case studies. Results of the RCT/case-control studies comparing the use of actigraphy with patients versus control were summarized. Actigraphy not only allows for the objective evaluation of sleep habits and circadian rhythm disorders, but also helps to clarify and compare sleep and activity patterns among severe psychiatric disorders such as schizophrenia. Additionally, actigraphy data can be used as an outcome measure for changes in sleep patterns either when primary psychotic disorders are treated and/or when the sleep disturbance associated with the psychotic disorder is treated. Finally, actigraphy serves as a supplementary tool to study neuropathology of movement-related psychiatric disorders including schizophrenia.

Misalignments of rest-activity rhythms in inpatients with schizophrenia

AIMS

Rest-activity rhythms of human beings generally synchronize to a 24-h time cue. Very few detailed research studies have examined rest-activity rhythms in patients with schizophrenia. The present study aimed to explore (i) rest-activity rhythms in patients with schizophrenia, and (ii) factors relevant to their rhythm characteristics.

METHODS

We selected only inpatients for this research, because the time cue for inpatients was considered more standardized than that of outpatients. Sixteen inpatients with schizophrenia wore an ActiTrac accelerometer-based activity monitor (IM Systems Inc., Baltimore, USA) for eight consecutive days to measure their activity. We used a chi(2) periodogram to compute rest-activity rhythms from the activity data, whereby the chi(2) value amplitude was regarded as an index of regularity. We conducted non-parametric tests to identify factors relevant to rhythm cycles and patterns.

RESULTS

Half of the participants exhibited prolonged rest-activity cycles, and 25% also had irregular rest-activity patterns defined by insufficient chi(2) value amplitude, even though they were clearly under a 24-h time cue. Participants with misaligned rest-activity rhythms had attended daytime non-medical treatment programs less frequently, and had received more anti-anxiety/hypnotic medications than those with proper rhythms.

CONCLUSION

Changes in rest-activity rhythms by optimizing pharmacological and non-pharmacological treatment could improve social adjustment or quality of life in patients with schizophrenia.

Ambulatory Activity Monitoring

Behavior is central to psychology in almost any definition. Although observable activity is a core aspect of behavior, assessment strategies have tended to focus on emotional, cognitive, or physiological responses. When physical activity is assessed, it is done so mostly with questionnaires. Converging evidence of only a moderate association between self-reports of physical activity and objectively measured physical activity does raise questions about the validity of these self-reports. Ambulatory activity monitoring, defined as the measurement strategy to assess physical activity, posture, and movement patterns continuously in everyday life, has made major advances over the last decade and has considerable potential for further application in the assessment of observable activity, a core aspect of behavior. With new piezoresistive sensors and advanced computer algorithms, the objective measurement of physical activity, posture, and movement is much more easily achieved and measurement precision has improved tremendously. With this overview, we introduce to the reader some recent developments in ambulatory activity monitoring. We will elucidate the discrepancies between objective and subjective reports of activity, outline recent methodological developments, and offer the reader a framework for developing insight into the state of the art in ambulatory activity-monitoring technology, discuss methodological aspects of time-based design and psychometric properties, and demonstrate recent applications. Although not yet main stream, ambulatory activity monitoring – especially in combination with the simultaneous assessment of emotions, mood, or physiological variables – provides a comprehensive methodology for psychology because of its suitability for explaining behavior in context.