A case series on the development of rest-activity rhythm and quality of sleep in patients hospitalized for treatment of uni- or bipolar depression: a potential role for quetiapine

Toward a Digital Future in Bipolar Disorder Assessment: A Systematic Review of Disruptions in the Rest-Activity Cycle as Measured by Actigraphy

BACKGROUND

Disruptions in rest and activity patterns are core features of bipolar disorder (BD). However, previous methods have been limited in fully characterizing the patterns. There is still a need to capture dysfunction in daily activity as well as rest patterns in order to more holistically understand the nature of 24-h rhythms in BD. Recent developments in the standardization, processing, and analyses of wearable digital actigraphy devices are advancing longitudinal investigation of rest-activity patterns in real time. The current systematic review aimed to summarize the literature on actigraphy measures of rest-activity patterns in BD to inform the future use of this technology.

METHODS

A comprehensive systematic review using PRISMA guidelines was conducted through PubMed, MEDLINE, PsycINFO, and EMBASE databases, for papers published up to February 2021. Relevant articles utilizing actigraphy measures were extracted and summarized. These papers contributed to three research areas addressed, pertaining to the nature of rest-activity patterns in BD, and the effects of therapeutic interventions on these patterns.

RESULTS

Seventy articles were included. BD was associated with longer sleep onset latency and duration, particularly during depressive episodes and with predictive value for worsening of future manic symptoms. Lower overall daily activity was also associated with BD, especially during depressive episodes, while more variable activity patterns within a day were seen in mania. A small number of studies linked these disruptions with differential patterns of brain functioning and cognitive impairments, as well as more adverse outcomes including increased suicide risk. The stabilizing effect of therapeutic options, including pharmacotherapies and chronotherapies, on activity patterns was supported.

CONCLUSION

The use of actigraphy provides valuable information about rest-activity patterns in BD. Although results suggest that variability in rhythms over time may be a specific feature of BD, definitive conclusions are limited by the small number of studies assessing longitudinal changes over days. Thus, there is an urgent need to extend this work to examine patterns of rhythmicity and regularity in BD. Actigraphy research holds great promise to identify a much-needed specific phenotypic marker for BD that will aid in the development of improved detection, treatment, and prevention options.

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.

Comparison of the Effects of Quetiapine XR and Lithium Monotherapy on Actigraphy-Measured Circadian Parameters in Patients With Bipolar II Depression

PURPOSE/BACKGROUND

The aim of this study was to evaluate the effects of quetiapine XR and lithium on actigraphy-measured circadian parameters in patients with bipolar II depression.

METHODS/PROCEDURES

This was an 8-week, open-label, prospective, randomized comparative study. The assessments included the 17-item Hamilton Depression Rating Scale score and actigraphic measures concerning the previous 7 days, collected at each visit (weeks 0 [baseline], 1, 2, 4, 6, and 8); the actigraphic data were analyzed with a cosinor analysis.

FINDINGS/RESULTS

Medication, time, and the interaction between medication and time were significantly associated with acrophase for the entire group (Ps = 0.003, 0.020, and 0.042, respectively). More specifically, acrophase was significantly delayed at weeks 1 and 6 (Ps = 0.004 and 0.039, respectively) in the quetiapine XR group. The F statistics significantly increased over time for the entire group (P < 0.001), and there was a significant increase in F statistics on weeks 4 and 6 in the quetiapine XR group (Ps = 0.016 and 0.020, respectively) and on weeks 4 and 8 in the lithium group (Ps = 0.001 and 0.016, respectively). In addition, scores on the 17-item Hamilton Depression Rating Scale were significantly associated with the F statistics during 8 weeks for the entire group (P = 0.008).

IMPLICATIONS/CONCLUSIONS

Both quetiapine XR and lithium affected several circadian parameters, including peak activity time and robustness of circadian rhythm, but exerted different effects on acrophase in patients with bipolar II depression. In particular, clinical depressive symptoms were associated with robustness of circadian rhythm during the course of the 8-week treatment.

Evidence-Based Design Features Improve Sleep Quality Among Psychiatric Inpatients

Objective:

The primary aim of the present study was to compare sleep characteristics pre- and post-move into a state-of-the-art mental health facility, which offered private sleeping quarters.

Background:

Significant evidence points toward sleep disruption among psychiatric inpatients. It is unclear, however, how environmental factors (e.g., dorm-style rooms) impact sleep quality in this population.

Methods:

To assess sleep quality, a novel objective technology, actigraphy, was used before and after a facility move. Subjective daily interviews were also administered, along with the Horne–Ostberg Morningness–Eveningness Questionnaire and the Pittsburgh Sleep Quality Index.

Results:

Actigraphy revealed significant improvements in objective sleep quality following the facility move. Interestingly, subjective report of sleep quality did not correlate with the objective measures. Circadian sleep type appeared to play a role in influencing subjective attitudes toward sleep quality.

Conclusions:

Built environment has a significant effect on the sleep quality of psychiatric inpatients. Given well-documented disruptions in sleep quality present among psychiatric patients undergoing hospitalization, design elements like single patient bedrooms are highly desirable.

Opportunities for clinical applications of rest-activity rhythms in detecting and preventing mood disorders

PURPOSE OF REVIEW

Rest-activity rhythm (RAR) measurements may aid in the detection of depression risk and serve as an important target for depression prevention. This review evaluates the strength of current evidence supporting these potential applications.

RECENT FINDINGS

Depression is associated with lower activity levels, that is less regularly patterned, and potentially shifted earlier or later in the day. Specific RAR patterns (combinations of several RAR characteristics) in patients with clinical depression may be unique or partially shared across disorders. Longitudinal research is limited but provides initial evidence that multiple distinct RAR patterns are associated with the risk of developing depression symptoms.

SUMMARY

RAR measures provide a comprehensive and objective assessment of depression's behavioral manifestations, and therefore may be useful as monitoring tool, providing additional information to help clinicians tailor behavioral treatments to specific patients. RARs also appear to contribute to depression risk and may be an important target for depression prevention. But research has not established valid predictive metrics using RARs to diagnose depression or detect depression risk. Future research should prioritize establishing the specific RAR patterns related to depression risk in high-risk groups, and should seek to place this risk within the known psychosocial and neurobiological risk architecture of depression.

Activity monitoring in patients with depression: a systematic review

BACKGROUND

Altered physical activity is an important feature of depression. It is manifested in psychomotor retardation, agitation and withdrawal from engagement in normal activities. Modern devices for activity monitoring (actigraphs) make it possible to monitor physical activity unobtrusively but the validity of actigraphy as an indicator of mood state is uncertain. We carried out a systematic review of digital actigraphy in patients with depression to investigate the associations between measured physical activity and depression.

METHODS

Systematic review and meta-analysis. Studies were identified from Medline, EMBASE and Psycinfo databases and included if they were either case control or longitudinal studies of actigraphy in adults aged between 18 and 65 diagnosed with a depressive disorder. Outcomes were daytime and night-time activity and actigraphic measures of sleep.

RESULTS

We identified 19 eligible papers from 16 studies (412 patients). Case control studies showed less daytime activity in patients with depression (standardised mean difference -0.76, 95% confidence intervals -1.05 to -0.47). Longitudinal studies showed moderate increase in daytime activity (0.53, 0.20 to 0.87) and a reduction in night-time activity (-0.36, -0.65 to -0.06) over the course of treatment.

LIMITATIONS

All study participants were unblinded. Only seven papers included patients treated in the community.

CONCLUSIONS

Actigraphy is a potentially valuable source of additional information about patients with depression. However, there are no clear guidelines for use of actigraphy in studies of patients with depression. Further studies should investigate patients treated in the community. Additional work to develop algorithms for differentiating behaviour patterns is also needed.

Epistemological and methodological significance of quantitative studies of psychomotor activity for the explanation of clinical depression

RATIONALE, AIMS AND OBJECTIVES

Psychomotor disturbances have been regarded as cardinal symptoms of depression for centuries and their objective assessment may have predictive value with respect to the severity of clinical depression, treatment outcome and prognosis of the affective disorder.

METHODS

Montgomery-Åsberg Depression Rating Scale (MADRS) and Hamilton Rating Scale for Anxiety (HAM-A). Psychomotor indicators of activity and reactivity were objectively recorded and measured by means of computerized ultrasonographic craniocorpography.

RESULTS

We found a statistically significant correlation between disturbances in psychomotor indicators and MADRS total score (r = 0.4; P < 0.0001). The severity of HAM-A total score had no statistically significant correlation with psychomotor indicators (P > 0.05). We found that different items of MADRS and HAM-A correlated with psychomotor disturbances of different strength and significance. Objectively, measured psychomotor retardation was associated with greater severity of depressive symptoms assessed at the clinical level.

CONCLUSIONS

Integration between different methods is needed in order to improve understanding of the psychopathology and the neurobiology of a disputable diagnosis such as clinical depression.