Mesoridazine and human sleep

G-protein coupled receptors and synaptic plasticity in sleep deprivation

Insufficient sleep has been correlated to many physiological and psychoneurological disorders. Over the years, our understanding of the state of sleep has transcended from an inactive period of rest to a more active state involving important cellular and molecular processes. In addition, during sleep, electrophysiological changes also occur in pathways in specific regions of the mammalian central nervous system (CNS). Activity mediated synaptic plasticity in the CNS can lead to long-term and sometimes permanent strengthening and/or weakening synaptic strength affecting neuronal network behaviour. Memory consolidation and learning that take place during sleep cycles, can be affected by changes in synaptic plasticity during sleep disturbances. G-protein coupled receptors (GPCRs), with their versatile structural and functional attributes, can regulate synaptic plasticity in CNS and hence, may be potentially affected in sleep deprived conditions. In this review, we aim to discuss important functional changes that can take place in the CNS during sleep and sleep deprivation and how changes in GPCRs can lead to potential problems with therapeutics with pharmacological interventions.

Antipsychotic Withdrawal Symptoms: A Systematic Review and Meta-Analysis

OBJECTIVE

Avoiding withdrawal symptoms following antipsychotic discontinuation is an important factor when planning a safe therapy. We performed a systematic review and meta-analysis concerning occurrence of withdrawal symptoms after discontinuation of antipsychotics.

DATA SOURCES

We searched the databases CENTRAL, Pubmed, and EMBASE with no restriction to the beginning of the searched time period and until October 1, 2019 (PROSPERO registration no. CRD42019119148).

STUDY SELECTION

Of the 18,043 screened studies, controlled and cohort trials that assessed withdrawal symptoms after discontinuation of oral antipsychotics were included in the random-effects model. Studies that did not implement placebo substitution were excluded from analyses. The primary outcome was the proportion of individuals with withdrawal symptoms after antipsychotic discontinuation. We compared a control group with continued antipsychotic treatment in the assessment of odds ratio and number needed to harm (NNH).

DATA EXTRACTION

We followed guidelines by the Cochrane Collaboration, PRISMA, and MOOSE.

RESULTS

Five studies with a total of 261 individuals were included. The primary outcome, proportion of individuals with withdrawal symptoms after antipsychotic discontinuation, was 0.53 (95% CI, 0.37-0.70; I² = 82.98%, P < 0.01). An odds ratio of 7.97 (95% CI, 2.39-26.58; I² = 82.7%, P = 0.003) and NNH of 3 was calculated for the occurrence of withdrawal symptoms after antipsychotic discontinuation.

CONCLUSION

Withdrawal symptoms appear to occur frequently after abrupt discontinuation of an oral antipsychotic. The lack of randomized controlled trials with low risk of bias on antipsychotic withdrawal symptoms highlights the need for further research.

Antipsychotic discontinuation syndromes: a narrative review of the evidence and its integration into Australian mental health nursing textbooks

In light of the high number of people discontinuing antipsychotics each year, it is essential that nurses develop a robust understanding of all aspects of the discontinuation experience. While there is a large body of published work documenting post-discontinuation relapse rates, less is known about other aspects of the discontinuation experience. This paper presents the results of a narrative review of international studies of antipsychotic discontinuation syndromes and their relevance to nursing practice. Four key mental health nursing textbooks used in student nurse education in Australia are examined to assess how this evidence has been incorporated into clinical recommendations. This review finds that the evidence for discontinuation syndromes could be more widely disseminated and applied than it is at present. Strikingly, this evidence has not been incorporated into key mental health nursing textbooks in Australia at all. Slow integration into nursing published work may be influenced by a number of clinical and research uncertainties. We consider the impact of this silence on key nursing roles of psycho-education and adverse event monitoring during antipsychotic discontinuation periods. Further robust research should be conducted into discontinuation syndromes as a matter of urgency. Given the high number of consumers potentially impacted upon by discontinuation syndromes, nurse authors and educators should consider revising key nursing textbooks to include the currently available information about discontinuation syndromes.

Sleep disturbances in patients with schizophrenia : impact and effect of antipsychotics

Difficulties initiating or maintaining sleep are frequently encountered in patients with schizophrenia. Disturbed sleep can be found in 30-80% of schizophrenic patients, depending on the degree of psychotic symptomatology. Measured by polysomnography, reduced sleep efficiency and total sleep time, as well as increased sleep latency, are found in most patients with schizophrenia and appear to be an important part of the pathophysiology of this disorder. Some studies also reported alterations of stage 2 sleep, slow-wave sleep (SWS) and rapid eye movement (REM) sleep variables, i.e. reduced REM latency and REM density. A number of sleep parameters, such as the amount of SWS and the REM latency, are significantly correlated to clinical variables, including severity of illness, positive symptoms, negative symptoms, outcome, neurocognitive impairment and brain structure.Concerning specific sleep disorders, there is some evidence that schizophrenic patients carry a higher risk of experiencing a sleep-related breathing disorder, especially those demonstrating the known risk factors, including being overweight but also long-term use of antipsychotics. However, it is still unclear whether periodic leg movements in sleep or restless legs syndrome (RLS) are found with a higher or lower prevalence in schizophrenic patients than in healthy controls.There are no consistent effects of first-generation antipsychotics on measures of sleep continuity and sleep structure, including the percentage of sleep stages or sleep and REM latency in healthy controls. In contrast to first-generation antipsychotics, the studied atypical antipsychotics (clozapine, olanzapine, quetiapine, risperidone, ziprasidone and paliperidone) demonstrate a relatively consistent effect on measures of sleep continuity, with an increase in either total sleep time (TST) or sleep efficiency, and individually varying effects on other sleep parameters, such as an increase in REM latency observed for olanzapine, quetiapine and ziprasidone, and an increase in SWS documented for olanzapine and ziprasidone in healthy subjects.The treatment of schizophrenic patients with first-generation antipsychotics is consistently associated with an increase in TST and sleep efficiency, and mostly an increase in REM latency, whereas the influence on specific sleep stages is more variable. On the other hand, withdrawal of such treatment is followed by a change in sleep structure mainly in the opposite direction, indicating a deterioration of sleep quality. On the background of the rather inconsistent effects of first-generation antipsychotics observed in healthy subjects, it appears possible that the high-potency drugs exert their effects on sleep in schizophrenic patients, for the most part, in an indirect way by suppressing stressful psychotic symptomatology. In contrast, the available data concerning second-generation antipsychotics (clozapine, olanzapine, risperidone and paliperidone) demonstrate a relatively consistent effect on measures of sleep continuity in patients and healthy subjects, with an increase in TST and sleep efficiency or a decrease in wakefulness. Additionally, clozapine and olanzapine demonstrate comparable influences on other sleep variables, such as SWS or REM density, in controls and schizophrenic patients. Possibly, the effects of second-generation antipsychotics observed on sleep in healthy subjects and schizophrenic patients might involve the action of these drugs on symptomatology, such as depression, cognitive impairment, and negative and positive symptoms.Specific sleep disorders, such as RLS, sleep-related breathing disorders, night-eating syndrome, somnambulism and rhythm disorders have been described as possible adverse effects of antipsychotics and should be considered in the differential diagnosis of disturbed or unrestful sleep in this population.

Subjective assessment of the effects of CNS-active drugs on sleep by the Leeds sleep evaluation questionnaire: a review

The Leeds sleep evaluation questionnaire (LSEQ) comprises ten self-rating 100 mm line analogue questions concerned with sleep and early morning behaviour. A literature search identified 83 studies in peer-reviewed journals that reported the use of the LSEQ for psychopharmacological investigations of drug effects on self-reported aspects of sleep. High internal consistency and reliability of the questionnaire have been demonstrated. Findings from studies involving a variety of psychoactive agents indicated that the LSEQ was able to quantify subjective impressions of sleep and waking and the effects of drugs in healthy volunteers, depressed and insomnia patients. In accordance with their known activity profile nocturnal administration of sedative hypnotic agents and antihistamines induced dose-related improvements in self-reported ease of getting to sleep, and quality of sleep but a decrease in alertness and behavioural integrity the following morning. Psychostimulants, on the other hand, impaired subjective ratings of sleep and increased early morning alertness. Antidepressants and certain anxiolytic agents improved both self-reported sleep aspects and early morning alertness. Treatment effects measured by the LSEQ corresponded to those measured for the same drugs by other assessment methods. These data indicate that the LSEQ is a robust and reliable instrument for psychopharmacological evaluations. Self-evaluations of sleep, as obtained by the LSEQ, can therefore provide consistent and meaningful measures for estimating the effectiveness of sleep modulators and sedative-hypnotic drugs.

A longitudinal study of EEG sleep in schizophrenia

Several abnormalities in sleep architecture have been described in schizophrenia. However, the question of whether sleep electroencephalographic (EEG) changes are influenced by treatment and phase of illness remains unclear. To examine the longitudinal stability of sleep data, we compared baseline sleep measures with measures obtained approximately 4 weeks and 1 year after the beginning of treatment in a series of schizophrenic patients. At the 4-week assessment, sleep continuity measures improved significantly; a modest increase in rapid eye movement (REM) latency was seen, but no other changes were found in sleep architecture. At the 1-year assessment, REM latency, REM time, and average automated REM counts increased. No significant changes were seen for slow-wave sleep (SWS) parameters at 1-year follow-up. These findings suggest that SWS parameters are relatively stable during follow-up, while REM parameters seem to change, perhaps in relation to phase of illness and treatment. SWS alterations may, at least in part, reflect more invariant, perhaps trait-related alterations in schizophrenia.

Effect of neuroleptic treatment on polysomnographic measures in schizophrenia

To study the effects of neuroleptic therapy on sleep EEG variables in schizophrenia, as well as the clinical correlates of these variables, we performed polysomnographic (PSG) studies on 14 schizophrenic inpatients before and during neuroleptic therapy. Sleep continuity measures improved after 3 weeks of neuroleptic therapy, showing decreased sleep latency and improved sleep efficiency. REM latency increased with treatment, although half the patients continued to exhibit REM latencies less than 60 min. Other sleep stages and measures of REM sleep (density, activity, number of periods) did not appear to change with neuroleptic treatment. At baseline, REM latency had strong negative correlations with BPRS and SANS scores, but with 3 weeks of such treatment, this association disappeared. Further work is needed to distinguish direct medication effects from the effects of the changing clinical state on PSG measures.

The dopamine D1 receptor is involved in the regulation of REM sleep in the rat

The dopamine D1 receptor agonist, SKF 38393, and the D1 antagonist, SCH 23390, were studied for their effects on sleep in the rat. Over 6 h, SKF 38393 (0.1-10 mg/kg s.c.) dose dependently reduced the amount of rapid eye movement (REM) sleep and enhanced the duration of wakefulness. The drug affected REM at low doses (ED50 = 0.4 mg/kg) at which wakefulness was unchanged and the characteristic grooming behavior was not apparent. REM changes were characterized by a decrease in the number of episodes with no alteration of latency to the first episode. Over a very low dose range (0.003-0.3 mg/kg s.c.), SCH 23390 enhanced the amount of REM by increasing both number and average duration of episodes. There was also a moderate increase of non-REM sleep but the percent change was less marked than that occurring for REM. Given at 0.003 mg/kg, SCH 23390 prevented the REM changes induced by SKF 38393 (0.3-3 mg/kg). It is suggested that D1 receptors are involved in the regulation of the REM sleep process.

Alterations in sleep polygraphy after neuroleptic withdrawal: a putative supersensitive dopaminergic mechanism

Although a number of studies have reported sleep disturbances following neuroleptic withdrawal, a full description of such changes in sleep architecture is not available. Polysomnographic, plasma prolactin, and clinical measurements were carried out in a small number of patients on chronic neuroleptic treatment and after drug withdrawal. Preliminary findings show that in these chronically treated schizophrenic patients with and without tardive dyskinesia (TD), abrupt neuroleptic withdrawal induces reductions in total sleep, rapid eye movement (REM) sleep, and plasma prolactin. Furthermore, an increase in delta sleep was observed only in patients without TD. The REM suppression occurred significantly earlier in TD patients compared to the non-TD schizophrenic patients. These changes were transient, and both sleep measures and plasma prolactin stabilized during the 2-4 weeks after withdrawal to levels somewhere between the values observed during chronic treatment and withdrawal (week 1) periods. As the withdrawal-induced exaggerated changes mimicked the dopamine agonist effect on these sleep and hormonal measures, one can hypothesize that the observed changes are due to unmasking of supersensitive dopamine receptors following drug cessation. Normalization of these receptors and/or adaptational changes in other nondopaminergic system(s) can hypothetically explain the eventual stabilization of these measures during the following weeks.

Agitation in the elderly: an often-treatable manifestation of acute brain syndrome

Agitation in elderly patients is often caused by acute cerebral failure, more commonly called acute brain syndrome, delirium, or acute confusional state. Defects in cognition, sleep-waking cycles, and psychomotor behavior result. Careful history taking, physical examination, and laboratory testing may reveal a specific, reversible organic factor related to the acute brain syndrome. This article outlines the clues to recognizing agitation due to a cerebral failure and gives guidelines for workup and management.

The Leeds Sleep Evaluation Questionnaire in psychopharmacological investigations - a review

The Leeds Sleep Evaluation Questionnaire comprises ten self-rating 100-mm-line analogue questions concerned with aspects of sleep and early morning behaviour. The questionnaire has been used to monitor subjectively perceived changes in sleep during psychopharmacological investigations involving a variety of psychoactive agents, including sedative-hypnotics, antidepressants, anxiolytics, CNS stimulants, and antihistamines. Dose-related improvements in the self-reported ratings of getting to sleep and perceived quality of sleep were generally associated with reductions in the self-reported levels of alertness and behavioural integrity the morning following the nocturnal administration of sedative hypnotic and anti-anxiety agents. Psychostimulants on the other hand, impaired subjective ratings of sleep and produced increases in early morning assessments of alertness. Certain antidepressant and antihistaminic agents produced effects similar to the sedative-hypnotics, while others did not affect self-reported aspects of sleep and early morning behaviour.