Sleep pathologies in depression and the clinical utility of polysomnography

Sleep architecture and the incidence of depressive symptoms in middle-aged and older adults: A community-based study

BACKGROUND

Rapid eye movement (REM) sleep and three stages of non-REM (NREM) sleep comprise the full sleep cycle. The changes in sleep have been linked to depression risk. This study aimed to explore the association between sleep architecture and depressive symptoms.

METHODS

A total of 3247 participants from the Sleep Heart Health Study (SHHS) were included in this cohort study. REM and NREM sleep were monitored by in-home polysomnography at SHHS visit 1. Depressive symptoms was reported as the first occurrence between SHHS visits 1 and 2 (mean follow-up of 5.3 years). Multivariable logistic regression was used to investigate the relationship between sleep stages and depressive symptoms.

RESULTS

In total, 225 cases of depressive symptoms (6.9 %) were observed between SHHS visits 1 and 2. A significant linear association between NREM Stage 1 and depressive symptoms was found after adjusting for potential covariates. Multivariable logistic regression analysis showed that percentage in NREM Stage 1 was associated with the incidence of depressive symptoms (odds ratio [OR], 1.06; 95 % confidence interval [CI], 1.02-1.10; P = 0.001), as were time in NREM Stage 1 and depressive symptoms (OR, 1.02; 95 % CI, 1.01-1.03; P = 0.001). However, no significant association with depressive symptoms was found for other sleep stage.

LIMITATIONS

The specific follow-up time for depressive symptoms diagnosis was missing.

CONCLUSIONS

Increased time or percentage in NREM Stage 1 was associated with a higher risk of developing depressive symptoms. The early change in sleep architecture were important for incidence of depressive symptoms and warrants constant concerns.

Inflammatory hypotheses of sleep disturbance - depression link: Update and research agenda

Studies in human and experimental animal models support a role of inflammation in the aetiology of depression, yet the precise role played by sleep disturbance (i.e., difficulties falling or maintaining sleep) is poorly understood. Consistent evidence from prospective epidemiological studies suggests sleep disturbance as a predictor of major depression episodes and depression recurrence. In parallel, up to 20% of individuals with sleep disturbance have low-grade peripheral inflammation (i.e., CRP>3 mg/l), and preliminary longitudinal evidence showed that sleep disturbance may even predict the levels of inflammation. Therefore, it is possible that sleep disturbance may increase inflammation, which in turn may contribute (i.e., mediate) to the onset - or worsening - of depression. Alternatively, sleep disturbance may serve as a vulnerability factor and increase the risk of developing depressive symptoms when facing an immune challenge. The aim of this review was to summarise the state of the science on the role of sleep disturbance in contributing to depression-related inflammation. A research agenda is also proposed to advance the study of sleep disturbance in the psychoneuroimmunology of depression.

Experimental Medicine Approaches in Early-Phase CNS Drug Development

Traditionally, Phase 1 clinical trials were largely conducted in healthy normal volunteers and focused on collection of safety, tolerability, and pharmacokinetic data. However, in the CNS therapeutic area, with more drugs failing in later phase development, Phase 1 trials have undergone an evolution that includes incorporation of novel approaches involving novel study designs, inclusion of biomarkers, and early inclusion of patients to improve the pharmacologic understanding of novel CNS-active compounds early in clinical development with the hope of improving success in later phase pivotal trials. In this chapter, the authors will discuss the changing landscape of Phase 1 clinical trials in CNS, including novel trial methodology, inclusion of pharmacodynamic biomarkers, and experimental medicine approaches to inform early decision-making in clinical development.

Sleep-Dependent Anomalous Cortical Information Interaction in Patients With Depression

Depression is a prevalent mental illness with high morbidity and is considered the main cause of disability worldwide. Brain activity while sleeping is reported to be affected by such mental illness. To explore the change of cortical information flow during sleep in depressed patients, a delay symbolic phase transfer entropy of scalp electroencephalography signals was used to measure effective connectivity between cortical regions in various frequency bands and sleep stages. The patient group and the control group shared similar patterns of information flow between channels during sleep. Obvious information flows to the left hemisphere and to the anterior cortex were found. Moreover, the occiput tended to be the information driver, whereas the frontal regions played the role of the receiver, and the right hemispheric regions showed a stronger information drive than the left ones. Compared with healthy controls, such directional tendencies in information flow and the definiteness of role division in cortical regions were both weakened in patients in most frequency bands and sleep stages, but the beta band during the N1 stage was an exception. The computable sleep-dependent cortical interaction may provide clues to characterize cortical abnormalities in depressed patients and should be helpful for the diagnosis of depression.

Effects of transcranial magnetic stimulation on sleep quality and mood in patients with major depressive disorder

STUDY OBJECTIVES

It is unknown whether sleep quality improvements after repetitive transcranial magnetic stimulation (rTMS) are inherent to the intervention or related to improvements in depressive symptoms. This retrospective study examined sleep quality in patients with major depressive disorder (MDD) before and after treatment with rTMS, adjusting for age, sex, sedative-hypnotic use, number of rTMS treatments, depression severity and changes in depressive symptoms.

METHODS

Adults with MDD underwent a six-week course of 10 Hz rTMS over the left dorsolateral prefrontal cortex (DLPFC). Patients completed the Patient Health Questionnaire-9 (PHQ-9) depression rating scale and Pittsburgh Sleep Quality Index (PSQI) before and after treatment. To limit confounding, analysis of depressive symptoms occurred without item 3 (the sleep item) of the PHQ-9.

RESULTS

Twenty-one patients completed the study, with a mean (± standard deviation) baseline PSQI score of 12.0 (±3.8), compared to 10.5 (±4.3) post-treatment (p = 0.01). The mean baseline PHQ-9 score without item 3 was 17.3 (±3.0), compared to 12.2 (±4.9) post-treatment (p = 0.0001). PSQI and modified PHQ-9 changes were uncorrelated in non-adjusted and adjusted linear regression models, as well as in Spearman's rank-order correlation.

CONCLUSIONS

Mood and sleep quality improved independently following rTMS treatment, even after adjusting for age, sex, sedative-hypnotic use, number of rTMS treatments and depression severity. These findings suggest that rTMS exerts direct effects on both mood and sleep in patients with MDD.

Association of Depressive Symptoms with Sleep Disturbance: A Co-twin Control Study

BACKGROUND

Few studies have comprehensively evaluated the association of depression with sleep disturbance using a controlled twin study design.

PURPOSE

To cross-sectionally evaluate the association of depression with both objective and subjective sleep disturbance.

METHODS

We studied 246 members of the Vietnam Era Twin Registry. We measured depressive symptoms using the Beck Depression Inventory-II (BDI) and assessed major depression using structured clinical interviews. Twins underwent one-night polysomnography and 7-day actigraphy to derive measures of objective sleep and completed the Pittsburgh Sleep Quality Index for subjective sleep. Multivariable mixed-effects models were used to examine the association.

RESULTS

Twins were all male, mostly white (97%), with a mean (SD) age of 68 (2). The mean (SD) BDI was 5.9 (6.3), and 49 (20%) met the criteria for major depression. For polysomnography, each 5-unit higher BDI, within-pair, was significantly associated with 19.7 min longer rapid eye movement (REM) sleep latency, and 1.1% shorter REM sleep after multivariable adjustment. BDI was not associated with sleep architecture or sleep-disordered breathing. For actigraphy, a higher BDI, within-pair, was significantly associated with lower sleep efficiency, more fragmentation and higher variability in sleep duration. BDI was associated with almost all dimensions of self-reported sleep disturbance. Results did not differ by zygosity, and remained consistent using major depression instead of BDI and were independent of the presence of comorbid posttraumatic stress disorder and antidepressant use.

CONCLUSIONS

Depression is associated with REM sleep disruption in lab and sleep fragmentation and sleep variability at home, but not with sleep architecture or sleep-disordered breathing.

Performance of an ambulatory electroencephalogram sleep monitor in patients with psychiatric disorders

Key clinical symptoms observed among individuals with psychiatric disorders include difficulty falling asleep or maintaining sleep, poor sleep quality and nightmares. Those suffering from sleep disorders often present with symptoms of discontent with regard to sleep quality, timing and quantity, and these symptoms have an adverse impact on function and quality of life. A minimally invasive technique would be preferable in patients with psychiatric disorders, who tend to be sensitive to environmental change. Accordingly, we evaluated the performance of Zmachine Insight Plus, an ambulatory electroencephalography sleep monitor, in patients with psychiatric disorders. One hundred and three patients undergoing polysomnography were enrolled in this study. Zmachine Insight Plus was performed simultaneously with polysomnography. Total sleep time, sleep efficiency, wake after sleep onset, rapid eye movement (REM) sleep, light sleep (stages N1 and N2) and deep sleep (stage N3) were assessed. Total sleep time, sleep efficiency, wake after sleep onset, REM sleep duration and non-REM sleep duration of Zmachine Insight Plus showed a significant correlation with those of polysomnography. Lower sleep efficiency and increased frequency of waking after sleep onset, the arousal index and the apnea-hypopnea index on polysomnography were significantly associated with the difference in sleep parameters between the two methods. Among patients with psychiatric disorders who are sensitive to environmental change, Zmachine Insight Plus would be a useful technique to objectively evaluate sleep quality.

Association of musculoskeletal pain with poor sleep quality in public school teachers

BACKGROUND

Teachers perform repetitive movements all day, which can cause pain in body regions. This article analyzes the association of pain with sleep quality in this population.

OBJECTIVE

The objective of the study was to analyze the relationship of musculoskeletal pain and sleep quality in teachers from public schools.

METHODS

The sample consisted of 242 teachers, selected in a random process. Musculoskeletal pain and sleep quality were evaluated by using a questionnaire. The association between sleep quality and musculoskeletal pain was evaluated using the chi-square test. The magnitude of the associations was verified by Binary Logistic Regression, adjusted by sex, age, BMI, and socioeconomic status.

RESULTS

Teachers with poor sleep quality presented higher body mass index (BMI) values when compared to teachers with good sleep quality (27.9 vs 26.0, p = 0.012). Teachers with poor sleep quality were approximately twice as likely to report thoracic pain (OR = 2.16[95% CI = 1.12-4.16]), wrist pain (OR = 3.28[95% CI = 1.18-9.07]), low back pain (OR = 3.09[95% CI = 1.29-7.41]), and ankle/foot pain (OR = 2.83[95% CI = 1.32-6.08]).

CONCLUSIONS

Teachers with poor sleep quality were approximately twice as likely to present pain in several body parts. Our findings revealed that poor sleep quality was significantly associated with musculoskeletal pain in Brazilian teachers of public schools, regardless of confounding factors.

Mood Disorders

PURPOSE OF REVIEW

This article discusses the prevalence of the major mood disorders (major depressive disorder and bipolar disorder) in the community and within neurologic settings, articulates the steps taken to make a diagnosis of major depressive disorder or bipolar disorder, and reviews old and newer treatment options with proven efficacy for the treatment of these two conditions.

RECENT FINDINGS

New medications are available as treatment options for major depressive disorder and bipolar disorder, such as intranasal and IV ketamine, and somatic treatments, such as deep brain stimulation and vagal nerve stimulators, are being used to target treatment-resistant depression.

SUMMARY

Mood disorders are common in neurologic settings. They are disabling and increase morbidity and mortality. Clinicians should have a high index of suspicion if they suspect their patients seem more distressed or incapacitated than would be warranted by their neurologic disorders. If a patient does have a mood disorder, validating the patient's experience, initiating treatment, and, if necessary, referring the patient to a primary care physician or psychiatrist are appropriate steps.

Experimental Assessment of Sleep-Related Parameters by Passive Infrared Sensors: Measurement Setup, Feature Extraction, and Uncertainty Analysis

A simple sleep monitoring measurement method is presented in this paper, based on a simple, non-invasive motion sensor, the Passive InfraRed (PIR) motion sensor. The easy measurement set-up proposed is presented and its performances are compared with the ones provided by a commercial, ballistocardiographic bed sensor, used as reference tool. Testing was conducted on 25 nocturnal acquisitions with a voluntary, healthy subject, using the PIR-based proposed method and the reference sensor, simultaneously. A dedicated algorithm was developed to correlate the bed sensor outputs with the PIR signal to extract sleep-related features: sleep latency (SL), sleep interruptions (INT), and time to wake (TTW). Such sleep parameters were automatically identified by the algorithm, and then correlated to the ones computed by the reference bed sensor. The identification of these sleep parameters allowed the computation of an important, global sleep quality parameter: the sleep efficiency (SE). It was calculated for each nocturnal acquisition and then correlated to the SE values provided by the reference sensor. Results show the correlation between the SE values monitored with the PIR and the bed sensor with a robust statistic confidence of 4.7% for the measurement of SE (coverage parameter k = 2), indicating the validity of the proposed, unobstructive approach, based on a simple, small, and low-cost sensor, for the assessment of important sleep-related parameters.

High rates of respiratory symptoms and airway disease in mental health inpatients in a tertiary centre

BACKGROUND

People with severe mental illness (SMI) have a lower life expectancy due in part to a higher prevalence of cardiac and metabolic disease. Less is known of the prevalence of respiratory disease in this group.

AIMS

This cross-sectional, observational study aimed to assess the prevalence of symptoms associated with respiratory disease in patients admitted to an inpatient mental health unit.

METHODS

A convenience sample of 82 inpatients had a structured interview and questionnaire completed. The questionnaire included self-reported diagnoses of common diseases and screening questions designed to detect respiratory disease and sleep disordered breathing. Targeted spirometry was performed on the basis of symptoms and smoking status.

RESULTS

Patients reported high rates of respiratory symptoms, including wheezing (38%) and dyspnoea (44%); 52% of patients reported daily tobacco use. Productive cough was significantly associated with tobacco use (P < 0.005). Ten patients (18%) had spirometry consistent with chronic obstructive pulmonary disease (COPD) of whom six did not have a formal diagnosis of COPD previously.

CONCLUSIONS

People with SMI have high rates of respiratory symptoms with a high prevalence of COPD on spirometry. Half of the COPD cases were not previously diagnosed, suggesting a hidden burden of respiratory disease in patients with SMI.

Insomnia From Drug Treatments: Evidence From Meta-analyses of Randomized Trials and Concordance With Prescribing Information

OBJECTIVE

To determine whether drugs used to treat diverse conditions cause insomnia symptoms and whether their prescription information is concordant with this evidence.

METHODS

We conducted a survey of meta-analyses (Cochrane Database of Systematic Reviews) and comparisons with package inserts compiled in the Physicians' Desk Reference (PDR). We identified randomized controlled trials (RCTs) in which any drug had been evaluated vs placebo and sleep had been assessed. We collectively referred to insomnia-related outcomes as sleep disturbance. We also searched the PDR to identify any insomnia symptoms listed for drugs with RCT evidence available.

RESULTS

Seventy-four Cochrane systematic reviews corresponding to 274 RCTs assessed 88 drugs in 27 different conditions, providing evidence on 109 drug-condition pairs. Of these 88 drugs, 5 decreased sleep problems and 19 increased sleep problems; 64 drugs had no nominally statistically significant effect on sleep. Acetylcholinesterase inhibitors, dopamine agonists, and selective serotonin reuptake inhibitors were the drug classes most importantly associated with sleep disturbance. Of 35 drugs that included disturbed sleep as an adverse effect in the PDR, only 14 had RCT evidence supporting such effect, and 2 had evidence of increasing and decreasing sleep problems in RCTs, although this was not shown in the PDR. We identified weak concordance between the PDR and RCTs (weighted κ=0.31; P<.001).

CONCLUSION

The RCTs offer substantial evidence about the common effects of drugs on the risk of sleep disturbance; currently, prescription information only partially agrees with the available randomized evidence.

Polysomnographic characteristics of bipolar hypomanic patients: Comparison with unipolar depressed patients

BACKGROUND

Sleep profile in bipolar disorder has received little attention in comparison to sleep studies in major depressive disorders. Specific sleep abnormalities especially in REM sleep parameters have been detected in depression. The current study aimed at investigating whether bipolar disorder shares the same polysomnographic (PSG) changes or not.

METHODS

All night polysomnographic assessments were made for 20 patients diagnosed to have hypomania, in addition to 20 patients with major depression and 20 healthy matched controls. All participants were examined using Standardized Sleep Questionnaire, SCID-I for psychiatric diagnosis, based on DSM-IV criteria, YMRS (for hypomanic patients), HAMD (for major depression patients), and all-night polysomnography (for all subjects).

RESULTS

The two patient groups differed significantly from controls in their sleep profile, especially regarding sleep continuity measures, Short REML (Rapid Eye Movement Latency), with increased REMD (Rapid Eye Movement sleep density). High similarity was found in EEG sleep profile of the two patient groups, though the changes were more robust in patients with depression

LIMITATIONS

A relatively small sample size, the absence of follow up assessment, lack of consideration of other variables like body mass index, nicotine and caffeine intake.

CONCLUSION

Similarity in EEG sleep profile between Bipolar disorder patients and patients with major depression suggests a common biological origin for both conditions, with the difference being "quantitative" rather than "qualitative". This quantitative difference in sleep efficiency and SWS (Slow wave sleep), being higher in hypomania, might explain the rather "refreshing" nature of sleep in hypomanic patients, compared to depression.

Long working hours and sleep problems among public junior high school teachers in Japan

OBJECTIVES

Long working hours may impact human health. In Japan, teachers tend to work long hours. From 2002 to 2012, the number of leaves of absence due to diseases other than mental disorders, or mental disorders among public school teachers increased by 1.3 times (from 2,616 to 3,381), or 1.8 times (from 2,687 to 4,960), respectively. The present study aimed to investigate the association between long working hours and sleep problems among public school teachers.

METHODS

This cross-sectional study was conducted from mid-July to September 2013 in Hokkaido Prefecture, Japan. Questionnaires were distributed to 1,245 teachers in public junior high schools. Information about basic characteristics including working hours, and responses to the Pittsburgh Sleep Quality Index were collected anonymously. Multiple logistic regression analysis was used to calculate odds ratios (ORs) for the association between long working hours and sleep problems separately by sex.

RESULTS

The response rate was 44.8% (n=558). After excluding ineligible responses, the final sample comprised 515 teachers (335 males and 180 females). Sleep problems was identified in 41.5% of males and 44.4% of females. Our results showed a significantly increased risk of sleep problems in males working >60 hours per week (OR 2.05 [95% CI 1.01-4.30]) compared with those working ≤40 hours per week. No significant association was found in females.

CONCLUSIONS

There is a significant association between long working hours and sleep problems in male teachers. Reducing working hours may contribute to a reduction in sleep problems.

Obstructive sleep apnea and psychiatric disorders: a systematic review

STUDY OBJECTIVES

Obstructive sleep apnea (OSA) has been associated with psychiatric pathology. Psychiatric comorbidity in OSA may affect patient quality of life and adherence to CPAP. A focused evaluation of OSA in highly selected groups of primarily psychiatric patients may provide further insights into the factors contributing to comorbidity of OSA and psychopathology. The goal of this study is to examine the prevalence and treatment of OSA in psychiatric populations.

METHODS

A systematic review following the PRISMA guidelines was conducted to determine the prevalence of OSA in schizophrenia and other psychotic disorders, mood disorders, and anxiety disorders, and to examine potential interventions. The PubMed, EMBASE, and PsycINFO databases were searched (last search April 26, 2014) using keywords based on the ICD-9-CM coding for OSA and the DSM-IV-TR diagnostic groups.

RESULTS

The search retrieved 47 records concerning studies of OSA in the selected disorders. The prevalence studies indicate that there may be an increased prevalence of OSA in individuals with major depressive disorder (MDD) and posttraumatic stress disorder (PTSD), despite considerable heterogeneity and a high risk of bias. There was insufficient evidence to support increased OSA in schizophrenia and psychotic disorders, bipolar and related disorders, and anxiety disorders other than PTSD. Studies of treatment of OSA indicate an improvement in both OSA and psychiatric symptoms. CPAP adherence was reduced in veterans with PTSD.

CONCLUSIONS

OSA prevalence may be increased in MDD and PTSD. In individuals with OSA and psychiatric illness, treatment of both disorders should be considered for optimal treatment outcomes.

Sleep Disturbances in Depression

Major depressive disorder is frequently accompanied by sleep disturbances such as insomnia or hypersomnia and polysomnographic sleep findings of increased rapid-eye-movement sleep and decreased slow wave sleep. For many patients, insomnia persists even after mood symptoms have been adequately treated. These patients have poorer outcomes than patients without sleep problems. These outcomes suggest that overlapping neural mechanisms regulate sleep and mood. Treatment of these patients can incorporate sedating antidepressants, nonbenzodiazepine γ-aminobutyric acid agonists, and cognitive behavioral therapy. Sleep restriction has been found to improve mood in depressed patients; however, the benefits typically disappear after recovery sleep.

The status of sleep abnormalities as a diagnostic test for major depressive disorder

BACKGROUND

Psychiatry lags other fields in development of diagnostic tests.

METHODS

A literature review and meta-analysis was conducted to ascertain if polysomnographic abnormalities (REM density, REM latency, sleep efficiency, slow wave sleep, stage 1 and stage 2 sleep) warrant additional effort to develop them into a clinical diagnostic test for major depressive disorder (MDD). The 31 publications meeting inclusion criteria were then classified into one of three progressive steps using guidelines for evaluating the clinical usefulness of a diagnostic test.

RESULTS

Most of the abnormalities found in MDD patients, when compared to healthy controls, occurred in the expected direction with moderate effect sizes but with substantial publication bias and heterogeneity. Eleven studies compared abnormalities in MDD to other psychiatric disorders (step 2a), and four studies provided data on the sensitivity or specificity of the findings in differentiating among the psychiatric disorders that frequently appear on the same differential diagnostic list as MDD (step 2b). No multicenter trial has been conducted prospectively to test the clinical utility of the diagnostic test (step 3).

LIMITATIONS

Only published articles in the English language were used.

CONCLUSIONS

Sleep studies for the detection of MDD appear replicable with a moderate effect size. However, additional step 1 studies are needed to define the sensitivity and specificity. The heterogeneity of sleep recording, scoring techniques, and MDD must also be addressed.

Sleep as a biomarker for depression

Sleep is a complex biological process that involves cyclic changes of brain activity. The smooth transition between wakefulness and sleep and cyclic succession of sleep stages depend on the function of numerous neurotransmitters that reciprocally influence each other. For this reason sleep is a very sensitive biomarker of brain functioning. This article provides an overview of sleep changes in depression, mechanisms involved in sleep regulation and pathophysiology underlying depression, studies on sleep as a biomarker for depression, effects of antidepressants on sleep EEG, and studies in depression with the use of quantitative sleep EEG analysis. Research on sleep in depression has provided several valuable biomarkers that are related to increased risk for depression, show worsening during depressive episode, and are related to treatment outcome and relapse risk during remission phase. Among many sleep parameters, increased REM density and diminished delta sleep ratio deserve special interest. Sleep studies are also an important research tool for antidepressant drug development. However, due to sensitivity of sleep parameters to pharmacological interventions, the patients have to be investigated before the start of pharmacological treatment or after washout from the antidepressant drug, to obtain reliable data on disease-related biological processes from polysomnography.

Chronobiology of mood disorders

OBJECTIVE

As part of a series of papers examining chronobiology ['Getting depression clinical guidelines right: time for change?' Kuiper et al. Acta Psychiatr Scand 2013;128(Suppl. 444):24-30; and 'Manipulating melatonin in managing mood' Boyce & Hopwood. ActaPsychiatrScand 2013;128(Suppl. 444):16-23], in this article, we review and synthesise the extant literature pertaining to the chronobiology of depression and provide a preliminary model for understanding the neural systems involved.

METHOD

A selective literature search was conducted using search engines such as MEDLINE/PubMed, combining terms associated with chronobiology and mood disorders.

RESULTS

We propose that understanding of sleep-wake function and mood can be enhanced by simultaneously considering the circadian system, the sleep homoeostat and the core stress system, all of which are likely to be simultaneously disrupted in major mood disorders. This integrative approach is likely to allow flexible modelling of a much broader range of mood disorder presentations and phenomenology.

CONCLUSION

A preliminary multifaceted model is presented, which will require further development and testing. Future depression research should aim to examine multiple systems concurrently in order to derive a more sophisticated understanding of the underlying neurobiology.

Sleep loss and its effects on health of family caregivers of individuals with primary malignant brain tumors

Sleep loss places caregivers at risk for poor health. Understanding correlates of sleep loss and relationships to health may enable improvement of health of caregivers of individuals with primary malignant brain tumors (PMBT). In this cross-sectional, descriptive study of 133 caregivers, relationships were examined between sleep loss and physical, mental, emotional, and social health at time of patient diagnosis. Sleep loss was not related to physical health. Shorter total sleep time was associated with greater fatigue and social support. Sleep quality was positively associated with quality of life. Further study is needed of the role of sleep loss in the PMBT caregiving trajectory and its long-term relationship with health outcomes.

Sleep America: managing the crisis of adult chronic insomnia and associated conditions

INTRODUCTION

Chronic insomnia, a public health crisis affecting 10-15% of the U.S. population and costing billions of dollars annually, typically presents with one or more comorbid psychiatric or organic conditions. Historical classification of chronic insomnia as "secondary" to a presenting comorbid condition has resulted in under-recognition and under-treatment of both the insomnia and comorbid condition(s). Though critical in any model of comorbid disease management, chronic insomnia receives little, if any, public policy attention.

METHOD

We conducted a systematic review of recent empirical studies, review papers, books, government documents, press releases, advertisements, and articles pertaining to the classification, epidemiology, treatment, and physiology of sleep, insomnia, and comorbid conditions. Data were located primarily through MEDLINE, PsycINFO, SCOPUS, and PUBMED databases.

OBJECTIVE AND RESULTS

Our goal was to provide an overview of the systems for classifying insomnia and available epidemiological data, and to review theoretical models regarding the etiology and maintaining factors of chronic insomnia along with research on the complex, bidirectional associations between chronic insomnia and various affective (and other) conditions.

CONCLUSIONS

After thorough review of the literature, we propose several public policy measures as an initial step in managing chronic insomnia in the United States. These include introducing a nation-wide multi-modal educational and awareness campaign titled "Sleep America;" increasing the availability and demand for behavioral sleep medicine - the initially preferred treatment approach; and increasing the use of monitoring and enforcement activities by regulatory authorities to curtail false and misleading claims by sponsors of supplements or treatments for insomnia. Through the adoption of such measures, we hope to galvanize a national interest in healthy sleep and the evidence-based treatment of chronic insomnia.

Treatment selection in depression: the role of clinical judgment

The selection of treatment in depression should be filtered by clinical judgment, taking into consideration a number of clinical variables, such as characteristics and severity of depressive episode, co-occurring symptomatology and problems (not necessarily syndromes), medical comorbidities, and patient’s history with particular reference to treatment of previous episodes, if they occurred. Such information should be placed within what is actually available in the specific treatment setting and should be integrated with the patient’s preferences. In clinical practice, on the one end, clinical decisions may be affected by irrational factors (eg, exposure to massive doses of pharmaceutical propaganda or familiarity with a specific psychotherapy or medication). On the other end, psychiatrists often use sophisticated forms of clinical judgment that are suitable for clinical challenges but are not addressed by current research strategies. There is increasing awareness of the need of differentiating depression according to specific subtypes, yet clear-cut indications for these subdivisions are still missing. The role of biomarkers, despite many promising research strategies, is still far from offering reliable clinical guidance. In the meanwhile, there are important indications that come from clinical research. Treatment of depression may be conceptualized as integrated treatment of the various components of symptomatology, lifestyle, and social adjustment. An integrated treatment model, discussed in detail elsewhere, is realistic and practical, and not just idealistic. It may be frustrating to those who like oversimplified biological models; however, approaches that integrate clinimetrics, patient priorities, lifestyle issues, and clinical judgment are more in keeping with the complexity of clinical situations and the challenge of depression treatment.