The effectiveness of melatonin for promoting healthy sleep: a rapid evidence assessment of the literature

Prevalence and patterns of sleep-related melatonin usage among adults in Saudi Arabia: A self-reported cross-sectional national study

Purpose

Despite the surge of melatonin supplement consumption in recent years, data on the prevalence and patterns of melatonin usage in Saudi Arabia is lacking. The aim of this study was to assess the prevalence and pattern of sleep-related melatonin usage among adults in Saudi Arabia.

Methods

This was a cross-sectional, web-based, self-administered survey study conducted across all regions of Saudi Arabia. Participants were recruited from the general population (≥18 years). The survey was distributed between February and April 2023. Chi-squared tests and t-tests were performed for comparative bivariate analyses where binary logistic regression was performed to derive the main predictors of melatonin consumption.

Results

Out of 5,606 participants, 536 (10 %) were consumers of melatonin. Older age (Adjusted OR = 1.01, 95 % CI = 1.01-1.02, p = 0.002), being a male (Adjusted OR = 1.76, 95 % CI = 1.46-2.14, p = 0.001), individuals with a doctorate degree or an equivalent (adjusted OR 2.37 95 % CI = 1.35-4.17, p = 0.003), perceived poor sleep quality (Adjusted OR = 1.52, 95 % CI = 1.10-2.11, p = 0.01), and being diagnosed with a sleep disorder (Adjusted OR = 2.55, 95 % CI = 2.04-3.18, p = 0.001) were all associated with increased likelihood of sleep-related melatonin usage. 35 % of consumers self-reported taking ≥1 tablet per day, while 26 % of them were uncertain about the dosage they consume.

Conclusion

With a notable prevalence of 10% among the general population in Saudi Arabia, melatonin usage was more common in older adults, males, and those with higher education.

Effect of daily light exposure on sleep in polar regions: A meta-analysis

Although studies have shown that light affects sleep in polar populations, the sample size of most studies is small. This meta-analysis provides the first systematic review of the effects of summer glare, spring and fall moderate daylight, and artificial lighting on general sleep problems (sleep duration, efficiency, and delay). This analysis included 18 studies involving 986 participants. We calculated the random effect size via an evidence-based meta-analysis that analysed the effect of bright/auxiliary light on sleep and the effect of three different types of light on sleep compared with conventional light. There was no significant correlation between specific light types and sleep duration. Intense summer light has a negative effect on sleep time and efficiency. Moderate, natural light in spring and autumn effectively delayed sleep but could not improve sleep efficiency. For artificial fill light, neither blue light nor enhanced white light has been found to have a significant effect. In summary, summer light has a detrimental effect on sleep in polar populations, and moderate natural light may be superior to conventional light. However, specific strategies to improve sleep and artificial lighting in polar populations must be explored further.

Significance of Melatonin in the Regulation of Circadian Rhythms and Disease Management

Melatonin, the 'hormone of darkness' is a neuronal hormone secreted by the pineal gland and other extra pineal sites. Responsible for the circadian rhythm and seasonal behaviour of vertebrates and mammals, melatonin is responsible for regulating various physiological conditions and the maintenance of sleep, body weight and the neuronal activities of the ocular sites. With its unique amphiphilic structure, melatonin can cross the cellular barriers and elucidate its activities in the subcellular components, including mitochondria. Melatonin is a potential scavenger of oxygen and nitrogen-reactive species and can directly obliterate the ROS and RNS by a receptor-independent mechanism. It can also regulate the pro- and anti-inflammatory cytokines in various pathological conditions and exhibit therapeutic activities against neurodegenerative, psychiatric disorders and cancer. Melatonin is also found to show its effects on major organs, particularly the brain, liver and heart, and also imparts a role in the modulation of the immune system. Thus, melatonin is a multifaceted candidate with immense therapeutic potential and is still considered an effective supplement on various therapies. This is primarily due to rectification of aberrant circadian rhythm by improvement of sleep quality associated with risk development of neurodegenerative, cognitive, cardiovascular and other metabolic disorders, thereby enhancing the quality of life.

Exploring the Role of Circadian Rhythms in Sleep and Recovery: A Review Article

Sleep is essential for every living organism. Humans spend about one-third of their lives sleeping. Sleep has been studied extensively, and the role of sleep in psychological, mental, and physical well-being is established to be the best. The rhythm of the brain between wakefulness and sleep is called the circadian rhythm, which is mainly controlled by melatonin and the pineal gland. The imbalance of this rhythm can lead to devastating effects on health. Vigorous workouts close to bedtime can interfere with falling asleep. Meal timing and composition can significantly affect sleep quality. It is advised to avoid large meals, caffeine, and alcohol before bedtime. Heavy meals close to bedtime can lead to poor sleep and hormone disruption. By following these guidelines enumerated in the article, individuals can improve sleep quality and overall health. Sleep cycles, especially rapid eye movement sleep, have a profound influence on mental and physical health. Adhering to recommended sleep practices enhances bodily restoration, fortifies the immune system, and upholds metabolic equilibrium. Sleep hygiene aligned with circadian rhythms is crucial for disease prevention and well-being. Healthcare professionals should prioritize sleep optimization strategies for patient care and public health.

Effects of (non)deceptive placebos on reported sleep quality and food cue reactivity

A lack of sleep can increase appetite, particularly for high-calorie food. The current study tested the effects of an open-label placebo for improving sleep quality and reducing food cue reactivity. In open-label placebo interventions, placebo recipients are informed that they are receiving a placebo without a pharmacologically active substance. Participants (n = 150) were randomly allocated to one of three groups that received either an open-label placebo to improve sleep quality, a deceptive placebo ("melatonin"), or no placebo. The placebo was administered daily before bedtime for 1 week. Sleep quality and reactivity to high-calorie food cues (appetite, visual attention to food images) were assessed. The deceptive placebo (but not the open-label placebo) reduced reported sleep-onset latency. The open-label placebo decreased perceived sleep efficiency. The placebo interventions did not change food cue reactivity. This study demonstrated that open-label placebos do not present an alternative to deceptive placebos for improving sleep quality. The undesirable open-label placebo effects found warrant further exploration.

The Safety and Comparative Effectiveness of Non-Psychoactive Cannabinoid Formulations for the Improvement of Sleep: A Double-Blinded, Randomized Controlled Trial

BACKGROUND

Clinical evidence on the use of cannabidiol (CBD) for sleep remains limited. Even fewer studies have tested the comparative effectiveness of cannabinoid formulations found within CBD products used for sleep or how they compare to other complementary therapies such as melatonin.

METHODS

Participants (N = 1,793 adults experiencing symptoms of sleep disturbance) were randomly assigned to receive a 4-week supply of 1 of 6 products (all capsules) containing either 15 mg CBD or 5 mg melatonin, alone or in combination with minor cannabinoids. Sleep disturbance was assessed over a period of 5 weeks (baseline week and 4 weeks of product use) using Patient-Reported Outcomes Measurement Information System (PROMIS™) Sleep Disturbance SF 8A, administered via weekly online surveys. A linear mixed-effects regression model was used to assess the differences in the change in sleep disturbance through time between each active product arm and CBD isolate.

RESULTS

All formulations exhibited a favorable safety profile (12% of participants reported a side effect and none were severe) and led to significant improvements in sleep disturbance (p < 0.001 in within-group comparisons). Most participants (56% to 75%) across all formulations experienced a clinically important improvement in their sleep quality. There were no significant differences in effect, however, between 15 mg CBD isolate and formulations containing 15 mg CBD and 15 mg cannabinol (CBN), alone or in combination with 5 mg cannabichromene (CBC). There were also no significant differences in effect between 15 mg CBD isolate and formulations containing 5 mg melatonin, alone or in combination with 15 mg CBD and 15 mg CBN.

CONCLUSIONS

Our findings suggest that chronic use of a low dose of CBD is safe and could improve sleep quality, though these effects do not exceed that of 5 mg melatonin. Moreover, the addition of low doses of CBN and CBC may not improve the effect of formulations containing CBD or melatonin isolate.

Approaches for Increasing Cerebral Efflux of Amyloid-β in Experimental Systems

Amyloid protein-β (Aβ) concentrations are increased in the brain in both early onset and late onset Alzheimer's disease (AD). In early onset AD, cerebral Aβ production is increased and its clearance is decreased, while increased Aβ burden in late onset AD is due to impaired clearance. Aβ has been the focus of AD therapeutics since development of the amyloid hypothesis, but efforts to slow AD progression by lowering brain Aβ failed until phase 3 trials with the monoclonal antibodies lecanemab and donanemab. In addition to promoting phagocytic clearance of Aβ, antibodies lower cerebral Aβ by efflux of Aβ-antibody complexes across the capillary endothelia, dissolving Aβ aggregates, and a "peripheral sink" mechanism. Although the blood-brain barrier is the main route by which soluble Aβ leaves the brain (facilitated by low-density lipoprotein receptor-related protein-1 and ATP-binding cassette sub-family B member 1), Aβ can also be removed via the blood-cerebrospinal fluid barrier, glymphatic drainage, and intramural periarterial drainage. This review discusses experimental approaches to increase cerebral Aβ efflux via these mechanisms, clinical applications of these approaches, and findings in clinical trials with these approaches in patients with AD or mild cognitive impairment. Based on negative findings in clinical trials with previous approaches targeting monomeric Aβ, increasing the cerebral efflux of soluble Aβ is unlikely to slow AD progression if used as monotherapy. But if used as an adjunct to treatment with lecanemab or donanemab, this approach might allow greater slowing of AD progression than treatment with either antibody alone.

Short-Wavelength Light-Blocking Filters and Oral Melatonin Administration in Patients With Retinitis Pigmentosa: Protocol for a Randomized Controlled Trial

BACKGROUND

The medical community is beginning to recognize that retinitis pigmentosa (RP), due to its disabling progression, eventually leads to a reduction in the patient´s quality of life, a direct economic impact, and an increase in the burden on the health care system. There is no curative treatment for the origin of the disease, and most of the current interventions fail in reducing the associated negative psychological states, such as anxiety and depression, which lead to increased variability of vision and pose a continuous threat to the patient's independence.

OBJECTIVE

The aim of this study is to assess the effect of oral melatonin (OM) administration alone and combined with short-wavelength light (SWL)-blocking filters on patients with RP and test their effectiveness in improving the level of stress and sleep problems in many of these patients.

METHODS

We have developed a low-cost therapy protocol for patients with RP with sleep disorders and negative psychological stress. Patients will be randomized to receive a combined intervention with SWL-blocking filters and OM, SWL-blocking filters alone, or OM alone. There will also be a nonintervention arm as a control group. This study will be conducted across 2 retinal units in patients with RP with sleep disorders and high perceived stress and anxiety score reports. Patients will be assessed in the preintervention period, weekly during the 4 weeks of intervention, and then at 6 months postintervention. The primary outcomes are the differences in changes from baseline to postintervention in hormone release (α-amylase, cortisol, and melatonin) and sleep quality, as measured with the visual analog scale. Secondary outcome measures include clinical macular changes, as measured with optical coherence tomography and optical coherence tomography angiography; retinal function, as measured using the visual field and best-corrected visual acuity; sleep data collected from personal wearables; and several patient-reported variables, such as self-recorded sleep diaries, quality of life, perceived stress, and functional status.

RESULTS

This project is still a study protocol and has not yet started. Bibliographic research for information for its justification began in 2020, and this working group is currently seeking start-up funding. As soon as we have the necessary means, we will proceed with the registration and organization prior to the preliminary phase.

CONCLUSIONS

In this feasibility randomized clinical controlled trial, we will compare the effects of SWL blocking alone, administration of OM alone, and a combined intervention with both in patients with RP. We present this study so that it may be replicated and incorporated into future studies at other institutions, as well as applied to additional inherited retinal dystrophies. The goal of presenting this protocol is to aid recent efforts in reducing the impact of sleeping disorders and other psychological disorders on the quality of life in patients with RP and recovering their self-autonomy. In addition, the results of this study will represent a significant step toward developing a novel low-cost therapy for patients with RP and validating a novel therapeutic target.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

PRR1-10.2196/49196.

Insomnia Medication Use by University Students: A Systematic Review

Problematic sleep or insomnia has been a recognised issue for many individuals in society, and university students can be of particular concern due to unique academic pressures. A systematic review was designed to summarise the current evidence about the extent of insomnia medication used by university students and identify characteristics of those more willing to use medication to manage insomnia. Searches were undertaken using Psych INFO, PubMed, Embase, and Web of Science, resulting in 25 eligible studies across multiple countries between 1994 and 2020. The prevalence of sleep medication use by students varied widely, from 2% to 41.2%, with an average of 13.1%. Female gender, students experiencing poor sleep, smoking, drinking stimulant beverages, and undertaking fewer physical activities were associated with the use of insomnia medication. Insomnia medication use exists within university student populations but appears to vary considerably worldwide; identifying multiple population characteristics associated with such use would offer opportunities to identify and support those affected.

Pharmacological interventions targeting α-synuclein aggregation triggered REM sleep behavior disorder and early development of Parkinson's disease

Rapid eye movement (REM) sleep behavior disorder (RBD) is a parasomnia characterized by elevated motor behaviors and dream enactments in REM sleep, often preceding the diagnosis of Parkinson's disease (PD). As RBD could serve as a biomarker for early PD developments, pharmacological interventions targeting α-synuclein aggregation triggered RBD could be applied toward early PD progression. However, robust therapeutic guidelines toward PD-induced RBD are lacking, owing in part to a historical paucity of effective treatments and trials. We reviewed the bidirectional links between α-synuclein neurodegeneration, progressive sleep disorders, and RBD. We highlighted the correlation between RBD development, α-synuclein aggregation, and neuronal apoptosis in key brainstem regions involved in REM sleep atonia maintenance. The current pharmacological intervention strategies targeting RBD and their effects on progressive PD are discussed, as well as current treatments for progressive neurodegeneration and their effects on RBD. We also evaluated emerging and potential pharmacological solutions to sleep disorders and developing synucleinopathies. This review provides insights into the mechanisms and therapeutic targets underlying RBD and PD, and explores bidirectional treatment effects for both diseases, underscoring the need for further research in this area.

A Series of Remote Melatonin Supplement Interventions for Poor Sleep: Protocol for a Feasibility Pilot Study for a Series of Personalized (N-of-1) Trials

BACKGROUND

Poor sleep, defined as short-duration or poor-quality sleep, is a frequently reported condition with many deleterious effects including poorer cognitive functioning, increased accidents, and poorer health. Melatonin has been shown to be an efficacious treatment to manage symptoms of poor sleep. However, the treatment effects of melatonin on sleep can vary greatly between participants. Personalized, or N-of-1, trial designs represent a method for identifying the best treatment for individual participants. Although using N-of-1 trials of melatonin to treat poor sleep is possible, the feasibility, acceptability, and effectiveness of N-of-1 trials using melatonin are unknown. Using the National Institutes of Health Stage Model for Behavioral Intervention Development, a stage IB (intervention refinement, modification, and adaptation and pilot testing) design appeared to be needed to address these feasibility questions.

OBJECTIVE

This trial series evaluates the feasibility, acceptability, and effectiveness of a series of personalized interventions for remote delivery of melatonin dose (3 and 0.5 mg) versus placebo supplements for self-reported poor sleep among 60 participants. The goal of this study is to provide valuable information about implementing remote N-of-1 randomized controlled trials to improve poor sleep.

METHODS

Participants will complete a 2-week baseline followed by six 2-week alternating intervention periods of 3 mg of melatonin, 0.5 mg of melatonin, and placebo. Participants will be randomly assigned to 2 intervention orders. The feasibility and acceptability of the personalized trial approach will be determined with participants' ratings of usability and satisfaction with the remote, personalized intervention delivery system. The effectiveness of the intervention will be measured using participants' self-reported sleep quality and duration and Fitbit tracker-measured sleep duration and efficiency. Additional measures will include ecological momentary assessment measures of fatigue, stress, pain, mood, concentration, and confidence as well as measures of participant adherence to the intervention, use of the Fitbit tracker, and survey data collection.

RESULTS

As of the submission of this protocol, recruitment for this National Institutes of Health stage IB personalized trial series is approximately 78.3% complete (47/60). We expect recruitment and data collection to be finalized by June 2023.

CONCLUSIONS

Evaluating the feasibility, acceptability, and effectiveness of a series of personalized interventions of melatonin will address the longer term aim of this program of research-is integrating N-of-1 trials useful patient care? The personalized trial series results will be published in a peer-reviewed journal and will follow the CONSORT (Consolidated Standards of Reporting Trials) extension for N-of-1 trials (CENT 2015) reporting guidelines. This trial series was approved by the Northwell Health institutional review board.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05349188; https://www.clinicaltrials.gov/study/NCT05349188.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/45313.

The clinical efficacy of melatonin in the treatment of patients with COVID-19: a systematic review and meta-analysis of randomized controlled trials

Background

The COVID-19 pandemic has resulted in significant morbidity and mortality worldwide, with cytokine storm leading to exaggerating immune response, multi-organ dysfunction and death. Melatonin has been shown to have anti-inflammatory and immunomodulatory effects and its effect on COVID-19 clinical outcomes is controversial. This study aimed to conduct a meta-analysis to evaluate the impact of melatonin on COVID-19 patients.

Methods

PubMed, Embase, and Cochrane Central Register of Controlled Trials were searched without any language or publication year limitations from inception to 15 Nov 2022. Randomized controlled trials (RCTs) using melatonin as therapy in COVID-19 patients were included. The primary outcome was mortality, and the secondary outcomes included were the recovery rate of clinical symptoms, changes in the inflammatory markers like C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), and neutrophil to lymphocyte ratio (NLR). A random-effects model was applied for meta-analyses, and further subgroup and sensitivity analyses were also conducted.

Results

A total of nine RCTs with 718 subjects were included. Five studies using melatonin with the primary outcome were analyzed, and the pooled results showed no significant difference in mortality between melatonin and control groups with high heterogeneity across studies identified (risk ratio [RR] 0.72, 95% confidence interval [CI] 0.47-1.11, p = 0.14, I2 = 82%). However, subgroup analyses revealed statistically significant effects in patients aged under 55 years (RR 0.71, 95% CI 0.62-0.82, p < 0.01) and in patients treated for more than 10 days (RR 0.07, 95% CI 0.01-0.53, p = 0.01). The recovery rate of clinical symptoms and changes in CRP, ESR, and NLR were not statistically significant. No serious adverse effects were reported from melatonin use.

Conclusion

In conclusion, based on low certainty of evidence, the study concluded that melatonin therapy does not significantly reduce mortality in COVID-19 patients, but there are possible benefits in patients under 55 years or treated for more than 10 days. With a very low certainty of evidence, we found no significant difference in the recovery rate of COVID-19 related symptoms or inflammatory markers in current studies. Further studies with larger sample sizes are warranted to determine the possible efficacy of melatonin on COVID-19 patients.

Systematic review registration

https://www.crd.york.ac.uk/prospero/, identifier CRD42022351424.

Melatonin and metformin counteract cognitive dysfunction equally in male rats with doxorubicin-induced chemobrain

Melatonin (Mel) and metformin (Met) show beneficial effects in various brain pathologies. However, the effects of Mel and Met on doxorubicin (DOX)-induced chemobrain remain in need of elucidation. We aimed to investigate whether Mel and Met provide neuroprotective effects on glial dysmorphologies, brain inflammation, oxidative stress, brain mitochondrial dysfunction, apoptosis, necroptosis, neurogenesis, hippocampal dysplasticity, and cognitive dysfunction in rats with DOX-induced chemobrain. Thirty-two male Wistar rats were divided into 2 groups and received normal saline (NSS, as control, n = 8) or DOX (3 mg/kg/day; n = 24) by intraperitoneal (i.p.) injection on days 0, 4, 8, 15, 22, and 29. The DOX-treated group was divided into 3 subgroups receiving either vehicle (NSS; n = 8), Mel (10 mg/kg/day; n = 8), or Met (250 mg/kg/day; n = 8) by gavage for 30 consecutive days. Following this, cognitive function was assessed in all rats. The number of glial cells and their fluorescence intensity had decreased, while the glial morphology in DOX-treated rats showed a lower process complexity. Brain mitochondrial dysfunction, an increase in brain inflammation, oxidative stress, apoptosis and necroptosis, a decrease in the number of hippocampal dendritic spines and neurogenesis, and cognitive decline were also observed in DOX-treated rats. Mel and Met equally improved those brain pathologies, resulting in cognitive improvement in DOX-treated rats. In conclusion, concomitant treatment with either Mel or Met counteract DOX-induced chemobrain by preservation of glial morphology, brain inflammation, brain oxidative stress, brain mitochondrial function, hippocampal plasticity, and brain apoptosis. This study highlighted the role of the glia as key mediators in DOX-induced chemobrain.

Melatonin for Insomnia in Medical Inpatients: A Narrative Review

In this narrative review, we describe what is known about non-pharmacological and pharmacological treatments for insomnia in medical inpatients, with a focus on melatonin. Hospital-acquired insomnia is common, resulting in shortened total sleep time and more nighttime awakenings. Sleep disturbance has been shown to increase systemic inflammation, pain, and the likelihood of developing delirium in hospital. Treatment for insomnia includes both non-pharmacological and pharmacological interventions, the latter of which requires careful consideration of risks and benefits given the known adverse effects. Though benzodiazepines and non-benzodiazepine benzodiazepine receptor agonists are commonly prescribed (i.e., sedative-hypnotics), they are relatively contraindicated for patients over the age of 65 due to the risk of increased falls, cognitive decline, and potential for withdrawal symptoms after long-term use. Exogenous melatonin has a comparatively low likelihood of adverse effects and drug-drug interactions and is at least as effective as other sedative-hypnotics. Though more research is needed on both its effectiveness and relative safety for inpatients, small doses of melatonin before bedtime may be an appropriate choice for inpatients when insomnia persists despite non-pharmacological interventions.

Nutritional Elements in Sleep

Sleep comprises one-third of our day and plays an integral role in human health and well-being. Many factors influence sleep, with nutrition being a key element that impacts various sleep parameters. Meal-timing through strategies like chrono-nutrition leads to positive sleep outcomes. In addition, consuming a high-protein diet with essential amino acids, low-glycemic-index foods, and certain fruits rich in antioxidants can all contribute to better sleep quality. Other facets of nutrition that can affect sleep outcomes include weight loss and limiting certain nutritional elements such as caffeine, nicotine, and alcohol. In this article, we will shed some light on how some of these factors can play a vital role in sleep quality.

International society of sports nutrition position stand: tactical athlete nutrition

This position stand aims to provide an evidence-based summary of the energy and nutritional demands of tactical athletes to promote optimal health and performance while keeping in mind the unique challenges faced due to work schedules, job demands, and austere environments. After a critical analysis of the literature, the following nutritional guidelines represent the position of the International Society of Sports Nutrition (ISSN).

General Recommendations

Nutritional considerations should include the provision and timing of adequate calories, macronutrients, and fluid to meet daily needs as well as strategic nutritional supplementation to improve physical, cognitive, and occupational performance outcomes; reduce risk of injury, obesity, and cardiometabolic disease; reduce the potential for a fatal mistake; and promote occupational readiness.

Military Recommendations

Energy demands should be met by utilizing the Military Dietary Reference Intakes (MDRIs) established and codified in Army Regulation 40-25. Although research is somewhat limited, military personnel may also benefit from caffeine, creatine monohydrate, essential amino acids, protein, omega-3-fatty acids, beta-alanine, and L-tyrosine supplementation, especially during high-stress conditions.

First Responder Recommendations

Specific energy needs are unknown and may vary depending on occupation-specific tasks. It is likely the general caloric intake and macronutrient guidelines for recreational athletes or the Acceptable Macronutrient Distribution Ranges for the general healthy adult population may benefit first responders. Strategies such as implementing wellness policies, setting up supportive food environments, encouraging healthier food systems, and using community resources to offer evidence-based nutrition classes are inexpensive and potentially meaningful ways to improve physical activity and diet habits. The following provides a more detailed overview of the literature and recommendations for these populations.

Response to Treatment with Melatonin and Clonazepam versus Placebo in Patients with Burning Mouth Syndrome

Objective: to evaluate the efficacy of melatonin and clonazepam versus placebo in patients with burning mouth syndrome (BMS). Methods: a prospective double-blind study was carried out in patients with BMS and randomized to three groups: melatonin (1 mg once a day), clonazepam (0.5 mg/twice a day), or a placebo once a day, for 8 weeks. The clinical changes were evaluated, including xerostomia, the Oral Health Impact Profile 14 (OHIP-14) score, Pittsburg Sleep Quality Index, and the Hospital Anxiety and Depression Scale (HADS). Oxygen saturation and heart rate were recorded, with an analysis of salivary biomarkers in the forms of oxytocin, ferritin, adenosine deaminase (ADA), total proteins, and alpha-amylase. Results: a total of 64 patients were analyzed. A significant decrease in burning sensation was recorded with melatonin (7.8 ± 1.54 pre-treatment, 5.78 ± 2.54 post-treatment; p < 0.001) and clonazepam (8.75 ± 1.2 pre-treatment, 5.5 ± 3.6 post-treatment (p < 0.01). With regard to quality of life (OHIP-14), significant improvements were observed before and after the administration of melatonin (p < 0.001) and clonazepam (p = 0.001). On the other hand, with regard to the changes in salivary biomarkers following treatment, negative correlations were found between oxytocin and drainage (r = −0.410; p = 0.009) and between the HADS-D score and ferritin (r = −0.312; p = 0.05). While salivary amylase showed positive correlation with heart rate (r = 0.346; p = 0.029) and oxygen saturation (r = 0.419; p = 0.007). Conclusions: melatonin and clonazepam were shown to be effective at reducing the burning sensation and improving quality of life. Both drugs were found to be safe, with no major adverse effects in patients with BMS. Melatonin may be regarded as an alternative treatment for patients with BMS, though further studies are needed to confirm its effectiveness.

The Role of Vitamin D in Sleep Disorders of Children and Adolescents: A Systematic Review

This review investigates the association between vitamin D and sleep disorders. Vitamin D is an essential nutrient known to play an important role in the growth and bone health of the human body, but it also appears to play a role in sleep. The goal of our review is to examine the association between vitamin D and sleep disorders in children and adolescents. We summarize the evidence about the role and the mechanism of action of vitamin D in children and adolescents with sleep disorders such as insomnia, obstructive sleep apnea (OSA), restless legs syndrome (RLS), and other sleep disorders. Systematic electronic database searches were conducted using Pubmed and Cochrane Library. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guideline was followed. The studies that met the established inclusion criteria were analyzed and compared. Results suggest a strict relationship between vitamin D deficiency in children and sleep disorders. There is evidence that vitamin D is implicated in the different neurochemical mechanisms involved in sleep regulation and mainly in the serotonergic and dopaminergic pathways. This might be responsible for the association of vitamin D deficiency and restless sleep, sleep hyperhidrosis, OSA, and RLS.

Amount of < 1Hz deep sleep correlates with melatonin dose in military veterans with PTSD

Military veterans with posttraumatic stress disorder often complain of non-restful sleep, which further exacerbates their symptoms. Our previous study showed a deficit in Lo Deep sleep, or slow oscillations, in the PTSD population compared to healthy control sleepers. Because Lo Deep sleep is likely a stage when the brain eliminates protein debris, it is critical to find the cause and effective therapeutics to reverse Lo Deep deficiency. The current study aims to replicate and extend this finding by examining several physiological and medication factors that may be responsible for the Lo Deep deficiency. We recorded overnight sleep electroencephalogram (EEG) via a 2-channel headband device on 69 veterans in a residential treatment facility. Dried urine samples were collected at 4 time points during one day to measure melatonin, cortisol, norepinephrine and other factors. EEG data were transformed into frequency power and submitted to an automated sleep scoring algorithm. The scoring corresponds to clear spectral patterns in the overnight spectrogram but does not align exactly with traditional visual scoring stages. As expected, veterans showed decreased Lo Deep (activity < 1 Hz) and more Hi Deep sleep (1-3 Hz activity) than healthy controls, replicating our previous study. Multiple linear regressions showed that melatonin dose and morning urine melatonin correlated with more Lo Deep sleep. Buspirone dose also correlated with more Lo Deep, but only 6 subjects were taking buspirone. Also replicating the findings from our last study were independent reductions of REM sleep with prazosin and sertraline. Other findings included decreased Lo and increased Hi Deep sleep with higher caffeine dose, and less Hi Deep percentage with higher testosterone. Finally, evening cortisol levels correlated with a higher percentage of Wake after sleep onset. These results confirm Lo Deep deficiency in this PTSD population and suggests melatonin as a possible therapeutic to reverse Lo Deep deficiency. This is a critical first step to establishing a systematic sleep assessment and treatment program in this and potentially other populations to prevent future brain pathology.

Exercise-induced oxidative stress and melatonin supplementation: current evidence

Melatonin possesses the indoleamine structure and exerts antioxidant and anti-inflammatory actions and other physiological properties. Physical exercise can influence secretion of melatonin. Melatonin is used as a natural supplement among athletes to regulate sleep cycles and protect muscles against oxidative damage. Despite decades of research, there is still a lack of a comprehensive and critical review on melatonin supplementation and physical activity relationship. The aim of this literature review is to examine the antioxidant, anti-inflammatory and other biological functions played by melatonin with reference to the effect of physical exercise on melatonin secretion and the effect of this compound supplementation on exercise-induced oxidative stress in athletes. Evidence shows that intense exercises disturb antioxidant status of competitive athletes, whereas supplementation with melatonin strengthens antioxidant status in trained athletes in various sports as the compound showed high potency in reduction of the oxidative stress and inflammation markers generated during intense and prolonged exercise.

Natural Supplements for COVID19-Background, Rationale, and Clinical Trials

Worldwide, the turmoil of the SARS-CoV-2 (COVID-19) pandemic has generated a burst of research efforts in search of effective prevention and treatment modalities. Current recommendations on natural supplements arise from mostly anecdotal evidence in other viral infections and expert opinion, and many clinical trials are ongoing. Here the authors review the evidence and rationale for the use of natural supplements for prevention and treatment of COVID-19, including those with potential benefit and those with potential harms. Specifically, the authors review probiotics, dietary patterns, micronutrients, antioxidants, polyphenols, melatonin, and cannabinoids. Authors critically evaluated and summarized the biomedical literature published in peer-reviewed journals, preprint servers, and current guidelines recommended by expert scientific governing bodies. Ongoing and future trials registered on clinicaltrials.gov were also recorded, appraised, and considered in conjunction with the literature findings. In light of the controversial issues surrounding the manufacturing and marketing of natural supplements and limited scientific evidence available, the authors assessed the available data and present this review to equip clinicians with the necessary information regarding the evidence for and potential harms of usage to promote open discussions with patients who are considering dietary supplements to prevent and treat COVID-19.

Melatonin Related Acneiform Lesions: A Case Report and Potential Mechanism

Melatonin (MLT) is a hormone secreted by the pineal gland according to the circadian rhythm, which is generated by the suprachiasmatic nucleus. The sleep-promoting effect of exogenous MLT is used to treat sleep disorders. The most common side effects reported are headache, somnolence, palpitations, and abdominal pain. Some studies showed dermatological side effects with the use of exogenous MLT, but did not list the specific symptoms. In this article, we describe a case of facial acne occurring after the use of MLT, which is generally known to have protective and healing effects on the skin, and the potential mechanism of this surprising side effect.

The Effects of Melatonin Supplementation on Sleep Quality and Assessment of the Serum Melatonin in ICU Patients: A Randomized Controlled Trial

OBJECTIVES

To evaluate whether the use of exogenous melatonin affects sleep, reduces the prevalence of delirium, and decreases the need for analgosedation and to assess whether serum melatonin indices correlate with exogenous administration in critically ill patients.

DESIGN

Double-blind, randomized, placebo-controlled study.

SETTING

Multicenter ICUs of two tertiary hospitals.

PATIENTS

A total of 203 adult patients who were admitted to the ICU and administered with analgesics and/or sedatives.

INTERVENTIONS

Oral melatonin (10 mg) or placebo for up to seven consecutive nights.

MEASUREMENTS AND MAIN RESULTS

The number of observed sleeping hours at night was assessed by the bedside nurse. Sleep quality was evaluated using the Richards Campbell Questionnaire Sleep (RCSQ). The prevalence of delirium, pain, anxiety, adverse reactions, duration of mechanical ventilation, length of ICU and hospital stays, and doses of sedative and analgesic drugs administered were recorded. The use of analgesics and sedatives was assessed daily. Melatonin levels were determined by enzyme-linked immunosorbent assay. Based on the RCSQ results, sleep quality was assessed to be better in the melatonin group than that in the placebo group with a mean (SD) of 69.7 (21.2) and 60.7 (26.3), respectively (p = 0.029). About 45.8% and 34.4% of participants in the melatonin and placebo groups had very good sleep (risk ratio, 1.33; 95% CI, 0.94-1.89), whereas 3.1% and 14.6% had very poor sleep (risk ratio, 0.21; 95% CI, 0.06-0.71), respectively. No significant difference was observed regarding the days free of analgesics or sedatives, the duration of night sleep, and the occurrence of delirium, pain, and anxiety. Melatonin serum peak levels at 2 AM were 150 pg/mL (range, 125-2,125 pg/mL) in the melatonin group and 32.5 pg/mL (range, 18.5-35 pg/mL) in the placebo group (p < 0.001).

CONCLUSIONS

Melatonin was associated with better sleep quality, which suggests its possible role in the routine care of critically ill patients in the future.

Melatonin as a Topical/Systemic Formulation for the Management of Periodontitis: A Systematic Review

OBJECTIVES

To qualitatively and quantitatively review the use of melatonin as a topical/systemic formulation for the management of periodontitis.

MATERIALS AND METHODS

PubMed; Scopus; and Web of Science databases were searched using the MesH terms "melatonin" and "periodontitis". Title and abstracts were screened to eliminate irrelevant and duplicate articles. The full text data of the screened articles were assessed using the selection criteria.

RESULTS

Of 176 identified articles (PubMed-66; Scopus-56; Web of Science-52; Cross-reference-2), only 12 studies qualified to be included in the systematic review. Four studies assessed the independent effect of 1% topical melatonin formulation while 8 articles assessed the adjunctive use of systemic melatonin formulation (1-10 mg) following scaling and root planing (SRP). All studies showed an improvement in periodontal parameters such as pocket depth, clinical attachment loss, periodontal disease index, community periodontal index, gingival bleeding scores, and prognostic marker levels in saliva and serum. A meta-analysis of data from 2 studies revealed that 1-2 mg (systemic) melatonin supplementation reduced pocket depth; although the difference was not statistically significant and hence cannot be interpreted or used for conclusive evidence. Risk of Bias Assessment tool (RoBANS) and Cochrane Collaboration RoB tool elicited a high risk of bias in the included studies. GRADE (recommendation assessment, development, and evaluation) inferred a weak recommendation for the use of melatonin in periodontitis management.

CONCLUSIONS

Melatonin supplementation (topical and systemic) in periodontitis patients improved key periodontal parameters including pocket depth and clinical attachment loss.

CLINICAL RELEVANCE

Melatonin could be a potential host modulatory agent for periodontitis management; although the data from the present review should be interpreted carefully due to the associated high risk of bias.

Pharmacokinetics of exogenous melatonin in relation to formulation, and effects on sleep: A systematic review

There is conflicting evidence on the clinical efficacy of exogenous melatonin for the treatment of sleep disorders. This may be due to differences in the pharmacokinetic (PK) properties of melatonin formulations used in clinical trials. The aim of this systematic review was to understand the relationship between melatonin formulations and PK parameters and, where possible, the effects on sleep outcomes. To this purpose, we conducted a systematic review and nineteen papers were included. The studies included three melatonin transdermal formulation, thirteen oral formulations, one topical, two buccal, two intravenous and two nasogastric formulations. Seven studies investigated the effect of the melatonin formulation on sleep and six of them found a significant improvement in one or more sleep parameters. The potential for an improved controlled release formulation that delays maximum concentration (C_max) was identified. The different formulations and doses affect melatonin PK, suggesting that treatment efficacy maybe affected. Based on the current evidence, we are unable to provide recommendations of specific melatonin formulations and PK parameters for specific sleep disorders. Future studies should systematically investigate how different PK parameters of melatonin formulations affect efficacy treatment of sleep as well as circadian disorders.

Relationships between the changes in sleep patterns and sleep quality among Chinese people during the 2019 coronavirus disease outbreak

Objective

Rapidly increasing numbers of confirmed cases and deaths during the 2019 coronavirus disease outbreak (COVID-19) resulted in widespread psychological problems in the Chinese population. The purpose of this study was to investigate the sleep quality and changes in sleep patterns before and during the outbreak in the general population in China and to determine factors related to sleep quality.

Methods

This cross-sectional study was conducted using an online questionnaire from 20 February to 29 February 2020 in China. Socio-demographic data, self-designed COVID-19-related characteristics, sleep patterns, and Pittsburgh Sleep Quality Index (PSQI) scores were obtained. Single factor analysis and multivariate binary logistic regression analysis were used.

Results

A total of 1897 individuals were included in our study, and 30.0% of participants reported suffering poor sleep quality (PSQI≥8). Logistic regression analysis found that the factors related to sleep quality included poor physical health (OR = 3.382, p < 0.001), respiratory disease (OR = 1.629, p = 0.008), other diseases (OR = 2.504, p = 0.012), suspected case of COVID-19 in the same community (OR = 1.928, p = 0.002), confirmed case of COVID-19 in the same community (OR = 2.183, p = 0.007), worry about being infected (OR = 2.336, p < 0.001), ≥1 h/day spent hearing COVID-19 information (OR = 1.960, p < 0.001), time difference in midpoint time in bed (OR = 1.230, p < 0.001), and time difference in time in bed (OR = 0.711, p < 0.001).

Conclusions

Our study revealed that more than one-fourth of the participants suffered poor sleep quality during the COVID-19 outbreak. In addition to the poor health status and COVID-19-related anxiety, delayed sleep phase and reduced time in bed impacted sleep quality in the general population in China.

Is Melatonin the Cornucopia of the 21st Century?

Melatonin, an indoleamine hormone produced and secreted at night by pinealocytes and extra-pineal cells, plays an important role in timing circadian rhythms (24-h internal clock) and regulating the sleep/wake cycle in humans. However, in recent years melatonin has gained much attention mainly because of its demonstrated powerful lipophilic antioxidant and free radical scavenging action. Melatonin has been proven to be twice as active as vitamin E, believed to be the most effective lipophilic antioxidant. Melatonin-induced signal transduction through melatonin receptors promotes the expression of antioxidant enzymes as well as inflammation-related genes. Melatonin also exerts an immunomodulatory action through the stimulation of high-affinity receptors expressed in immunocompetent cells. Here, we reviewed the efficacy, safety and side effects of melatonin supplementation in treating oxidative stress- and/or inflammation-related disorders, such as obesity, cardiovascular diseases, immune disorders, infectious diseases, cancer, neurodegenerative diseases, as well as osteoporosis and infertility.

The Circadian Hormone Melatonin Inhibits Morphine-Induced Tolerance and Inflammation via the Activation of Antioxidative Enzymes

Opioids are commonly prescribed for clinical pain management; however, dose-escalation, tolerance, dependence, and addiction limit their usability for long-term chronic pain. The associated poor sleep pattern alters the circadian neurobiology, and further compromises the pain management. Here, we aim to determine the correlation between constant light exposure and morphine tolerance and explore the potential of melatonin as an adjuvant of morphine for neuropathic pain treatment. Methods: Wistar rats were preconditioned under constant light (LL) or a regular light/dark (LD) cycle before neuropathic pain induction by chronic constriction injury. An intrathecal (i.t.) osmotic pump was used for continued drug delivery to induce morphine tolerance. Pain assessments, including the plantar test, static weight-bearing symmetry, and tail-flick latency, were used to determine the impact of the light disruption or exogenous melatonin on the morphine tolerance progression. Results: constant light exposure significantly aggravates morphine tolerance in neuropathic rats. Continued infusion of low-dose melatonin (3 μg/h) attenuated morphine tolerance in both neuropathic and naïve rats. This protective effect was independent of melatonin receptors, as shown by the neutral effect of melatonin receptors inhibitors. The transcriptional profiling demonstrated a significant enhancement of proinflammatory and pain-related receptor genes in morphine-tolerant rats. In contrast, this transcriptional pattern was abolished by melatonin coinfusion along with the upregulation of the Kcnip3 gene. Moreover, melatonin increased the antioxidative enzymes SOD2, HO-1, and GPx1 in the spinal cord of morphine-tolerant rats. Conclusion: Dysregulated circadian light exposure significantly compromises the efficacy of morphine’s antinociceptive effect, while the cotreatment with melatonin attenuates morphine tolerance/hyperalgesia development. Our results suggest the potential of melatonin as an adjuvant of morphine in clinical pain management, particularly in patients who need long-term opioid treatment.

Management of Sleep Disturbances Associated with Smith-Magenis Syndrome

Smith-Magenis syndrome is a genetic disorder caused by a microdeletion involving the retinoic acid-induced 1 (RAI1) gene that maps on the short arm of chromosome 17p11.2 or a pathogenic mutation of RAI1. Smith-Magenis syndrome affects patients through numerous congenital anomalies, intellectual disabilities, behavioral challenges, and sleep disturbances. The sleep abnormalities associated with Smith-Magenis syndrome can include frequent nocturnal arousals, early morning awakenings, and sleep attacks during the day. The sleep problems associated with Smith-Magenis syndrome are attributed to haploinsufficiency of the RAI1 gene. One consequence of reduced function of RAI1, and characteristic of Smith-Magenis syndrome, is an inversion of melatonin secretion resulting in a diurnal rather than nocturnal pattern. Treatment of sleep problems in people with Smith-Magenis syndrome generally involves a combination of sleep hygiene techniques, supplemental melatonin, and/or other medications, such as melatonin receptor agonists, β₁-adrenergic antagonists, and stimulant medications, to improve sleep outcomes. Improvement in sleep has been shown to improve behavioral outcomes, which in turn improves the quality of life for both patients and their caregivers.

Dietary Ingredients as an Alternative Approach for Mitigating Chronic Musculoskeletal Pain: Evidence-Based Recommendations for Practice and Research in the Military

OBJECTIVE

Approximately 55-76% of Service members use dietary supplements for various reasons, including pain and related outcomes. This work evaluates current research on dietary ingredients for chronic musculoskeletal pain to inform decisions for practice and self-care, specifically for Special Operations Forces personnel.

METHODS

A steering committee convened to develop research questions and factors required for decision-making. Key databases were searched through August 2016. Eligible systematic reviews and randomized controlled trials were assessed for methodological quality. Meta-analysis was applied where feasible. GRADE was used to determine confidence in the effect estimates. The committee made evidence-informed judgments and recommendations for practice and self-care use.

RESULTS

Nineteen eligible dietary ingredients were assessed for quality, efficacy, and safety. Avocado soybean unsaponifiables, capsaicin, curcuma, ginger (as a food source), glucosamine, melatonin, polyunsaturated fatty acids, and vitamin D were conditionally recommended as their benefits outweighed risks, but there was still some uncertainty about the trade-offs. No recommendations were made for boswellia, ginger (as a dietary supplement), rose hip, or s-adenosyl-L-methionine. Recommendations were made against the use of collagen, creatine, devil's claw, l-carnitine, methylsulfonylmethane, pycnogenol, willow bark extract, and vitamin E. Research priorities were developed to address gaps precluding stronger recommendations.

CONCLUSIONS

Currently the scientific evidence is insufficiently robust to establish definitive clinical practice guidelines, but processes could be established to track the impact of these ingredients. Until then, providers have the evidence needed to make informed decisions about the safe use of these dietary ingredients, and future research can address existing gaps.

The efficacy of melatonin and melatonin agonists in insomnia - An umbrella review

We conducted an umbrella review to summarize all available systematic reviews and meta-analyses investigating the efficacy of melatonin and melatonin agonists in primary and comorbid insomnia disorders. Two independent reviewers conducted a search of Pubmed, EMBASE, Cochrane Database of Systematic Reviews, Google Scholar, PROSPERO and grey literature from inception to July 2018. Methodological quality was assessed using the revised Assessment of Multiple Systematic Reviews Instrument. Eighteen studies were found, with methodological quality ranging from Moderate to Critically Low. Of the twelve papers evaluating melatonin, there is statistically significant improvement in sleep latency and total sleep time, with a lack of consensus on whether these are clinically meaningful. Similar results are observed across the three reviews on ramelteon. The evidence for other melatonin agonists is sparse. We conclude that existing evidence is limited by disparate methodological quality of the papers, as well as a lack of consensus regarding the type, definition and interpretation of outcome measures in the evaluation of efficacy for insomnia.

Adverse Events Associated with Melatonin for the Treatment of Primary or Secondary Sleep Disorders: A Systematic Review

BACKGROUND

Melatonin is widely available either on prescription for the treatment of sleep disorders or as an over-the-counter dietary supplement. Melatonin has also recently been licensed in the UK for the short-term treatment of jetlag. Little is known about the potential for adverse events (AEs), in particular AEs resulting from long-term use. Concern has been raised over the possible risks of exposure in certain populations including pre-adolescent children and patients with epilepsy or asthma.

OBJECTIVES

The aim of this systematic review was to assess the evidence for AEs associated with short-term and longer-term melatonin treatment for sleep disorders.

METHODS

A literature search of the PubMed/Medline database and Google Scholar was conducted to identify randomised, placebo-controlled trials (RCTs) of exogenous melatonin administered for primary or secondary sleep disorders. Studies were included if they reported on both the types and frequencies of AEs. Studies of pre-term infants, studies of < 1 week in duration or involving single doses of melatonin and studies in languages other than English were excluded. Findings from open-label studies that raised concerns relating to AE reports in patients were also examined. Studies were assessed for quality of reporting against the Consolidated Standards of Reporting Trials (CONSORT) checklist and for risk of bias against the Cochrane Collaboration risk-of-bias criteria.

RESULTS

37 RCTs met criteria for inclusion. Daily melatonin doses ranged from 0.15 mg to 12 mg. Subjects were monitored for up to 29 weeks, but most studies were of much shorter duration (4 weeks or less). The most frequently reported AEs were daytime sleepiness (1.66%), headache (0.74%), other sleep-related AEs (0.74%), dizziness (0.74%) and hypothermia (0.62%). Very few AEs considered to be serious or of clinical significance were reported. These included agitation, fatigue, mood swings, nightmares, skin irritation and palpitations. Most AEs either resolved spontaneously within a few days with no adjustment in melatonin, or immediately upon withdrawal of treatment. Melatonin was generally regarded as safe and well tolerated. Many studies predated publication of the CONSORT checklist and consequently did not conform closely to the guidelines. Similarly, only eight studies were judged 'good' overall with respect to the Cochrane risk-of-bias criteria. Of the remaining papers, 16 were considered 'fair' and 13 'poor' but publication of almost half of the papers preceded that of the earliest version of the guidelines.

CONCLUSION

Few, generally mild to moderate, AEs were associated with exogenous melatonin. No AEs that were life threatening or of major clinical significance were identified. The scarcity of evidence from long-term RCTs, however, limits the conclusions regarding the safety of continuous melatonin therapy over extended periods. There are insufficient robust data to allow a meaningful appraisal of concerns that melatonin may result in more clinically significant adverse effects in potentially at-risk populations. Future studies should be designed to comply with appropriate quality standards for RCTs, which most past studies have not.

Comparative effectiveness and safety of pharmacological and non-pharmacological interventions for insomnia: an overview of reviews

BACKGROUND

This review aimed to assess the existing evidence regarding the clinical effectiveness and safety of pharmacological and non-pharmacological interventions in adults with insomnia and identify where research or policy development is needed.

METHODS

MEDLINE, Embase, PsycINFO, The Cochrane Library, and PubMed were searched from inception until June 14, 2017, along with relevant gray literature sites. Two reviewers independently screened titles/abstracts and full-text articles, and a single reviewer with an independent verifier completed charting, data abstraction, and quality appraisal.

RESULTS

A total of 64 systematic reviews (35 with meta-analysis) were included after screening 5024 titles and abstracts and 525 full-text articles. Eight of the included reviews were rated as high quality using the Assessment of Multiple Systematic Reviews 2 (AMSTAR2) tool, and over half of the included articles (n = 40) were rated as low or critically low quality. Consistent evidence of effectiveness across multiple outcomes based on more than one high- or moderate quality review with meta-analysis was found for zolpidem, suvorexant, doxepin, melatonin, and cognitive behavioral therapy (CBT), and evidence of effectiveness across multiple outcomes based on one high-quality review with meta-analysis was found for temazepam, triazolam, zopiclone, trazodone, and behavioral interventions. These interventions were mostly evaluated in the short term (< 16 weeks), and there was very little harms data available for the pharmacological interventions making it difficult to evaluate their risk-benefit ratio.

CONCLUSIONS

Assuming non-pharmacological interventions are preferable from a safety perspective CBT can be considered an effective first-line therapy for adults with insomnia followed by other behavioral interventions. Short courses of pharmacological interventions can be supplements to CBT or behavioral therapy; however, no evidence regarding the appropriate duration of pharmacological therapy is available from these reviews.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42017072527.

Comparative effectiveness and safety of pharmacological and non-pharmacological interventions for insomnia: an overview of reviews

BACKGROUND

This review aimed to assess the existing evidence regarding the clinical effectiveness and safety of pharmacological and non-pharmacological interventions in adults with insomnia and identify where research or policy development is needed.

METHODS

MEDLINE, Embase, PsycINFO, The Cochrane Library, and PubMed were searched from inception until June 14, 2017, along with relevant gray literature sites. Two reviewers independently screened titles/abstracts and full-text articles, and a single reviewer with an independent verifier completed charting, data abstraction, and quality appraisal.

RESULTS

A total of 64 systematic reviews (35 with meta-analysis) were included after screening 5024 titles and abstracts and 525 full-text articles. Eight of the included reviews were rated as high quality using the Assessment of Multiple Systematic Reviews 2 (AMSTAR2) tool, and over half of the included articles (n = 40) were rated as low or critically low quality. Consistent evidence of effectiveness across multiple outcomes based on more than one high- or moderate quality review with meta-analysis was found for zolpidem, suvorexant, doxepin, melatonin, and cognitive behavioral therapy (CBT), and evidence of effectiveness across multiple outcomes based on one high-quality review with meta-analysis was found for temazepam, triazolam, zopiclone, trazodone, and behavioral interventions. These interventions were mostly evaluated in the short term (< 16 weeks), and there was very little harms data available for the pharmacological interventions making it difficult to evaluate their risk-benefit ratio.

CONCLUSIONS

Assuming non-pharmacological interventions are preferable from a safety perspective CBT can be considered an effective first-line therapy for adults with insomnia followed by other behavioral interventions. Short courses of pharmacological interventions can be supplements to CBT or behavioral therapy; however, no evidence regarding the appropriate duration of pharmacological therapy is available from these reviews.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42017072527.

Sleep – the yet underappreciated player in cardiovascular diseases: A clinical review from the German Cardiac Society Working Group on Sleep Disordered Breathing

Patients with a wide variety of cardiovascular diseases, including arterial and pulmonary hypertension, arrhythmia, coronary artery disease and heart failure, are more likely to report impaired sleep with reduced sleep duration and quality, and also, sometimes, sleep interruptions because of paroxysmal nocturnal dyspnoea or arrhythmias. Overall, objective short sleep and bad sleep quality (non-restorative sleep) and subjective long sleep duration are clearly associated with major cardiovascular diseases and fatal cardiovascular outcomes. Sleep apnoea, either obstructive or central in origin, represents the most prevalent, but only one, of many sleep-related disorders in cardiovascular patients. However, observations suggest a bidirectional relationship between sleep and cardiovascular diseases that may go beyond what can be explained based on concomitant sleep-related disorders as confounding factors. This makes sleep itself a modifiable treatment target. Therefore, this article reviews the available literature on the association of sleep with cardiovascular diseases, and discusses potential pathophysiological mechanisms. In addition, important limitations of the current assessment, quantification and interpretation of sleep in patients with cardiovascular disease, along with a discussion of suitable study designs to address future research questions and clinical implications are highlighted. There are only a few randomised controlled interventional outcome trials in this field, and some of the largest studies have failed to demonstrate improved survival with treatment (with worse outcomes in some cases). In contrast, some recent pilot studies have shown a benefit of treatment in selected patients with underlying cardiovascular diseases.

Update on Research and Practices in Major Sleep Disorders: Part II-Insomnia, Willis-Ekbom Disease (Restless Leg Syndrome), and Narcolepsy

PURPOSE

This review (Part II of a series on sleep disorders) presents an update of the characteristics, epidemiology, assessment, and latest management of insomnia, restless legs syndrome (Willis-Ekbom disease; RLS/WED), and narcolepsy. Insomnia, the most common sleep disorder and most prevalent of all psychological health disorders, is a problem of difficulty initiating and maintaining sleep and early morning awakenings. RLS/WED is characterized by a crawling sensation or urge to move the legs in the evening and nighttime. Narcolepsy is a sleep disorder that commonly results in chronic daytime sleepiness and cataplexy. Nonpharmacological management, which includes education, cognitive behavioral therapy, and complementary therapy, is used as primary or adjunctive to pharmacotherapy for the treatment of these disorders.

METHODS

This narrative review utilized medical databases such as PubMed to identify relevant English-language original and systematic review articles predominantly from peer-reviewed journals from 2012 to 2019. However, as background, findings from classic articles prior to 2012 were also included.

CLINICAL RELEVANCE

Assessment of sleep problems, excessive sleepiness, and difficulty performing activities or being productive should be routine in the care of all patients. Utilization of behavioral interventions, including cognitive behavioral therapy, in addition to education and sleep hygiene, can promote sleep quality. Management of insomnia, RLS/WED, and narcolepsy should include helping patients adjust to treatment, managing cataplexy triggers in narcolepsy, and initiating strategies to live with chronic illness to improve quality of life.

Characteristics of stakeholder involvement in systematic and rapid reviews: a methodological review in the area of health services research

OBJECTIVE

Engaging stakeholders in reviews is considered to generate more relevant evidence and to facilitate dissemination and use. As little is known about stakeholder involvement, we assessed the characteristics of their engagement in systematic and rapid reviews and the methodological quality of included studies. Stakeholders were people with a particular interest in the research topic.

DESIGN

Methodological review.

SEARCH STRATEGY

Four databases (Medline, Embase, Cochrane database of systematic reviews, databases of the University of York, Center for Reviews and Dissemination (CRD)) were searched based on an a priori protocol. Four types of reviews (Cochrane and non-Cochrane systematic reviews, rapid and CRD rapid reviews) were retrieved between January 2011 and October 2015, pooled by potential review type and duplicates excluded. Articles were randomly ordered and screened for inclusion and exclusion criteria until 30 reviews per group were reached. Their methodological quality was assessed using AMSTAR and stakeholder characteristics were collected.

RESULTS

In total, 57 822 deduplicated citations were detected with potential non-Cochrane systematic reviews being the biggest group (56 986 records). We found stakeholder involvement in 13% (4/30) of Cochrane, 20% (6/30) of non-Cochrane, 43% (13/30) of rapid and 93% (28/30) of CRD reviews. Overall, 33% (17/51) of the responding contact authors mentioned positive effects of stakeholder involvement. A conflict of interest statement remained unmentioned in 40% (12/30) of non-Cochrane and in 27% (8/30) of rapid reviews, but not in Cochrane or CRD reviews. At most, half of non-Cochrane and rapid reviews mentioned an a priori study protocol in contrast to all Cochrane reviews.

CONCLUSION

Stakeholder engagement was not general practice, except for CRD reviews, although it was more common in rapid reviews. Reporting factors, such as including an a priori study protocol and a conflict of interest statement should be considered in conjunction with involving stakeholders.

Melatonin: An important anticancer agent in colorectal cancer

Colorectal cancer is one of the most common cancers among the elderly, which is also seen in the forms of hereditary syndromes occurring in younger individuals. Numerous studies have been conducted to understand the molecular and cellular pathobiology underlying colorectal cancer. These studies have found that cellular signaling pathways are at the core of colorectal cancer pathology. Because of this, new agents have been proposed as possible candidates to accompany routine therapy regimens. One of these agents is melatonin, a neuro-hormone known best for its essential role in upholding the circadian rhythm and orchestrating the many physiologic changes it accompanies. Melatonin is shown to be able to modulate many signaling pathways involved in many essential cell functions, which if deregulated cause an accelerated pace towards cancer. More so, melatonin is involved in the regulation of immune function, tumor microenvironment, and acts as an antioxidant agent. Many studies have focused on the beneficial effects of melatonin in colorectal cancers, such as induction of apoptosis, increased sensitivity to chemotherapy agents and radiotherapy, limiting cellular proliferation, migration, and invasion. The present review aims to illustrate the known significance of melatonin in colorectal cancer and to address possible clinical use.

Insomnia in patients with schizophrenia: current understanding and treatment options

In patients with schizophrenia, insomnia is a common yet often overlooked comorbidity. With sleep disturbances inextricably linked to increased severity of schizophrenia and worsening clinical outcomes, insomnia is an important therapeutic target within this patient population. Thus, through a review of the current literature, this paper reiterates the important etiological link between these two conditions, while evaluating the safety, efficacy, and limitations of current therapeutic options for the treatment of comorbid insomnia in schizophrenia. Despite the continued use of benzodiazepine receptor agonists (BZRAs) for insomnia, the use of other therapies such as Cognitive Behavioral Therapy for Insomnia (CBT-I) and suvorexant warrants increased consideration. More large-scale clinical trials are needed to assess the efficacy of such therapeutic options in the schizophrenia patient population.

Melatonin Increases Brown Adipose Tissue Volume and Activity in Patients With Melatonin Deficiency: A Proof-of-Concept Study

Melatonin, a pineal hormone synthesized at night, is critical for the synchronization of circadian and seasonal rhythms, being a key regulator of energy metabolism in many animal species. Although studies in humans are lacking, several reports, mainly on hibernating animals, demonstrated that melatonin supplementation and a short photoperiod increase brown adipose tissue (BAT) mass. The present proof-of-concept study is the first, to our knowledge, to evaluate BAT in patients with melatonin deficiency (radiotherapy or surgical removal of pineal gland) before and after daily melatonin (3 mg) replacement for 3 months. All four studied patients presented increased BAT volume and activity measured by positron emission tomography-MRI. We also found an improvement in total cholesterol and triglyceride blood levels without significant effects on body weight, liver fat, and HDL and LDL levels. Albeit not statistically significant, fasting insulin levels and HOMA of insulin resistance decreased in all four patients. The present results show that oral melatonin replacement increases BAT volume and activity and improves blood lipid levels in patients with melatonin deficiency, suggesting that melatonin is a possible BAT activator. Future studies are warranted because hypomelatoninemia is usually present in aging and appears as a result of light-at-night exposure and/or the use of β-blocker drugs.

Melatonin Affects Mitochondrial Fission/Fusion Dynamics in the Diabetic Retina

Mitochondrial fission and fusion are dependent on cellular nutritional states, and maintaining this dynamics is critical for the health of cells. Starvation triggers mitochondrial fusion to maintain bioenergetic efficiency, but during nutrient overloads (as with hyperglycemic conditions), fragmenting mitochondria is a way to store nutrients to avoid waste of energy. In addition to ATP production, mitochondria play an important role in buffering intracellular calcium (Ca2+). We found that in cultured 661W cells, a photoreceptor-derived cell line, hyperglycemic conditions triggered an increase of the expression of dynamin-related protein 1 (DRP1), a protein marker of mitochondrial fission, and a decrease of mitofusin 2 (MFN2), a protein for mitochondrial fusion. Further, these hyperglycemic cells also had decreased mitochondrial Ca2+ but increased cytosolic Ca2+. Treating these hyperglycemic cells with melatonin, a multifaceted antioxidant, averted hyperglycemia-altered mitochondrial fission-and-fusion dynamics and mitochondrial Ca2+ levels. To mimic how people most commonly take melatonin supplements, we gave melatonin to streptozotocin- (STZ-) induced type 1 diabetic mice by daily oral gavage and determined the effects of melatonin on diabetic eyes. We found that melatonin was not able to reverse the STZ-induced systemic hyperglycemic condition, but it prevented STZ-induced damage to the neural retina and retinal microvasculature. The beneficial effects of melatonin in the neural retina in part were through alleviating STZ-caused changes in mitochondrial dynamics and Ca2+ buffering.

Effect of Radiance-Dimmer Devices Simulating Natural Sunlight Rhythm on the Plasma Melatonin Levels and Anxiety and Depression Scores of the Submarine Personnel

Objective: Not perceiving circadian shifts of sunlight due to living in enclosed environments may have deleterious effects on mental health and plasma parameters. This study aimed to determine the effect of dim regulation on the submarine personnel of Iranian Navy forces by radiating devices according to natural circadian sunlight shifts. Also, this study aimed to investigate the impact of mimicking sunlight circadian by artificial radiance luminating devices on the serological and psychological measures of submarine personnel. Method : Participants were randomly assigned to experimental and control groups in this non-randomized controlled trial. There were 26 participants in each group, and they were all male aged 21-29 years. Both groups were living in the submarine underground hall, with 120 meters 2 area with constant radiance with the same intensity. The experimental group had been given extra lighting devices with changing radiance intensity according to the natural sunlight circadian cycles. Plasma melatonin levels and depression and anxiety scores were determined before and after the experiment for both groups. Minnesota Multiphasic Personality Inventory (MMPI) and Cattell's Anxiety Scale Questionnaire (IPAT) were used to measure depression and anxiety, respectively. Results: Findings indicate that the plasma melatonin levels (-16.2±13.6 vs 8.0±9.3 mg/dL, respectively; p<0.001), depression scores (-6±6 vs 3.9±5.4, respectively; p<0.001), and anxiety scores (-1±1.2 vs 0.73±1.04, respectively; p<0.001) significantly reduced in the experimental group compared to the control group. Conclusion: Using radiance dimmers, with a radiance intensity regularity according to the sunlight, is effective in improving psychiatric and plasma parameters and can be used in closed occupational environments such as underground environments and submarine halls.

Psychogenic stress in hospitalized veterinary patients: Causation, implications, and therapies

OBJECTIVE

To review the sources, adverse effects, diagnosis, treatment, and prevention of psychogenic stress in hospitalized human and veterinary patients.

DATA SOURCES

Data were collected by searching PubMed for veterinary and human literature from the past 10 years.

HUMAN DATA SYNTHESIS

Psychogenic stress has been linked to immune suppression; gastrointestinal, cardiovascular, and cutaneous diseases; delayed wound healing; alterations in pain perception; and neurologic impairment. Sources of psychogenic stress include environmental alterations such as excessive noise and light, social and physical factors, sleep disruption, drugs, and underlying disease. Nonpharmacologic options for stress reduction include environmental and treatment modifications, music therapy, and early mobilization. Pharmacologic options include sedation with benzodiazepines and dexmedetomidine. Trazodone and melatonin have been examined for use in sleep promotion but are not currently recommended as standard treatments in ICU.

VETERINARY DATA SYNTHESIS

Activation of the stress response in veterinary patients is largely the same as in people, as are the affected body systems. Possible sources of stress can include social, physical, and environmental factors. No gold standard currently exists for the identification and quantification of stress. A combination of physical examination findings and the results of serum biochemistry, CBC, and biomarker testing can be used to support the diagnosis. Stress scales can be implemented to identify stressed patients and assess severity. Nonpharmacologic treatment options include low-stress handling, pheromones, environmental modifications, and sleep promotion. Pharmacologic options include trazodone, benzodiazepines, dexmedetomidine, and melatonin.

CONCLUSION

The prevalence and clinical significance of psychogenic stress in hospitalized veterinary patients is unknown. Future studies are needed to specifically examine the causative factors of psychogenic stress and the effects of various therapies on stress reduction. The recognition and reduction of psychogenic stress in veterinary patients can lead to improvements in patient care and welfare.

[CME: Jet Lag Jetlag]

CME: Jet Lag Jetlag Abstract. Crossing several time zones by air travel leads to a temporary desynchronization of the internal clock with the external light/dark cycle. In the following jet lag occurs typically including difficulties falling asleep or waking up early as well as day-time sleepiness and significant reduction of wellbeing and fitness. To provide optimal medical advice, it is necessary to understand the human circadian rhythm and sleep-wake regulation. In consideration with additional information on travel plans, an approach to alleviate jet lag symptoms can be developed. This article addresses different supportive measures and advice on how to adjust to a new time zone and reduce jet lag symptoms.

Is Hyperbaric Oxygen Therapy Effective for Traumatic Brain Injury? A Rapid Evidence Assessment of the Literature and Recommendations for the Field

Supplemental Digital Content is Available in the Text.

Objective:

This systematic review examines the efficacy of hyperbaric oxygen (HBO₂) for traumatic brain injury (TBI) to make evidence-based recommendations for its application and future research.

Methods:

A comprehensive search was conducted to identify studies through 2014. Methodological quality was assessed and synthesis and interpretation of relevant data was performed.

Results:

Twelve randomized trials were included. All mild TBI studies demonstrated minimal bias and no statistically significant differences between HBO₂ and sham arms. Statistically significant improvement occurred over time within both groups. Moderate-to-severe TBI studies were of mixed quality, with majority of results favoring HBO₂ compared with “standard care.” The placebo analysis conducted was limited by lack of details.

Conclusions:

For mild TBI, results indicate HBO₂ is no better than sham treatment. Improvements within both HBO₂ and sham groups cannot be ignored. For acute treatment of moderate-to-severe TBI, although methodology appears flawed across some studies, because of the complexity of brain injury, HBO₂ may be beneficial as a relatively safe adjunctive therapy if feasible. Further research should be considered to resolve the controversy surrounding this field, but only if methodological flaws are avoided and bias minimized.

Caffeine to optimize cognitive function for military mission-readiness: a systematic review and recommendations for the field

Context

In 2001 the Institute of Medicine (IOM) released a report on the use of caffeine during sustained military operations in which recommendations for research and practice were made.

Objective

This systematic review serves as an update on the current quality of the evidence and addresses gaps in the current literature surrounding the effects of caffeinated foods and beverages on cognitive functioning in healthy adult populations exposed to military-like moderators.

Data Sources

PubMed, CINAHL, Embase, PsycInfo, and the Cochrane Library were searched.

Study Selection

Peer-reviewed randomized controlled trials published in the English language since 1998 were eligible.

Data Extraction

Twenty-five trials were included and assessed for methodological quality, and descriptive data were extracted according to each military-like moderator identified.

Data Synthesis

Moderators included sleep deprivation (n = 17), physical or mental exertion (n = 4), sleep deprivation combined with a sustained military operation (n = 3), and physical exertion combined with low ambient temperature (n = 1).

Conclusions

The effects of caffeine supplementation on cognitive functioning in sleep-deprived subjects included improvements in attention and vigilance, complex reaction time, and problem solving and reasoning in the trials reviewed. These findings are consistent with the conclusions reached in the 2001 IOM report. This review contributes to the field by addressing gaps outlined in the IOM report.