Psychological distress of patients suffering from restless legs syndrome: a cross-sectional study

Prevalence and clinical correlates of restless legs syndrome in psychiatric patients: A cross-sectional study from North India

Background

Restless legs syndrome (RLS) is a neuro-sensorimotor disorder which is scarcely researched and is commonly missed in routine psychiatry practice.

Aim

To evaluate the prevalence of RLS and its correlates in patients with anxiety, depression, and somatoform disorders.

Methods

A cross-sectional single-center study was undertaken in patients aged 18-65 years suffering from ICD-10 (International Statistical Classification of Diseases-10th edition) diagnosis of anxiety, depressive, and somatoform disorders. RLS was evaluated by using diagnostic criteria of International Restless Legs Syndrome Study Group (IRLSSG) and severity measured on IRLSSG scale. Depression and anxiety were rated on Hamilton Depression and Anxiety Rating Scales respectively, insomnia severity measured by Insomnia Severity Index (ISI), and quality of life measured by WHO Quality of Life-Brief version (WHO-QOL BREF) scale. Serum ferritin levels were measured for evaluating iron deficiency.

Results

The rate of RLS was 66.7%, 50%, and 48% in patients with depressive, anxiety, and somatoform disorders, respectively, with no significant inter-group difference. Nearly one-third of patients suffered from severe to very severe symptoms of RLS, and quality of life was poorest in those with depressive disorders. RLS was significantly higher in females (P = 0.019), who were married (P = 0.040), diagnosed with severe depression (P = 0.029), and abused benzodiazepines (P = 0.045). On binary logistic regression, female gender and presence of clinical insomnia predicted occurrence of RLS.

Conclusion

The prevalence of RLS is very high in patients with common psychiatric disorders which is often missed. Clinical enquiry and examination for reversible causes such as iron deficiency may assist in its diagnosis and improve clinical outcome.

Assessment of Sleep Disturbances on Mental Health in Patients with Restless Legs Syndrome

Background and Objective

In our study, we aimed to evaluate the sleep disturbances of patients diagnosed with restless legs syndrome (RLS) regarding their mental health according to the severity of the disease.

Materials and Methods

The study included 166 patients diagnosed with RLS and 161 healthy controls in the same age interval as patients. Sleep disturbances of patients were defined with the "personal information form" (PIF) prepared by the researchers, while the mental health status of patients was defined with the "Brief Symptom Inventory" (BSI).

Results

All RLS patients had an increase in BSI subscale points, with a positive correlation to disease severity, and subscale points were significantly higher than the control group (p < 0.05). Those with the "frequent waking" problem had higher BSI subscale points compared to those without the problem (p<0.01 or 0.001). Those with "waking with respiratory distress," "daytime sleepiness," "very early waking," and "sleep disorder" problems had statistically significantly high BSI subscale points for all subscales, apart from hostility, compared to those without these problems (p<0.01 or 0.001).

Conclusion

It is considered that assessment of sleep disturbances causing disrupted quality of life and mood disorders is beneficial for the treatment of patients with RLS. Our study data appears to be related to the result that sleep disturbances and mental health disruptions might be associated with the disease severity among RLS patients.

Leveraging Accelerometry as a Prognostic Indicator for Increase in Opioid Withdrawal Symptoms

Treating opioid use disorder (OUD) is a significant healthcare challenge in the United States. Remaining abstinent from opioids is challenging for individuals with OUD due to withdrawal symptoms that include restlessness. However, to our knowledge, studies of acute withdrawal have not quantified restlessness using involuntary movements. We hypothesized that wearable accelerometry placed mid-sternum could be used to detect withdrawal-related restlessness in patients with OUD. To study this, 23 patients with OUD undergoing active withdrawal participated in a protocol involving wearable accelerometry, opioid cues to elicit craving, and non-invasive Vagal Nerve Stimulation (nVNS) to dampen withdrawal symptoms. Using accelerometry signals, we analyzed how movements correlated with changes in acute withdrawal severity, measured by the Clinical Opioid Withdrawal Scale (COWS). Our results revealed that patients demonstrating sinusoidal-i.e., predominantly single-frequency oscillation patterns in their motion almost exclusively demonstrated an increase in the COWS, and a strong relationship between the maximum power spectral density and increased withdrawal over time, measured by the COWS (R = 0.92, p = 0.029). Accelerometry may be used in an ambulatory setting to indicate the increased intensity of a patient's withdrawal symptoms, providing an objective, readily-measurable marker that may be captured ubiquitously.

Zinc and Magnesium Levels of Pregnant Women with Restless Leg Syndrome and Their Relationship with Anxiety: A Case-Control Study

Restless leg syndrome (RLS) is a multifactorial movement disorder, and pregnancy is seen as a risk factor. This study aims to determine the clinical and psychiatric causes of RLS with a case-control study. The hemogram, biochemistry data, thyroid function tests, and serum element levels of healthy pregnant women (n = 134) and pregnant women diagnosed with RLS (n = 119) were compared. Total Ca, Mg, K, and Na concentrations were measured with an inductively coupled plasma optical emission spectrometry (ICP-OES), and an atomic absorption spectrophotometer was used to measure total concentrations of Zn in all samples. The Beck Anxiety Inventory (BAI), the Beck Depression Inventory (BDI), and the Pittsburg Sleep Quality Index (PSQI) scores were also compared in both groups. Sonographic measurements showed that the fetal biparietal diameter and femur lengths were higher in the RLS group (p = 0.001, p = 0.048, respectively), and abortion history was higher in the RLS group (p = 0.016). Magnesium and zinc levels were lower (p < 0.001 for both) and BAI and PSQI scores were higher (p < 0.001 for both) in the RLS group, and there was no difference between the BDI (p = 0.269) scores. A statistically significant relationship was detected between the BAI and RLS scores in the control and RLS groups (p < 0.001 for both). This is the first study to show that magnesium and zinc deficiency may play a role in the etiology of RLS during pregnancy; the results also showed adverse perinatal outcomes such as high miscarriage.

Acupuncture and related techniques for restless legs syndrome: A protocol for systematic review and meta-analysis

BACKGROUND

Restless legs syndrome (RLS) is a common sensory disorder of the nervous system, which often affects the sleep quality of patients. Acupuncture and related techniques are increasingly used to treat neurological diseases, but their efficacy and safety for RLS are yet to be established. The purpose of this study is to summarize the effectiveness and safety of acupuncture and related techniques for RLS.

METHODS

We will conduct a comprehensive data retrieval, and the electronic databases will include PubMed, Embase, Cochrane Library, WangFang Database, China National Knowledge Infrastructure, Chinese Scientific Journal Database, Chinese Biomedical Literature Database, from establishment to October 2020. We will also manually search unpublished studies and references, and contact lead authors. Randomized clinical trials (RCTs) of acupuncture and related techniques for RLS will be included. The outcomes of interest include: The total effective rate and International Restless Leg Syndrome rating scale (IRLS), Pittsburgh Sleep Quality Index (PSQI), Hamilton Anxiety Scale (HAMA), Hamilton Depression Scale (HAMD), adverse events, quality of life. To assess the methodological quality, we will use the Cochrane risk assessment tool. RevMan 5.3.5 software will be used to conduct data synthesis. The evidence quality of each outcome will be appraised according to Grades of Recommendation, Assessment, Development, and Evaluation (GRADE).

RESULTS

The results will be published in a peer-reviewed journal.

CONCLUSION

This study will provide a high-quality evidence to evaluate the efficacy and adverse reactions of acupuncture and related techniques for RLS.

PROSPERO REGISTRATION NUMBER

CRD42020157957.

The Effects of Psychological and Environmental Stress on Micronutrient Concentrations in the Body: A Review of the Evidence

Stress is the nonspecific response of the body to any demand for change. Excess or chronic psychological or environmental stress is associated with an increased risk of mental and physical diseases, with several mechanisms theorized to be associated with its detrimental effects. One underappreciated potential mechanism relates to the effects of psychological and environmental stress on micronutrient concentrations. Micronutrients (vitamins and minerals) are essential for optimal physical and mental function, with deficiencies associated with an array of diseases. In this article, animal and human studies investigating the effects of various psychological and environmental stressors on micronutrient concentrations are reviewed. In particular, the effects of psychological stress, sleep deprivation, and physical exercise on micronutrient concentrations and micronutrient excretion are summarized. Micronutrients identified in this review include magnesium, zinc, calcium, iron, and niacin. Overall, the bulk of evidence suggests stress can affect micronutrient concentrations, often leading to micronutrient depletion. However, before definitive conclusions about the effects of stress can be made, the impact of different stressors, stress severity, and acute versus chronic stress on micronutrient concentrations requires investigation. Moreover, the impact of stress on micronutrients in different populations varying in age, gender, and premorbid health status and the durability of changes after a stressor is resolved require examination. The medical, physical, and psychological implications of nutrient changes caused by a stressor also remain to be determined.

The experience of living with restless legs syndrome: A qualitative study

Restless legs syndrome is a sensorimotor disorder that significantly affects quality of life. This study explored the experience of people living with restless legs syndrome. Focus groups were analysed thematically resulting in five themes. Participants described disempowerment in managing symptoms, difficulty coping and poor understanding of the condition. Participants tried many therapies with little relief and were unable to monitor treatment effects. Concerns with healthcare services were common. Feeling understood provided validation and empowerment. Healthcare providers can help people with restless legs syndrome by improving restless legs syndrome awareness, providing psychosocial support and education, and assisting people to monitor treatment effects.

Attention-Deficit Hyperactivity and Obsessive-Compulsive Symptoms in Adult Patients With Primary Restless Legs Syndrome: Different Phenotypes of the Same Disease?

OBJECTIVES

To investigate the prevalence of attention deficit hyperactivity disorder (ADHD) and obsessive-compulsive disorder (OCD) symptoms in adult patients with primary restless legs syndrome (RLS) and to determine the iron biological correlates of these comorbidities.

PARTICIPANTS AND METHODS

We obtained demographic and clinical data from consecutive 105 outpatients with idiopathic RLS who answered validated questionnaires designed to assess the presence of ADHD and OCD symptoms. In these patients, iron blood parameters were routinely checked.

RESULTS

Of the total sample, 42.86% of the patients with RLS showed symptoms reminiscent either of ADHD or OCD. Prevalence of ADHD and OCD symptoms was 27.62% and 7.62%, respectively. Compared to other groups, a significantly higher percentage of RLS patients with ADHD symptoms was on antidepressant (p = 0.012); and women with ADHD symptoms, either alone or combined with OCD symptoms, showed significant reduced ferritin concentrations compared to men with either isolated ADHD symptoms or with combined ADHD and OCD symptoms (p = 0.028 and p = 0.025, respectively).

CONCLUSIONS

Our findings highlight the high prevalence of ADHD and OCD symptoms in adult patients with primary RLS and independently of serum iron stores decrease, except for women with ADHD symptoms either alone or in combination with OCD symptoms. This may suggest an overlapping neurobiological dopaminergic and serotoninergic dysfunction in ADHD, OCD, and RLS, and question the expression of different RLS phenotypes. The efficacy of dopamine agonists in these groups of patients should be questioned in future studies.

Investigation of alexithymia and levels of anxiety and depression among patients with restless legs syndrome

PURPOSE

The purpose of this study was to examine alexithymia among restless legs syndrome (RLS) patients, compare with healthy controls, and argue the clinical inferences of this relationship. We searched for anxiety and depression and their clinical outcomes among patients and searched whether the results are similar to previous studies.

PATIENTS AND METHODS

Eighty-seven RLS patients and 88 age, gender, and educationally matched healthy controls were assessed in Bezmialem Foundation University Hospital. RLS patients and healthy controls were assessed with the Sociodemographic Data Form constructed for the present study, 20-item Toronto Alexithymia Scale (TAS-20), Beck Depression Inventory (BDI), and Beck Anxiety Scale (BAS). The patient group was also assessed with the International Restless Legs Syndrome Study Group (IRLSSG) RLS Severity Scale.

RESULTS

RLS patients were found to have greater TAS-20, BDI, and BAS scores compared with the control group (P < 0.05). RLS severity score was positively correlated with the scores of anxiety and depression scales. However, no significant relationship was found between scores of IRLSSG RLS scale and TAS-20 total and subscale scores.

CONCLUSION

RLS patients were found to be more alexithymic than healthy controls, whereas no significant relationship was found between RLS severity and levels of alexithymia. Still, alexithymia might be a predictor for early diagnosis and may be considered in the treatment and follow-up of RLS. RLS patients have higher depression and anxiety scores than healthy individuals. Thus, depression and anxiety should be taken into consideration throughout the RLS treatment.

Haste makes waste: Decision making in patients with restless legs syndrome with and without augmentation

Objectives

To investigate decision making in patients with primary restless legs syndrome (RLS) with and without augmentation treated with dopaminergic medication.

Methods

A total of 64 non-demented RLS patients treated with dopaminergic medication with and without augmentation were included in this study. We used an information sampling task to assess how much evidence participants gather before making a decision. Performance was compared to the results of 21 healthy controls.

Results

All patients with and without augmentation gathered less information than healthy controls before making a decision (p<0.001), but there was no difference between the two patient groups (p = 1.0). Furthermore, both patient groups made more irrational decisions (e.g. decisions against the evidence they had at the time) than healthy controls (p≤0.002). In addition, RLS patients with augmentation made significantly more irrational decisions than RLS patients without augmentation (p = 0.037) and controls (p<0.001).

Conclusions

Our results show that RLS patients treated with dopaminergic drugs, regardless of having augmentation or not, jumped to conclusions and decided significantly more often against the evidence they had at the time of their decision. However, those with augmentation performed worse than all other groups and made more often irrational decisions, a phenomenon which is also common in patients with substance abuse or behavioural addictions. Thus, jumping to conclusions and deciding with a higher degree of uncertainty as well as irrational decision making is more common in RLS patients treated with dopaminergic medication particularly in those with augmentation.

Movement Disorders: A Brief Guide in Medication Management

Movement disorders can be challenging to manage and often use a specific set of medications. Because it is a complex and broad field within neurology, many providers are unfamiliar with the classes of medications. This paper details medications used for specific conditions, explains why these medications are helpful, and shares pearls and pitfalls related to each agent, focusing on parameters such as dose titration, side effect profiles, and specific drug-drug interactions and challenges. We focus on the most commonly encountered movement disorders, including essential tremor, Parkinson's disease, rapid eye movement sleep behavior disorder, and restless leg syndrome.

Selective Serotonin Reuptake Inhibitor/Serotonin-Norepinephrine Reuptake Inhibitor Use as a Predictor of a Diagnosis of Restless Legs Syndrome

OBJECTIVE/BACKGROUND

Because restless legs syndrome (RLS) is a problematic syndrome, demonstrating an association between use of selective serotonin reuptake inhibitors (SSRIs)/serotonin-norepinephrine reuptake inhibitors (SNRIs) and RLS may help direct patient care. The goals of this study were (1) to establish the incidence of RLS in mental health patients being treated with SSRIs or SNRIs in a local Veterans Affairs medical center and (2) to evaluate the frequency with which certain SSRIs or SNRIs are associated with RLS and the trend in frequency of the diagnosis since the revision of the criteria for RLS offered by the International Restless Leg Syndrome Study Group (IRLSSG), the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), and the International Classification of Sleep Disorders, Revised (ICSD-3).

METHODS

A retrospective chart review was used to evaluate the number of patients receiving SSRI/SNRI therapy with and without a diagnosis of RLS, with the date of the RLS diagnosis and initiation of SSRI/SNRI therapy noted. The frequency with which certain SSRIs/SNRIs were associated with RLS, and the frequency of RLS diagnoses since January 2012 were also noted. Descriptive statistics and logistic regression were used for data analysis.

RESULTS

A total of 254 charts were reviewed. A majority of the patients (89.8%) were male, and 14 (5.5%) were diagnosed with RLS. A logistic regression equation approached significance in predicting RLS (P=0.053). Age and sex emerged as significant predictors of RLS. The prevalence of any individual SSRI or SNRI being associated with RLS was indeterminable. No difference was seen in the number of RLS diagnoses since the refining of the IRLSSG, DSM-5, and ICSD-3 criteria.

CONCLUSIONS

The use of SSRIs/SNRIs does not seem to be associated with a diagnosis of RLS. In addition, the diagnosis of RLS does not seem to have become more common since the revision of the diagnostic criteria for the disorder.

The Effect of Gabapentin Enacarbil on Quality of Life and Mood Outcomes in a Pooled Population of Adult Patients with Moderate-to-Severe Primary Restless Legs Syndrome

OBJECTIVE

The aim was to assess gabapentin enacarbil (GEn) treatment effects on quality of life (QOL) and mood in adults with moderate-to-severe primary restless legs syndrome (RLS).

METHODS

Data were pooled from three placebo-controlled, randomized, double-blind, 12-week trials for adults receiving GEn (600 mg or 1200 mg) or placebo once daily. QOL was assessed with the RLS QOL questionnaire in two studies. Mood was examined with the Profile of Mood States Brief Form (POMS-B), and as an exploratory analysis with International Restless Legs Scale (IRLS) item 9 (daily affairs) and item 10 (mood disturbance) across all three studies. Mood and QOL were secondary endpoints in the individual clinical trials. No adjustments for multiplicity were applied.

RESULTS

The QOL analysis modified intent-to-treat (MITT) population included 541 adults (placebo, n = 204; GEn 600 mg, n = 114; GEn 1200 mg, n = 223). Both GEn doses significantly improved QOL versus placebo (week 12; p < 0.01). The mood analysis MITT population included 671 adults (placebo, n = 244; GEn 600 mg, n = 161; GEn 1200 mg, n = 266). GEn 600 mg significantly improved POMS vigor-activity versus placebo (week 12; p < 0.05); other POMS criteria were not significantly affected. GEn 1200 mg significantly improved POMS scores for total mood disturbance, depression-dejection, fatigue-inertia, vigor-activity, and confusion-bewilderment versus placebo at week 12 (p < 0.05); tension-anxiety and anger-hostility were not significantly affected. Both GEn doses significantly improved IRLS item 9 and item 10 versus placebo at week 12 (p < 0.05). The most frequent treatment-emergent adverse events with GEn were somnolence and dizziness.

CONCLUSIONS

GEn (600 mg and 1200 mg) once daily significantly improved QOL in adults with moderate-to-severe primary RLS at all time points examined. While the only POMS item significantly improved by GEn 600 mg versus placebo at week 12 was vigor-activity, GEn 1200 mg significantly improved total mood disturbance and several other POMS items versus placebo at week 12. Both QOL and mood improvements were numerically greater with GEn 1200 mg versus 600 mg.

TRIAL REGISTRATIONS

Clinicaltrials.gov identifiers NCT00298623, NCT00365352, NCT01332305.

Incidence of Augmentation in Primary Restless Legs Syndrome Patients May Not Be That High: Evidence From A Systematic Review and Meta-Analysis

Augmentation is a common complication of primary restless legs syndrome (RLS) during treatment; however, its incidence rate remains unclear.The aim of this study is investigate the rate of augmentation during RLS treatment.We searched 6 databases, including PubMed, OVID, Embase, Wiley citations, Web of Science research platform (including SciELO Citation Index, Medline, KCI Korean Journal Database, the Web of Science™ Core Collection), and the Cochrane library, and screened the reference lists of the included trials and recently published reviews.Randomized controlled trials and observational studies that reported augmentation events during RLS treatment.Primary RLS patients older than 18 years.No restrictions regarding intervention types were applied.Three investigators independently extracted and pooled the data to analyze the augmentation rate of the total sample and of patient subgroups with different interventions, treatment durations and drug regimens and different geographic origins. Fixed-effects or random-effects model was used for pooled analysis.A total of 60 studies involving 11,543 participants suggested an overall augmentation rate of 5.6% (95% confidence intervals (CI), 4.0-7.7). The augmentation incidence was 6.1% (95% CI, 4.1-9.1) for long-term treatment and 3.3% (95% CI, 1.4-7.3) for short-term treatment. In addition, 27.1% (95% CI, 12.3-49.5) of the levodopa-treated patients, 6.0% (95% CI, 4.1-8.8) of the patients treated with dopamine agonists, and 0.9% (95% CI, 0.2-3.3) of the patients taking pregabalin or gabapentin developed augmentation. Augmentation occurred in 7.2% (95% CI, 5.0-10.3) of the patients taking immediate-release drugs and in 1.7% (95% CI, 0.6-5.0) of the patients taking transdermal application.The main limitations are that the augmentation rates were not evaluated according to drug dosage, gender, and age and symptom severity.Approximately 5 to 6 in 100 RLS patients developed augmentation during treatment.

The Humanistic and Economic Burden of Restless Legs Syndrome

Objectives

To evaluate the humanistic and economic burden of a restless legs syndrome (RLS) diagnosis with regard to health-related quality of life, work productivity loss, healthcare resource use, and direct and indirect costs.

Study Design

Self-reported data came from the 2012 National Health and Wellness Survey (NHWS), a large, annual, nationally representative cross-sectional general health survey of US adults.

Methods

RLS patients (n = 2,392) were matched on demographic and health characteristics to Non-RLS respondents via propensity score matching differences between groups were tested with Bivariate and multivariable analyses.

Results

RLS patients had significantly lower health-related quality of life scores: Mental Component Summary (44.60 vs. 48.92, p<.001), Physical Component Summary (40.57 vs. 46.78, p<.001), Health Utilities (.63 vs. .71, p<.001) and higher levels of work productivity loss in the past seven days including absenteeism (8.1% vs. 9.3%, p<.001), presenteeism (26.5% vs. 15.8%, p<.001), and overall productivity loss (30.1% vs. 18.1%, p<.001) as well as general activity impairment (46.1% vs. 29.7%, p<.001). RLS patients had significantly higher healthcare resource use in the past 6 months than non-RLS patients: healthcare provider visits (7.46 vs. 4.42%, p<.001), ER visits (0.45 vs. 0.24, p<.001), and hospitalizations (0.24 vs. 0.15, p<.001). RLS patients also had higher estimated direct and indirect costs than non-RLS patients. Finally, it was found that across outcomes increasing severity is associated with increased economic and humanistic burden for RLS patients.

Conclusions

RLS patients suffer a greater humanistic and economic burden than those without RLS. Moreover as severity increases so does the burden of RLS.

Restless Legs Syndrome/Willis-Ekbom Disease Morbidity: Burden, Quality of Life, Cardiovascular Aspects, and Sleep

Restless legs syndrome (RLS)/Willis-Ekbom disease (WED) has a significant negative effect on quality of life. The decreased quality of life is similar to that of other chronic diseases, such as diabetes type 2, depression, and osteoarthritis. RLS/WED disrupts sleep length, sleep quality, and daytime alertness. Sleep disruption can contribute to depression. RLS/WED has been associated with cardiovascular disease and high blood pressure, possibly because of increased sympathetic tone caused by periodic limb movements of sleep. RLS/WED is underdiagnosed, leading to chronic sleep disruption and daytime consequences. Patients with RLS/WED have decreased productivity at work, which potentially has far-reaching economic consequences.

Treatment response to sleep, pain, and mood disturbance and their correlation with sleep disturbance in adult patients with moderate-to-severe primary restless legs syndrome: Pooled analyses from 3 trials of gabapentin enacarbil

INTRODUCTION

This pooled analysis investigated the effects of gabapentin enacarbil (GEn) on clinical correlates of sleep disturbance in adults with moderate-to-severe primary restless legs syndrome (RLS) and no-to-moderate or severe-to-very severe baseline sleep disturbance.

METHODS

Co-primary end-points were mean change from baseline to week 12 in International Restless Legs Scale (IRLS) total score and proportion of responders ('much'/'very much' improved) on the investigator-rated Clinical Global Impression-Improvement (CGI-I) scale (week 12). Pain, mood, individual IRLS items, and safety were assessed.

RESULTS

The modified intent-to-treat population was 671 adults randomized to GEn 600 mg (n = 161), GEn 1200 mg (n = 266), or placebo (n = 244). GEn significantly improved least squares mean change in IRLS total score from baseline versus placebo for no-to-moderate (GEn 600 mg,- 12.3; 1200 mg, - 11.3; placebo, - 7.7) and severe-to-very severe (- 16.6; - 17.0; - 12.7) groups (all P < 0.01). Significantly more GEn-treated patients (both doses) were CGI-I responders (week 12) versus placebo in both sleep subgroups (all P < 0.01). GEn substantially improved mood and pain scores for both sleep subgroups versus placebo. The most frequent treatment-emergent adverse events were somnolence and dizziness.

CONCLUSION

GEn (600 mg and 1200 mg) was effective and well tolerated in adults with moderate-to-severe primary RLS regardless of baseline sleep disturbance level.

Psychological distress in patients with restless legs syndrome (Willis-Ekbom disease): a population-based door-to-door survey in rural Ecuador

Background

Reported prevalence of restless legs syndrome (RLS), also known as Willis-Ekbom disease (WED), varies from country to country, and methodologic inconsistencies limit comparison of data. Impact of RLS on quality of life and health has been studied primarily in industrialized countries, particularly Europe and the United States. Many studies have relied exclusively on self-report of symptoms or have assessed only medical populations. Recently, interest has emerged on the impact of WED in rural, underserved populations globally.

Methods

In a population-based survey conducted in rural Ecuador, we assessed the relationship of psychological distress to WED, evaluated with the Depression Anxiety Stress Scales–21. WED was diagnosed through a 2-phase method in which all residents were screened with the International Restless Legs Syndrome Study Group (IRLSSG) questionnaire and all suspected cases were subsequently confirmed through expert medical examination. WED severity was assessed with the IRLSSG rating scale.

Results

Of 665 persons (mean [SD] age, 59.5 [12.6] years; women, 386 [58%]), 76 had depression, 93 had anxiety, and 60 reported stress. Forty persons (6%) had WED, with 15 (38%) having severe disease. In a regression model adjusted for age and sex, the prevalence of depression, anxiety, and stress was about 3 times greater among persons with WED than the general population.

Conclusions

Although cross-sectional data cannot establish causation, this study shows the large behavioral health burden associated with WED in an untreated, rural population.

Anxiety levels among Turkish public transportation drivers: a relation to restless legs syndrome?

The aim of this study was to estimate the prevalence of individuals who are at high risk for state and trait anxiety as well as to investigate the relationship of anxiety levels of urban transportation drivers from Istanbul, Turkey with restless legs syndrome (RLS). The data was gathered between April 2013 and June 2013 by the use of a questionnaire prepared for the purpose of this study, completed anonymously. Restless leg syndrome and anxiety level were evaluated in the group; data obtained was analyzed using the SPSS version 16. Chi-square, correlation and student-t tests were used. Restless leg syndrome symptoms were determined by a self-assessment questionnaire, including the International Restless Legs Syndrome Study Group (IRLSSG) diagnostic criteria, to determine RLS symptoms and Spielberger State-Trait Anxiety Inventory (STAI) to determine anxiety levels of the participants. In the present study, the four RLS criteria were reported in 31.2%. STAI-state and STAI-trait scores were 40.82 ± 9.55 and 42.99 ± 8.54 respectively. The state and trait anxiety mean scores were different among participants with RLS in this study (p < 0.05). It was found a significant difference between tobacco usage and state anxiety (p < 0.05). There were a significant difference between RLS and age, number of cigarettes daily consumed and employment time (p < 0.05). The state and trait anxiety scores were found high among bus drivers with RLS in this study.

Distress screening in chronic disease: essential for cancer survivors

Distress is a psychological state that is often observed in patients with chronic disease. Many cancers are considered chronic in nature, with patients experiencing long, disease-free states and intervals of metastatic disease. Distress can negatively affect the biopsychosocial balance in cancer survivors and impede their progress along the cancer trajectory. Distress can also affect medical and psychological outcomes and hinder advancement into long-term survivorship. Distress may contribute to disease progression, although despite research findings, health-care providers seldom screen for indications of persistent or unresolved distress. This article discusses research findings related to the prevalence of distress in multiple chronic diseases. Validated instruments used to screen for distress in cancer survivors, such as the Distress Thermometer and symptom checklist from the National Comprehensive Cancer Network, are reviewed. With the availability of brief and concise instruments to screen for distress, providers have the ability to provide holistic and comprehensive care for cancer survivors. The overall financial impact of cancer-related distress is understudied, although similar psychological studies indicate that prevention or elimination of distress is beneficial. Cancer is a lifelong, chronic disease; patients have ongoing needs and varied sources of distress. As the number of cancer survivors exponentially increases, their psychosocial needs will likewise expand.

A study examining depression in restless legs syndrome

BACKGROUND

Distress is known to occur in RLS subjects consequent to symptoms. However, studies regarding prevalence of depression in RLS are scarce. This study was conducted to find out prevalence of depression in RLS patients and to explore possible underlying factors.

METHOD

112 consecutive RLS subjects presenting to sleep-clinic were included in this study. History regarding RLS, depression and sleep-disturbances was sought. Depression and insomnia were diagnosed using DSM-IV-TR criteria. Subjects were specifically asked whether they had depressive episodes in past one year. Severity of RLS and insomnia was measured using Hindi versions of IRLS and ISI, respectively. Family history of depression and RLS was also asked.

RESULTS

One year prevalence of depression was 41.8%. MDD was reported by 33% and dysthymia by 8.8%. Both the groups were comparable with respects to demographic and clinical features, viz., age, gender, duration, severity and family history of RLS. Duration, number of episodes and severity of insomnia were comparable between groups, so was the family history of depression. In 37.8% of the subjects with MDD, depressive symptoms preceded RLS while in 51.4% of them, they followed onset of RLS. Total duration of RLS symptoms did not correlate with total duration of depression (r(2)=0.07; P=0.64).

CONCLUSION

Clinical depression is seen in more than a third of RLS patients. Depression is not affected by clinical picture of RLS and it is not consequent to sleep disturbance. Perhaps, it is a co-morbid condition.

What treatment works best for restless legs syndrome? Meta-analyses of dopaminergic and non-dopaminergic medications

BACKGROUND

At the time of writing only dopamine agonists are licensed for the treatment of restless legs syndrome (RLS) in various countries, but randomized controlled trials (RCTs) have been performed with other treatments. We performed comprehensive meta-analyses and indirect comparisons of RCTs for all currently recommended treatments of RLS.

METHODS

We searched the Central, Medline, Embase, PsycINFO and CINAHL databases. Outcome measures were the international RLS study group severity scale (IRLS), clinical global impression-improvement, (CGI-I), periodic limb movement index (PLMI), and psychosocial parameters such as quality of life (QoL). We also conducted indirect comparisons by testing for heterogeneity between the substance groups.

RESULTS

Placebo (58 trials) and actively (4 trials) controlled RCTs with dopamine agonists (38 trials), levodopa (4 trials), anticonvulsants (13 trials), most of them with α₂δ ligands (11 trials), opioids (1 trial), and iron treatments (6 trials) were included (9596 patients). Although treatment effects showed large variations, changes in the IRLS in the substance groups were comparable (P = 0.78), with a mean reduction in the IRLS of -5.47 points for dopamine agonists, -5.12 points for anticonvulsants (α₂δ ligands and levetiracetam), and -4.59 points for iron treatments. The CGI-I indicated slightly different treatment effects between the substance groups, while PLMI changes during treatment differed (P = 0.002), showing a marked decrease with dopamine agonists (-22.50/h), levodopa (-26.01/h), and oxycodone (-34.46/h) compared with a slight decrease for anticonvulsants (α₂δ ligands and levetiracetam; -8.48/h) and iron treatments (-13.10/h). Quality of sleep and QoL improved moderately in most of the RCTs investigating these parameters (standardized mean difference, SMD) 0.40 and 0.33, respectively). In the few studies evaluating the change of depressive (n = 4) or anxiety symptoms (n = 3), these symptoms improved slightly (SMD -0.24, and -0.21). Adverse effects and dropouts were comparable in number across all substance groups. In meta-regressions, the treatment effect was predicted by the design of the trial (the more sites involved in a trial the lower the effect) and by the duration of action of a medication (the longer the duration of action, expressed as the half-life time of a substance, the greater the improvement), the latter indicating potential superiority of treatments with stable blood concentration.

CONCLUSION

This first meta-analysis of all RCTs for the pharmacological treatment of RLS provides evidence that, besides the well-defined efficacy of dopaminergic treatment, other treatments with different pharmacological principles show efficacy in small samples and may be well-tolerated alternatives for the treatment of RLS. In the group of anticonvulsants, only the trials performed with α₂δ ligands such as gabapentin, gabapentin enacarbil, and pregabalin showed good efficacy. This indicates a specific mechanism of action of these substances in RLS. The group of iron treatments consisted of a few trials with different compounds in oral and intravenous application form, respectively. For a more differentiated evaluation of the efficacy of iron treatments further studies are necessary. The large efficacy of one opioid RCT in RLS has to be confirmed in further studies.

Comorbid sleep disorders in neuropsychiatric disorders across the life cycle

The association between psychopathology and poor sleep has long been recognized. The current review focuses on the association between the most prevalent sleep disorders (insomnia, sleep-related breathing disorders and restless legs syndrome) and four major psychiatric disorders: alcohol dependence, schizophrenia, depression and anxiety disorders. Decreased total sleep time and increased sleep onset latency as measured by polysomnography as well an increase of the prevalence of insomnia has been reported in all of these psychiatric disorders. Furthermore, sleep disturbance is a risk factor for their development. Cognitive-behavioral therapy for insomnia has been shown to have a positive impact on both sleep and symptoms of depression and anxiety. Whether adequate treatment of sleep disorders can prevent the incidence of psychiatric disorders, remains to be investigated.

Motor restlessness, sleep disturbances, thermal sensory alterations and elevated serum iron levels in Btbd9 mutant mice

Restless legs syndrome (RLS), also known as Willis-Ekbom disease, is a sensory-motor neurological disorder with a circadian component. RLS is characterized by uncomfortable sensations in the extremities, generally at night or during sleep, which often leads to an uncontrollable urge to move them for relief. Recently, genomic studies identified single-nucleotide polymorphisms in BTBD9, along with three other genes, as being associated with a higher risk of RLS. Little is known about the function of BTBD9 or its potential role in the pathophysiology of RLS. We therefore examined a line of Btbd9 mutant mice we recently generated for phenotypes similar to symptoms found in RLS patients. We observed that the Btbd9 mutant mice had motor restlessness, sensory alterations likely limited to the rest phase, and decreased sleep and increased wake times during the rest phase. Additionally, the Btbd9 mutant mice had altered serum iron levels and monoamine neurotransmitter systems. Furthermore, the sensory alterations in the Btbd9 mutant mice were relieved using ropinirole, a dopaminergic agonist widely used for RLS treatment. These results, taken together, suggest that the Btbd9 mutant mice model several characteristics similar to RLS and would therefore be the first genotypic mouse model of RLS. Furthermore, our data provide further evidence that BTBD9 is involved in RLS, and future studies of the Btbd9 mutant mice will help shine light on its role in the pathophysiology of RLS. Finally, our data argue for the utility of Btbd9 mutant mice to discover and screen novel therapeutics for RLS.