Manipulating the sleep-wake cycle and circadian rhythms to improve clinical management of major depression

Directional associations among real-time activity, sleep, mood, and daytime symptoms in major depressive disorder using actigraphy and ecological momentary assessment

Previous research has suggested that individuals with major depressive disorder (MDD) experienced alterations in sleep and activity levels. However, the temporal associations among sleep, activity levels, mood, and daytime symptoms in MDD have not been fully investigated. The present study aimed to fill this gap by utilizing real-time data collected across time points and days. 75 individuals with MDD and 75 age- and gender-matched healthy controls were recruited. Ecological momentary assessments (EMA) were adopted to assess real-time mood status for 7 days, and actigraphy was employed to measure day-to-day sleep-activity patterns. Multilevel modeling analyses were performed. Results revealed a bidirectional association between mood/daytime symptoms and activity levels across EMA intervals. Increased activity levels were predictive of higher alert cognition and positive mood, while an increase in positive mood also predicted more increase in activity levels in depressed individuals. A bidirectional association between sleep and daytime symptoms was also found. Alert cognition was found to be predictive of better sleep in the subsequent night. Contrariwise, higher sleep efficiency predicted improved alert cognition and sleepiness/fatigue the next day. A unidirectional association between sleep and activity levels suggested that higher daytime activity levels predicted a larger increase in sleep efficiency among depressed individuals. This study indicated how mood, activity levels, and sleep were temporally and intricately linked to each other in depressed individuals using actigraphy and EMA. It could pave the way for novel and efficacious treatments for depression that target not just mood but sleep and activity levels.

Endogenous circadian rhythms in mood and well-being

OBJECTIVES

We examined whether the endogenous circadian timing system modulates proxies of mood vulnerability and well-being.

METHODS

Nineteen healthy participants (mean age: 26.6 years [23.0-30.2], seven females, body-mass index: 22.8 kg/m2 [21.1-25]) completed a laboratory protocol with a 32-hour Constant Routine, a stringently controlled protocol designed to isolate assessment of endogenous circadian rhythms. We assessed hourly anxiety- and depression-like mood (i.e., those typically observed in depression and anxiety) and well-being (i.e., associated with mental fatigue and physical comfort).

RESULTS

Significant endogenous circadian rhythms were observed in anxiety-like and depression-like mood, as well as well-being (p values from the mixed-model analysis using false discovery rates < .001). Post-hoc comparisons revealed more anxiety-like and depression-like mood during the circadian phase 60°-75° (∼8-9 a.m.), and more mental fatigue and less physical comfort during the circadian phase 30°-60° (∼6-8 a.m.).

CONCLUSIONS

Our data indicate endogenous circadian rhythms in anxiety-like and depression-like mood and well-being in healthy young adults. Future studies will help establish circadian-based therapeutics for individuals experiencing mood and anxiety disorders.

[Depression: Low-threshold Cardinal Measures as a Complement or Alternative to Pharmacological or Psychotherapeutic Interventions]

The third edition of the German National Clinical Practice Guideline for Depression emphasizes the significance of cardinal measures much more strongly than before. Low-threshold cardinal measures are an indispensable component of every depression treatment, regardless of severity and setting. They are suitable as a standalone treatment for mild and moderate depression. If inadequate improvement is observed, additional therapies should be supplemented. They should be implemented immediately after diagnosis to enhance the success rate.Regarding cardinal measures, among other things, comprehensive patient education in understandable language is essential. Patients with depressive disorders require guidance on structuring their day and building healthy activities. Patients with depression-related sleep disturbances benefit from sleep hygiene rules. Wake therapy constitutes an excellent and low-risk treatment method with immediate effect, which is a standard component of adequate depression treatment. Patients with a seasonal pattern of depression should be advised on light therapy. All patients should be encouraged to engage in regular physical activity with moderate intensity.

Continuous home cage monitoring of activity and sleep in mice during repeated paroxetine treatment and discontinuation

RATIONALE

Non-invasive home cage monitoring is emerging as a valuable tool to assess the effects of experimental interventions on mouse behaviour. A field in which these techniques may prove useful is the study of repeated selective serotonin reuptake inhibitor (SSRI) treatment and discontinuation. SSRI discontinuation syndrome is an under-researched condition that includes the emergence of sleep disturbances following treatment cessation.

OBJECTIVES

We used passive infrared (PIR) monitoring to investigate changes in activity, sleep, and circadian rhythms during repeated treatment with the SSRI paroxetine and its discontinuation in mice.

METHODS

Male mice received paroxetine (10 mg/kg/day, s.c.) for 12 days, then were swapped to saline injections for a 13 day discontinuation period and compared to mice that received saline injections throughout. Mice were continuously tracked using the Continuous Open Mouse Phenotyping of Activity and Sleep Status (COMPASS) system.

RESULTS

Repeated paroxetine treatment reduced activity and increased behaviourally-defined sleep in the dark phase. These effects recovered to saline-control levels within 24 h of paroxetine cessation, yet there was also evidence of a lengthening of sleep bouts in the dark phase for up to a week following discontinuation.

CONCLUSIONS

This study provides the first example of how continuous non-invasive home cage monitoring can be used to detect objective behavioural changes in activity and sleep during and after drug treatment in mice. These data suggest that effects of paroxetine administration reversed soon after its discontinuation but identified an emergent change in sleep bout duration, which could be used as a biomarker in future preclinical studies to prevent or minimise SSRI discontinuation symptoms.

The Influence of Light Wavelength on Human HPA Axis Rhythms: A Systematic Review

Environmental light entrains many physiological and behavioural processes to the 24 h solar cycle. Such light-driven circadian rhythms are centrally controlled by the suprachiasmatic nucleus (SCN), which receives information from the short-wavelength-sensitive intrinsically photosensitive retinal ganglion cells. The SCN synchronizes local clocks throughout the body affecting sleep/wake routines and the secretion of neuroendocrine-linked hormones such as melatonin from the pineal gland and cortisol via the hypothalamic pituitary adrenal (HPA) axis. Although the effects of light parameters on melatonin have been recently reviewed, whether the experimental variation of the spectral power distribution and intensity of light can induce changes in cortisol rhythms remains unclear. Thus, this systematic review evaluated the effects of daytime exposure to lights of different spectral wavelength characteristics and luminance intensity on the cortisol levels in healthy individuals. A search of the PubMed, Web of Science, EMBASE, CINAHL, Medline, PsycINFO and Cochrane Library databases on 19 June 2023 identified 3418 articles, of which 12 studies (profiling 337 participants) met the inclusion and risk of bias criteria. An analysis of the literature indicated that exposure to bright lights of any colour during the late night or early morning can induce significant increases in cortisol secretion relative to time-matched dim light comparison conditions. Furthermore, exposure to bright lights with stronger short-wavelength (blue/green) components in the early morning typically induced greater increases in cortisol relative to lights with stronger long-wavelength (red) components. Thus, the circadian regulation of cortisol is sensitive to the wavelength composition of environmental lighting, in line with the more commonly studied melatonin. As such, wavelength characteristics should be optimized and reported in light intervention studies (particularly for the investigation of cortisol-associated disorders and HPA axis function), and exposure to short-wavelength light during sensitive periods should be carefully considered in constructed environments (e.g., bedroom and classroom lighting and device screens).

Role of adjunctive nonpharmacological strategies for treatment of rapid-cycling bipolar disorder

Rapid-cycling bipolar disorder (RCBD) is a phase of bipolar disorder defined by the presence of ≥ 4 mood episodes in a year. It is a common phenomenon characterized by greater severity, a predominance of depression, higher levels of disability, and poorer overall outcomes. It is resistant to treatment by conventional pharmacotherapy. The existing literature underlines the scarcity of evi-dence and the gaps in knowledge about the optimal treatment strategies for RCBD. However, most reviews have considered only pharmacological treatment options for RCBD. Given the treatment-refractory nature of RCBD, nonpharmacological interventions could augment medications but have not been adequately examined. This review carried out an updated and comprehensive search for evidence regarding the role of nonpharmacological therapies as adjuncts to medications in RCBD. We identified 83 reviews and meta-analyses concerning the treatment of RCBD. Additionally, we found 42 reports on adjunctive nonpharmacological treatments in RCBD. Most of the evidence favoured concomitant electroconvulsive therapy as an acute and maintenance treatment. There was pre-liminary evidence to suggest that chronotherapeutic treatments can provide better outcomes when combined with medications. The research on adjunctive psychotherapy was particularly scarce but suggested that psychoeducation, cognitive behavioural therapy, family interventions, and supportive psychotherapy may be helpful. The overall quality of evidence was poor and suffered from several methodological shortcomings. There is a need for more methodologically sound research in this area, although clinicians can use the existing evidence to select and individualize nonpharmacological treatment options for better management of RCBD. Patient summaries are included to highlight some of the issues concerning the implementation of adjunctive nonpharmacological treatments.

Circadian rhythm in systemic autoimmune conditions: Potential of chrono-immunology in clinical practice: A narrative review

The circadian rhythm (CR) is a fundamental biological process regulated by the Earth's rotation and solar cycles. It plays a critical role in various bodily functions, and its dysregulation can have systemic effects. These effects impact metabolism, redox homeostasis, cell cycle regulation, gut microbiota, cognition, and immune response. Immune mediators, cycle proteins, and hormones exhibit circadian oscillations, supporting optimal immune function and defence against pathogens. Sleep deprivation and disruptions challenge the regulatory mechanisms, making immune responses vulnerable. Altered CR pathways have been implicated in diseases such as diabetes, neurological conditions, and systemic autoimmune diseases (SADs). SADs involve abnormal immune responses to self-antigens, with genetic and environmental factors disrupting self-tolerance and contributing to conditions like Systemic Lupus Erythematosus, Rheumatoid Arthritis, and Inflammatory Myositis. Dysregulated CR may lead to increased production of pro-inflammatory cytokines, contributing to the systemic responses observed in SADs. Sleep disturbances significantly impact the quality of life of patients with SADs; however, they are often overlooked. The relationship between sleep and autoimmune conditions, whether causal or consequential to CR dysregulation, remains unclear. Chrono-immunology investigates the role of CR in immunity, offering potential for targeted therapies in autoimmune conditions. This paper provides an overview of the connections between sleep and autoimmune conditions, highlighting the importance of recognizing sleep disturbances in SADs and the need for further research into the complex relationship between the CR and autoimmune diseases.

Resilience by design: How nature, nurture, environment, and microbiome mitigate stress and allostatic load

Resilience to psychological stress is defined as adaption to challenging life experiences and not the absence of adverse life events. Determinants of resilience include personality traits, genetic/epigenetic modifications of genes involved in the stress response, cognitive and behavioral flexibility, secure attachment with a caregiver, social and community support systems, nutrition and exercise, and alignment of circadian rhythm to the natural light/dark cycle. Therefore, resilience is a dynamic and flexible process that continually evolves by the intersection of different domains in human’s life; biological, social, and psychological. The objective of this minireview is to summarize the existing knowledge about the multitude factors and molecular alterations that result from resilience to stress response. Given the multiple contributing factors in building resilience, we set out a goal to identify which factors were most supportive of a causal role by the current literature. We focused on resilience-related molecular alterations resulting from mind-body homeostasis in connection with psychosocial and environmental factors. We conclude that there is no one causal factor that differentiates a resilient person from a vulnerable one. Instead, building resilience requires an intricate network of positive experiences and a healthy lifestyle that contribute to a balanced mind-body connection. Therefore, a holistic approach must be adopted in future research on stress response to address the multiple elements that promote resilience and prevent illnesses and psychopathology related to stress allostatic load.

Physiological Rhythms and Biological Variation of Biomolecules: The Road to Personalized Laboratory Medicine

The concentration of biomolecules in living systems shows numerous systematic and random variations. Systematic variations can be classified based on the frequency of variations as ultradian (<24 h), circadian (approximately 24 h), and infradian (>24 h), which are partly predictable. Random biological variations are known as between-subject biological variations that are the variations among the set points of an analyte from different individuals and within-subject biological variation, which is the variation of the analyte around individuals’ set points. The random biological variation cannot be predicted but can be estimated using appropriate measurement and statistical procedures. Physiological rhythms and random biological variation of the analytes could be considered the essential elements of predictive, preventive, and particularly personalized laboratory medicine. This systematic review aims to summarize research that have been done about the types of physiological rhythms, biological variations, and their effects on laboratory tests. We have searched the PubMed and Web of Science databases for biological variation and physiological rhythm articles in English without time restrictions with the terms “Biological variation, Within-subject biological variation, Between-subject biological variation, Physiological rhythms, Ultradian rhythms, Circadian rhythm, Infradian rhythms”. It was concluded that, for effective management of predicting, preventing, and personalizing medicine, which is based on the safe and valid interpretation of patients’ laboratory test results, both physiological rhythms and biological variation of the measurands should be considered simultaneously.

Relationship between APOE, PER2, PER3 and OX2R Genetic Variants and Neuropsychiatric Symptoms in Patients with Alzheimer's Disease

Alzheimer's disease (AD) is characterized by the presence of neuropsychiatric or behavioral and psychological symptoms of dementia (BPSD). BPSD have been associated with the APOE_ε4 allele, which is also the major genetic AD risk factor. Although the involvement of some circadian genes and orexin receptors in sleep and behavioral disorders has been studied in some psychiatric pathologies, including AD, there are no studies considering gene-gene interactions. The associations of one variant in PER2, two in PER3, two in OX2R and two in APOE were evaluated in 31 AD patients and 31 cognitively healthy subjects. Genotyping was performed using real-time PCR and capillary electrophoresis from blood samples. The allelic-genotypic frequencies of variants were calculated for the sample study. We explored associations between allelic variants with BPSD in AD patients based on the NPI, PHQ-9 and sleeping disorders questionnaires. Our results showed that the APOE_ε4 allele is an AD risk variant (p = 0.03). The remaining genetic variants did not reveal significant differences between patients and controls. The PER3_rs228697 variant showed a nine-fold increased risk for circadian rhythm sleep-wake disorders in Mexican AD patients, and our gene-gene interaction analysis identified a novel interaction between PERIOD and APOE gene variants. These findings need to be further confirmed in larger samples.

Sex-Dependent Effects of Piromelatine Treatment on Sleep-Wake Cycle and Sleep Structure of Prenatally Stressed Rats

Prenatal stress (PNS) impairs the circadian rhythm of the sleep/wake cycle. The melatonin (MT) analogue Piromelatine (Pir) was designed for the treatment of insomnia. The present study aimed to explore effects of Pir on circadian rhythmicity, motor activity, and sleep structure in male and female rats with a history of prenatal stress (PNS). In addition, we elucidated the role of MT receptors and brain-derived neurotrophic factor (BDNF) to ascertain the underlying mechanism of the drug. Pregnant rats were exposed to different stressors from day seven until birth. Piromelatine (20 mg/kg/day/14 days) was administered to young adult offspring. Home-cage locomotion, electroencephalographic (EEG) and electromyographic (EMG) recordings were conducted for 24 h. Offspring treated with vehicle showed sex-and phase-dependent disturbed circadian rhythm of motor activity and sleep/wake cycle accompanied by elevated rapid eye movement (REM) pattern and theta power and diminished non-rapid eye movement (NREM) sleep and delta power. While Pir corrected the PNS-induced impaired sleep patterns, the MT receptor antagonist luzindol suppressed its effects in male and female offspring. In addition, Pir increased the BDNF expression in the hippocampus in male and female offspring with PNS. Our findings suggest that the beneficial effect of Pir on PNS-induced impairment of sleep/wake cycle circadian rhythm and sleep structure is exerted via activation of MT receptors and enhanced BDNF expression in the hippocampus in male and female offspring.

Human fertility and sleep disturbances: A narrative review

INTRODUCTION

Many factors may be hidden behind the global fertility decline observed in Western countries. Alongside the progressively increased age of infertile couples, environmental and behavioural factors, including non-optimal lifestyle habits, should be considered. Among these, sleep disorders have been suggested to be linked to human fertility.

METHODS

This is a narrative review, describing first sleep physiology, its disturbances, and the tools able to quantify sleep dysfunction. Then, we consider all available studies aimed at investigating the connection between sleep disorders and human fertility, providing a comprehensive view on this topic.

RESULTS

Forty-two studies investigating the relationship between sleep habits and human reproduction were included. All the published evidence was grouped according to the aspect of human fertility considered, i.e. i) female reproductive functions, ii) male reproductive functions, iii) natural conception and iv) assisted reproduction. For each of the sub-groups considered, the connection between sleep dysregulation and human fertility was classified according to specific sleep characteristics, such as sleep duration, quality, and habits. In addition, possible physio-pathological mechanisms proposed to support the link between sleep and fertility were summarized.

CONCLUSION

This review summarizes the most relevant findings about the intricate and still largely unknown network of molecular pathways involved in the regulation of circadian homeostasis, to which sleep contributes, essential for reproductive physiology. Thus, many mechanisms seem correlate sleep disorders to reproductive health, such as adrenal activation, circadian dysregulation, and genetic influences. This review highlights the need to properly designed trials on the topic.

Melatonergic Receptors (Mt1/Mt2) as a Potential Additional Target of Novel Drugs for Depression

A complex pathogenesis involving several physiological systems is theorized to underline the development of depressive disorders. Depression is accompanied by circadian regulation disruption and interaction with the functioning of both central and peripheral oscillators. Many aspects of melatonin function unite these systems. The use of drugs for circadian rhythm disorders could inspire a potential treatment strategy for depression. Melatonin plays an essential role in the regulation of circadian rhythms. It exerts effect by activating two types of melatonin receptors, type 1A (MT1) and 1B (MT2). These are G-protein-coupled receptors, predominantly located in the central nervous system. MT1/MT2 agonists could be a useful treatment approach according to all three prevalent theories of the pathogenesis of depression involving either monoamines, synaptic remodeling, or immune/inflammatory events. MT1/MT2 receptors can be a potential target for novel antidepressants with impact on concentrations of neurotrophins or neurotransmitters, and reducing levels of pro-inflammatory cytokines. There is an interesting cross-talk mediated via the physical association of melatonin and serotonin receptors into functional heteromers. The antidepressive and neurogenetic effects of MT1/MT2 agonists can also be caused by the inhibition of the acid sphingomyelinase, leading to reduced ceramide, or increasing monoamine oxidase A levels in the hippocampus. Compounds targeting MT1 and MT2 receptors could have potential for new anti-depressants that may improve the quality of therapeutic interventions in treating depression and relieving symptoms. In particular, a combined effect on MT1 and/or MT2 receptors and neurotransmitter systems may be useful, since the normalization of the circadian rhythm through the melatonergic system will probably contribute to improved treatment. In this review, we discuss melatonergic receptors as a potential additional target for novel drugs for depression.

Guidelines for the management of psychosis in the context of mood disorders

Psychotic episodes occur in a substantial proportion of patients suffering from major mood disorders (both unipolar and bipolar) at some point in their lives. The nature of these episodes is less well understood than the more common, non-psychotic periods of illness and hence their management is also less sophisticated. This is a concern because the risk of suicide is particularly high in this subtype of mood disorder and comorbidity is far more common. In some cases psychotic symptoms may be signs of a comorbid illness but the relationship of psychotic mood to other forms of psychosis and in particular its interactions with schizophrenia is poorly understood. Therefore, our targeted review draws upon extant research and our combined experience to provide clinical context and a framework for the management of these disorders in real-world practice - taking into consideration both biological and psychological interventions.

Transcorneal Electrical Stimulation Induces Long-Lasting Enhancement of Brain Functional and Directional Connectivity in Retinal Degeneration Mice

To investigate neuromodulation of functional and directional connectivity features in both visual and non-visual brain cortices after short-term and long-term retinal electrical stimulation in retinal degeneration mice. We performed spontaneous electrocorticography (ECoG) in retinal degeneration (rd) mice following prolonged transcorneal electrical stimulation (pTES) at varying currents (400, 500 and 600 μA) and different time points (transient or day 1 post-stimulation, 1-week post-stimulation and 2-weeks post-stimulation). We also set up a sham control group of rd mice which did not receive any electrical stimulation. Subsequently we analyzed alterations in cross-frequency coupling (CFC), coherence and directional connectivity of the primary visual cortex and the prefrontal cortex. It was observed that the sham control group did not display any significant changes in brain connectivity across all stages of electrical stimulation. For the stimulated groups, we observed that transient electrical stimulation of the retina did not significantly alter brain coherence and connectivity. However, for 1-week post-stimulation, we identified enhanced increase in theta-gamma CFC. Meanwhile, enhanced coherence and directional connectivity appeared predominantly in theta, alpha and beta oscillations. These alterations occurred in both visual and non-visual brain regions and were dependent on the current amplitude of stimulation. Interestingly, 2-weeks post-stimulation demonstrated long-lasting enhancement in network coherence and connectivity patterns at the level of cross-oscillatory interaction, functional connectivity and directional inter-regional communication between the primary visual cortex and prefrontal cortex. Application of electrical stimulation to the retina evidently neuromodulates brain coherence and connectivity of visual and non-visual cortices in retinal degeneration mice and the observed alterations are largely maintained. pTES holds strong possibility of modulating higher cortical functions including pathways of cognition, awareness, emotion and memory.

Change in circadian preference predicts sustained treatment outcomes in patients with unipolar depression and evening preference

STUDY OBJECTIVES

Eveningness is associated with worse outcomes in depression. It remained unclear if eveningness could be altered with chronobiological therapy and whether such a change would predict long-term outcomes of depression.

METHODS

Data from a randomized controlled trial of 5-week adjunctive bright light therapy with a gradual advance protocol conducted in 91 adult patients with nonseasonal unipolar depression and eveningness (Morningness-Eveningness Questionnaire, score ≤ 41) was examined. "Change of eveningness" was defined by Morningness-Eveningness Questionnaire score over 41 at posttreatment week 5 and "persistent change of eveningness" was defined as maintenance of Morningness-Eveningness Questionnaire score > 41 throughout the follow-up period from week 5 to posttreatment 5 months.

RESULTS

Thirty-three participants (36%) had change of eveningness at week 5. Generalized estimating equations models showed that a change of eveningness at week 5 predicted a 2-fold increase in remission of depression over the 5-month follow up (odds ratio = 2.61 95% confidence interval 1.20-5.71, P = .016). Twenty-five participants (75.7%) had a persistent change and were more likely to achieve a remission of depression over the 5-month follow up (odds ratio = 3.18, 95% confidence interval: 1.35-7.50, P = .008).

CONCLUSIONS

One-third of the patients with depression changed their evening-preference after 5-week of chronotherapeutic treatment, and such change predicted a higher likelihood of depression remission over 5 months of follow-up.

CLINICAL TRIAL REGISTRATION

Registry: Chinese Clinical Trial Registry; Name: Adjunctive light treatment in major depressive disorder patients with evening chronotype-A randomized controlled trial; URL: https://www.chictr.org.cn/showprojen.aspx?proj=11672; Identifier: ChiCTR-IOR-15006937.

CITATION

Chan JWY, Chan NY, Li SX, et al. Change in circadian preference predicts sustained treatment outcomes in patients with unipolar depression and evening preference. J Clin Sleep Med. 2022;18(2):523-531.

The Association Between Morningness-Eveningness Preference, Depression, Anxiety and Insomnia Among Chinese Textile Workers With or Without Shift Work

OBJECTIVE

Circadian preference and mental health disorders are closely related to insomnia. This study aimed to evaluate insomnia symptoms in textile factory workers with different work schedules, and to investigate the association between insomnia, morningness-eveningness preference, anxiety, and depression.

METHODS

A total of 3,883 textile workers were assessed using the 3-items of Pittsburg Sleep Quality Index, Composite Scale of Morningness, Beck Anxiety Inventory, Center for Epidemiologic Studies-Depression Scale, and socio-demographic questionnaires.

RESULTS

The prevalence rate of insomnia in textile workers was 16.7% (N = 646), with 49.8% (N = 322) were shift workers. Among shift workers (N = 1,833), 9.5% had difficulty initiating sleep, and almost 9.0% suffered from early morning awakening, a rate significantly higher than among daytime workers. Logistics regressions revealed that work schedule was insignificantly associated with insomnia. Depression (OR = 1.034, 95% CI = 1.022-1.046) and anxiety (OR = 1.031, 95% CI = 1.018-1.043) positively predicted insomnia, whereas morningness preference (OR = 0.977, 95% CI = 0.960-0.995) decreased the likelihood of insomnia. Furthermore, mediation analysis showed that both anxiety and depression independently mediated the association between circadian preferences and insomnia in textile workers with or without shift work.

CONCLUSION

This study highlighted the insomnia, depression, and anxiety of textile factory workers in a Chinese textile factory. To improve insomnia symptoms, interventions to promote morningness circadian preference and reduce depressive and anxious symptoms among workers are encouraged.

Difference in the regulation of biological rhythm symptoms of Major depressive disorder between escitalopram and mirtazapine

BACKGROUND

Biological rhythm plays an important role in major depressive disorder (MDD). The efficacy of antidepressant in biological rhythm remains unclear. This study is designed to explore the efficiency of escitalopram and mirtazapine in improving circadian rhythm, diurnal mood variation(DMV) and daily activity in MDD patients.

METHODS

Four-hundred and fifty participants diagnosed with MDD were randomized to receive treatment with escitalopram (TWE), treatment with mirtazapine (TWM) or treatment as usual (TAU). Biological rhythm symptoms were assessed by relevant biological subscale in the Hamilton depression scale (HAMD) and the quick inventory of depressive symptomatology self-report (QIDS). The participants were assessed by trained evaluators at baseline and week 2, 4, 6 and 8.

RESULTS

The differences of HAMD score among TWE(58%, 69%, 72%), TWM(56%, 64%, 76%) and TAU(49%, 57%, 68%) were significant(P<0.05). But the differences were significant only in patients without DMV; (2) Sleep rhythm items (difficulty falling asleep and early-wake) were significantly improved in TWM (P <0 .05) for both HAMD and QIDS. Decreased appetite and weight were significantly improved in TWM (P<0 .05) for both scales. (3) For daily activity-related items, feeling slowed down and concentration were significantly improved in TWE. And the retardation was significantly improved in TWE and in TWM.

CONCLUSIONS

Both escitalopram and mirtazapine have superior anti-depressive effect, especially for MDD patients without DMV. Escitalopram was significantly more effective in daily activity, feeling slowed down and concentration difficulty, while mirtazapine was significantly more effective in improving sleep, appetite and weight of MDD.

Per1 gene polymorphisms influence the relationship between brain white matter microstructure and depression risk

BACKGROUND

Circadian rhythm was involved in the pathogenesis of depression. The detection of circadian genes and white matter (WM) integrity achieved increasing focus for early prediction and diagnosis of major depressive disorder (MDD). This study aimed to explore the effects of PER1 gene polymorphisms (rs7221412), one of the key circadian genes, on the association between depressive level and WM microstructural integrity.

MATERIALS AND METHODS

Diffusion tensor imaging scanning and depression assessment (Beck Depression Inventory, BDI) were performed in 77 healthy college students. Participants also underwent PER1 polymorphism detection and were divided into the AG group and AA group. The effects of PER1 genotypes on the association between the WM characteristics and BDI were analyzed using tract-based spatial statistics method.

RESULTS

Compared with homozygous form of PER1 gene (AA), more individuals with risk allele G of PER1 gene (AG) were in depression state with BDI cutoff of 14 (χ² = 7.37, uncorrected p = 0.007). At the level of brain imaging, the WM integrity in corpus callosum, internal capsule, corona radiata and fornix was poorer in AG group compared with AA group. Furthermore, significant interaction effects of genotype × BDI on WM characteristics were observed in several emotion-related WM tracts. To be specific, the significant relationships between BDI and WM characteristics in corpus callosum, internal capsule, corona radiata, fornix, external capsule and sagittal stratum were only found in AG group, but not in AA group.

CONCLUSION

Our findings suggested that the PER1 genotypes and emotion-related WM microstructure may provide more effective measures of depression risk at an early phase.

Topoisomerase IIIβ Deficiency Induces Neuro-Behavioral Changes and Brain Connectivity Alterations in Mice

Topoisomerase IIIβ (Top3β), the only dual-activity topoisomerase in mammals that can change topology of both DNA and RNA, is known to be associated with neurodevelopment and mental dysfunction in humans. However, there is no report showing clear associations of Top3β with neuropsychiatric phenotypes in mice. Here, we investigated the effect of Top3β on neuro-behavior using newly generated Top3β deficient (Top3β^-/-) mice. We found that Top3β^-/- mice showed decreased anxiety and depression-like behaviors. The lack of Top3β was also associated with changes in circadian rhythm. In addition, a clear expression of Top3β was demonstrated in the central nervous system of mice. Positron emission tomography/computed tomography (PET/CT) analysis revealed significantly altered connectivity between many brain regions in Top3β^-/- mice, including the connectivity between the olfactory bulb and the cerebellum, the connectivity between the amygdala and the olfactory bulb, and the connectivity between the globus pallidus and the optic nerve. These connectivity alterations in brain regions are known to be linked to neurodevelopmental as well as psychiatric and behavioral disorders in humans. Therefore, we conclude that Top3β is essential for normal brain function and behavior in mice and that Top3β could be an interesting target to study neuropsychiatric disorders in humans.

Molecular Link between Circadian Rhythmicity and Mood Disorders

BACKGROUND

The internal clock is driven by circadian genes [e.g., Clock, Bmal1, Per1-3, Cry1-2], hormones [e.g., melatonin, cortisol], as well as zeitgeber ['synchronisers']. Chronic disturbances in the circadian rhythm in patients diagnosed with mood disorders have been recognised for more than 50 years.

OBJECTIVES

The aim of this review is to summarise the current knowledge and literature regarding circadian rhythms in the context of mood disorders, focussing on the role of circadian genes, hormones, and neurotransmitters.

METHOD

The review presents the current knowledge and literature regarding circadian rhythms in mood disorders using the Pubmed database. Articles with a focus on circadian rhythms and mood disorders [n=123], particularly from 1973 to 2020, were included.

RESULTS

The article suggests a molecular link between disruptions in the circadian rhythm and mood disorders. Circadian disturbances, caused by the dysregulation of circadian genes, hormones, and neurotransmitters, often result in a clinical picture resembling depression.

CONCLUSION

Circadian rhythms are intrinsically linked to affective disorders, such as unipolar depression and bipolar disorder.

Circadian rhythm sleep-wake disturbances and depression in young people: implications for prevention and early intervention

A rate-limiting step in the prevention and early intervention of depressive disorders in young people is our insufficient understanding of causal mechanisms. One plausible pathophysiological pathway is disturbance in the 24 h sleep-wake cycle and the underlying circadian system. Abnormalities in circadian rhythms are well documented in adults with various depressive disorders and have been linked to core clinical features, including unstable mood, daytime fatigue, non-restorative sleep, reduced motor activity, somatic symptoms, and appetite and weight change. In this Review, we summarise four areas of research: basic circadian biology and animal models of circadian disturbances; developmental changes in circadian rhythms during adolescence and implications for the emergence of adolescent-onset depressive syndromes; community and clinical studies linking 24 h sleep-wake cycle disturbances and depressive disorders; and clinical trials of circadian-based treatments. We present recommendations based on a highly personalised, early intervention model for circadian-linked depression in young people.

Actigraphy-measured rest-activity circadian rhythm disruption in patients with advanced cancer: a scoping review

PURPOSE

Patients with later-stage cancer have been reported to demonstrate more disrupted rest-activity circadian rhythms (RACR) than those with earlier-stage cancer, but consolidated evidence of this is lacking. The aim of this review was to examine and map the existing evidence on actigraphy-measured RACR in terms of their (1) pattern, (2) prevalence, (3) related factors, and (4) outcomes in advanced cancer patients.

METHODS

A comprehensive scoping review was conducted using Arksey and O'Malley's framework. A literature search was performed using nine databases: MEDLINE, Embase, PsycINFO, CINAHL, British Nursing Index, Cochrane Library, Scopus, Web of Science, and SINTA.

RESULTS

Twenty-one studies were included in the review. Compared with the healthy population, advanced cancer patients were more likely to display weaker RACR, manifesting as lower activity levels during the day, more frequent and longer daytime naps, and fragmented nighttime sleep. The prevalence of RACR disruption among advanced cancer patients ranged from 31.3 to 54.9%. It was found to be linked to the presence of physical and psychological symptoms (fatigue, appetite loss, pain, dyspnoea, sleep disturbance, depression, and anxiety), chemotherapy, male sex, and also predict the lower quality of life and survival.

CONCLUSION

Disruption of the RACR is prevalent in advanced cancer patients and is associated with a set of physical and psychological symptoms. It was also found to be a predictor of the quality of life and survival among these patients. These results indicate the importance of interventions to restabilise the disrupted RACR among advance cancer patients to improve their health outcomes.

The Emerging Circadian Phenotype of Borderline Personality Disorder: Mechanisms, Opportunities and Future Directions

PURPOSE OF REVIEW

We review the recent evidence suggesting that circadian rhythm disturbance is a common unaddressed feature of borderline personality disorder (BPD); amelioration of which may confer substantial clinical benefit. We assess chronobiological BPD studies from a mechanistic and translational perspective and highlight opportunities for the future development of this hypothesis.

RECENT FINDINGS

The emerging circadian phenotype of BPD is characterised by a preponderance of comorbid circadian rhythm sleep-wake disorders, phase delayed and misaligned rest-activity patterns and attenuated amplitudes of usually well-characterised circadian rhythms. Such disturbances may exacerbate symptom severity, and specific maladaptive personality dimensions may produce a liability towards extremes in chronotype. Pilot studies suggest intervention may be beneficial, but development is limited. Endogenous and exogenous circadian rhythm disturbances appear to be common in BPD. The interface between psychiatry and chronobiology has led previously to novel efficacious strategies for the treatment of psychiatric disorders. We believe that better characterisation of the circadian phenotype in BPD will lead to a directed biological target for treatment in a condition where there is a regrettable paucity of accessible therapies.

Peripheral body temperature rhythm is associated with suicide risk in major depressive disorder: a case-control study

Background

Patients with major depressive disorder (MDD) may have an abnormal peripheral body temperature rhythm, but its relationship with suicidal risk and the response to treatment with antidepressants remain unknown.

Aims

This study aimed to investigate the feature of peripheral body temperature in patients with MDD and its relationship with suicide risk before and after treatment with antidepressants.

Methods

This is a prospective case-control study. Patients diagnosed as MDD were enrolled into MDD group. Healthy subjects who matched in terms of gender, age and body mass index were enrolled into normal control (NC) group. The 24-hour peripheral body temperatures were monitored by TM’ Holter the next day after assessment. Patients with MDD were re-assessed after a 2-week treatment with antidepressants. All temperature data were fitted into cosine curves by Python.

Result

There were 41 patients with MDD, and 21 NC participants enrolled and completed the baseline assessments before the treatment. Patients with MDD were further divided into subgroup of with suicide risk or without suicide risk. In patients with MDD, the mesor of peripheral body temperature rhythm was higher in both patients with (36.17 (0.30)) and without suicide risk (36.22 (0.27)) than the mesor in NC participants before treatment (35.84 (0.38), Z=11.82, p=0.003, Kruskal-Wallis test). The phase-delay of temperature before treatment was greater in patients with MDD with suicidal risk (4.71 (1.68)) in comparison with those without suicidal risk (3.05 (2.19)) and NC participants (3.19 (1.82), Z=9.68, p=0.008, Kruskal-Wallis test). Moreover, phase-delay of temperature was associated with suicide risk in patients with MDD before treatment (OR=1.046, 95% CI: 1.009 to 1.085, p=0.015, unadjusted; OR=1.080, 95% CI: 1.020 to 1.144, p=0.009, adjusted by age and sex).

Conclusion

Patients with MDD might have abnormal peripheral body temperature. The abnormal phase-delay of peripheral body temperature may indicate suicide risk in patients with MDD, depending on validation in large-scale cohorts.

Metastasis of Breast Cancer Promoted by Circadian Rhythm Disruption due to Light/Dark Shift and its Prevention by Dietary Quercetin in Mice

Epidemiological studies have indicated that a disturbed circadian rhythm resulting from night-shift work is a potential risk factor for breast cancer. However, the mechanism of increased risk of breast cancer by night-shift work remains unclear, and there have been few in vivo studies conducted to definitively associate the two factors. In this study, BJMC3879Luc2 mouse breast cancer cells were transplanted into BALB/c mice. Mice were maintained under lighting conditions that modeled the two-shift system and were investigated for the effect of light/dark cycle disruption on tumor growth and lymph node metastasis. Circadian dysfunction, which was confirmed by measuring circadian locomotor activities using a nano tag device in our light/dark shift model, did not affect tumor growth. However, a significant increase in the number of lymph nodes with distant metastasis was observed. Neutrophil-to-lymphocyte ratio, which is an adverse prognostic factor of breast cancer and also indicator of inflammation, also increased. It has been demonstrated that a chronic inflammatory response is associated with cancer malignancy and poor prognosis in various cancers. These results suggest that night-shift work may also affect distant metastasis and prognosis. In addition, we investigated whether dietary quercetin has anti-metastatic activity against light/dark shift-induced metastasis. A diet containing 0.3 % quercetin significantly inhibited distant lymph node metastasis, particularly metastasis to the iliac and kidney lymph nodes. Our results contribute to our understandings of the effects of the external light environment on breast cancer metastasis and provide a glimpse into potential protective effects of dietary quercetin on light/dark disturbance-induced metastasis.

Irregular sleep-wake patterns in older adults with current or remitted depression

BACKGROUND

Disturbed sleep and irregular sleep-wake patterns have been associated with poor outcomes in older adults. Sleep regularity however has not been studied in a sample with current or remitted major depression.

METHODS

138 participants (63.8±8.6 years; n=27 current major depression, n=64 remitted, and n=47 healthy controls) were monitored using wrist-worn actigraphy. The Sleep Regularity Index (SRI), sleep-wake fragmentation and stability, sleep onset and offset timing, number of awakenings and measures from cosinor analysis were computed.

RESULTS

Compared with controls, older adults with current depression had lower SRI (p < 0.01), lower relative amplitude (p < 0.05), and higher activity during sleeping and post-midnight hours (p < 0.05). Older adults with remitted depression displayed lower activity during the day (p < 0.05), showed reduced average activity and lower amplitude than controls. Total sleep time, sleep timing, and number of awakenings did not differ between groups. All groups differed significantly in self-reported sleep quality and depression severity.

LIMITATIONS

Longitudinal studies which examine how sleep-wake patterns change based on depressive episode recency, severity and how medications may influence these patterns are needed.

CONCLUSIONS

Older adults with current or remitted major depression do not differ from controls on traditional sleep metrics but do report poor quality sleep and show differences in sleep regularity and rest-activity patterns. Reducing the risk of poor outcomes in both groups may be aided by interventions that help promote sleep regularity and increased activity.

The Revised Mood Rhythm Instrument: A Large Multicultural Psychometric Study

Background: Recent studies with the mood rhythm instrument (MRhI) have shown that the presence of recurrent daily peaks in specific mood symptoms are significantly associated with increased risk of psychiatric disorders. Using a large sample collected in Brazil, Spain, and Canada, we aimed to analyze which MRhI items maintained good psychometric properties across cultures. As a secondary aim, we used network analysis to visualize the strength of the association between the MRhI items. Methods: Adults (n = 1275) between 18–60 years old from Spain (n = 458), Brazil (n = 415), and Canada (n = 401) completed the MRhI and the self-reporting questionnaire (SRQ-20). Psychometric analyses followed three steps: Factor analysis, item response theory, and network analysis. Results: The factor analysis indicated the retention of three factors that grouped the MRhI items into cognitive, somatic, and affective domains. The item response theory analysis suggested the exclusion of items that displayed a significant divergence in difficulty measures between countries. Finally, the network analysis revealed a structure where sleepiness plays a central role in connecting the three domains. These psychometric analyses enabled a psychometric-based refinement of the MRhI, where the 11 items with good properties across cultures were kept in a shorter, revised MRhI version (MRhI-r). Limitations: Participants were mainly university students and, as we did not conduct a formal clinical assessment, any potential correlations (beyond the validated SRQ) cannot be ascertained. Conclusions: The MRhI-r is a novel tool to investigate self-perceived rhythmicity of mood-related symptoms and behaviors, with good psychometric properties across multiple cultures.

Measuring the Effects of Circadian Rhythm-Related Manipulations on Depression-Like Behavior in Rodents: Forced Swim and Tail Suspension Tests

The forced swim and tail suspension tests are commonly used to determine the effects of circadian-related pharmacological, genetic, and environmental manipulations on depression-like behavior in rodents. Both tests involve scoring immobility of rodents in an inescapable condition. Here we describe how to set up and carry out these tests.

Circadian Melatonin Secretion In Obese Adolescents With Or Without Obstructive Sleep Apnea

Objective — To compare melatonin levels in saliva during a 24-hr day in order to identify the specificities of circadian melatonin secretion in obese adolescents with or without obstructive sleep apnea (OSA). Material and Methods — We examined 18 obese adolescents with OSA, 12 obese adolescents without OSA, and 15 healthy adolescents with a normal body weight, from whom saliva was sampled four time during the 24-hr day. Polysomnography was used to diagnose OSA. Saliva samples (n=180) were subjected to enzyme-linked immunosorbent assay. Results — Obese adolescents with OSA had higher evening melatonin levels than obese adolescents without OSA. For example, this indicator in OSA patients was 5.3 times higher than in participants without OSA, who had the lowest evening melatonin level among all groups. In both obese groups, nighttime melatonin levels were significantly lower than in the control group. A positive correlation was detected between the levels of morning and afternoon melatonin and body mass index only in obese adolescents without OSA (r=0.58; p=0.03 and r=0.68; p=0.01, respectively). It was found that evening melatonin correlated with minimum blood oxygen saturation (SaO2) in the entire sample of adolescents with OSA (r=-0.69; p=0.008), and it also correlated with time with SaO2 <90% in the group with clinical manifestations of OSA (r=0.76; p=0.003). Nighttime melatonin levels negatively correlated with the minimum SaO2 value solely in the group with clinical manifestations of OSA (r=-0.58; p=0.035). Conclusion — The circadian melatonin secretion in obese adolescents differed, depending on the presence or absence of OSA, and correlated with the level of oxygen desaturation in OSA patients, to a greater extent – in the presence of clinical manifestations.

Screening for Depression in Daily Life: Development and External Validation of a Prediction Model Based on Actigraphy and Experience Sampling Method

Background

In many countries, depressed individuals often first visit primary care settings for consultation, but a considerable number of clinically depressed patients remain unidentified. Introducing additional screening tools may facilitate the diagnostic process.

Objective

This study aimed to examine whether experience sampling method (ESM)-based measures of depressive affect and behaviors can discriminate depressed from nondepressed individuals. In addition, the added value of actigraphy-based measures was examined.

Methods

We used data from 2 samples to develop and validate prediction models. The development data set included 14 days of ESM and continuous actigraphy of currently depressed (n=43) and nondepressed individuals (n=82). The validation data set included 30 days of ESM and continuous actigraphy of currently depressed (n=27) and nondepressed individuals (n=27). Backward stepwise logistic regression analysis was applied to build the prediction models. Performance of the models was assessed with goodness-of-fit indices, calibration curves, and discriminative ability (area under the receiver operating characteristic curve [AUC]).

Results

In the development data set, the discriminative ability was good for the actigraphy model (AUC=0.790) and excellent for both the ESM (AUC=0.991) and the combined-domains model (AUC=0.993). In the validation data set, the discriminative ability was reasonable for the actigraphy model (AUC=0.648) and excellent for both the ESM (AUC=0.891) and the combined-domains model (AUC=0.892).

Conclusions

ESM is a good diagnostic predictor and is easy to calculate, and it therefore holds promise for implementation in clinical practice. Actigraphy shows no added value to ESM as a diagnostic predictor but might still be useful when ESM use is restricted.

How does ECT work? A new explanatory model and suggestions for non-convulsive applications

In this article a new hypothesis is presented concerning the causal mechanism underlying electroconvulsive therapy (ECT). According to this model the antidepressant effect is caused by a change in sleep architecture triggered by the ictal events induced by ECT. This change in sleep architecture - a profound change in the neurophysiological and neurochemical state of the organism - is what causes the therapeutic effects of ECT and not any simple change in the release of neurotransmitters, neurotrophic factors and/or hormones. This realization also means that a comparable antidepressant effect could be achieved without the need of inducing seizures, but with the help of behavioral interventions that explicitly take aim at changing sleep architecture. The article presents and discusses evidence in favor of this thesis and also puts forth two simple, non-convulsive, applications of the theory.

Sleep and Microbiome in Psychiatric Diseases

Objectives: Disturbances in the gut–brain barrier play an essential role in the development of mental disorders. There is considerable evidence showing that the gut microbiome not only affects digestive, metabolic and immune functions of the host but also regulates host sleep and mental states through the microbiota–gut–brain axis. The present review summarizes the role of the gut microbiome in the context of circadian rhythms, nutrition and sleep in psychiatric disorders. Methods: A PubMed search (studies published between April 2015–April 2020) was conducted with the keywords: “sleep, microbiome and psychiatry”; “sleep, microbiome and depression”; “sleep, microbiome and bipolar disorder”, “sleep, microbiome and schizophrenia”, “sleep, microbiome and anorexia nervosa”, “sleep, microbiome and substance use disorder”, “sleep, microbiome and anxiety”; “clock gene expression and microbiome”, “clock gene expression and nutrition”. Only studies investigating the relationship between sleep and microbiome in psychiatric patients were included in the review. Results: Search results yielded two cross-sectional studies analyzing sleep and gut microbiome in 154 individuals with bipolar disorder and one interventional study analyzing the effect of fecal microbiota transplantation in 17 individuals with irritable bowel syndrome on sleep. In patients with bipolar disorder, Faecalibacterium was significantly associated with improved sleep quality scores and a significant correlation between Lactobacillus counts and sleep. Conclusion: Translational research on this important field is limited and further investigation of the bidirectional pathways on sleep and the gut microbiome in mood disorders is warranted.

The preclinical discovery and development of agomelatine for the treatment of depression

INTRODUCTION

Under the treatment of commonly used antidepressants, many patients with major depressive disorder (MDD) do not achieve remission. All previous first-line treatments for depression have focused on the enhancement of monoaminergic activity. Agomelatine was the first antidepressant with a mechanism of action extending beyond monoaminergic neurotransmission.

AREAS COVERED

The aim of this case history is to describe the discovery strategy and development of agomelatine. The pharmacodynamic profile of the drug is briefly presented. The article summarizes (a) the preclinical behavioral data on agomelatine's effects on depressive-like behavior, anxiety, and circadian rhythmicity disruptions, and (b) the results of early preclinical studies on safety, efficacy in MDD, and the risk-benefit pharmacological profile. Furthermore, the article examines findings of post-marketing research on safety, efficacy, and cost-effectiveness of the drug.

EXPERT OPINION

There is now evidence supporting the clinical efficacy and safety profile of agomelatine in the acute-phase treatment of MDD. Agomelatine may be more effective in specific subgroups of MDD patients, those with severe anxiety symptoms or disturbed circadian profiles. Its antidepressant and anxiolytic activities are due to synergy between its melatonergic and 5-hydroxytryptaminergic effects. Since its discovery, novel compounds acting on the melatonergic system have been under investigation for the treatment of MDD.

Cohort profile: the Brain and Mind Centre Optymise cohort: tracking multidimensional outcomes in young people presenting for mental healthcare

PURPOSE

The Brain and Mind Centre (BMC) Optymise cohort assesses multiple clinical and functional domains longitudinally in young people presenting for mental health care and treatment. Longitudinal tracking of this cohort will allow investigation of the relationships between multiple outcome domains across the course of care. Subsets of Optymise have completed detailed neuropsychological and neurobiological assessments, permitting investigation of associations between these measures and longitudinal course.

PARTICIPANTS

Young people (aged 12-30) presenting to clinics coordinated by the BMC were recruited to a research register (n=6743) progressively between June 2008 and July 2018. To date, 2767 individuals have been included in Optymise based on the availability of at least one detailed clinical assessment.

MEASURES

Trained researchers use a clinical research proforma to extract key data from clinical files to detail social and occupational functioning, clinical presentation, self-harm and suicidal thoughts and behaviours, alcohol and other substance use, physical health comorbidities, personal and family history of mental illness, and treatment utilisation at the following time points: baseline, 3, 6, 12, 24, 36, 48, and 60 months, and time last seen.

FINDINGS TO DATE

There is moderate to substantial agreement between raters for data collected via the proforma. While wide variations in individual illness course are clear, social and occupational outcomes suggest that the majority of cohort members show no improvement in functioning over time. Differential rates of longitudinal transition are reported between early and late stages of illness, with a number of baseline factors associated with these transitions. Furthermore, there are longitudinal associations between prior suicide attempts and inferior clinical and functional outcomes.

FUTURE PLANS

Future reports will detail the longitudinal course of each outcome domain and examine multidirectional relationships between these domains both cross-sectionally and longitudinally, and explore in subsets the associations between detailed neurobiological measures and clinical, social and functional outcomes.

Right care, first time: a highly personalised and measurement-based care model to manage youth mental health

Mood and psychotic syndromes most often emerge during adolescence and young adulthood, a period characterised by major physical and social change. Consequently, the effects of adolescent-onset mood and psychotic syndromes can have long term consequences. A key clinical challenge for youth mental health is to develop and test new systems that align with current evidence for comorbid presentations and underlying neurobiology, and are useful for predicting outcomes and guiding decisions regarding the provision of appropriate and effective care. Our highly personalised and measurement-based care model includes three core concepts: ▶ A multidimensional assessment and outcomes framework that includes: social and occupational function; self-harm, suicidal thoughts and behaviour; alcohol or other substance misuse; physical health; and illness trajectory. ▶ Clinical stage. ▶ Three common illness subtypes (psychosis, anxious depression, bipolar spectrum) based on proposed pathophysiological mechanisms (neurodevelopmental, hyperarousal, circadian). The model explicitly aims to prevent progression to more complex and severe forms of illness and is better aligned to contemporary models of the patterns of emergence of psychopathology. Inherent within this highly personalised approach is the incorporation of other evidence-based processes, including real-time measurement-based care as well as utilisation of multidisciplinary teams of health professionals. Data-driven local system modelling and personalised health information technologies provide crucial infrastructure support to these processes for better access to, and higher quality, mental health care for young people. CHAPTER 1: MULTIDIMENSIONAL OUTCOMES IN YOUTH MENTAL HEALTH CARE: WHAT MATTERS AND WHY?: Mood and psychotic syndromes present one of the most serious public health challenges that we face in the 21st century. Factors including prevalence, age of onset, and chronicity contribute to substantial burden and secondary risks such as alcohol or other substance misuse. Mood and psychotic syndromes most often emerge during adolescence and young adulthood, a period characterised by major physical and social change; thus, effects can have long term consequences. We propose five key domains which make up a multidimensional outcomes framework that aims to address the specific needs of young people presenting to health services with emerging mental illness. These include social and occupational function; self-harm, suicidal thoughts and behaviours; alcohol or other substance misuse; physical health; and illness type, stage and trajectory. Impairment and concurrent morbidity are well established in young people by the time they present for mental health care. Despite this, services and health professionals tend to focus on only one aspect of the presentation - illness type, stage and trajectory - and are often at odds with the preferences of young people and their families. There is a need to address the disconnect between mental health, physical health and social services and interventions, to ensure that youth mental health care focuses on the outcomes that matter to young people. CHAPTER 2: COMBINING CLINICAL STAGE AND PATHOPHYSIOLOGICAL MECHANISMS TO UNDERSTAND ILLNESS TRAJECTORIES IN YOUNG PEOPLE WITH EMERGING MOOD AND PSYCHOTIC SYNDROMES: Traditional diagnostic classification systems for mental disorders map poorly onto the early stages of illness experienced by young people, and purport categorical distinctions that are not readily supported by research into genetic, environmental and neurobiological risk factors. Consequently, a key clinical challenge in youth mental health is to develop and test new classification systems that align with current evidence on comorbid presentations, are consistent with current understanding of underlying neurobiology, and provide utility for predicting outcomes and guiding decisions regarding the provision of appropriate and effective care. This chapter outlines a transdiagnostic framework for classifying common adolescent-onset mood and psychotic syndromes, combining two independent but complementary dimensions: clinical staging, and three proposed pathophysiological mechanisms. Clinical staging reflects the progression of mental disorders and is in line with the concept used in general medicine, where more advanced stages are associated with a poorer prognosis and a need for more intensive interventions with a higher risk-to-benefit ratio. The three proposed pathophysiological mechanisms are neurodevelopmental abnormalities, hyperarousal and circadian dysfunction, which, over time, have illness trajectories (or pathways) to psychosis, anxious depression and bipolar spectrum disorders, respectively. The transdiagnostic framework has been evaluated in young people presenting to youth mental health clinics of the University of Sydney's Brain and Mind Centre, alongside a range of clinical and objective measures. Our research to date provides support for this framework, and we are now exploring its application to the development of more personalised models of care. CHAPTER 3: A COMPREHENSIVE ASSESSMENT FRAMEWORK FOR YOUTH MENTAL HEALTH: GUIDING HIGHLY PERSONALISED AND MEASUREMENT-BASED CARE USING MULTIDIMENSIONAL AND OBJECTIVE MEASURES: There is an urgent need for improved care for young people with mental health problems, in particular those with subthreshold mental disorders that are not sufficiently severe to meet traditional diagnostic criteria. New comprehensive assessment frameworks are needed to capture the biopsychosocial profile of a young person to drive highly personalised and measurement-based mental health care. We present a range of multidimensional measures involving five key domains: social and occupational function; self-harm, suicidal thoughts and behaviours; alcohol or other substance misuse; physical health; and illness type, stage and trajectory. Objective measures include: neuropsychological function; sleep-wake behaviours and circadian rhythms; metabolic and immune markers; and brain structure and function. The recommended multidimensional measures facilitate the development of a comprehensive clinical picture. The objective measures help to further develop informative and novel insights into underlying pathophysiological mechanisms and illness trajectories to guide personalised care plans. A panel of specific multidimensional and objective measures are recommended as standard clinical practice, while others are recommended secondarily to provide deeper insights with the aim of revealing alternative clinical paths for targeted interventions and treatments matched to the clinical stage and proposed pathophysiological mechanisms of the young person. CHAPTER 4: PERSONALISING CARE OPTIONS IN YOUTH MENTAL HEALTH: USING MULTIDIMENSIONAL ASSESSMENT, CLINICAL STAGE, PATHOPHYSIOLOGICAL MECHANISMS, AND INDIVIDUAL ILLNESS TRAJECTORIES TO GUIDE TREATMENT SELECTION: New models of mental health care for young people require that interventions be matched to illness type, clinical stage, underlying pathophysiological mechanisms and individual illness trajectories. Narrow syndrome-focused classifications often direct clinical attention away from other key factors such as functional impairment, self-harm and suicidality, alcohol or other substance misuse, and poor physical health. By contrast, we outline a treatment selection guide for early intervention for adolescent-onset mood and psychotic syndromes (ie, active treatments and indicated and more specific secondary prevention strategies). This guide is based on experiences with the Brain and Mind Centre's highly personalised and measurement-based care model to manage youth mental health. The model incorporates three complementary core concepts: ▶A multidimensional assessment and outcomes framework including: social and occupational function; self-harm, suicidal thoughts and behaviours; alcohol or other substance misuse; physical health; and illness trajectory. ▶Clinical stage. ▶Three common illness subtypes (psychosis, anxious depression, bipolar spectrum) based on three underlying pathophysiological mechanisms (neurodevelopmental, hyperarousal, circadian). These core concepts are not mutually exclusive and together may facilitate improved outcomes through a clinical stage-appropriate and transdiagnostic framework that helps guide decisions regarding the provision of appropriate and effective care options. Given its emphasis on adolescent-onset mood and psychotic syndromes, the Brain and Mind Centre's model of care also respects a fundamental developmental perspective - categorising childhood problems (eg, anxiety and neurodevelopmental difficulties) as risk factors and respecting the fact that young people are in a period of major biological and social transition. Based on these factors, a range of social, psychological and pharmacological interventions are recommended, with an emphasis on balancing the personal benefit-to-cost ratio. CHAPTER 5: A SERVICE DELIVERY MODEL TO SUPPORT HIGHLY PERSONALISED AND MEASUREMENT-BASED CARE IN YOUTH MENTAL HEALTH: Over the past decade, we have seen a growing focus on creating mental health service delivery models that better meet the unique needs of young Australians. Recent policy directives from the Australian Government recommend the adoption of stepped-care services to improve the appropriateness of care, determined by severity of need. Here, we propose that a highly personalised approach enhances stepped-care models by incorporating clinical staging and a young person's current and multidimensional needs. It explicitly aims to prevent progression to more complex and severe forms of illness and is better aligned to contemporary models of the patterns of emergence of psychopathology. Inherent within a highly personalised approach is the incorporation of other evidence-based processes, including real-time measurement-based care and use of multidisciplinary teams of health professionals. Data-driven local system modelling and personalised health information technologies provide crucial infrastructure support to these processes for better access to, and higher quality of, mental health care for young people.

Association between sleep-wake habits and use of health care services of middle-aged and elderly adults in China

OBJECTIVE

To examine the relationship between sleep-wake habits and the use of health care services.

RESULTS

The proportions of the participants who were "early to bed" and "late to bed" were 48.7% and 51.3%, respectively. In the full sample, compared with those who were early to bed and early to rise, participants who went to bed late were more likely to report physician visits (late to bed and early to rise: OR = 1.13, 95% CI: 1.08-1.19, late to bed and late to rise: OR = 1.27, 95% CI: 1.18-1.38, respectively). We found no significant association between sleep-wake habits and the number of hospitalization.

CONCLUSIONS

Those middle-aged and elderly people who stayed up late and got up late are more likely to visit the doctors than those who went to bed early and got up early.

METHODS

We obtained data from a cohort study of retired employees in China, and 36,601 (95.59%) involved in the present study. The participants were allocated into 4 sleep-wake habits groups: Early-bed/Early-rise, Early-bed/Late-rise, Late-bed/Early-rise, and Late-bed/Late-rise. We explored the association between sleep-wake habits with the number of physician visits and hospitalizations.

Flexible, low volume detection of chronobiology biomarkers from human sweat

The work demonstrates the development of a chronobiology tracking system using an affinity-based electrochemical detection modality. This serpentine electrode based system is non-invasive, label free, and economical enabling passive sweat tracking.

How Does Light Regulate Mood and Behavioral State?

The idea that light affects mood and behavioral state is not new. However, not much is known about the particular mechanisms and circuits involved. To fully understand these, we need to know what properties of light are important for mediating changes in mood as well as what photoreceptors and pathways are responsible. Increasing evidence from both human and animal studies imply that a specialized class of retinal ganglion cells, intrinsically photosensitive retinal ganglion cells (ipRGCs), plays an important role in the light-regulated effects on mood and behavioral state, which is in line with their well-established roles in other non-visual responses (pupillary light reflex and circadian photoentrainment). This paper reviews our current understanding on the mechanisms and paths by which the light information modulates behavioral state and mood.

Twin-based heritability of actimetry traits

There is a critical need for phenotypes with substantial heritability that can be used as endophenotypes in behavioral genetic studies. Activity monitoring, called actimetry, has potential as a means of assessing sleep and circadian rhythm traits that could serve as endophenotypes relevant to a range of psychopathologies. This study examined a range of actimetry traits for heritability using a classic twin design. The sample consisted of 195 subjects from 45 monozygotic (MZ) and 50 dizygotic (DZ) twin pairs aged 16-40 years. Subjects wore both a research-grade actimeter (GENEActiv) and a consumer-oriented device (FitBit) for 2 weeks. Sleep and circadian traits were extracted from GENEActiv data using PennZzz and ChronoSapiens software programs. Sleep statistics for a limited number of FitBit-collected traits were generated by its accompanying mobile app. Broad sense heritability was computed on a set of 33 MZ and 38 DZ twin pairs with complete data using both OpenMX and SOLAR software. These analyses yielded a large number of actimetry-derived traits, 20 of which showed high heritability (h² > 0.6), seven of which remain significant after Bonferroni correction. These results indicate that actimetry enables assessing a range of phenotypes with substantial heritability that may be useful as endophenotypes for genetic studies.

The physiological significance of the circadian dynamics of the HPA axis: Interplay between circadian rhythms, allostasis and stress resilience

Circadian time-keeping mechanisms preserve homeostasis by synchronizing internal physiology with predictable variations in the environment and temporally organize the activation of physiological signaling mechanisms to promote survival and optimize the allocation of energetic resources. In this paper, we highlight the importance of the robust circadian dynamics of allostatic mediators, with a focus on the hypothalamic-pituitary-adrenal (HPA) axis, for the optimal regulation of host physiology and in enabling organisms to adequately respond and adapt to physiological stressors. We review studies showing how the chronic disruption of circadian rhythms can result in the accumulation of allostatic load, which impacts the appropriate functioning of physiological systems and diminishes the resilience of internal systems to adequately respond to subsequent stressors. A careful consideration of circadian rhythm dynamics leads to a more comprehensive characterization of individual variability in allostatic load and stress resilience. Finally, we suggest that the restoration of circadian rhythms after pathological disruption can enable the re-engagement of allostatic mechanisms and re-establish stress resilience.

Treating Circadian Rhythm Disruption in Bipolar Disorder

PURPOSE OF REVIEW

Disruptions in circadian rhythms are believed to underlie the illness course of bipolar disorder (BD). This review evaluates recent studies on the treatment of circadian dysfunction in BD.

RECENT FINDINGS

Targeted social rhythm therapy may be useful for bipolar depression though some studies suggest that a non-targeted psychosocial or pharmacological intervention may be just as efficacious. Lithium holds potential for addressing circadian dysfunction in BD. Blue-blocking therapy may be useful for mania and midday bright light therapy may relieve depression.

CONCLUSIONS

Psychosocial, pharmacological, and light-based approaches are promising avenues for treating circadian dysfunction in BD.

Developmental pathways towards mood disorders in adult life: Is there a role for sleep disturbances?

INTRODUCTION

Mood disorders are among the most prevalent and serious mental disorders and rank high among to the leading global burdens of disease. The developmental psychopathology framework can offer a life course perspective on them thus providing a basis for early prevention and intervention. Sleep disturbances, are considered risk factors for mood disorders across childhood, adolescence and adulthood. Assuming that sleep disturbances may play a pivotal role in the pathogenesis of mood disorders from a life course point of view, we reviewed the data on developmental pathways towards mood disorders in adult life in relation to sleep disturbances.

METHOD

From February 2017, a systematic search was conducted in PubMed, PsycINFO and Embase electronic databases for literature on developmental pathways to mood disorders in adult life in relation to sleep disturbances and to 1) pre-natal stress, 2) early brain developmental processes, and 3) temperaments, character and attachment style.

RESULTS

Eleven, 54 and 15 articles were respectively selected.

CONCLUSIONS

Experimental and clinical studies revealed that exposure to prenatal/early life stress results in sleep disturbances such as poor sleep and altered circadian regulation phases and may predict or even precipitate mood disorders in adulthood. Chronic sleep disruption may interfere with neuronal plasticity, connectivity and the developing brain thus contributing to the development of mood disorders. In addition sleep and circadian dysregulations have been shown to be related to those temperaments, character and attachment styles which are considered precursors of mood disorders. Sleep and circadian behaviours may serve as early targets regarding mood disorders.

JA, Jortberg E, Bhatkar V, Ceruolo M, Ghaffari R, Clason DL, Maynard JP, Combs AH. A Pivotal Study to Validate the Performance of a Novel Wearable Sensor and System for Biometric Monitoring in Clinical and Remote Environments

BACKGROUND

Increasingly, drug and device clinical trials are tracking activity levels and other quality of life indices as endpoints for therapeutic efficacy. Trials have traditionally required intermittent subject visits to the clinic that are artificial, activity-intensive, and infrequent, making trend and event detection between visits difficult. Thus, there is an unmet need for wearable sensors that produce clinical quality and medical grade physiological data from subjects in the home. The current study was designed to validate the BioStamp nPoint® system (MC10 Inc., Lexington, MA, USA), a new technology designed to meet this need.

OBJECTIVE

To evaluate the accuracy, performance, and ease of use of an end-to-end system called the BioStamp nPoint. The system consists of an investigator portal for design of trials and data review, conformal, low-profile, wearable biosensors that adhere to the skin, a companion technology for wireless data transfer to a proprietary cloud, and algorithms for analyzing physiological, biometric, and contextual data for clinical research.

METHODS

A prospective, nonrandomized clinical trial was conducted on 30 healthy adult volunteers over the course of two continuous days and nights. Supervised and unsupervised study activities enabled performance validation in clinical and remote (simulated "at home") environments. System outputs for heart rate (HR), heart rate variability (HRV) (including root mean square of successive differences [RMSSD] and low frequency/high frequency ratio), activity classification during prescribed activities (lying, sitting, standing, walking, stationary biking, and sleep), step count during walking, posture characterization, and sleep metrics including onset/wake times, sleep duration, and respiration rate (RR) during sleep were evaluated. Outputs were compared to FDA-cleared comparator devices for HR, HRV, and RR and to ground truth investigator observations for activity and posture classifications, step count, and sleep events.

RESULTS

Thirty participants (77% male, 23% female; mean age 35.9 ± 10.1 years; mean BMI 28.1 ± 3.6) were enrolled in the study. The BioStamp nPoint system accurately measured HR and HRV (correlations: HR = 0.957, HRV RMSSD = 0.965, HRV ratio = 0.861) when compared to ActiheartTM. The system accurately monitored RR (mean absolute error [MAE] = 1.3 breaths/min) during sleep when compared to a Capnostream35TM end-tidal CO2 monitor. When compared with investigator observations, the system correctly classified activities and posture (agreement = 98.7 and 92.9%, respectively), step count (MAE = 14.7, < 3% of actual steps during a 6-min walk), and sleep events (MAE: sleep onset = 6.8 min, wake = 11.5 min, sleep duration = 13.7 min) with high accuracy. Participants indicated "good" to "excellent" usability (average System Usability Scale score of 81.3) and preferred the BioStamp nPoint system over both the Actiheart (86%) and Capnostream (97%) devices.

CONCLUSIONS

The present study validated the BioStamp nPoint system's performance and ease of use compared to FDA-cleared comparator devices in both the clinic and remote (home) environments.

Effect of chronic corticosterone-induced depression on circadian rhythms and age-related phenotypes in mice

Disrupted circadian rhythms are a recognized effect of depression, and our previous article demonstrated an association between depression and premature aging, but the underlying mechanisms are not well understood. In the present study, we used a mouse model of chronic corticosterone (CORT)-treated depression to elucidate a mechanism by which depression may be associated with the circadian clock and mediate age-related phenotypes. Mice received a daily injection of 20 mg/kg CORT for 21 consecutive days, and the depression-like behaviors of mice were identified by the sucrose intake test, tail suspension test and open field test. Our findings indicated that CORT injection may be correlated with the circadian clock by impairing circadian rhythms or shifting the phase values of clock genes. We also showed that CORT-treated mice exhibited a significant gradual reduction in body weight gain with increased oxidative stress, including reduced activity of antioxidant-related enzymes, reduced glutathione:glutathione disulfide ratio and cytochrome (Cyt)-C level, and elevated reactive oxygen species content. Moreover, chronic CORT injection affected inflammatory responses, the production of mitochondrial ATP and telomere shortening, which may be associated with the Sirtuin 3 (SIRT3) signaling pathway. Additionally, chronic CORT injection disrupted the circadian rhythms of some indexes of aging phenotypes and altered the phase values of these indexes. Our findings suggest that psychologically stressful conditions such as depression are linked to changes in circadian rhythms and age-related phenotypes.