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Berardelli I, Amerio A, Bartoli F, Cuomo A, Deste G, Orsolini L, Sampogna G, Pompili M. Rethinking the role of trazodone in the different depressive dimensions. Expert Rev Neurother 2024; 24:619-632. [PMID: 38881379 DOI: 10.1080/14737175.2024.2363843] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2024] [Accepted: 05/31/2024] [Indexed: 06/18/2024]
Abstract
INTRODUCTION The efficacy of trazodone for several psychopathologic dimensions of depression has been shown in the literature. Trazodone has been widely used in some clinical contexts (e.g. for insomnia and depression in the elderly). However, the role of trazodone in several aspects of depression is not well known. AREA COVERED Eight experts from academic and medical centers across Italy met to identify the difficulties and barriers faced in daily clinical practice in the assessment and management of major depressive disorder and how the use of trazodone could address some unmet needs. The objective of the expert meetings and the present document was to increase knowledge of particular areas of treatment with trazodone. EXPERT OPINION Evidence of the role of trazodone in patients affected by major depressive disorder with anxiety symptoms, insomnia, agitation, cognitive deficits, alcohol use disorders, physical comorbidities, and suicide risk has been identified, showing the effectiveness of trazodone in different presentations of major depressive disorder. The main characteristics of patients with depression for whom trazodone seems to be most effective have been identified, providing clinicians with information on possible uses of this drug in such population of patients.
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Affiliation(s)
- Isabella Berardelli
- Department of Neurosciences, Mental Health and Sensory Organs, Suicide Prevention Centre, Sant'Andrea Hospital, Sapienza University of Rome, Rome, Italy
| | - Andrea Amerio
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DINOGMI), Section of Psychiatry, University of Genoa, Genoa, Italy
- IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Francesco Bartoli
- School of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
| | - Alessandro Cuomo
- Department of Molecular and Developmental Medicine, University of Siena, Siena, Italy
| | - Giacomo Deste
- Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
- Department of Mental Health and Addiction Services, ASST Valcamonica, Esine, Italy
| | - Laura Orsolini
- Unit of Clinical Psychiatry, Department of Neurosciences/DIMSC, Polytechnic University of Marche, Ancona, Italy
| | - Gaia Sampogna
- Department of Psychiatry, University of Campania 'L. Vanvitelli', Naples, Italy
| | - Maurizio Pompili
- Department of Neurosciences, Mental Health and Sensory Organs, Suicide Prevention Centre, Sant'Andrea Hospital, Sapienza University of Rome, Rome, Italy
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Zhabenko O, Linskiy IV, Minko OI, Kuzminov VN, Gmeinwieser M, Kiefer LP, Conroy DA. A qualitative assessment of insomnia in recovering alcohol-dependent patients. Neuropsychopharmacol Rep 2023; 43:641-646. [PMID: 37904621 PMCID: PMC10739062 DOI: 10.1002/npr2.12390] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2023] [Revised: 09/21/2023] [Accepted: 09/29/2023] [Indexed: 11/01/2023] Open
Abstract
Insomnia is a common symptom that may interfere with the efforts of alcohol-dependent patients to initiate and maintain sobriety. This study investigates the experiences of recovering alcohol-dependent patients with insomnia as well as preferences for treatment strategies. Semi-structured interviews were conducted with 27 patients in Ukraine and Germany. Most of the patients experienced negative psychological (n = 21), physiological (n = 14) effects and negative daytime consequences during insomnia. All 27 patients were engaged in nonpharmacological approaches to insomnia and 52% used pharmacological approaches to manage insomnia. This study provides insight for understanding how alcohol-dependent patients in recovery perceive insomnia.
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Affiliation(s)
- Olena Zhabenko
- Center for Integrative PsychiatryPsychiatric University Hospital ZurichRheinauSwitzerland
| | - Igor V. Linskiy
- Department of Urgent Psychiatry and NarcologyState Institution, “Institute of Neurology, Psychiatry and Narcology of the Academy of Medical Science of Ukraine”KharkivUkraine
| | - Oleksandr I. Minko
- Department of Clinical and Social NarcologyState Institution, “Institute of Neurology, Psychiatry and Narcology of the Academy of Medical Science of Ukraine”KharkivUkraine
| | - Valeriy N. Kuzminov
- Department of Urgent Psychiatry and NarcologyState Institution, “Institute of Neurology, Psychiatry and Narcology of the Academy of Medical Science of Ukraine”KharkivUkraine
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Khalifian CE, Titone M, Wooldridge JS, Knopp K, Seibert G, Monson C, Morland L. The role of veterans' PTSD symptoms in veteran couples' insomnia. FAMILY PROCESS 2023; 62:1725-1739. [PMID: 36347178 DOI: 10.1111/famp.12835] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/08/2021] [Revised: 09/14/2022] [Accepted: 09/25/2022] [Indexed: 06/16/2023]
Abstract
Insomnia contributes to individual mental and physical health and relationship well-being. Veterans' PTSD symptoms are associated with their own insomnia. However, research has not explored whether and how veterans' PTSD symptoms are associated with their partners' insomnia. The present study examined the association between veterans' PTSD symptom severity and veterans' and partners' insomnia. Veterans (n = 192) and their partners (n = 192; total N = 384) completed baseline assessments in a PTSD treatment study for veterans with PTSD and their partners. Path analysis was used to examine the relation between veterans' PTSD symptom severity, as measured by the PTSD symptom checklist-5 (PCL-5) and veterans' and partners' insomnia, as measured by the Insomnia Severity Index (ISI). Veterans' full-scale PCL-5 was positively related to veterans' and partners' insomnia. For veterans, intrusion and arousal symptoms were positively related to their own insomnia severity, while veterans' negative alterations in cognition and mood were associated with partners' insomnia severity. In exploratory analyses, partners' depressive symptoms fully mediated the relation between veterans' negative cognitions and mood and partners' insomnia. PTSD symptoms impact both veterans' and partners' insomnia. However, different PTSD symptom clusters were related to insomnia for each partner, and the link for partners was explained by their own depression symptoms. PTSD, insomnia, and integrated treatments should consider strategies for including partners in treatment to address these interconnected problems.
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Affiliation(s)
- Chandra E Khalifian
- Veterans Affairs San Diego Healthcare System, San Diego, California, USA
- Department of Psychiatry, University of California, San Diego, La Jolla, California, USA
| | - Madison Titone
- Veterans Affairs San Diego Healthcare System, San Diego, California, USA
- Department of Psychiatry, University of California, San Diego, La Jolla, California, USA
| | - Jennalee S Wooldridge
- Veterans Affairs San Diego Healthcare System, San Diego, California, USA
- Department of Psychiatry, University of California, San Diego, La Jolla, California, USA
| | - Kayla Knopp
- Veterans Affairs San Diego Healthcare System, San Diego, California, USA
- Department of Psychiatry, University of California, San Diego, La Jolla, California, USA
| | - Gregory Seibert
- Department of Psychiatry, University of California, San Diego, La Jolla, California, USA
| | | | - Leslie Morland
- Veterans Affairs San Diego Healthcare System, San Diego, California, USA
- Department of Psychiatry, University of California, San Diego, La Jolla, California, USA
- National Center for PTSD -Pacific Islands division, Honolulu, Hawaii, USA
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Ek J, Jacobs W, Kaylor B, McCall WV. Addiction and Sleep Disorders. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2021; 1297:163-171. [PMID: 33537944 DOI: 10.1007/978-3-030-61663-2_12] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Shared neurophysiology of addiction and sleep disorders results in a bidirectional interplay. Diagnosing and treating primary sleep disorders, particularly in adolescents, can prevent the development of addiction in susceptible individuals. Addressing sleep issues in early recovery, and throughout maintenance, can prevent relapse. Cannabis use for insomnia shows mixed results; assisting with onset sleep latency in early use, this subsides with chronic use and holds addiction risk. Insomnia is a primary complaint of cannabis withdrawal syndrome and a primary cause of relapse in cannabis use disorder. An ideal sleep aid would prevent relapse and have low abuse potential. Pharmaceutical and behavioral options include suvorexant, mirtazapine, trazodone, and aerobic exercise, but clinical trials are lacking to demonstrate efficacy.
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Affiliation(s)
- Jonathan Ek
- Division of Addiction Medicine, Augusta University-Medical College of Georgia, Augusta, GA, USA.
| | - William Jacobs
- Division of Addiction Medicine, Augusta University-Medical College of Georgia, Augusta, GA, USA
| | - Brett Kaylor
- Division of Addiction Medicine, Augusta University-Medical College of Georgia, Augusta, GA, USA
| | - W Vaughn McCall
- Division of Addiction Medicine, Augusta University-Medical College of Georgia, Augusta, GA, USA
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Chaudhary NS, Wong MM, Kolla BP, Kampman KM, Chakravorty S. The relationship between insomnia and the intensity of drinking in treatment-seeking individuals with alcohol dependence. Drug Alcohol Depend 2020; 215:108189. [PMID: 32768993 PMCID: PMC10082590 DOI: 10.1016/j.drugalcdep.2020.108189] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2019] [Revised: 06/16/2020] [Accepted: 07/13/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND Although insomnia is highly prevalent in alcohol use disorders(AUD), its associations with the severity of alcohol use, pre-existing psychiatric comorbidities and psychosocial problems are understudied. The present study evaluates the interplay between these factors using a structural equation model (SEM). METHODS We assessed baseline cross-sectional data on patients with AUD (N = 123) recruited to a placebo-controlled medication trial. Severity of alcohol use was measured by the Brief Michigan Alcoholism Screening Test (B-MAST). Insomnia Severity Index was used to assess insomnia symptoms. The Hamilton scales for Depression and Anxiety, Short Index of Problems and Timeline Follow Back evaluated psychiatric symptoms, psychosocial consequences of drinking and level of alcohol consumption respectively. We used logistic regression to evaluate the association between insomnia and severity of alcohol use while controlling for covariates. We constructed a SEM with observed variables to delineate the effect of psychiatric symptoms, psychosocial factors and current alcohol use on the pathway between alcohol use severity and insomnia. RESULTS The sample was predominately male(83.9 %), Black(54.6 %) and employed(60.0 %). About 45 % of the participants reported moderate-severe insomnia.The association between insomnia and B-MAST attenuated after adjustment for demographics, psychiatric symptoms and psychosocial problems(OR[95 % CI] = 1.17(0.99-1.47). SEM findings demonstrated that B-MAST and insomnia were linked to psychiatric symptoms (95 % Asymptotic-Confidence Interval (ACI): 0.015-0.159, p < 0.05) but not to psychosocial problems or current alcohol use. CONCLUSION Among treatment-seeking patients with AUD, psychiatric burden mediated the relationship between severity of alcohol use and insomnia. Clinicians should screen for underlying psychiatric disorders among treatment-seeking patients with AUD complaining of insomnia.
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Affiliation(s)
- Ninad S Chaudhary
- University of Alabama at Birmingham School of Public Health, 1665 University Blvd, Birmingham, AL, 35211, USA.
| | - Maria M Wong
- Idaho State University, 921 S 8th Ave, Stop 8112, Pocatello, ID, 83209, USA
| | - Bhanu Prakash Kolla
- Department of Psychiatry and Psychology, Mayo Clinic, 2nd ST SW, Rochester, MN, 55905, USA
| | - Kyle M Kampman
- Department of Psychiatry, Perelman School of Medicine, 3400 Civic Center Blvd, Philadelphia, PA, 19104, USA; Cpl. Michael J. Crescenz VA Medical Center, 3900 Woodland Ave, Philadelphia, PA, 19104, USA
| | - Subhajit Chakravorty
- Department of Psychiatry, Perelman School of Medicine, 3400 Civic Center Blvd, Philadelphia, PA, 19104, USA; Cpl. Michael J. Crescenz VA Medical Center, 3900 Woodland Ave, Philadelphia, PA, 19104, USA.
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Geoffroy PA, Tebeka S, Blanco C, Dubertret C, Le Strat Y. Shorter and longer durations of sleep are associated with an increased twelve-month prevalence of psychiatric and substance use disorders: Findings from a nationally representative survey of US adults (NESARC-III). J Psychiatr Res 2020; 124:34-41. [PMID: 32114030 DOI: 10.1016/j.jpsychires.2020.02.018] [Citation(s) in RCA: 43] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2020] [Revised: 02/17/2020] [Accepted: 02/19/2020] [Indexed: 01/15/2023]
Abstract
The lack of comprehensive data on the association between psychiatric and substance use disorders and habitual sleep duration represents a major health information gap. This study examines the 12-month prevalence of mental disorders stratified by duration of sleep. Data were drawn from face-to-face interviews conducted in the National Epidemiologic Survey on Alcohol and Related Conditions III, a nationally representative survey of US adults (N = 36,309). There were 1893 (5.26%) participants who reported <5h of sleep/night; 2434(6.76%) 5 h/night; 7621(21.17%) 6 h/night; 9620(26.72%) 7 h/night; 11,186(31.07%) 8 h/night, and 3245(9.01%) ≥9 h/night. A U-shaped association was observed between sleep duration and all mental disorders. The prevalence of mental disorders was 55% for individuals with <5 h/night and 47.81% for ≥9 h/night, versus 28.24% for the 7 h/night (aOR = 1.90 and 1.39 respectively). The greatest odds ratios were for the <5 h/night group, with an increased risk above 3-fold for panic disorder (PD), post-traumatic stress disorder (PTSD), psychotic disorder, and suicide attempt; between 2 and 3 fold for major depressive disorder (MDD), bipolar disorder (BD), and generalized anxiety disorder (GAD); and between 1 and 2 fold for tobacco and drug use disorders, specific and social phobias. The ≥9 h/night group had an increased risk above 1 to 2-fold regarding tobacco and drug use disorders, MDD, BD, PD, social phobia, GAD, PTSD, psychotic disorder, and suicide attempt. U-shaped associations exist between sleep duration and mental disorders, calling for respect to recommendations for adequate sleep duration in routine clinical care as well as to actions for primary prevention in public health settings.
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Affiliation(s)
- Pierre A Geoffroy
- Département de Psychiatrie et D'addictologie, AP-HP, Hopital Bichat - Claude Bernard, F-75018, Paris, France; Université de Paris, NeuroDiderot, Inserm, F-75019, Paris, France.
| | - Sarah Tebeka
- Paris Diderot University - Paris VII, 5 Rue Thomas Mann, 75013, Paris, France; Department of Psychiatry, Assistance Publique-Hôpitaux de Paris (AP-HP), Louis Mourier Hospital, 178 Rue des Renouillers, 92700, Colombes, France
| | - Carlos Blanco
- National Institute on Drug Abuse, 6001 Executive Boulevard, Bethesda, MD, 20892, USA
| | - Caroline Dubertret
- Paris Diderot University - Paris VII, 5 Rue Thomas Mann, 75013, Paris, France; Department of Psychiatry, Assistance Publique-Hôpitaux de Paris (AP-HP), Louis Mourier Hospital, 178 Rue des Renouillers, 92700, Colombes, France
| | - Yann Le Strat
- Paris Diderot University - Paris VII, 5 Rue Thomas Mann, 75013, Paris, France; Department of Psychiatry, Assistance Publique-Hôpitaux de Paris (AP-HP), Louis Mourier Hospital, 178 Rue des Renouillers, 92700, Colombes, France
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Bjorøy I, Jørgensen VA, Pallesen S, Bjorvatn B. The Prevalence of Insomnia Subtypes in Relation to Demographic Characteristics, Anxiety, Depression, Alcohol Consumption and Use of Hypnotics. Front Psychol 2020; 11:527. [PMID: 32265811 PMCID: PMC7105746 DOI: 10.3389/fpsyg.2020.00527] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2020] [Accepted: 03/05/2020] [Indexed: 11/13/2022] Open
Abstract
Objective The aim of the present study was to examine the prevalence of insomnia subtypes in relation to several demographic characteristics, as well as to investigate the prevalence of possible anxiety and depression, alcohol consumption and use of hypnotics within the different insomnia subtypes. Methods The present study was based on an extensive web-based survey made publicly available in 2012. The data was downloaded in January 2019, after 113 887 people had responded to parts of, or the entire questionnaire. The 64 503 participants who met the criteria for chronic insomnia disorder according to the Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5) comprised the study population. The present study divided insomnia into seven subtypes based on type of sleep difficulty reported; sleep onset insomnia (SOL-insomnia), sleep maintenance insomnia (WASO-insomnia), early morning awakening insomnia (EMA-insomnia) and combinations of these. Data were analyzed with chi-square tests and logistic regression analyses adjusted for sex, age, level of education and marital status. Results More than 60% of the study population met the criteria of either SOL-insomnia or a mixed insomnia subtype consisting of SOL-, WASO- and EMA-insomnia (SOL + WASO + EMA-insomnia). The percentage distribution of insomnia subtypes within the demographic characteristics showed that participants with female sex, high age, low level of education and who were divorced, separated or a widow/widower had a higher prevalence of SOL + WASO + EMA-insomnia compared to their respective demographic counterparts. The prevalence of possible anxiety, possible depression and use of hypnotics were higher among participants with SOL + WASO + EMA-insomnia compared to the other insomnia subtypes. The combination of WASO- and EMA-insomnia (WASO + EMA-insomnia) was associated with the most frequent alcohol consumption. Conclusion Our findings suggest that there are major differences between the insomnia subtypes, both regarding demographics, but also in terms of how the complaints may affect daily life. Participants with combinations of SOL, WASO and EMA were more likely than participants with the other subtypes to have possible anxiety and possible depression, high alcohol consumption and to use hypnotics.
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Affiliation(s)
- Ingrid Bjorøy
- Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
| | | | - Ståle Pallesen
- Norwegian Competence Center for Sleep Disorders, Haukeland University Hospital, Bergen, Norway.,Department of Psychosocial Science, University of Bergen, Bergen, Norway
| | - Bjørn Bjorvatn
- Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway.,Norwegian Competence Center for Sleep Disorders, Haukeland University Hospital, Bergen, Norway
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Geoffroy PA, Lejoyeux M, Rolland B. Management of insomnia in alcohol use disorder. Expert Opin Pharmacother 2020; 21:297-306. [DOI: 10.1080/14656566.2019.1705279] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Affiliation(s)
- Pierre A. Geoffroy
- Département de psychiatrie et d’addictologie, AP-HP, Hopital Bichat - Claude Bernard, Paris, France
- NeuroDiderot, Inserm, Université de Paris, Paris, France
| | - Michel Lejoyeux
- Département de psychiatrie et d’addictologie, AP-HP, Hopital Bichat - Claude Bernard, Paris, France
- Department of Epidemiology, Paris Hospital Group - Psychiatry & Neurosciences, Paris, France
| | - Benjamin Rolland
- Pôle MOPHA, CH Le Vinatier, Service Universitaire d’Addictologie de Lyon (SUAL), Bron, France
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Kolla BP, Mansukhani MP, Biernacka J, Chakravorty S, Karpyak VM. Sleep disturbances in early alcohol recovery: Prevalence and associations with clinical characteristics and severity of alcohol consumption. Drug Alcohol Depend 2020; 206:107655. [PMID: 31744670 DOI: 10.1016/j.drugalcdep.2019.107655] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2019] [Revised: 08/01/2019] [Accepted: 08/05/2019] [Indexed: 11/24/2022]
Abstract
AIMS We aimed to assess the prevalence of sleep disturbance in early alcohol recovery and its association with psychiatric comorbidity, cravings, propensity and severity of alcohol consumption. DESIGN The sample consisted of 18-80 year old patients (n = 303) receiving treatment for alcohol dependence. Sleep disturbance was measured using the Pittsburgh Sleep Quality Index (PSQI). Additional measures included PHQ-9, GAD-7 and Penn alcohol cravings scale (PACS), Inventory of Drug Taking Situations (IDTS) and alcohol consumption was measured utilizing the Time Line Follow Back (TLFB).Bivariate analyses evaluated the association between PSQI total score and other clinical characteristics. A multivariable model was computed for sleep disturbance with predictors entered into the model using automated stepwise selection. FINDINGS The sample was majority male (66%), White (93%) with a mean age of 42.2 ± 11.6 years. Baseline PSQI score was 10.2 ± 4.13 and most subjects (88%) reported sleep disturbance at baseline. Baseline sleep disturbance was associated with depressive symptoms (p < .0001), anxiety symptoms (p < .0001), craving (p < .0001), propensity to drink when experiencing unpleasant emotions (p < .0001), physical discomfort (p < .0001), loss of personal control (p = 0.03), conflict (p = 0.002), number of drinks consumed (p = 0.004), drinking days (p = 0.004) and hazardous drinking days (p = 0.03) in bivariate analyses. However, in the multivariable model, only PHQ-9 total score and IDTS physical discomfort subscale were associated with sleep disturbance. CONCLUSION Sleep disruption is common in early alcohol recovery. Future studies should examine the prognostic and clinical implications of its association with current depressive symptoms and a propensity to drink while experiencing physical discomfort.
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Affiliation(s)
- Bhanu Prakash Kolla
- Department of Psychiatry and Psychology, Mayo Clinic, 2nd ST SW, Rochester, MN 55905, USA; Center for Sleep Medicine, Mayo Clinic, 2nd ST SW, Rochester, MN 55905, USA.
| | - Meghna P Mansukhani
- Department of Psychiatry and Psychology, Mayo Clinic, 2nd ST SW, Rochester, MN 55905, USA
| | - Joanna Biernacka
- Department of Biostatistics, Mayo Clinic, 2nd ST SW, Rochester, MN 55905, USA
| | - Subhajit Chakravorty
- Department of Psychiatry, Perelman School of Medicine, 3400 Civic Center Blvd, Philadelphia, PA 19104, USA
| | - Victor M Karpyak
- Department of Biostatistics, Mayo Clinic, 2nd ST SW, Rochester, MN 55905, USA
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Gilchrist EEA, Sadler DW. The role of depression in unnatural death: A case-based retrospective study. J Affect Disord 2019; 259:7-14. [PMID: 31437704 DOI: 10.1016/j.jad.2019.08.013] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2019] [Revised: 08/02/2019] [Accepted: 08/12/2019] [Indexed: 10/26/2022]
Abstract
BACKGROUND Depression affects the life of millions around the globe and perhaps also the manner of death. This study examined the role of depression in specific causes of unnatural death and whether alcohol and substance use affect this relationship, in one locality in Scotland. METHODS The research used a retrospective case-based study approach to analyse 168 cases, quantifying data reported in mortuary files to allow for quantitative statistical analysis of associations and differences amongst the variables. RESULTS A diagnosis of depression was associated with a higher likelihood of unnatural death due to suicide, drugs or homicide. A diagnosis of substance abuse was associated with a diagnosis of depression and with an increased likelihood of death due to suicide or drugs. A diagnosis of alcohol abuse was associated with a reduced likelihood of a diagnosis of depression but was associated with an increased likelihood of suicide. LIMITATIONS This study relied on a small sample from one locality in Scotland which limited the ability to generalise the results and the retrospective case-based design also limited the potential for checking data accuracy or to consider temporal relationships, which limited the ability to interpret causality. CONCLUSIONS This study found that there was a relationship between depression and unnatural death, which was mediated by alcohol and substance use. The importance of this study lies within the recognition of these relationships which identified the complexities of these relationships but suggested that some unnatural deaths within this population could be prevented.
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Affiliation(s)
- Eilidh E A Gilchrist
- School of Medicine, University of Dundee, Ninewells Hospital & Medical School, Dundee, DD1 9SY, United Kingdom.
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Sleep disturbances in HIV-HCV coinfected patients: indications for clinical management in the HCV cure era (ANRS CO13 HEPAVIH cohort). Eur J Gastroenterol Hepatol 2019; 31:1508-1517. [PMID: 31094856 DOI: 10.1097/meg.0000000000001441] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
OBJECTIVES Although common among patients coinfected with HIV and hepatitis C virus (HCV), sleep disturbances (SD) are still poorly documented in this population in the HCV cure era. This longitudinal study aimed at analysing SD in HIV-HCV coinfected patients and identifying their clinical and sociobehavioural correlates. METHODS We used 5-year annual follow-up data from 1047 participants in the French National Agency for Research on Aids and Viral Hepatitis Cohort 13 'Hépatite et VIH' (ANRS CO13 HEPAVIH) cohort of HIV-HCV coinfected patients to identify clinical (medical records) and behavioural (self-administered questionnaires) correlates of SD (mixed-effects logistic regression). SD were identified using one item documenting the occurrence of insomnia or difficulty falling asleep (ANRS 'Action Coordonnée 24' self-reported symptoms checklist), and two items documenting perceived sleep quality (Center for Epidemiologic Studies Depression and WHO Quality of Life HIV-specific brief scales). RESULTS Seven hundred and sixteen (68.4%) patients with completed self-administered questionnaires reported SD at their most recent follow-up visit. In the multivariable model, hazardous alcohol consumption (Alcohol Use Disorders Identification Test-Consumption score ≥ 4 for men, ≥ 3 for women) (adjusted odds ratio = 1.61; 95% confidence interval: 1.09-2.36), depressive symptoms (6.78; 4.36-10.55) and the number of other physical and psychological self-reported symptoms (1.10; 1.07-1.13) were associated independently with SD after adjustment for sex, age and employment status. HCV cure was not associated significantly with SD. CONCLUSION SD remain frequent in HIV-HCV coinfected patients and are associated with a series of modifiable behavioural risk factors. Independent of HCV cure, improved screening and comprehensive management of alcohol use, physical and psychological self-reported symptoms and depression are essential in this population. Closer investigation of these risk factors of SDs may both increase sleep quality and indirectly improve patients' clinical outcomes.
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Influence of comorbid alcohol use disorders on the clinical patterns of major depressive disorder: A general population-based study. Drug Alcohol Depend 2018; 187:40-47. [PMID: 29626745 DOI: 10.1016/j.drugalcdep.2018.02.009] [Citation(s) in RCA: 79] [Impact Index Per Article: 13.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2017] [Revised: 01/30/2018] [Accepted: 02/01/2018] [Indexed: 11/21/2022]
Abstract
BACKGROUND To compare the symptom patterns of major depressive disorder (MDD) among subjects with MDD and 1) no alcohol use disorder (AUD), 2) alcohol abuse and 3) alcohol dependence, respectively. METHODS In a general population survey of 38,694 French individuals, MDD and AUDs were assessed using the Mini International Neuropsychiatric Interview 5.0.0 (MINI). A total of 4339 subjects (11.2%) in the sample met the criteria for MDD. Among them, 413 (9.5%) AUD subjects were identified: 138 (3.2%) for alcohol abuse and 275 (6.3%) for alcohol dependence. The associations of each of the ten MDD criteria of the MINI and psychiatric clinical features were compared among the three groups. The relative profiles of 'MDD + AUD' vs. 'MDD alone' were determined using a multivariable stepwise regression model. RESULTS With the noAUD group as the reference, sadness (OR = 0.46; 95%CI, 0.29-0.74) and anhedonia (OR = 1.66; 95%CI, 1.06-2.73) were only associated with alcohol abuse. Sleep disorders (OR = 2.07; 95%CI, 1.51-2.88), feelings of guilt (OR = 1.41; 95%CI, 1.05-1.90), diminished concentration/indecisiveness (OR = 1.52; 95%CI, 1.12-2.07) and thoughts of death (OR = 1.95; 95%CI 1.49-2.55) were only associated with alcohol dependence. Weight or appetite variations were both associated with alcohol abuse (OR = 1.7; 95%CI, 1.15-2.53) and dependence (OR = 1.41; 95%CI, 1.06-1.88). Bipolar disorder and PTSD were only associated with alcohol dependence. Psychotic features, previous suicide attempts, and panic disorder were more frequent in the MDD-AUD group. CONCLUSION MDD-AUD subjects displayed a more severe profile with specific symptomatology and comorbidity profiles compared to MDD-only subjects.
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Kim KW, Kang SH, Yoon IY, Lee SD, Ju G, Han JW, Kim TH, Lee CS, Kim T. Prevalence and clinical characteristics of insomnia and its subtypes in the Korean elderly. Arch Gerontol Geriatr 2016; 68:68-75. [PMID: 27665575 DOI: 10.1016/j.archger.2016.09.005] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2015] [Revised: 09/13/2016] [Accepted: 09/16/2016] [Indexed: 01/13/2023]
Abstract
BACKGROUND Insomnia is known to be associated with psychiatric disorders, other sleep disorders and medical conditions, but the prevalence of insomnia diagnosis has never been estimated according to its subtypes. We studied the prevalence and clinical characteristics of insomnia diagnosis and its subtypes in the Korean elderly population. METHODS Among 1423 sampled elderly individuals aged 60 years or older, 881 subjects participated in this study. The Athens Insomnia Scale was applied to detect insomnia symptoms, and insomnia diagnosis was finally evaluated using the international classification of sleep disorders, 2nd edition. To define insomnia subtypes, the DSM-IV-based interview, detailed history on sleep disorders and semi-structured interview for medical conditions were performed. Subsyndromal depression was defined when depressive symptoms did not meet the criteria for depressive disorders. RESULTS The prevalence of insomnia disorder was 32.8% in all subjects, with the prevalence being significantly higher in women than in men (37.9% vs. 25.2%; p<0.001). The prevalence of insomnia subtypes was as follows; psychophysiological insomnia (PI), 20.5%; insomnia due to mental disorder 7.2%; insomnia due to general medical conditions 2.9%; insomnia in other sleep disorders 2.2%, and insomnia due to substance use 0.2%. Among subjects with PI, subsyndromal depression was diagnosed in 53.7%. CONCLUSIONS Nearly one third of Korean elderly individuals suffer from insomnia and insomnia patients showed diverse comorbid conditions, especially depressive symptoms. By establishing insomnia subtypes, we can plan to treat comorbid conditions as well as insomnia itself.
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Affiliation(s)
- Ki Woong Kim
- Department of Neuropsychiatry, Seoul National University Bundang Hospital, Gyeonggi-do, South Korea; Department of Psychiatry, Seoul National University College of Medicine, Seoul, South Korea
| | - Suk-Hoon Kang
- Department of Psychiatry, Veterans Health Service Medical Center, Seoul, South Korea; Department of Psychiatry, Center for Sleep Medicine, Seoul, South Korea
| | - In-Young Yoon
- Department of Neuropsychiatry, Seoul National University Bundang Hospital, Gyeonggi-do, South Korea; Department of Psychiatry, Seoul National University College of Medicine, Seoul, South Korea.
| | - Sang Don Lee
- Department of Psychiatry, Korean Armed Forces Capital Hospital, Gyeonggi-do, South Korea
| | - Gawon Ju
- Department of Neuropsychiatry, Chungbuk National University Hospital, Cheongju, South Korea
| | - Ji Won Han
- Department of Neuropsychiatry, Seoul National University Bundang Hospital, Gyeonggi-do, South Korea
| | - Tae Hui Kim
- Department of Neuropsychiatry, Seoul National University Bundang Hospital, Gyeonggi-do, South Korea
| | - Chung Suk Lee
- Department of Neuropsychiatry, Seoul National University Bundang Hospital, Gyeonggi-do, South Korea
| | - Tae Kim
- Department of Psychiatry, Kyung Hee University Hospital at Gangdong, Seoul,Seoul, South Korea
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Brower KJ. Assessment and treatment of insomnia in adult patients with alcohol use disorders. Alcohol 2015; 49:417-27. [PMID: 25957855 DOI: 10.1016/j.alcohol.2014.12.003] [Citation(s) in RCA: 74] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2014] [Accepted: 12/03/2014] [Indexed: 11/25/2022]
Abstract
Insomnia in patients with alcohol dependence has increasingly become a target of treatment due to its prevalence, persistence, and associations with relapse and suicidal thoughts, as well as randomized controlled studies demonstrating efficacy with behavior therapies and non-addictive medications. This article focuses on assessing and treating insomnia that persists despite 4 or more weeks of sobriety in alcohol-dependent adults. Selecting among the various options for treatment follows a comprehensive assessment of insomnia and its multifactorial causes. In addition to chronic, heavy alcohol consumption and its effects on sleep regulatory systems, contributing factors include premorbid insomnia; co-occurring medical, psychiatric, and other sleep disorders; use of other substances and medications; stress; environmental factors; and inadequate sleep hygiene. The assessment makes use of history, rating scales, and sleep diaries as well as physical, mental status, and laboratory examinations to rule out these factors. Polysomnography is indicated when another sleep disorder is suspected, such as sleep apnea or periodic limb movement disorder, or when insomnia is resistant to treatment. Sobriety remains a necessary, first-line treatment for insomnia, and most patients will have some improvement. If insomnia-specific treatment is needed, then brief behavioral therapies are the treatment of choice, because they have shown long-lasting benefit without worsening of drinking outcomes. Medications work faster, but they generally work only as long as they are taken. Melatonin agonists; sedating antidepressants, anticonvulsants, and antipsychotics; and benzodiazepine receptor agonists each have their benefits and risks, which must be weighed and monitored to optimize outcomes. Some relapse prevention medications may also have sleep-promoting activity. Although it is assumed that treatment for insomnia will help prevent relapse, this has not been firmly established. Therefore, insomnia and alcohol dependence might be best thought of as co-occurring disorders, each of which requires its own treatment.
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Nadorff MR, Salem T, Winer ES, Lamis DA, Nazem S, Berman ME. Explaining alcohol use and suicide risk: a moderated mediation model involving insomnia symptoms and gender. J Clin Sleep Med 2014; 10:1317-23. [PMID: 25325605 DOI: 10.5664/jcsm.4288] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2014] [Accepted: 07/29/2014] [Indexed: 11/13/2022]
Abstract
STUDY OBJECTIVES The purpose of the study was to examine whether insomnia symptoms and nightmares mediated the relation between alcohol use and suicide risk. Further, we examined whether this mediation was moderated by gender. DESIGN The study consisted of questionnaires administered online examining insomnia symptoms, nightmares, alcohol use, and suicide risk. SETTING University. PATIENTS OR PARTICIPANTS 375 undergraduate students at a large, public university in the southeastern United States. INTERVENTIONS N/A. MEASUREMENTS AND RESULTS Results indicated that insomnia symptoms significantly mediated the relation between alcohol use and suicide risk; however, this mediation was moderated by gender. For women, there was both a direct effect of alcohol use on suicide risk as well as an indirect effect of alcohol use through insomnia symptoms increasing suicide risk. For men, there was no direct effect of alcohol use on suicide risk, but there was a significant indirect effect of alcohol use increasing suicide risk through insomnia symptoms. Nightmares were not related to alcohol use, and the association between nightmares and suicide risk was found to be independent of alcohol use. CONCLUSIONS Insomnia symptoms are an important factor in explaining the mechanism by which alcohol use increases suicide risk.
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Affiliation(s)
- Michael R Nadorff
- Mississippi State University, Mississippi State, MS; Baylor College of Medicine, Houston, TX
| | - Taban Salem
- Mississippi State University, Mississippi State, MS
| | | | | | - Sarra Nazem
- VISN 19 Mental Illness Research, Education and Clinical Center, Denver, CO
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16
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Conroy DA. Improve Sleep during Midlife: Address Mental Health Problems Early. Sleep 2014; 37:1733-5. [DOI: 10.5665/sleep.4160] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
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Abstract
Substance use disorders (SUD) are common and individuals who suffer from them are prone to relapse. One of the most common consequences of the use of and withdrawal from substances of abuse is sleep disturbance. Substances of abuse affect sleep physiology, including the neurotransmitter systems that regulate the sleep-wake system. Emerging research now highlights an interactive effect between sleep disorders and substance use. New findings in alcohol and sleep research have utilized sophisticated research designs and expanded the scope of EEG and circadian rhythm analyses. Research on marijuana and sleep has progressed with findings on the effects of marijuana withdrawal on objective and subjective measures of sleep. Treatment studies have focused primarily on sleep in alcohol use disorders. Therapies for insomnia in cannabis disorders are needed. Future research is poised to further address mechanisms of sleep disturbance in alcoholics and the effect of medical marijuana on sleep and daytime functioning.
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18
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Donnadieu-Rigole H, Daien V, Blanc D, Michau S, Villain M, Nalpas B, Perney P. The prevalence of optic neuropathy in alcoholic patients--a pilot study. Alcohol Clin Exp Res 2014; 38:2034-8. [PMID: 24961289 DOI: 10.1111/acer.12468] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2013] [Accepted: 04/10/2014] [Indexed: 01/04/2023]
Abstract
BACKGROUND Alcohol has particularly toxic effects on the central and peripheral nervous systems. Optic neuropathy (ON) is one of these neurological complications. Its diagnosis has not been codified, and its prevalence is poorly known. The aim of this pilot study was to assess the prevalence of ON and identify risk factors in a cohort of patients hospitalized for alcohol withdrawal. METHODS This was a single-center prospective study. A complete standardized eye examination was performed during the patient's alcohol withdrawal; The data collected included: sociodemographic status; the number of withdrawals; the type and amount of alcohol drunk, tobacco, and illicit drug consumption; and ophthalmological results. RESULTS One hundred patients were included prospectively from January 2010 to June 2011 (67 men and 33 women) with a mean age of 47 ± 12 and 46 ± 10 years, respectively. The average alcohol consumption was higher for men than women: 207 ± 122 vs. 146 ± 92 g/d, p = 0.013. The most frequent definition of ON in the literature is a decrease in visual acuity associated with impaired color vision. Thirteen percent of men and 3% of women met these criteria. But monocular ON was observed in 22% of men and 18% women, and partial damage was demonstrated in 27% of men and 7% of women. CONCLUSIONS ON is a relatively rare complication of chronic alcohol consumption, but the high prevalence of incomplete forms should prompt screening and early treatment.
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Affiliation(s)
- Hélène Donnadieu-Rigole
- Department of Internal Medicine and Addiction, Hôpital Saint-Eloi, University Hospital of Montpellier, Montpellier Cedex 5, France; INSERM U844, Montpellier, France; Montpellier University of Medicine (UM1), Rue de l'école de médecine, Montpellier, France
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Blum K, Oscar-Berman M, Badgaiyan RD, Khurshid KA, Gold MS. Dopaminergic Neurogenetics of Sleep Disorders in Reward Deficiency Syndrome (RDS). JOURNAL OF SLEEP DISORDERS & THERAPY 2014; 3:126. [PMID: 25657892 PMCID: PMC4314958 DOI: 10.4172/2167-0277.1000e126] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
It is well-known that sleep has a vital function especially as it relates to prevention of substance-related disorders as discussed in the DSM-V. We are cognizant that certain dopaminergic gene polymorphisms have been associated with various sleep disorders. The importance of "normal dopamine homeostasis" is tantamount for quality of life especially for the recovering addict. Since it is now know that sleep per se has been linked with metabolic clearance of neurotoxins in the brain, it is parsonomiuos to encourage continued research in sleep science, which should ultimately result in attenuation of sleep deprivation especially associated with substance related disorders.
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Affiliation(s)
- Kenneth Blum
- Department of Psychiatry, & McKnight Brain Institute, University of Florida College of Medicine, Gainesville, Florida, USA
- Department of Addiction Research & Therapy, Malibu Beach Recovery Center, Malibu Beach, California, USA
- Department of Nutrigenomics, IGENE, LLC, Austin, Texas, USA
- Dominion Diagnostics, LLC ., North Kingstown, Rhode Island, USA
- Department of Clinical Neurology, PATH Foundation NY., USA
| | - Marlene Oscar-Berman
- Department of Psychiatry and Anatomy & Neurobiology, Boston University School of Medicine and Boston VA Healthcare System, Boston, Massachusetts, USA
| | - Rajendra D Badgaiyan
- Department of Neuroimaging and Psychiatry, University of Buffalo College of Medicine, Buffalo, New York., USA
| | - Khurshid A. Khurshid
- Department of Psychiatry, & McKnight Brain Institute, University of Florida College of Medicine, Gainesville, Florida, USA
| | - Mark S. Gold
- Department of Psychiatry, & McKnight Brain Institute, University of Florida College of Medicine, Gainesville, Florida, USA
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Perng CL, Shen CC, Hu LY, Yeh CM, Chen MH, Tsai CF, Chiang HL, Hung YP, Su VYF, Hu YW, Su TP, Chen PM, Hung JH, Liu CJ, Huang MW. Risk of depressive disorder following non-alcoholic cirrhosis: a nationwide population-based study. PLoS One 2014; 9:e88721. [PMID: 24533141 PMCID: PMC3922987 DOI: 10.1371/journal.pone.0088721] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2013] [Accepted: 01/10/2014] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND & AIMS To evaluate the risk of depressive disorders among non-alcoholic patients by using the Taiwan National Health Insurance Research Database (NHIRD). METHODS We conducted a retrospective study of a matched cohort of 52 725 participants (10 545 non-alcoholic cirrhotic patients and 42 180 control patients) who were selected from the NHIRD. Patients were observed for a maximum of 11 years to determine the rates of newly onset depressive disorders, and Cox regression was used to identify the risk factors associated with depressive disorders in cirrhotic patients. RESULTS During the 11-year follow-up period, 395 (3.75%) non-alcoholic cirrhotic patients and 1 183 (2.80%) control patients were diagnosed with depressive disorders. The incidence risk ratio of depressive disorders between non-alcoholic cirrhotic patients and control patients was 1.76 (95% CI, 1.57-1.98, P<.001). After adjusting for age, sex, and comorbidities, non-alcoholic cirrhotic patients were 1.75 times more likely to develop depressive disorders (95% CI, 1.56-1.96, P<.001) compared with the control patients. The hazard ratios for patients younger than 60 years old (1.31) and female (1.25) indicated that each is an independent risk factor for depressive disorders in non-alcoholic cirrhotic patients. CONCLUSIONS The likelihood of developing depressive disorders is greater among non-alcoholic cirrhotic patients than among patients without cirrhosis. Symptoms of depression should be sought in patients with cirrhosis.
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Affiliation(s)
- Chin-Lin Perng
- Division of Gastroenterology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
- School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Cheng-Che Shen
- Department of Psychiatry, Chiayi Branch, Taichung Veterans General Hospital, Chiayi, Taiwan
- Department of Information Magagement, National Chung-Cheng University, Chiayi, Taiwan
| | - Li-Yu Hu
- Department of Psychiatry, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
| | - Chiu-Mei Yeh
- Department of Family Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Mu-Hong Chen
- Department of Psychiatry, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Chia-Fen Tsai
- School of Medicine, National Yang-Ming University, Taipei, Taiwan
- Department of Psychiatry, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Huey-Ling Chiang
- Department of Psychiatry, Far Eastern Memorial Hospital, New Taipei City, Taiwan
- Department of Psychiatry, National Taiwan University Hospital and College of Medicine, Taipei, Taiwan
| | - Yi-Ping Hung
- School of Medicine, National Yang-Ming University, Taipei, Taiwan
- Division of Hematology and Oncology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Vincent Yi-Fong Su
- School of Medicine, National Yang-Ming University, Taipei, Taiwan
- Department of Chest Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Yu-Wen Hu
- School of Medicine, National Yang-Ming University, Taipei, Taiwan
- Cancer Center, Taipei Veterans General Hospital, Taipei, Taiwan
- Institute of Public Health, National Yang-Ming University, Taipei, Taiwan
| | - Tung-Ping Su
- Division of Gastroenterology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
- Department of Psychiatry, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Pan-Ming Chen
- Department of Psychiatry, Su-Ao and Yuanshan Branch, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Jeng-Hsiu Hung
- Department of Obstetrics and Gynecology, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Taipei, Taiwan
- School of Medicine, Tzu Chi University, Hualien, Taiwan
| | - Chia-Jen Liu
- Division of Hematology and Oncology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
- Institute of Public Health, National Yang-Ming University, Taipei, Taiwan
| | - Min-Wei Huang
- Department of Psychiatry, Chiayi Branch, Taichung Veterans General Hospital, Chiayi, Taiwan
- * E-mail:
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