Prevalence and Clinical Correlates of Insomnia in Depressive Disorders: The CRESCEND Study

The impact of insomnia on brain networks topology in depressed patients: A resting-state fMRI study

OBJECTIVE

Depression and insomnia frequently co-occur, but the neural mechanisms between patients with varying degrees of these conditions are not fully understood. The specific topological features and connectivity patterns of this co-morbidity have not been extensively studied. This study aimed to investigate the topological characteristics of topological characteristics and functional connectivity of brain networks in depressed patients with insomnia.

METHODS

Resting-state functional magnetic resonance imaging data from 32 depressed patients with a high level of insomnia (D-HI), 35 depressed patients with a low level of insomnia (D-LI), and 81 healthy controls (HC) were used to investigate alterations in brain topological organization functional networks. Nodal and global properties were analyzed using graph-theoretic techniques, and network-based statistical analysis was employed to identify changes in brain network functional connectivity.

RESULTS

Compared to the HC group, both the D-HI and D-LI groups showed an increase in the global efficiency (Eglob) values, local efficiency (Eloc) was decreased in the D-HI group, and Lambda and shortest path length (Lp) values were decreased in the D-LI group. At the nodal level, the right parietal nodal clustering coefficient (NCp) values were reduced in D-HI and D-LI groups compared to those in HC. The functional connectivity of brain networks in patients with D-HI mainly involves default mode network (DMN)-cingulo-opercular network (CON), DMN-visual network (VN), DMN-sensorimotor network (SMN), and DMN-cerebellar network (CN), while that in patients with D-LI mainly involves SMN-CON, SMN-SMN, SMN-VN, and SMN-CN. The values of the connection between the midinsula and postoccipital gyrus was negatively correlated with scores for early awakening in D-HI.

CONCLUSION

These findings may contribute to our understanding of the underlying neuropsychological mechanisms in depressed patients with insomnia.

The Combined Influence of Sleep Disturbance and Depression on 12-month Outcomes After Lumbar Spine Surgery

STUDY DESIGN

Retrospective analysis of prospectively collected data.

OBJECTIVE

To examine the combined influence of preoperative sleep disturbance and depression on 12-month patient-reported outcomes after lumbar spine surgery (LSS).

SUMMARY OF BACKGROUND DATA

Psychological and behavioral factors are considered major risk factors for poor outcomes after LSS. However, there is a need to explore the combined effects of preoperative factors such as sleep disturbance and depression. Understanding the influence of sleep disturbance and depression can inform evidence-based preoperative assessment and shared-decision making of preoperative and postoperative treatment.

METHODS

Data from 700 patients undergoing LSS were analyzed. Preoperative sleep disturbance and depression were assessed with PROMIS subscales. Established thresholds defined patients with moderate/severe symptoms. Outcomes for disability (Oswestry Disability Index) and back and leg pain (Numeric Rating Scales) were assessed preoperatively and at 12 months. Separate multivariable linear regressions examined the influence of each factor on 12-month outcomes with and without accounting for the other and in combination as a 4-level variable: (1) moderate/severe sleep disturbance alone, (2) moderate/severe depression alone, (3) both moderate/severe sleep disturbance and depression, (4) no moderate/severe sleep disturbance or depression.

RESULTS

Preoperative sleep disturbance and depression were associated with 12-month disability and pain ( P <0.05). After accounting for depression, preoperative sleep disturbance remained associated with disability, while preoperative depression adjusting for sleep disturbance remained associated with all outcomes ( P <0.05). Patients reporting both moderate/severe sleep disturbance and moderate/severe depression had 12.6 points higher disability and 1.5 points higher back and leg pain compared with patients without moderate/severe sleep disturbance or depression.

CONCLUSIONS

The combination of sleep disturbance and depression impacts postoperative outcomes considerably. The high-risk group of patients with moderate/severe sleep disturbance and depression could benefit from targeted treatment strategies.

LEVEL OF EVIDENCE

Level II.

Disrupted brain functional asymmetry at rest in patients with major depressive disorder associated with sleep disturbances

Sleep disturbances (SD) are common in major depressive disorder (MDD) patients. Brain functional asymmetry is crucial for understanding MDD pathophysiology. Previous studies using the parameter of asymmetry (PAS) approach have found brain functional asymmetry disruption in MDD. However, this has not been explored in MDD patients with SD. This study examined 26 MDD patients with SD, 34 MDD patients without SD, and 34 healthy controls using resting-state functional magnetic resonance imaging scans. SD symptoms were quantified using the 17-item Hamilton Rating Scale for Depression. PAS approach was used to evaluate functional asymmetry. MDD patients with SD displayed increased PAS in the left middle frontal gyrus (MFG)/inferior frontal gyrus (IFG) and decreased PAS in the left parahippocampal gyrus (PHG) compared to MDD patients without SD. Increased PAS in the left MFG/IFG was positively correlated with SD severity, and a negative correlation was found between decreased PAS in the left PHG and SD scores in all MDD patients. Receiver operating characteristic analysis indicated that increased PAS in the left MFG/IFG and decreased PAS in the left PHG may serve as potential neuroimaging markers to differentiate MDD patients with SD from those without SD with Area Under Curve values of 0.8157 and 0.8068, respectively. These results highlighted that increased PAS in the left MFG/IFG and decreased PAS in the left PHG may be considered a prominent feature associated with SD symptoms of MDD patients, potentially serving as imaging markers to discriminate between MDD patients with and without SD.

User Experiences of Ball Blankets in Adults with Depression-Related Insomnia: A Qualitative Content Analysis Study

Insomnia is prevalent in patients suffering from depression and may itself exacerbate the disability associated with depression and impede the path to recovery. Although crucial in ensuring meaningful interactions and interventions for patients, research on patients' experiences of depression-related insomnia and its treatment is limited. The purpose of this study was therefore to investigate how adult patients with depression-related insomnia experience sleeping with a weighted Protac Ball Blanket®, focusing on how the blanket feels and works and contributes to their subjective sleep quality experience. An inductive content analysis approach was adopted. Semi-structured interviews were conducted with 13 patients. Four categories were identified: 1) Deep and dynamic touch pressure from the plastic balls induced calmness; 2) Changing sensory impressions from the rolling balls distracted attention from distressing thoughts and emotions; 3) The ball blanket improved the quality and quantity of sleep, which increased daily well-being; 4) Sleeping with the ball blanket was associated with positive as well as negative experiences depending on personal preferences for sensory stimulation. This study explains how the Protac Ball Blanket® as a potential non-pharmacological sleep-intervention improved the sleep of adult patients with depression-related insomnia. The blanket was found meaningful for coping with sleeplessness and with mental and physical unrest.

A genome-wide association study identifies candidate genes for sleep disturbances in depressed individuals

OBJECTIVE

This study aimed to identify candidate loci and genes related to sleep disturbances in depressed individuals and clarify the co-occurrence of sleep disturbances and depression from the genetic perspective.

METHODS

The study subjects (including 58,256 self-reported depressed individuals and 6,576 participants with PHQ-9 score ≥ 10, respectively) were collected from the UK Biobank, which were determined based on the Patient Health Questionnaire (PHQ-9) and self-reported depression status, respectively. Sleep related traits included chronotype, insomnia, snoring and daytime dozing. Genome-wide association studies (GWASs) of sleep related traits in depressed individuals were conducted by PLINK 2.0 adjusting age, sex, Townsend deprivation index and 10 principal components as covariates. The CAUSALdb database was used to explore the mental traits associated with the candidate genes identified by the GWAS.

RESULTS

GWAS detected 15 loci significantly associated with chronotype in the subjects with self-reported depression, such as rs12736689 at RNASEL (P = 1.00 × 10- 09), rs509476 at RGS16 (P = 1.58 × 10- 09) and rs1006751 at RFX4 (P = 1.54 × 10- 08). 9 candidate loci were identified in the subjects with PHQ-9 ≥ 10, of which 2 loci were associated with insomnia such as rs115379847 at EVC2 (P = 3.50 × 10- 08), and 7 loci were associated with daytime dozing, such as rs140876133 at SMYD3 (P = 3.88 × 10- 08) and rs139156969 at ROBO2 (P = 3.58 × 10- 08). Multiple identified genes, such as RNASEL, RGS16, RFX4 and ROBO2 were reported to be associated with chronotype, depression or cognition in previous studies.

CONCLUSION

Our study identified several candidate genes related to sleep disturbances in depressed individuals, which provided new clues for understanding the biological mechanism underlying the co-occurrence of depression and sleep disorders.

Mindfulness-based cognitive therapy improves insomnia symptoms in individuals with recurrent depression: secondary analyses from a randomized controlled trial

Background

Embedded within a randomized efficacy trial, the present study aimed to investigate whether mindfulness-based cognitive therapy (MBCT) for recurrent depression improved symptoms of insomnia.

Methods

Sixty-eight remitted participants with at least three prior episodes of depression were randomized to 8 weeks of MBCT (n = 33) or a waitlist control condition (n = 35). The Bergen Insomnia Scale was used to screen for insomnia symptoms before and after the intervention. The analyses were conducted using one-way between-groups analyses of covariance.

Results

Twenty-five MBCT participants and 30 waitlist controls completed the study (74.5% females; mean age 40.7 ± 12.9 years). At baseline, 83.6% screened positive for the insomnia diagnosis. Following the intervention and after controlling for corresponding insomnia parameters at baseline, MBCT completers reported significantly less severe insomnia symptoms (p = 0.017), as well as less problems with prolonged sleep onset (p = 0.047) and nocturnal awakenings (p = 0.023), relative to controls. No group differences were found on early morning awakening, daytime impairment, or dissatisfaction with sleep.

Conclusion

The results suggest that MBCT improves certain insomnia symptoms. However, additional sleep-specific interventions may be needed to further improve this population's sleep.Clinical Trial Registration: ISRCTN, ISRCTN18001392, registered 22/11/2018. URL: 10.1186/ISRCTN18001392.

The relationship between sleep, gut microbiota, and metabolome in patients with depression and anxiety: A secondary analysis of the observational study

BACKGROUND

Growing attention is paid to the association between alterations in the gut microbiota and their metabolites in patients with psychiatric disorders. Our study aimed to determine how gut microbiota and metabolomes are related to the sleep quality among patients with depression and anxiety disorders by analyzing the datasets of our previous study.

METHODS

Samples were collected from 40 patients (depression: 32 patients [80.0%]); anxiety disorders: 8 patients [20.0%]) in this study. Gut microbiomes were analyzed using 16S rRNA gene sequencing and gut metabolomes were analyzed by a mass spectrometry approach. Based on the Pittsburgh Sleep Quality Index (PSQI), patients were categorized into two groups: the insomnia group (PSQI score ≥ 9, n = 20) and the non-insomnia group (PSQI score < 9, n = 20).

RESULTS

The insomnia group showed a lower alpha diversity in the Chao1 and Shannon indices than the non-insomnia group after the false discovery rate (FDR) correction. The relative abundance of genus Bacteroides showed a positive correlation with PSQI scores in the non-insomnia group. The concentrations of glucosamine and N-methylglutamate were significantly higher in the insomnia group than in the non-insomnia group.

CONCLUSIONS

Our findings suggest that specific taxa could affect the sleep quality among patients with depression and anxiety disorders. Further studies are needed to elucidate the impact of sleep on specific gut microbiota and metabolomes in depression and anxiety disorders.

Alterations of functional connectivity in young people with depression mediate the relationship between sleep quality and cognitive function

BACKGROUND

Sleep disturbances is common in young people with depression, and poor sleep quality affects the ability to learn. In this study, we examined possible resting-state functional connectivity abnormalities between regions of interest, and clarified the relationship with depressive symptoms, sleep quality, and cognitive function.

METHODS

Resting-state functional magnetic resonance imaging (fMRI) was collected on 42 healthy controls (HCs), 82 youth depressive patients (44 without sleep disturbances (NSD), and 38 with sleep disturbances (SD)). Regions of interest were defined by using Brainnetome Atlas. Functional connectivity was calculated, and its associations with depressive symptoms, sleep quality, and cognitive function were examined using correlation analysis and mediation analysis.

RESULTS

The left and right caudal of cingulate gyrus, tongue and larynx region of postcentral gyrus were significant brain regions in NSD versus SD. The average functional connectivity between these regions was associated with poor sleep quality (r = 0.368, p = 0.001) and worse working memory (r = -0.256, p = 0.023) and mediated the relationship between sleep quality and working memory (c = -0.738, c' = -0.500).

LIMITATION

Data consistency in this study was not good enough. This study did not monitor sleep rhythms to provide objective sleep-related data.

CONCLUSION

The functional connectivity between the left and right caudal of cingulate gyrus with tongue and larynx region of postcentral gyrus may be the neural mechanism by which sleep disturbances affect working memory. This provides an intervention target for clinically improving cognitive function in young people with depression.

Suprachiasmatic nucleus functional connectivity related to insomnia symptoms in adolescents with major depressive disorder

Background

Insomnia is a commonly seen symptom in adolescents with major depressive disorder (MDD). The suprachiasmatic nucleus (SCN), which is the circadian rhythm regulation center, plays a crucial role in the regulation of sleep-wake circulation. Nevertheless, how SCN function contributes to the exact neural mechanisms underlying the associations between insomnia and depressive symptoms has not been explored in adolescents. In the current study, we aimed to explore the relationship between SCN functional connectivity (FC) and insomnia symptoms in adolescents with MDD using a seed-based FC method.

Methods

In the current study, we recruited sixty-eight first-episode drug-naïve adolescents with MDD and classified them into high insomnia (MDD-HI) and low insomnia (MDD-LI) groups according to the sleep disturbance subscale of the Hamilton Depression Rating Scale (HAMD-S). Forty-three age/gender-matched healthy controls (HCs) were also recruited. SCN FC maps were generally for all subjects and compared among three groups using one-way ANOVA with age, gender and adjusted HAMD score as covariates. We used partial correlations to explore associations between altered FC and clinical symptoms, including sleep quality scores.

Results

Adolescents with MDD showed worse sleep quality, which positively correlated with the severity of depression. Compared to MDD-LI and HCs, MDD-HI adolescents demonstrated significantly decreased FC between the right SCN and bilateral precuneus, and there was no significant difference between the MDD-LI and HC groups. The HAMD-S scores were negatively correlated with bilateral SCN-precuneus connectivity, and the retardation factor score of HAMD was negatively correlated with right SCN-precuneus connectivity.

Conclusion

The altered FC between the SCN and precuneus may underline the neural mechanism of sleep-related symptoms in depressive adolescents and provide potential targets for personalized treatment strategies.

What are patients completing Cognitive Behavioral Insomnia Therapy telling us with their post-treatment Insomnia Severity Index scores?

STUDY OBJECTIVE

Cognitive Behavioral Insomnia Therapy (CBT-I) is the gold standard insomnia treatment and the Insomnia Severity Index (ISI) is a frequently used treatment outcome measure. The ISI has strong psychometric properties and is purported to measure perceived insomnia symptom severity. However, little is known about the factors that drive insomnia severity perception and the psychometric properties of the ISI post-CBT-I.

METHODS

Participants were treatment-seeking adults meeting DSM-5 Insomnia Disorder criteria (n = 203, ages 18-77, M = 45.95 years). Participants completed sleep and mood questionnaires, including the ISI, pre- and post-CBT-I. They completed daily Consensus Sleep Diaries each morning throughout two pre-treatment weeks, eight weeks of treatment and two weeks post-treatment. A hierarchical regression analysis examined what predicted post-CBT-I ISI scores and Cronbach's alpha was computed to examine post-treatment reliability of the ISI.

RESULTS

The regression analysis revealed that lower post-treatment ISI scores were associated with lower pre-treatment ISI, and greater decreases in fatigue and generalized anxiety symptoms. The model did not significantly improve when pre-treatment sleep effort or changes in sleep diary indices were added. The post-treatment ISI Cronbach's alpha was .88.

CONCLUSIONS

Although the ISI has been shown to have sound psychometric properties, clinicians should consider that post CBT-I ISI scores are not related to their sleep improvements. Instead, they seem to be related to whether patients perceive themselves as poor sleepers pre-treatment and whether they felt less tired and anxious after CBT-I. Researchers should consider the impact of factors other than sleep when using the ISI at post-treatment. Patients are telling us that CBT-I should focus on addressing symptoms of fatigue and general anxiety; perhaps CBT-I could be improved further to address these concerns more effectively.

SUMMARY

This investigation shows that when individuals are rating their symptom severity after CBT-I, they are also integrating how they felt before treatment and whether they experienced a change in their fatigue or anxiety.

Abnormal amygdala functional connectivity in MDD patients with insomnia complaints

BACKGROUND

Insomnia is one of the major symptom relevant factors in major depressive disorder (MDD), but the neurological mechanisms underlying the multiple effect between insomnia and depression have not been well interpreted. This study aimed at exploring the potential mechanisms between insomnia and depression based on amygdala-based resting-state functional connectivity (RSFC).

METHODS

In total 56 MDD patients with low insomnia (MDD-LI) patients, 46 MDD patients with high insomnia (MDD-HI) patients, and 57 healthy controls (HCs) were employed and underwent a resting-state functional magnetic resonance imaging (fMRI) scan. ANOVA test was performed on RSFC value for three groups. Correlation analysis was conducted to evaluate the relationship between abnormal RSFC values and clinical features.

RESULTS

We found that MDD-HI mainly showed increased RSFC in (bilateral superior temporal gyrus (STG), and decreased RSFC in left supplementary motor area (SMA) and bilateral postcentral gyrus (PoCG) compared with MDD-LI. Correlation analysis indicated that RSFC of the bilateral amygdala with STG were positively associated with the sleep disturbance score and adjust HAMD score.

CONCLUSION

Our findings suggest that RSFC in temporal lobe and other specifically activated regions may be associated with neural circuits involved with insomnia in MDD. These provide new evidence for understanding the potential mechanisms of major depression and insomnia from the perspective of functional connectivity.

[Management of patients with insomnia and polymorbidity: expert consensus]

Sleep disorders are becoming increasingly important due to the high comorbidity with other diseases and a significant impact on the patient's quality of life. Insomnia is the most common sleep disorder both in the general population and in patients with multimorbid pathology. Its prevalence in the general population is 6-15%, while in patients with somatic diseases it increases up to 20-40% and can reach 90% in patients with comorbid mental disorders. Another problem is the development of drug-induced insomnia. Insomnia has negative impact on the prognosis of comorbid diseases, including an increased risk of death, more severe disease, and a worse quality of life. The presence of sleep disorders makes it difficult to effectively treat the underlying disease, so it is extremely important to identify and correct these disorders in the early stages, therefore recommendations for the diagnosis of insomnia in polymorbid patients are proposed. Modern methods of treating acute and chronic insomnia and features of insomnia treatment in polymorbid patients are also discussed.

Associations between sleep-related heart rate variability and both sleep and symptoms of depression and anxiety: A systematic review

There is a bidirectional relationship between poor sleep and both mood- and anxiety-related disorders, which are among leading global health concerns. Additionally, both disordered sleep and these psychiatric disorders appear to be independently associated with altered autonomic nervous system (ANS) function. We hypothesise that ANS dysregulation during sleep may explain part of the relationship between poor sleep and mood- and anxiety-related disorders. Heart rate variability (HRV) is a frequently used marker of ANS function and gives an indication of ANS input to the heart - in particular, of the relative contributions of sympathetic and parasympathetic activity. A systematic review of PubMed, Scopus and Web of Science yielded 41 studies dealing with sleep, mood- and anxiety-related disorders and sleep-related HRV. Hyperarousal during sleep, reflecting a predominance of sympathetic activation and indicative of ANS dysregulation, may be an important factor in the association between poor sleep and mood-related disorders. Longitudinal studies and mediation analyses are necessary to further understand the potential mediating role of ANS dysregulation on the relationship between poor sleep and mood- and anxiety-related disorders.

Sleep disorder as a clinical risk factor of major depression: associated with cognitive impairment

BACKGROUND

This research aims explored the sleep disorder (SD) role in major depressive disorder (MDD), and the SD influencing their cognition.

METHODS

372 MDD patients and 457 healthy controls (HCs) were enrolled.

RESULTS

Patients increased a 38.88 times SD risk compared with HCs. In patients, visuospatial/constructional score was lower in SD than non-SD, and PSQI score was negatively associated with visuospatial/constructional score of SD. In SD and non-SD, RBANS scores were lower in MDD than HCs, excepted for visuospatial/constructional in non-SD.

CONCLUSION

The SD as a MDD risk factor, has more serious visuospatial/constructional impairment alleviated via improving sleep/depression in patients.

Insomnia disorders are associated with increased cardiometabolic disturbances and death risks from cardiovascular diseases in psychiatric patients treated with weight-gain-inducing psychotropic drugs: results from a Swiss cohort

STUDY OBJECTIVES

Insomnia disorders as well as cardiometabolic disorders are highly prevalent in the psychiatric population compared to the general population. We aimed to investigate their association and evolution over time in a Swiss psychiatric cohort.

METHODS

Data for 2861 patients (8954 observations) were obtained from two prospective cohorts (PsyMetab and PsyClin) with metabolic parameters monitored routinely during psychotropic treatment. Insomnia disorders were based on the presence of ICD-10 "F51.0" diagnosis (non-organic insomnia), the prescription of sedatives before bedtime or the discharge letter. Metabolic syndrome was defined using the International Diabetes Federation definition, while the 10-year risk of cardiovascular event or death was assessed using the Framingham Risk Score and the Systematic Coronary Risk Estimation, respectively.

RESULTS

Insomnia disorders were observed in 30% of the cohort, who were older, predominantly female, used more psychotropic drugs carrying risk of high weight gain (olanzapine, clozapine, valproate) and were more prone to suffer from schizoaffective or bipolar disorders. Multivariate analyses showed that patients with high body mass index (OR = 2.02, 95%CI [1.51-2.72] for each ten-kg/m2 increase), central obesity (OR = 2.20, [1.63-2.96]), hypertension (OR = 1.86, [1.23-2.81]), hyperglycemia (OR = 3.70, [2.16-6.33]), high density lipoprotein hypocholesterolemia in women (OR = 1.51, [1.17-1.95]), metabolic syndrome (OR = 1.84, [1.16-2.92]) and higher 10-year risk of death from cardiovascular diseases (OR = 1.34, [1.17-1.53]) were more likely to have insomnia disorders. Time and insomnia disorders were associated with a deterioration of cardiometabolic parameters.

CONCLUSIONS

Insomnia disorders are significantly associated with metabolic worsening and risk of death from cardiovascular diseases in psychiatric patients.

Does Insomnia Increase the Risk of Suicide in Hospitalized Patients with Major Depressive Disorder? A Nationwide Inpatient Analysis from 2006 to 2015

Introduction. Insomnia is an important symptom associated with major depressive disorder (MDD). In addition, it is one of the risk factors for suicide. Studies have shown the relationship be-tween insomnia and suicidal behavior in patients with MDD. However, this association has not been evaluated in a large sample of hospitalized patients. Objectives. To evaluate the suicidal be-havior in MDD patients with insomnia compared to those without insomnia. Methods. From the National Inpatient Sample (NIS 2006−2015) database using the ICD-9 code, patients’ data were obtained with the primary diagnosis of MDD and comorbid diagnosis of insomnia disorders (MDD+I). These patients were compared with MDD patients without insomnia disorders (MDD−I) by performing a 1:2 match for the primary diagnosis code. Suicidal ideation/attempt da-ta were compared between the groups by multivariate logistic regression analysis. Results. After the diagnostic code matching, 139061 patients were included in the MDD+I group and 276496 patients in the MDD−I group. MDD+I patients were older (47 years vs. 45 years, p < 0.001) com-pared to the MDD−I group. The rate of suicidal ideation/attempt was 56.0% in the MDD+I group and 42.0% in the MDD−I group (p < 0.001). After adjusting for age, sex, race, borderline personal-ity disorders, anxiety disorders, and substance use disorders, ‘insomnia’ was associated with 1.71 times higher odds of suicidal behavior among MDD patients admitted to the hospital. (Odds ratio: 1.71, 95% confidence interval 1.60−1.82, p < 0.001). Conclusions. Insomnia among MDD patients is significantly associated with the risk of suicide. MDD patients with insomnia need to be closely monitored for suicidal behavior.

The relationship between the HDRS insomnia items and polysomnographic (PSG) measures in individuals with treatment-resistant depression

The Hamilton Depression Rating Scale (HDRS), which includes several insomnia-related items, is potentially valuable in evaluating both depressive and sleep symptoms. However, the HDRS insomnia items have not been fully assessed by objective measures. This study compared the three HDRS insomnia items (Early, Middle, and Late) with the corresponding objective polysomnography (PSG) measures of Sleep Latency (SL), middle wakefulness, and late wakefulness. The study used HDRS and PSG data from 130 baseline nights, drawn from 80 participants enrolled in clinical trials for treatment-resistant depression (TRD). Mixed models evaluated the relationship between the HDRS and PSG, and primary analyses examined the Early, Middle, and Late Insomnia HDRS items and the PSG variables SL and Waking After Sleep Onset (WASO). To approximate the Middle and Late HDRS Insomnia items more closely, WASO was divided into WASO before 4:00 a.m. (waking between Sleep Onset and 0400 h) and WASO after 4:00 a.m. (waking between 0400 h and 0700 h). Secondary analyses included summed HDRS Global Insomnia score. HDRS Early and Late Insomnia items predicted objective PSG measures of early and late wakefulness. For Early Insomnia, each additional point in severity was associated with 61% [95%CI: 35%, 93%] longer SL. For Late Insomnia, each additional point was associated with a 35% [95% CI: 13%, 63%] increase in WASO after 4:00 a.m. Middle Insomnia was marginally related to WASO before 4:00 a.m. HDRS Early and Late Insomnia items may thus provide an index of wakefulness in TRD and help monitor treatment response when objective measures such as PSG are not feasible. CLINICAL TRIALS IDENTIFIER: www.clinicaltrials.gov (NCT01204918, NCT00054704, NCT00088699).

Correlation Between Body Mass Index and Depression/Depression-Like Symptoms Among Different Genders and Races

Background

While being overweight is a risk factor for hyperlipidemia, type 2 diabetes, cancer, and heart disease, it can also be a risk factor for depression and vice versa. In this study, we aimed to evaluate the relationship between body mass index (BMI) and the prevalence of depression symptoms between genders and races.

Methodology

A nationally representative sample was utilized to explore the relationship between depression-related symptoms and BMI status by comparing different genders and racial identities. The National Health and Nutrition Examination Survey (NHANES) data, managed by the Centers for Disease Control and Prevention, was used in this study. Data from 2013 to 2016 were included in the analysis. The Patient Health Questionnaire was used to collect information regarding responses to eight primary questions based on gender, race, and BMI status. Statistical analysis was conducted using descriptive analysis and the chi-square test.

Results

Data were presented as percentages. A majority of both men and women who admitted to having depression or depression-like symptoms more than half the days or nearly every day were overweight or obese. However, men had a higher prevalence compared to women for most questions. Statistical analysis showed that among men and women who felt down, depressed, or hopeless nearly every day, 61.5% (χ² = 5.045, p = 0.992) and 50.9% (χ² = 17.186, p = 0.308) were overweight, respectively. Among the races, those who felt down, depressed, or hopeless nearly every day, non-Hispanic Asian individuals had the lowest percentage of being overweight at 47.7% (χ² = 7.099, p = 0.955), while Hispanic individuals other than Mexican Americans had the highest percentage of being overweight at 67.4% (χ² = 8.792, p = 0.721).

Conclusions

Being overweight or obese appears to have a positive relationship with depression and depression-like symptoms for each gender and race. Similarly, individuals who report having depression-like symptoms are likely to be overweight or obese. Further research is needed to determine other differences in etiologies between genders and races, along with determining whether more individuals become depressed due to being overweight or obese or whether more individuals become overweight or obese due to being depressed. The results of this study are limited to the data obtained through NHANES.

The aberrant dynamic amplitude of low-frequency fluctuations in melancholic major depressive disorder with insomnia

BACKGROUND

Insomnia is considered one of the manifestations of sleep disorders, and its intensity is linked to the treatment effect or suicidal thoughts. Major depressive disorder (MDD) is classified into various subtypes due to heterogeneous symptoms. Melancholic MDD has been considered one of the most common subtypes with special sleep features. However, the brain functional mechanisms in melancholic MDD with insomnia remain unclear.

MATERIALS AND METHODS

Melancholic MDD and healthy controls (HCs, n = 46) were recruited for the study. Patients were divided into patients with melancholic MDD with low insomnia (mMDD-LI, n = 23) and patients with melancholic MDD with high insomnia (mMDD-HI, n = 30), according to the sleep disturbance subscale of the 17-item Hamilton Depression Rating Scale. The dynamic amplitude of low-frequency fluctuation was employed to investigate the alterations of brain activity among the three groups. Then, the correlations between abnormal dALFF values of brain regions and the severity of symptoms were investigated.

RESULTS

Lower dALFF values were found in the mMDD-HI group in the right middle temporal gyrus (MTG)/superior temporal gyrus (STG) than in the mMDD-LI (p = 0.014) and HC groups (p < 0.001). Melancholic MDD groups showed decreased dALFF values than HC in the right middle occipital gyri (MOG)/superior occipital gyri (SOG), the right cuneus, the bilateral lingual gyrus, and the bilateral calcarine (p < 0.05). Lower dALFF values than HC in the left MOG/SOG and the left cuneus in melancholic MDD groups were found, but no significant difference was found between the mMDD-LI group and HC group (p = 0.079). Positive correlations between the dALFF values in the right MTG/STG and HAMD-SD scores (the sleep disturbance subscale of the HAMD-17) in the mMDD-HI group (r = 0.41, p = 0.042) were found. In the pooled melancholic MDD, the dALFF values in the right MOG/SOG and the right cuneus (r = 0.338, p = 0.019), the left MOG/SOG and the left cuneus (r = 0.299, p = 0.039), and the bilateral lingual gyrus and the bilateral calcarine (r = 0.288, p = 0.047) were positively correlated with adjusted HAMD scores.

CONCLUSION

The occipital cortex may be related to depressive symptoms in melancholic MDD. Importantly, the right MTG/STG may play a critical role in patients with melancholic MDD with more severe insomnia.

Shared genetic liability and causal effects between major depressive disorder and insomnia

Deciphering the genetic relationships between major depressive disorder (MDD) and insomnia may facilitate understanding biological mechanisms as well as inform more effective treatment regimens for these conditions. Here we attempted to investigate mechanisms underlying relationships between MDD and insomnia in the context of shared genetic variations. Shared genetic variation was evaluated by polygenic analysis. In two-sample bidirectional Mendelian randomization analysis, causal relationships between MDD and insomnia were investigated; the list of shared genomic loci was identified using cross-trait meta-analysis. Putatively causal genes for the two diseases were prioritized by fine-mapping of transcriptome-wide associations. Polygenic analysis identified 15.1 thousand variants as causally influencing MDD, and 10.8 thousand variants as influencing insomnia. Among these variants, 8.5 thousand were shared between the two diseases. Mendelian randomization analysis suggests that genetic liability to MDD and to insomnia have mutual causal effects (MDD on insomnia with OR = 1.25 and insomnia on MDD with OR = 2.23). Cross-trait meta-analyses identified 89 genomic loci as being shared between MDD and insomnia, with some of them being prioritized as causal in subsequent fine-mapping of transcriptome-wide association signals. Analysis highlights possible role of endogenous production of nitric oxide in the brain, and the gonadotropic secretion in the pituitary as possibly physiological connectors of MDD and insomnia. Here we show a substantial shared genetic liability and mutual causal links between MDD and insomnia. Presented findings provide novel insight into phenotypic relationship between these two interconnected conditions.

Impact of Insomnia Symptoms on the Clinical Presentation of Depressive Symptoms: A Cross-Sectional Population Study

Objective: Insomnia and depression are prevalent disorders that often co-occur. This study aimed to investigate the impact of clinically significant insomnia symptoms on the prevalence and clinical presentation of clinically significant depressive symptoms and vice versa. Methods: This study used data from the Korean Headache-Sleep Study (KHSS), a nationwide cross-sectional population-based survey regarding headache and sleep. Clinically significant insomnia symptoms were defined as Insomnia Severity Index (ISI) scores ≥ 10 and clinically significant depressive symptoms were defined as Patient Health Questionnaire-9 (PHQ-9) scores ≥ 10, respectively. We referred clinically significant insomnia symptoms and clinically significant depressive symptoms as insomnia symptoms and depressive symptoms, respectively. Results: Of 2,695 participants, 290 (10.8%) and 116 (4.3%) were classified as having insomnia and depressive symptoms, respectively. The prevalence of depressive symptoms was higher among participants with insomnia symptoms than in those without insomnia symptoms (25.9 vs. 1.7%, respectively, P < 0.001). Among participants with depressive symptoms, the PHQ-9 scores were not significantly different between participants with and without insomnia symptoms (P = 0.124). The prevalence of insomnia symptoms was significantly higher among participants with depressive symptoms than in those without depressive symptoms (64.7 vs. 8.3%, respectively, P < 0.001). The ISI scores were significantly higher among participants with insomnia and depressive symptoms than in participants with insomnia symptoms alone (P < 0.001). Conclusions: Participants with depressive symptoms had a higher risk of insomnia symptoms than did those without depressive symptoms. The severity of depressive symptoms did not significantly differ based on insomnia symptoms among participants with depressive symptoms; however, the severity of insomnia symptoms was significantly higher in participants with depressive symptoms than in those without depressive symptoms.

Molecular genetic overlap between posttraumatic stress disorder and sleep phenotypes

STUDY OBJECTIVES

Sleep problems are common, serving as both a predictor and symptom of posttraumatic stress disorder (PTSD), with these bidirectional relationships well established in the literature. While both sleep phenotypes and PTSD are moderately heritable, there has been a paucity of investigation into potential genetic overlap between sleep and PTSD. Here, we estimate genetic correlations between multiple sleep phenotypes (including insomnia symptoms, sleep duration, daytime sleepiness, and chronotype) and PTSD, using results from the largest genome-wide association study (GWAS) to date of PTSD, as well as publicly available GWAS results for sleep phenotypes within UK Biobank data (23 variations, encompassing four main phenotypes).

METHODS

Genetic correlations were estimated utilizing linkage disequilibrium score regression (LDSC), an approach that uses GWAS summary statistics to compute genetic correlations across traits, and Mendelian randomization (MR) analyses were conducted to follow up on significant correlations.

RESULTS

Significant, moderate genetic correlations were found between insomnia symptoms (rg range 0.36-0.49), oversleeping (rg range 0.32-0.44), undersleeping (rg range 0.48-0.49), and PTSD. In contrast, there were mixed results for continuous sleep duration and daytime sleepiness phenotypes, and chronotype was not correlated with PTSD. MR analyses did not provide evidence for casual effects of sleep phenotypes on PTSD.

CONCLUSION

Sleep phenotypes, particularly insomnia symptoms and extremes of sleep duration, have shared genetic etiology with PTSD, but causal relationships were not identified. This highlights the importance of further investigation into the overlapping influences on these phenotypes as sample sizes increase and new methods to investigate directionality and causality become available.

Disease Trajectories for Hidradenitis Suppurativa in the Danish Population

Importance

Hidradenitis suppurativa (HS) is a chronic skin disease characterized by recurrent inflamed nodular lesions and is associated with multiple comorbidities; previous studies have been of cross-sectional design, and the temporal association of HS with multiple comorbidities remains undetermined.

Objective

To evaluate and characterize disease trajectories in patients with HS using population-wide disease registry data.

Design, Setting, and Participants

This retrospective registry-based cohort study included the entire Danish population alive between January 1, 1994, and April 10, 2018 (7 191 519 unique individuals). Among these, 14 488 Danish inhabitants were diagnosed with HS or fulfilled diagnostic criteria identified through surgical procedure codes.

Exposures

Citizens of Denmark with a diagnosis code of HS as defined by International Statistical Classification of Diseases and Related Health Problems, Tenth Revision (ICD-10) or as identified through surgical procedures.

Main Outcomes and Measures

Disease trajectories experienced more frequently by patients with HS than by the overall Danish population. Strength of associations between disease co-occurrences was evaluated using relative risk (RR). All significant disease pairs were tested for directionality using a binomial test, and pairs with directionality were merged into disease trajectories of 3 consecutive diseases. Numerous disease trajectories were combined into a disease progression network showing the most frequent disease paths over time for patients with HS.

Results

A total of 11 929 individuals were identified by ICD-10 diagnosis codes (8392 [70.3%] female; mean [SD] age, 37.72 [13.01] years), and 2791 were identified by procedural codes (1686 [60.4%] female; mean [SD] age, 37.38 [15.83]). The set of most common temporal disease trajectories included 25 diagnoses and had a characteristic appearance in which genitourinary, respiratory, or mental and behavioral disorders preceded the diagnosis of HS and chronic obstructive pulmonary disease (604 cases [4.2%]; RR, 1.57; 95% CI, 1.55-1.59; P < .001), pneumonia (827 [5.7%]; RR, 1.18; 95% CI, 1.15-1.20; P < .001), and acute myocardial infarction (293 [2.0%]; RR, 1.37; 95% CI, 1.35-1.39; P < .001) developed after the diagnosis.

Conclusions and Relevance

The findings suggest that patients with newly diagnosed HS may have a high frequency of manifest type 1 diabetes and subsequent high risk of acute myocardial infarction, pneumonia, and chronic obstructive pulmonary disease.

Associations Between High Plasma Methylxanthine Levels, Sleep Disorders and Polygenic Risk Scores of Caffeine Consumption or Sleep Duration in a Swiss Psychiatric Cohort

Objective: We first sought to examine the relationship between plasma levels of methylxanthines (caffeine and its metabolites) and sleep disorders, and secondarily between polygenic risk scores (PRS) of caffeine consumption or sleep duration with methylxanthine plasma levels and/or sleep disorders in a psychiatric cohort. Methods: Plasma levels of methylxanthines were quantified by ultra-high performance liquid chromatography/tandem mass spectrometry. In inpatients, sleep disorder diagnosis was defined using ICD-10 "F51.0," sedative drug intake before bedtime, or hospital discharge letters, while a subgroup of sedative drugs was used for outpatients. The PRS of coffee consumption and sleep duration were constructed using publicly available GWAS results from the UKBiobank. Results: 1,747 observations (1,060 patients) were included (50.3% of observations with sleep disorders). Multivariate analyses adjusted for age, sex, body mass index, setting of care and psychiatric diagnoses showed that patients in the highest decile of plasma levels of methylxanthines had more than double the risk for sleep disorders compared to the lowest decile (OR = 2.13, p = 0.004). PRS of caffeine consumption was associated with plasma levels of caffeine, paraxanthine, theophylline and with their sum (β = 0.1; 0.11; 0.09; and 0.1, p_corrected = 0.01; 0.02; 0.02; and 0.01, respectively) but not with sleep disorders. A trend was found between the PRS of sleep duration and paraxanthine levels (β = 0.13, p_corrected = 0.09). Discussion: Very high caffeine consumption is associated with sleep disorders in psychiatric in- and outpatients. Future prospective studies should aim to determine the benefit of reducing caffeine consumption in high caffeine-consuming patients suffering from sleep disorders.

Abnormal functional connectivity density in patients with major depressive disorder with comorbid insomnia

BACKGROUND

Insomnia is a common comorbidity symptom in patients with major depressive disorder (MDD). However, the brain functional alteration in MDD with higher level insomnia (MDD-HI) and lower level insomnia (MDD-LI) remains unclear. Here, we investigated the association of insomnia with global functional connectivity density (gFCD) in patients with MDD.

METHODS

A total of 148 participants were recruited and underwent resting-state functional magnetic resonance imaging. A voxel-wise analysis of covariance was employed to explore group differences in gFCD among the MDD-HI, MDD-LI and healthy control (HC) groups.

RESULTS

The gFCD in the bilateral parahippocampal/hippocampal gyri (PHG/HIP) was higher in the two MDD than in the HC group, and it was higher in the MDD-LI than in the MDD-HI group; the gFCD in the left fusiform area was lower in the MDD than in the HC group. The gFCD in the left inferior temporal gyrus (ITG) was higher in the MDD-HI than in the MDD-LI and HC groups. The gFCD in the left ITG and posterior PHG/HIP was associated with insomnia, while the gFCD in the left anterior PHG/HIP was correlated with non-insomnia depressive symptoms in the MDD group.

LIMITATIONS

The cross-sectional design and the use of brief/subjective insomnia assessments.

CONCLUSIONS

The present study showed that the abnormal brain features of MDD with different insomnia symptom. Importantly, the posterior and anterior parts of the hippocampus may play different roles in the presence or absence of insomnia in patients with MDD.

Bypassing the blues: Insomnia in the depressed post-CABG population

BACKGROUND

BACKGROUND: Recovery from coronary artery bypass graft (CABG) surgery often is complicated by depression and insomnia, resulting in poorer health-related quality of life and clinical outcomes. We explored the relationships among depression, insomnia, quality of life, and the impact of a collaborative care strategy on reducing insomnia in patients after CABG surgery.

METHODS

METHODS: Patients with a Patient Health Questionnaire score ≥10 were randomized to nurse-delivered collaborative care for depression (n = 150) or their physician’s usual care (n = 152). A convenience sample of patients without depression (n = 151) served as the control group. Using the Hamilton Depression Rating Scale sleep questions, we created an “insomnia index.”

RESULTS

RESULTS: At baseline, 63% of participants who were depressed vs 12% of those who were not depressed reported insomnia. Compared with usual care, fewer collaborative care participants reported insomnia at 8 months, and they tended to have a lower insomnia score (insomnia index change score −0.95 and −1.47, respectively; P = .05) with no time-by- randomization interaction, Cohen’s d = 0.22 (95% confidence interval, −0.001 to 0.43). Participants with baseline insomnia reported greater improvements in mental health–related quality of life (Medical Outcomes Survey 36-item Short Form Mental Component Summary score; −3.32, P = .02), but insomnia was not a significant moderator of the effect of collaborative care.

CONCLUSIONS

CONCLUSIONS: This is the first study to examine the long-term impact on insomnia among post-CABG patients treated for depression. Future collaborative care studies could consider including a therapeutic focus for insomnia.

Neuroimaging insights into the link between depression and Insomnia: A systematic review

BACKGROUND

Insomnia is a common symptom of Major Depressive Disorder (MDD) and genome-wide association studies pointed to their strong genetic association. Although the prevalence of insomnia symptoms in MDD is noticeable and evidence supports their strong bidirectional association, the number of available neuroimaging findings on patients of MDD with insomnia symptoms is limited. However, such neuroimaging studies could verily improve our understanding of their shared pathophysiology and advance corresponding theories.

METHODS

Based on the preferred reporting items for systematic reviews and meta-analysis (PRISMA) guideline, we have conducted a literature search using PubMed, EMBASE, and Scopus databases and systematically explored 640 studies using various neuroimaging modalities in MDD patients with different degrees of insomnia symptoms.

RESULTS

Despite inconsistencies, current findings from eight studies suggested structural and functional disturbances in several brain regions including the amygdala, prefrontal cortex and anterior cingulate cortex and insula. The aberrant functional connectivity within and between the main hubs of the salience and default mode networks could potentially yield new insights into the link between MDD and insomnia, which needs further assessment.

LIMITATIONS

The number of studies reviewed herein is limited. The applied methods for assessing structural and functional neural mechanisms of insomnia and depression were variable.

CONCLUSION

Neuroimaging methods demonstrated the overlapping underlying neural mechanisms between MDD and insomnia. Future studies may facilitate better understanding of their pathophysiology to allow development of specific treatment.

Sleep problems and depression among 237 023 community-dwelling adults in 46 low- and middle-income countries

Sleep problems are considered a core symptom of depression. However, there is little information about the comorbidity of sleep problems and depression in low- and middle-income countries (LMICs), and whether sleep problems with depression confer additional risk for decrements in health compared to sleep problems alone. This study thus examined the association between sleep problems and depression and whether sleep problems with depression are associated with an increased risk for poorer health in 46 LMICs. Cross-sectional, community-based data from 237 023 adults aged ≥18 years from the World Health Survey (WHS) 2002–2004 were analyzed. Information on sleep problems (severe/extreme) and International Classification of Diseases 10th Revision depression/depression subtypes was collected. Multivariable logistic (binary and multinomial) and linear regression analyses were performed. Sleep problems were associated with subsyndromal depression (odds ratio [OR]: 2.23, 95% confidence interval [CI]: 1.84–2.70), brief depressive episode (OR = 2.48, 95% CI = 2.09–2.95) and depressive episode (OR = 3.61, 95% CI = 3.24–4.03). Sleep problems with depression (vs. sleep problems alone) conferred additional risk for anxiety, perceived stress and decrements in health in the domains of mobility, self-care, pain, cognition, and interpersonal activities. Clinicians should be aware that the co-occurrence of sleep problems and depression is associated with a variety of adverse health outcomes in LMICs. Detecting this co-occurrence may be important for treatment planning.

Auricular Plaster Therapy for Comorbid Insomnia: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

Background

Although the effectiveness of auricular plaster therapy (APT) on primary insomnia has been systematically reviewed, no systematic review of studies has focused on the effect on comorbid insomnia.

Objective

To evaluate the efficacy and safety of APT for comorbid insomnia.

Methods

Fifteen databases were searched from inception to July 2018. Randomized controlled trials (RCTs) of APT as an exclusive intervention for comorbid insomnia against Western medications, sham APT or no treatment were identified.

Results

Fourteen studies involving 928 participants were identified. The pooled outcomes revealed that APT was superior to control conditions for the global score on PSQI (SMD = -1.13, and 95% CI = -1.48—-0.78) and the effective rate (RR = 1.24, 95% CI = 1.13—1.36, NNT = 5, and 95% CI =4—7). Furthermore, the results of subgroup analyses were similar to the pooled results. Additionally, the pooled results were verified to be stable by sensitivity analyses. Regarding safety, no significant difference was identified between APT and Western medications.

Conclusions

APT appears to be an effective and safe treatment for comorbid insomnia. However, the benefits of APT for comorbid insomnia could not be ascertained due to the paucity of the quantity and quality of the included studies. Large-scale studies using proper methodology are needed to yield a firm conclusion.

The Orbitofrontal Cortex Gray Matter Is Associated With the Interaction Between Insomnia and Depression

Insomnia and depression are highly comorbid symptoms in both primary insomnia (PI) and major depressive disorder (MDD). In the current study, we aimed at exploring both the homogeneous and heterogeneous brain structure alteration in PI and MDD patients. Sixty-five MDD patients and 67 matched PI patients were recruited and underwent a structural MRI scan. The subjects were sub-divided into four groups, namely MDD patients with higher or lower insomnia, and PI patients with higher or lower severe depression. A general linear model was employed to explore the changes in cortical thickness and volume as a result of depression or insomnia, and their interaction. In addition, partial correlation analysis was conducted to detect the clinical significance of the altered brain structural regions. A main effect of depression on cortical thickness was seen in the superior parietal lobe, middle cingulate cortex, and parahippocampal gyrus, while a main effect of insomnia on cortical thickness was found in the posterior cingulate cortex. Importantly, the interaction between depression and insomnia was associated with decreased gray matter volume in the right orbitofrontal cortex, i.e., patients with co-occurring depression and insomnia showed smaller brain volume in the right orbitofrontal cortex when compared to patients with lower insomnia/depression. These findings highlighted the role of the orbitofrontal cortex in the neuropathology of the comorbidity of insomnia and depression. Our findings provide new insights into the understanding of the brain mechanism underlying comorbidity of insomnia and depression.

Development of an Algorithm to Identify Patients with Physician-Documented Insomnia

We developed an insomnia classification algorithm by interrogating an electronic medical records (EMR) database of 314,292 patients. The patients received care at Massachusetts General Hospital (MGH), Brigham and Women’s Hospital (BWH), or both, between 1992 and 2010. Our algorithm combined structured variables (such as International Classification of Diseases 9th Revision [ICD-9] codes, prescriptions, laboratory observations) and unstructured variables (such as text mentions of sleep and psychiatric disorders in clinical narrative notes). The highest classification performance of our algorithm was achieved when it included a combination of structured variables (billing codes for insomnia, common psychiatric conditions, and joint disorders) and unstructured variables (sleep disorders and psychiatric disorders). Our algorithm had superior performance in identifying insomnia patients compared to billing codes alone (area under the receiver operating characteristic curve [AUROC] = 0.83 vs. 0.55 with 95% confidence intervals [CI] of 0.76–0.90 and 0.51–0.58, respectively). When applied to the 314,292-patient population, our algorithm classified 36,810 of the patients with insomnia, of which less than 17% had a billing code for insomnia. In conclusion, an insomnia classification algorithm that incorporates clinical notes is superior to one based solely on billing codes. Compared to traditional methods, our study demonstrates that a classification algorithm that incorporates physician notes can more accurately, comprehensively, and quickly identify large cohorts of insomnia patients.

Prevalence of sleep disorders and severity of insomnia in psychiatric outpatients attending a tertiary level mental health care facility in Punjab, India

BACKGROUND

Sleep disorders are frequently associated with psychiatric disorders and can be both cause and effect of the same.

AIM

To study the prevalence of sleep disorders and the severity of insomnia in psychiatric outpatients.

METHODS

500 patients were randomly selected using purposive sampling from patients attending a tertiary level mental health care facility were evaluated for the presence of any sleep disorder along with their sleep quality. In patients having insomnia, severity of the same was determined.

RESULTS

83.4% of the population had some type of sleep disorder. Symptoms of insomnia were reported by 78.2% of the population and 29.2% had moderate to severe insomnia. 78.4% of the population had poor sleep quality. Significant difference was noted among the different psychiatric groups when insomnia severity index (ISI) was compared. In multinomial logistic regression, chance of severe insomnia is more if the diagnosis is depression, but less if mania or ocd, compared to psychosis.

CONCLUSION

This study was the first in India to assess the prevalence of sleep disorders in psychiatric outpatients. Our study underscores the importance of careful evaluation of sleep problems for proper management of the patients.

Increased Salience Network Activity in Patients With Insomnia Complaints in Major Depressive Disorder

BACKGROUND

Insomnia is one of the main symptom correlates of major depressive disorder (MDD), but the neural mechanisms underlying the multifaceted interplay between insomnia and depression are not fully understood.

MATERIALS AND METHODS

Patients with MDD and high insomnia (MDD-HI, n = 24), patients with MDD and low insomnia (MDD-LI, n = 37), and healthy controls (HCs, n = 51) were recruited to participate in the present study. The amplitude of low-frequency fluctuations (ALFF) during the resting state were compared among the three groups.

RESULTS

We observed ALFF differences between the three groups in the right inferior frontal gyrus/anterior insula (IFG/AI), right middle temporal gyrus, left calcarine, and bilateral dorsolateral prefrontal cortex (dlPFC). Further region of interest (ROI) comparisons showed that the increases in the right IFG/AI reflected an abnormality specific to insomnia in MDD, while increases in the bilateral dlPFC reflected an abnormality specific to MDD generally. Increased ALFF in the right IFG/AI was also found to be correlated with sleep disturbance scores when regressing out the influence of the severity of anxiety and depression.

CONCLUSION

Our findings suggest that increased resting state ALLF in IFG/AI may be specifically related to hyperarousal state of insomnia in patients with MDD, independently of the effects of anxiety and depression.

Sleep disturbances and upregulation of brain arousal during daytime in depressed versus non-depressed elderly subjects

OBJECTIVES

Although patients with depression often suffer from sleep disturbances, most of them are not sleepy. Upregulation of brain arousal has been proposed as pathophysiological mechanism explaining sleep disturbances, inner tension, autonomic hyperarousal and anhedonia in depression. The aim of the current study was to examine the association between night-time sleep disturbances and brain arousal regulation the next day in depressed versus non-depressed subjects.

METHODS

Twenty-eight elderly subjects (21 female; age = 70.5 ± 4.4 years) with depressive syndromes without psychotropic medication, and 28 controls (22 female; age = 70.9 ± 4.5 years), underwent a 15-min resting electroencephalogram; the Vigilance Algorithm Leipzig (VIGALL 2.1) provided an objective measure of brain arousal regulation. Sleep disturbances were assessed by a validated and self-rated sleep questionnaire.

RESULTS

In the depressive group, but not in controls, more sleep disturbances were associated with a higher brain arousal stability score (high score corresponds to upregulation) the next day (sleep onset latency: r_s = 0.69, P < .0001; sleep quality: r_s = -0.59, P < .001).

CONCLUSIONS

The data confirm the hypothesis that in persons with depressive syndromes sleep disturbances are related to upregulation of brain arousal the next day. This finding is in line with the concept that dysregulation of brain arousal is a central pathophysiological aspect in depression.

Self-reported obstructive sleep apnea is associated with nonresponse to antidepressant pharmacotherapy in late-life depression

BACKGROUND

Obstructive sleep apnea (OSA) is frequently comorbid with late-life depression. The purpose of this project was to determine, using a sample of older adults with major depressive disorder, whether patient-reported diagnosis of OSA was associated with rate of response to venlafaxine.

METHODS

Participants from this multisite study were adults ≥60 years old (n = 468) with major depressive disorder and a Montgomery Asberg Depression Rating Scale (MADRS) score of ≥15. Depression response was the outcome variable, defined as a MADRS score of ≤10 for two consecutive assessments at the end of 12 weeks of open-label treatment with venlafaxine 300 mg/day. To assess OSA, participants were asked if they had been diagnosed with OSA using polysomnography.

RESULTS

Eighty participants (17.1%) reported a diagnosis of OSA prior to baseline. Participants with OSA were more likely to be male, report greater impairment on measures of health, experience a longer duration of the index episode, and receive an adequate antidepressant trial prior to entering the study. During the 12 weeks of treatment, 40.8% responded to treatment with venlafaxine (43.6%, n = 169/388 of the no OSA group, and 27.5%, n = 22/80 of the OSA group). Participants without OSA were 1.79 times more likely to respond to treatment (HR: 1.79 [95%CI: 1.13-2.86], P < .05) compared to those with OSA.

CONCLUSIONS

OSA may impair response to antidepressant pharmacotherapy in depressed older adults. Future studies of antidepressant response rates among depressed older adults with OSA should both prospectively diagnose OSA and monitor adherence to treatments such as continuous positive airway pressure.

Sleep disturbance among people with major depressive disorders (MDD) in Singapore

BACKGROUND

Sleep problems are common with major depressive disorder (MDD), which has been identified as the most pervasive mental disorder in Singapore.

AIMS

This study aimed to establish the prevalence of sleep disturbance among adults with lifetime and 12-month MDD, as well as its socio-demographic and clinical correlates.

METHOD

Data were collected from the Singapore Mental Health Study, a cross-sectional epidemiological survey of the local residential population aged ≥18 years. Using the CIDI 3.0, 417 and 181 respondents with lifetime and 12-month MDD were included in the analysis.

RESULTS

The prevalence of insomnia-related sleep disturbance among those with lifetime and 12-month MDD was 90.9% and 91.4%, respectively. Multiple logistic regression analyses revealed ethnicity, education and the number of depressive episodes as well as clinical comorbidities such as obsessive compulsive disorder, diabetes and hypertension to be significantly associated with sleep disturbance among those with lifetime MDD. However, only 28.6% of those with sleep disturbance sought help from a professional.

CONCLUSIONS

The proportion of Singaporeans with MDD who have sleep disturbance is high, with increased risk for mental and physical health problems. Given the low rate of treatment contact, individuals with MDD must be screened and treated for sleep disturbance.

Clinical and sociodemographic correlates of severe insomnia in psychotropic drug-free, Asian outpatients with major depressive disorder

BACKGROUND

Little has been known regarding the correlates of severe insomnia in major depressive disorder (MDD). This post-hoc analysis aimed to examine the sociodemographic and clinical correlates of severe insomnia in psychotropic drug-free, Asian adult outpatients with MDD.

METHODS

Participants were psychotropic drug-free patients with MDD, aged 18-65 years. By using the Symptom Checklist-90 Items, Revised (SCL-90-R), a score of 4 (severe distress) on any one of three insomnia items was defined as severe insomnia. Other measures included the Montgomery-Asberg Depression Rating Scale (MADRS), the Fatigue Severity Scale (FSS), the nine psychopathology subscales of SCL-90-R, the Physical and Mental Component Summaries of Short Form Health Survey (SF-36 PCS and SF-36 MCS), and the Sheehan Disability Scale (SDS).

RESULTS

Of 528 participants, their mean age being 39.5 (SD=13.26) years, 64.2% were females, and 239 (45.3%) had severe insomnia. The logistic regression model revealed that low educational qualifications (less than secondary school completion), high SCL-90-R Depression scores, high SCL-90-R Anxiety scores, and low SF-36 PCS scores were independently correlated with severe insomnia (p's<.05).

LIMITATIONS

Insomnia was determined only by the patient's distress. Middle insomnia was not assessed. Psychotropic drug-free patients with MDD are not commonly seen in psychiatric practice.

CONCLUSION

Severe insomnia is common in patients with MDD. It is closely related with low educational qualification, subjective depression and anxiety severity, and poor physical health. These findings may implicate the treatment of comorbid MDD and severe insomnia, for example, sleep hygiene education, pharmacological treatment.

Gender differences in depressive symptom profiles and patterns of psychotropic drug usage in Asian patients with depression: Findings from the Research on Asian Psychotropic Prescription Patterns for Antidepressants study

OBJECTIVES

The purpose of this study was to investigate whether there were gender-specific depressive symptom profiles or gender-specific patterns of psychotropic agent usage in Asian patients with depression.

METHOD

Clinical data from the Research on Asian Psychotropic Prescription Patterns for Antidepressant study (1171 depressed patients) were used to determine gender differences by analysis of covariates for continuous variables and by logistic regression analysis for discrete variables. In addition, a binary logistic regression model was fitted to identify independent clinical correlates of the gender-specific pattern on psychotropic drug usage.

RESULTS

Men were more likely than women to have loss of interest (adjusted odds ratio = 1.379, p = 0.009), fatigue (adjusted odds ratio = 1.298, p = 0.033) and concurrent substance abuse (adjusted odds ratio = 3.793, p = 0.008), but gender differences in other symptom profiles and clinical features were not significant. Men were also more likely than women to be prescribed adjunctive therapy with a second-generation antipsychotic (adjusted odds ratio = 1.320, p = 0.044). However, men were less likely than women to have suicidal thoughts/acts (adjusted odds ratio = 0.724, p = 0.028). Binary logistic regression models revealed that lower age (odds ratio = 0.986, p = 0.027) and current hospitalization (odds ratio = 3.348, p < 0.0001) were independent clinical correlates of use of second-generation antipsychotics as adjunctive therapy for treating depressed Asian men.

CONCLUSION

Unique gender-specific symptom profiles and gender-specific patterns of psychotropic drug usage can be identified in Asian patients with depression. Hence, ethnic and cultural influences on the gender preponderance of depression should be considered in the clinical psychiatry of Asian patients.

Is the BPRS-5 subscale of the psychotic depression assessment scale a reliable screening tool for psychotic depression?: Results from the CRESCEND study

BACKGROUND

The detection of psychotic depression (PD) among patients with depressive disorders is important for both treatment and monitoring. Therefore, in continuation of our previous work, this study aimed to test the ability of the five-item Brief Psychiatric Rating Scale (BPRS-5) of the Psychotic Depression Assessment Scale (PDAS) in separating patients with psychotic depression from those with non-psychotic depression (non-PD) and to compare this discriminative validity to that of other item sets.

METHODS

A receiver operating characteristics curve was used to identify the optimal cut-off score of the BPRS-5 subscale for sensitive and specific distinction between PD and non-PD in a sample of 494 patients with depressive disorders (53 with PD and 441 with non-PD).

RESULTS

Using an optimal cut-off score of 1, the sensitivity and the specificity of the BPRS-5 subscale in detecting PD were 71.2% and 87.2%, respectively. The BPRS-5 outperformed other item sets of the PDAS and the positive symptom subscale of the BPRS in identifying patients with PD.

LIMITATIONS

The inter-rater reliability of the PDAS and the BPRS-5 subscale was not evaluated in this study.

CONCLUSIONS

The BPRS-5 subscale can be regarded as a more sensitive screening method for PD compared to other item sets from the PDAS and the BPRS. Hence, from a screening perspective, a positive score on any of the five symptoms of the BPRS-5 subscale (hallucinatory behavior, unusual thought content, suspiciousness, blunted affect, and emotional withdrawal) is indicative of PD, and should lead to more thorough diagnostic assessment.

Hazardous drinking-related characteristics of depressive disorders in Korea: the CRESCEND study

This study aimed to identify clinical correlates of hazardous drinking in a large cohort of Korean patients with depression. We recruited a total of 402 depressed patients aged > 18 yr from the Clinical Research Center for Depression (CRESCEND) study in Korea. Patients' drinking habits were assessed using the Korean Alcohol Use Disorder Identification Test (AUDIT-K). Psychometric scales, including the HAMD, HAMA, BPRS, CGI-S, SSI-Beck, SOFAS, and WHOQOL-BREF, were used to assess depression, anxiety, overall psychiatric symptoms, global severity, suicidal ideation, social functioning, and quality of life, respectively. We compared demographic and clinical features and psychometric scores between patients with and without hazardous drinking behavior after adjusting for the effects of age and sex. We then performed binary logistic regression analysis to identify independent correlates of hazardous drinking in the study population. Our results revealed that hazardous drinking was associated with current smoking status, history of attempted suicide, greater psychomotor retardation, suicidal ideation, weight loss, and lower hypochondriasis than non-hazardous drinking. The regression model also demonstrated that more frequent smoking, higher levels of suicidal ideation, and lower levels of hypochondriasis were independently correlates for hazardous drinking in depressed patients. In conclusion, depressed patients who are hazardous drinkers experience severer symptoms and a greater burden of illness than non-hazardous drinkers. In Korea, screening depressed patients for signs of hazardous drinking could help identify subjects who may benefit from comprehensive therapeutic approaches.

Does age at onset of first major depressive episode indicate the subtype of major depressive disorder?: the clinical research center for depression study

PURPOSE

The purpose of this study was to evaluate the effects of age at onset of the first major depressive episode on the clinical features of individuals with major depressive disorder (MDD) in a large cohort of Korean depressed patients.

MATERIALS AND METHODS

We recruited 419 MDD patients of age over 18 years from the Clinical Research Center for Depression study in South Korea. At the start of the study, the onset age of the first major depressive episode was self-reported by the subjects. The subjects were divided into four age-at-onset subgroups: childhood and adolescent onset (ages <18), early adult onset (ages 18-44), middle adult onset (ages 45-59), and late onset (ages 60+). Using analysis of covariance (ANCOVA) and ordinal logistic regression analysis with adjusting the effect of age, the relationships between clinical features and age at onset of MDD were evaluated.

RESULTS

There was an apparent, but inconsistent correlation between clinical features and age at onset. Earlier onset MDD was significantly associated with higher proportion of female gender [adjusted odds ratio (AOR)=0.570, p=0.022], more previous suicide attempts (AOR=0.635, p=0.038), greater number of previous depressive episodes (F=3.475, p=0.016) and higher scores on the brief psychiatric rating scale (F=3.254, p=0.022), its negative symptom subscale (F=6.082, p<0.0001), and the alcohol use disorder identification test (F=7.061, p<0.0001).

CONCLUSION

Early age at onset may increase the likelihood of distinguishable MDD subtype, and age at onset of the first major depressive episode is a promising clinical indicator for the clinical presentation, course, and outcome of MDD.

Wen-dan decoction improves negative emotions in sleep-deprived rats by regulating orexin-a and leptin expression

Wen-Dan Decoction (WDD), a formula of traditional Chinese medicine, has been clinically used for treating insomnia for approximately 800 years. However, the therapeutic mechanisms of WDD remain unclear. Orexin-A plays a key role in the sleep-wake cycle, while leptin function is opposite to orexin-A. Thus, orexin-A and leptin may be important factors in sleep disorders. In this study, 48 rats were divided into control, model, WDD-treated, and diazepam-treated groups. The model of insomnia was produced by sleep deprivation (SD) for 14 days. The expressions of orexin-A, leptin, and their receptors in blood serum, prefrontal cortex, and hypothalamus were detected by enzyme-linked immunosorbent assay, immunohistochemistry, and real time PCR. Open field tests showed that SD increased both crossing movement (Cm) and rearing-movement (Rm) times. Orexin-A and leptin levels in blood serum increased after SD but decreased in brain compared to the control group. mRNA expressions of orexin receptor 1 and leptin receptor after SD were decreased in the prefrontal cortex but were increased in hypothalamus. WDD treatment normalized the behavior and upregulated orexin-A, leptin, orexin receptor 1 and leptin receptor in brain. The findings suggest that WDD treatment may regulate SD-induced negative emotions by regulating orexin-A and leptin expression.

Dopaminergic Neurogenetics of Sleep Disorders in Reward Deficiency Syndrome (RDS)

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.