Circadian Reinforcement Therapy in Combination With Electronic Self-Monitoring to Facilitate a Safe Postdischarge Period for Patients With Major Depression: Randomized Controlled Trial

BACKGROUND

Patients with major depression exhibit circadian disturbance of sleep and mood, and when they are discharged from inpatient wards, this disturbance poses a risk of relapse. We developed a circadian reinforcement therapy (CRT) intervention to facilitate the transition from the inpatient ward to the home for these patients. CRT focuses on increasing the zeitgeber strength for the circadian clock through social contact, physical activity, diet, daylight exposure, and sleep timing.

OBJECTIVE

In this study, we aimed to prevent the worsening of depression after discharge by using CRT, supported by an electronic self-monitoring system, to advance and stabilize sleep and improve mood. The primary outcome, which was assessed by a blinded rater, was the change in the Hamilton Depression Rating Scale scores from baseline to the end point.

METHODS

Participants were contacted while in the inpatient ward and randomized 1:1 to the CRT or the treatment-as-usual (TAU) group. For 4 weeks, participants in both groups electronically self-monitored their daily mood, physical activity, sleep, and medication using the Monsenso Daybuilder (MDB) system. The MDB allowed investigators and participants to simultaneously view a graphical display of registrations. An investigator phoned all participants weekly to coinspect data entry. In the CRT group, participants were additionally phoned between the scheduled calls if specific predefined trigger points for mood and sleep were observed during the daily inspection. Participants in the CRT group were provided with specialized CRT psychoeducation sessions immediately after inclusion, focusing on increasing the zeitgeber input to the circadian system; a PowerPoint presentation was presented; paper-based informative materials and leaflets were reviewed with the participants; and the CRT principles were used during all telephone consultations. In the TAU group, phone calls focused on data entry in the MDB system. When discharged, all patients were treated at a specialized affective disorders service.

RESULTS

Overall, 103 participants were included. Participants in the CRT group had a significantly larger reduction in Hamilton Depression Scale score (P=.04) than those in the TAU group. The self-monitored MDB data showed significantly improved evening mood (P=.02) and sleep quality (P=.04), earlier sleep onset (P=.009), and longer sleep duration (P=.005) in the CRT group than in the TAU group. The day-to-day variability of the daily and evening mood, sleep offset, sleep onset, and sleep quality were significantly lower in the CRT group (all P<.001) than in the TAU group. The user evaluation was positive for the CRT method and the MDB system.

CONCLUSIONS

We found significantly lower depression levels and improved sleep quality in the CRT group than in the TAU group. We also found significantly lower day-to-day variability in daily sleep, mood parameters, and activity parameters in the CRT group than in the TAU group. The delivery of the CRT intervention should be further refined and tested.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02679768; https://clinicaltrials.gov/study/NCT02679768.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.1186/s12888-019-2101-z.

Acetate kinase isozymes confer robustness in acetate metabolism

Acetate kinase (ACK) (EC no: 2.7.2.1) interconverts acetyl-phosphate and acetate to either catabolize or synthesize acetyl-CoA dependent on the metabolic requirement. Among all ACK entries available in UniProt, we found that around 45% are multiple ACKs in some organisms including more than 300 species but surprisingly, little work has been done to clarify whether this has any significance. In an attempt to gain further insight we have studied the two ACKs (AckA1, AckA2) encoded by two neighboring genes conserved in Lactococcus lactis (L. lactis) by analyzing protein sequences, characterizing transcription structure, determining enzyme characteristics and effect on growth physiology. The results show that the two ACKs are most likely individually transcribed. AckA1 has a much higher turnover number and AckA2 has a much higher affinity for acetate in vitro. Consistently, growth experiments of mutant strains reveal that AckA1 has a higher capacity for acetate production which allows faster growth in an environment with high acetate concentration. Meanwhile, AckA2 is important for fast acetate-dependent growth at low concentration of acetate. The results demonstrate that the two ACKs have complementary physiological roles in L. lactis to maintain a robust acetate metabolism for fast growth at different extracellular acetate concentrations. The existence of ACK isozymes may reflect a common evolutionary strategy in bacteria in an environment with varying concentrations of acetate.

Development of selective antibodies against the human somatostatin receptor subtypes sst1-sst5

Antisera selective for five somatostatin receptor subtypes, human sst1-sst5, were raised in rabbits. C-terminal parts of human sst1-sst5 receptors were expressed as fusion proteins with glutathione S-transferase. Fusion proteins were affinity-purified and used for raising polyclonal antibodies. In Western blot analysis, all five antisera were tested on preparations of mammalian cell lines transfected with human sst1-sst5, respectively. sst1 antiserum reacted with a broad band of 53-72 kDa. A band of 71-95 kDa was detected with the antiserum raised against sst2, 65-85 kDa with sst3 antiserum, 45 kDa with sst4 antiserum and 52-66 kDa with sst5 antiserum. No cross-reactivity could be detected to any of the other four somatostatin receptor subtypes. Enzymatical deglycosylation of the receptors revealed that sst1, sst2, sst5 and possibly sst3 in this system are subjected to N-linked glycosylation, whereas sst4 is not. Two of the antisera (sst2 and sst5) were used for immunohistochemical localization of the receptors. sst2 and sst5 antisera labeled neurons in e.g. the amygdaloid complex, hippocampus, fascia dentata and the neocortex in rat and monkey tissue. This is the first report on antisera against all five somatostatin receptor subtypes and the first immunohistochemical visualization of sst5 receptors in the mammalian brain.

The effect of carbohydrate diet on intermittent exercise performance

To determine the effect of a carbohydrate-(CHO) enriched diet on long-term, intermittent exercise performance, seven professional soccer players (mean maximum oxygen uptake: 60.6 (range: 56.0-65.1) ml.min-1.kg-1) were tested twice. The standardized test consisted initially of a field part (6856 m) followed by treadmill running to exhaustion. The relative work rates were 65, 57 and 81% of maximum oxygen uptake during the field test, and during the first and last part of the treadmill running, respectively. The players ingested a diet containing either 39% (C-diet) or 65% carbohydrate (CHO-diet) during the two days prior to each test. The order of the diets was assigned randomly. Neither blood lactate nor glucose concentrations at exhaustion differed after the two diets. The total mean running distance after the CHO-diet was 17.1 km, which was 0.9 km longer (p less than 0.05) than after the C-diet. Nevertheless, three subjects had a difference in running distance of less than 420 m. In contrast to the remaining players, these players had a higher RER-value during treadmill running in association with the CHO-diet. The mean CHO intake of 46% in the normal diet of the players was below the Nordic Nutritional Recommendation. In conclusion, performance during intermittent running was enhanced following the ingestion of a CHO enriched diet for two days. However, not all players benefited from the CHO-diet perhaps because they, in contrast to the other players, responded with a higher utilization of CHO after the CHO-diet.

Activity profile of competition soccer

In order to study the movement pattern of soccer players, 14 top-level players were filmed during several competitive matches. In addition, the relationship between the observed activity during match play and blood lactate values was examined. The mean distance covered during competitive matches was 10.80 km, and the average individual difference between matches was 0.92 km, with no difference in regard to high intensity activities. Midfielders covered a 10% longer (p less than 0.05) distance (11.4 km) than defenders and forwards, with no difference concerning high intensity running. There was a significant correlation (r = 0.61, p less than 0.05) between the amount of high intensity running during the match and lactate concentration in the blood. The results suggest that high intensity running can be used for making comparisons in soccer and that the interpretation of blood lactate in soccer is limited to giving an indication of the type of activity that has been carried out a few minutes before sampling.