EEG sleep and affective psychosis

Le sommeil de sujets dépressifs endogenes avant, pendant et apres un décalage des horaires de sommeil

Cette étude décrit la structure et l'organisation temporelle du sommeil de 5 sujets dépressifs endogènes qui participèrent à un processus de décalage en avance de 5 heures des horaires de sommeil maintenu pendant deux semaines.

Comparée à ces témoins du même âage, I'architecture du sommeil est, chez les dépressifs avant décalage, très perturbée avec, notamment, fragmentation et inefficacité du sommeil, réduction du taux de sommeil lent et raccourcissement de la latence du sommeil paradoxal. L'organisation temporelle semble traduire, elle, une lutte entre tendance au sommeil lent et tendance au sommeil paradoxal.

Le sommeil des mêmes sujets s'est pratiquement normalisé pendant et surtout après le decalage des horaires de sommeil, exceptée la persistance de la réduction importante de la latence du sommeil paradoxal.

Il serait ainsi possible d'associer la dépression à une désynchronisation entre rythmicités contrôlant sommeil lent, sommeil paradoxal et d'autres rythmes circadiens. Une resynchronisation forcée par décalage des horaires de sommeil pourrait alors rendre compte des améliorations cliniques et biologiques qui ont été observées.

Does major depressive disorder with somatic delusions constitute a distinct subtype of major depressive disorder with psychotic features?

BACKGROUND

Among patients with major depression with psychotic features, little is known about the extent to which those with and without somatic delusions differ.

METHODS

The first 183 participants in the STOP-PD study were divided into two groups based on the presence or absence of somatic delusions and were compared on multiple demographic and clinical characteristics.

RESULTS

In the multivariate analysis, those with somatic delusions reported more somatic symptoms, rated their health as worse, and were less likely to have persecutory delusions.

CONCLUSIONS

Based on the methods we used, we could not detect meaningful differences between subjects with and without somatic delusions. This suggests that the presence of irrational somatic ideation does not define a distinct clinical subgroup among patients with psychotic depression. This finding needs to be replicated.

Rapid eye movements during paradoxical sleep in patients with cerebrovascular disease

Rapid eye movements that occur during paradoxical sleep are generated from the brainstem and are modulated by cerebral hemispheres. In an attempt to establish the participation of cerebral hemispheres on rapid eye movements, we carried out a quantitative study of eye movements density in patients bearing hemispheres vascular lesions. The polysomnographic recordings of 24 patients were compared to those of 24 healthy volunteers. Density of rapid eye movements was defined as the percentage of eye movements during the respective time of paradoxical sleep. Based on the present results, we concluded that: stroke patients with hemispheric lesions displayed increased density of rapid eye movements; there was no difference on the density of rapid eye movements according to the hemispheric lesion; higher density of rapid eye movements was observed in patients with anterior hemispheric lesion.

Sleep-onset rapid eye movement after electroconvulsive therapy is more frequent in patients who respond less well to electroconvulsive therapy

The response to electroconvulsive therapy (ECT) was monitored with sleep polysomnography studies (SPS) performed pre- and post-ECT, in 25 patients with major depressive disorder (MDD). Patients included in this study met research diagnostic criteria for MDD and had been free of psychotropic medication for at least 10 days before SPS were performed. We compared ECT responders and nonresponders on SPS, demographic, and clinical parameters. Many SPS parameters, regardless of the clinical response, changed significantly with ECT. The presence of delusions was significantly associated with SOREM post-ECT. The presence of sleep-onset REM periods post-ECT was associated with poor response to ECT. SPS performed during a course of ECT may help identify patients at risk of responding less well to this modality of treatment.

Reduced REM latency predicts response to tricyclic medication in depressed outpatients

Forty-two outpatients with major depressive disorder entered a double-blind, randomized trial of either desipramine or amitriptyline for a minimum of 6 weeks. Pretreatment polysomnographic and clinical measures were used to predict response. Response was defined as a 17-item Hamilton Rating Scale for Depression score less than or equal to 9 at the end of treatment. There was a 61.1% response rate for patients treated with amitriptyline and a 66.7% response rate for patients treated with desipramine. Reduced REM latency (2-night mean less than or equal to 65.0 min) predicted a positive response to these tricyclic antidepressants. REM latency did not differentiate between desipramine or amitriptyline responders. More patients with reduced REM latency (80%) responded to treatment compared with patients with nonreduced REM latency (50%). The 80% response rate in reduced REM latency depressed patients confirms our previous findings in a mixed inpatient and outpatient sample. Contrary to our hypothesis, in this sample, endogenous depression was not associated with a good response to tricyclic medication.

Biology of depression

Research over the past three decades has led to a greater understanding of the biologic basis of depression. Observations that certain medications could improve or worsen mood led to the development of hypotheses describing the possible role of specific neurotransmitters in the brain in depression. Modifications of these original hypotheses focused on altered receptor function, failures in the regulation of neurotransmitter systems, and interactions of the monoamines with cholinergic systems. Strategies using endocrinologic measurements in the evaluation of the depressed patient have provided researchers with new clues regarding disordered neuroendocrine function in depression and clinicians with new tests to aid in diagnosis and management. Moreover, the development of standardized sleep EEG methodology has proven useful for the identification of characteristic sleep abnormalities in depression. Although there are many methodologic and clinical problems still to be resolved, the use of biological markers in the assessment of the depressed patient is increasing, and is likely to be of significant importance in the future. Finally, recent advances in molecular genetics hold promise for further advances in our understanding of the inheritance and biochemistry of depression.

Urinary free cortisol in psychotic depression

Major depression with psychotic features may be associated with higher cortisol secretion and a greater probability of dexamethasone nonsuppression of serum cortisol than is found in major depression without psychotic features. In this study, urinary free cortisol (UFC), a sensitive parameter of 24-hr cortisol production, was examined both before and after dexamethasone administration in 32 patients with major depression, 18 with psychotic features (MDPF), and 14 without psychotic features (MDD). A significantly larger number of MDPF patients had UFC excretion greater than 90 micrograms/24 hr before dexamethasone administration and greater than 20 micrograms/24 hr after dexamethasone administration. Although some clinical variables other than psychotic features differed between the two groups, these could not account for the UFC differences. However, the older patients (greater than 55 years) in the MDPF group accounted for the high UFC excretion, suggesting an interaction between age and diagnosis.

REM sleep and depression: further use of computer simulation to test the phase-advance hypothesis

A phase advance of the circadian rhythm of rapid eye movement (REM) sleep propensity relative to the sleep-wake cycle has been proposed to account for the abnormalities of REM sleep commonly found in depressed patients. One implication of this hypothesis is that a phase delay of sleep in normal subjects should produce the same abnormalities of REM sleep. The hypothesis was tested by computer simulation using equations based on data derived from normal subjects who had experienced phase shifts of their bedtime. At phase delays of between 4 and 6 hours (an estimate of the putative phase advance in depressed patients), the mean REM latency and the mean duration of the first REM period predicted by the equations did not differ significantly from those observed in depressed patients. The findings with respect to the distribution of REM latency were more equivocal.

Delusional depression: phenomenology and response to treatment. A prospective study

In a prospective study, the authors compared 22 delusional and 36 non-delusional depressive patients with respect to demographic and clinical variables, personality, and response to treatment. Delusional depressives had a higher total score than non-delusional depressives on Hamilton's Rating Scale for Depression, as well as a higher score for depressed mood and psychomotor retardation. The type of treatment failed to differentiate the two groups as to outcome at discharge. However, six of the seven delusional depressives who did not respond to tricyclic antidepressants had a full recovery with ECT. The results indicate that delusional depression represents a more severe type of major depression.

The circadian rhythm of plasma thyrotropin in depression and recovery

The 24-hr patterns of plasma thyrotropin have been observed in 12 endogenous depressed patients in both depressed and recovered states and in 13 normal subjects. A clear circadian rhythm was detected in controls with high values at night. In depression, the circadian rhythm was altered with amplitude reduction and blunted nocturnal secretion, abnormalities particularly relevant in bipolar patients. This flattened profile could be linked to the blunted response of TSH to TRH administration reported in depressed patients. Normal nyctohemeral patterns have been restored after recovery. These chronobiological abnormalities as well as their normalization under antidepressant drugs seem to be similar to those reported for various parameters (e.g. temperature, cortisol, etc) in depression which could support the chronobiological hypothesis for affective disorders.

Cholinergic REM induction response: separation of anxiety and depression

Five groups of subjects underwent EEG sleep recordings, arecoline rapid eye movement (REM) induction response testing, and Schedule for Affective Disorders and Schizophrenia (SADS) interview. Group I: 20 patients with primary major depressive disorder (MDD) (endogenous) without any coexisting anxiety disorder; Group II: 19 primary MDD (endogenous) patients with secondary panic, GAD, or phobic disorders; Group III: 18 patients with primary anxiety disorder without coexisting MDD; Group IV: 14 patients with primary anxiety plus secondary MDD; Group V: 26 normal controls. Modified Research Diagnostic Criteria (RDC) were used for diagnosis, based on the SADS interview. There was considerable overlap of SADS scaled scores between patient groups, which is consistent with a heterogeneous clinical presentation of depressive and anxiety states. REM latency was significantly shorter in patients with primary MDD (without anxiety) as compared with that in patients with primary anxiety (no MDD) and normals. Arecoline REM induction response time was significantly shorter in both primary affective groups (I and II) as compared with primary anxiety (no MDD) patients and normal controls. REM latency and arecoline REM induction time was not significantly different between the primary anxiety groups (III and IV) and normals. The study highlights the use of biological markers in differentiating between clinical syndromes confounded by mixed or overlapping phenomenology.

Sleep and neuroendocrine disturbances in catatonia. A case report

Sleep EEG investigations were performed in a 31-year-old catatonic male patient before and after electroconvulsive therapy and 3 months after recovery. The dexamethasone suppression test was also performed longitudinally together with measurements of CSF 5-HIAA, HVA and 24-h urinary MHPG. A normal male control aged 32 was also investigated. Sleep analysis showed reduced REM latency and increased REM activity and density during the catatonic phase before treatment when compared to the age-matched control. REM latency remained shortened after recovery following ECT treatment and 3 months after recovery. Dexamethasone suppression test, abnormal before treatment normalized with clinical improvement during ECT. Urinary MHPG values were low in the catatonic state and did not change after ECT treatment. CSF HVA and 5-HIAA were also low in the pretreatment period and increased during the 3 months follow-up period. There results indicate that some cases of catatonic behavior may be linked to affective disorders.

Repeated dexamethasone suppression test during depressive illness. Normalisation of test result compared with clinical improvement

Serial plasma cortisol concentrations were recorded under controlled conditions after an overnight dexamethasone suppression (DST) in 20 depressed patients with initially abnormal test results. The cortisol levels were related to clinical course. All 20 patients showed normalisation of hypothalamic-pituitary-adrenal (HPA) hyperactivity, a mean of 3.4 +/- 1.8 weeks before clinical recovery was achieved. In 4 clinically remitted patients the endocrine disturbance as evidenced by abnormal DST results preceded a depressive relapse. DST results did not appear to be affected by psychotropic drugs including benzodiazepines.

REM density in the differential diagnosis of psychiatric from medical-neurologic disorders: a replication

The discriminatory power of rapid eye movement (REM) density in 61 outpatients with medical, neurologic, and psychiatric disorders and 8 noncase controls was assessed. REM density was significantly lower in a group of patients with medical-neurologic disease as compared with psychiatric and control subjects without evidence for such disease. Furthermore, low scores discriminated depressions occurring in the context of somatic disease when compared with those in the absence of such disease. The differences between groups were not accounted for by age or sex. The cutoff REM density score of 12.56, based on the 99% lower confidence limit of the noncase controls, provided the highest sensitivity (0.82) without loss of specificity (0.80). It was concluded that REM density may have merit as a general measure of diffuse central nervous system pathology, whether primary or secondary to widespread systemic disease. The findings of Kupfer's group are upheld and extended to a broader medical and neuropsychiatric population than in the original Pittsburgh study.

Age-related changes in sleep in depressed and normal subjects

All-night electroencephalographic (EEG) sleep data were examined a function of age in normal control subjects and hospitalized, unmedicated depressed patients with primary affective illness. By analysis of variance, Total Sleep time, Delta Sleep, Sleep Efficiency, Rapid Eye Movement (REM) Sleep, and REM Latency decreased as a function of age, whereas Early Morning Awake time and Intermittent Awake time increased. Compared with normal controls, after the effects of age were covaried out, depressed patients had a greater Sleep Latency, Early Morning Awake time, Intermittent Awake time, Duration and REM Density of the first REM period, and average REM Density for the night, as well as less Sleep Efficiency, less Delta Sleep, and shorter REM Latency, Early Morning Awake time increased with age in depressives but not in normals.