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

Efficacy and safety of each class of sleep medication for major depressive disorder with insomnia symptoms: A systematic review and meta-analysis of double-blind randomized controlled trials

Combination therapy with antidepressants and sleep medications is a promising candidate treatment for major depressive disorder (MDD) with insomnia. This systematic review and meta-analysis examined the efficacy and safety of combination therapy with antidepressants and sleep medication for treating MDD with insomnia compared to antidepressant monotherapy by sleep medication class (benzodiazepine, Z-drug, melatonin receptor agonist, and orexin receptor antagonist). This study was preregistered with PROSPERO (CRD42025636571). PubMed, CENTRAL, and Embase were searched for double-blind randomized controlled trials published until June 2024, resulting in eight eligible studies (1945 participants; eszopiclone = 4, zolpidem = 2, triazolam = 1, ramelteon = 1). Meta-analyses were performed based on six trials of Z-drugs. Compared with antidepressant monotherapy, combination therapy with antidepressants and Z-drugs resulted in higher remission rates from depressive symptoms (risk ratio: 1.25, 95% confidence interval [CI]: 1.08-1.45, P = 0.003), greater improvement in depressive symptoms (standardized mean difference [SMD]: 0.17, 95% CI: 0.01-0.33, P = 0.04) and insomnia symptoms (SMD: 0.43, 95% CI: 0.28-0.59, P < 0.001) in the short-term (within 12 weeks), with no difference in safety outcomes except for dizziness. Combination therapy with antidepressants and Z-drugs may be more useful for MDD with insomnia symptoms than antidepressant monotherapy in the short term. However, this study did not evaluate the benefits and harms of long-term adjunctive Z-drug therapy. Further long-term studies are needed to draw definitive conclusions regarding the efficacy and safety of combination therapy with antidepressants and Z-drugs. Moreover, further research is warranted to assess whether the findings of this study are applicable to other sleep medication classes.

Prevalence and clinical correlates of benzodiazepine use in the patients with major depressive disorder

BACKGROUND

Major depressive disorder (MDD) is a serious and disabling condition characterized by abnormal mood changes. Clinical guidelines for depression treatment recommend antidepressant medications, with benzodiazepines acting as short-term synergists. However, little is currently known about the prevalence and associated clinical risk factors of benzodiazepine use among Chinese patients with MDD. This study aimed to explore the prevalence and clinical risk factors associated with benzodiazepine use in this population.

METHODS

A total of 2742 patients with MDD (males/females = 816/1926, aged 14-60 years) participated in this cross-sectional observational study. General information and psychosis assessments were collected online. Depressive symptoms were assessed using the Patient Health Questionnaire-9 (PHQ-9), anxiety symptoms using the Generalized Anxiety Disorder-7 (GAD-7), and sleep problems and suicidal tendencies using the third and ninth items of the PHQ-9. Multivariable logistic regression analysis models were employed to identify factors associated with benzodiazepine use.

RESULTS

The prevalence of benzodiazepine use among patients with MDD was 42.9 %. Among these patients, 99.6 % used a single benzodiazepine, with oxazepam being the most frequently prescribed. Age, severity of sleep problems, depressive symptoms, and anxiety symptoms were significantly correlated with benzodiazepine use (all P < 0.001).

LIMITATIONS

The cross-sectional design of this study precludes establishing causal relationships.

CONCLUSION

Our findings indicate a high prevalence of benzodiazepine use among Chinese patients with MDD. Factors such as severe depressive symptoms, anxiety symptoms, age, and sleep problems appear to be associated with benzodiazepine use. These results underscore the importance of vigilance regarding benzodiazepine use in patients with MDD.

Psychosocial characteristics of the general population who habitually use hypnotics: Results from a national survey on drug use among the Japanese

Aim

The aim of this study was to examine the characteristics of habitual hypnotic users in Japan.

Methods

This nationwide, cross-sectional survey used self-administered questionnaires. Data were collected from four national surveys conducted every 2 years between 2015 and 2021. The participants were Japanese individuals who had taken prescription hypnotics in the past year or had never taken them. We divided 13,396 participants into three groups to compare the social background and status of taking medication and controlled drugs, drinking, and smoking among the three groups: people who use hypnotics habitually daily (habitual hypnotic users [HUs]), people who use them only occasionally (occasional hypnotic users [OUs]), and people who do not use them (hypnotic non-users [NUs]). We compared the perception of using hypnotics between the HU and OU groups.

Results

HUs were more likely to be older, unemployed, and to habitually use anxiolytics and analgesics than NUs. The main reasons for taking anxiolytics in HUs were alleviating insomnia and reducing anxiety, whereas the main reason for taking analgesics was improving joint pain. Additionally, the HU group had a higher proportion of habitual smokers than the OU group. There was no difference in drinking status or taking of controlled drugs among the three groups. HUs were more likely to use hypnotics and to have concerns about their side-effects than OUs.

Conclusion

HUs were more likely to be unemployed, habitually use anxiolytics and analgesics, smoke heavily, and take hypnotic drugs with concerns regarding side-effects. These results may help encourage the appropriate use of hypnotics.

Effects of Japanese policies and novel hypnotics on long-term prescriptions of hypnotics

AIM

The current study aimed to examine the effect of Japanese policies for appropriate hypnotics use and novel hypnotics (e.g. melatonin receptor agonist and orexin receptor antagonist [ORA]) on long-term prescriptions of hypnotics.

METHODS

This retrospective study was conducted using a large-scale health insurance claims database. Among subscribers prescribed hypnotics at least once between April 2005 and March 2021, those prescribed hypnotics for the first time after being included in the database in three periods (period 1: April 2012-March 2013; period 2: April 2016-March 2017; and period 3: April 2018-March 2019) were eligible. These were set considering the timing of the 2014 and 2018 medical fee revisions (2014 for polypharmacy of three or more hypnotics, 2018 for long-term prescription of benzodiazepine receptor agonists for >12 months). The duration of consecutive prescriptions of hypnotics over 12 months was evaluated. Factors associated with short-term prescriptions of hypnotics were also investigated.

RESULTS

In total, 186 535 participants were newly prescribed hypnotics. The mean duration of prescriptions was 2.9 months, and 9.3% of participants were prescribed hypnotics for 12 months. Prescription periods were not associated with short-term prescriptions of hypnotics. ORA use was associated with short-term prescriptions of hypnotics (adjusted hazard ratio, 1.077 [95% confidence interval, 1.035-1.120]; P < 0.001), but melatonin receptor agonist use was not.

CONCLUSION

Japanese policies had no statistically significant effect on long-term prescriptions of hypnotics. Although this study suggests initiating ORA for insomniacs as a candidate strategy to prevent long-term prescriptions of hypnotics, further research is necessary to draw conclusions.

Efficacy of Electroacupuncture on Treating Depression-Related Insomnia: A Randomized Controlled Trial

OBJECTIVE

To evaluate the efficacy of electroacupuncture (EA) on treating insomnia in patients with depression.

PATIENTS AND METHODS

In a patient-assessor-blind, randomized and sham controlled trial, 90 depression patients with insomnia were assigned into three different groups, receiving EA in the treatment group, superficial acupuncture at sham points in the control group A, or Streitberger non-insertion sham acupuncture in the control group B. Treatment was applied 3 times weekly for 8 consecutive weeks. The primary outcome was measured using the Pittsburgh Sleep Quality Index (PSQI). Secondary outcomes were sleep parameters including sleep efficiency (SE), total sleep time (TST) and numbers of sleep awakenings (SA) recorded in the actigraphy, as well as applying the Hamilton Rating Scale for Depression (HAMD-17), Self-Rating Depression Scale (SDS) and Hamilton Rating Scale for Anxiety (HAMA). Assessments were performed at the baseline (week 0), week 4, week 8, and week 12. Linear mixed-effects models were used for analyses and all statistical tests were two-sided.

RESULTS

Patients in the EA group had more significant improvement in PSQI scores than those in the control groups over time (respectively p<0.001 and p=0.04 for treatment and time interaction). At 8-week posttreatment, the EA group reported a reduction of -6.64 points in PSQI scores compared with -2.23 points in the control group A (95% CI= -5.74 to -2.39) and -2.94 points in the control group B (95% CI= -5.73 to -2.47). Compared with the two control groups, significant between-group differences were seen in SE (both p<0.01) and TST (both p<0.01) at week 8; similar results can be found in HAMD-17, SDS, and HAMA scores as well. However, there were no between-group differences in SA (respectively p=0.24 and p=0.08) after 8-weeks of treatment.

CONCLUSION

Electroacupuncture may improve the sleep quality of patients with depression.

TRIAL REGISTRATION

Chinese Clinical Trial Registry (ChiCTR); URL: http://www.chictr.org.cn/showproj.aspx?proj=12327; Trial ID: ChiCTR-IIR-16008058.

Perception of Stigma and Its Associated Factors Among Patients With Major Depressive Disorder: A Multicenter Survey From an Asian Population

Stigma of major depressive disorder (MDD) is an important public health problem. This study aimed to examine the level of perceived stigma and its associated factors in MDD patients in five Asian countries, including China, Korea, Malaysia, Singapore, and Thailand. A total of 547 outpatients with MDD were included from Asian countries. We used the stigma scale of the Explanatory Model Interview Catalogue (EMIC) to assess stigma. The Montgomery-Asberg Depression Rating Scale (MADRS), Symptoms Checklist 90-Revised (SCL-90-R), Fatigue Severity Scale (FSS), Sheehan Disability Scale (SDS), 36-Item Short-Form Health Survey (SF-36), and Multidimensional Scale of Perceived Social Support (MSPSS) were used to assess symptoms, clinical features, functional impairment, health status, and social support. The stigma scores of patients under 55 years old were significantly higher than those equal to or greater than 55 years old (P < 0.001). The stigma scores exhibited significant negative correlation with age; MSPSS scores of family, friends, and others; and SF-36 subscale of mental health, but significant positive correlation with MADRS, FSS, SDS, and SCL-90-R subscale scores of depression, interpersonal sensitivity, obsession-compulsion, psychoticism, and somatization. Multivariate regression analysis revealed that age, SCL-90-R interpersonal sensitivity, obsession-compulsion, psychoticism, MSPSS scores of friends and others, and SF-36 of mental health were significantly associated with the level of perceived stigma. These findings suggest that MDD patients who are young, have a high degree of interpersonal sensitivity and psychoticism, have low health-related quality of life, and have low social support are the target population for stigma interventions in Asia.

A technology developed from concept of acupuncture and meridian system, the clinical effect of BIOCERAMIC resonance on psychological related sleep disturbance with findings on questionnaire, EEG and fMRI

Under the concept of meridian channels that belongs to traditional Chinese medicine, BIOCERAMIC Resonance (BR) has already been applied to many clinical medical research projects with functions mimicking of traditional acupuncture. Forty-five patients were recruited with chronic sleep disorders; 36 patients were given, applied to the device with BIOCERAMIC material and sound rhythm on chest skin surface; 9 patients were included as controls. All study participants completed a sleep pattern and quality of life questionnaire (assessment on psychological and physical causes of sleep disturbances), which was repeated before, during and after treatment. Electroencephalograph (EEG) recordings were analyzed before, during and after treatment. Functional MRI (fMRI) was also used for demonstration of BR effect for another 8 candidates. During the first 3 days of treatment, sleep quality improved in all 36 patients especially to psychological reasons; in 91.7% (33/36) treatment was associated with an elevation in the beta spectrum of the EEG (at 15-27 Hz). The result of fMRI found corresponding cerebral and cerebellar areas of activation and deactivation. BIOCERAMIC Resonance can improve sleep disorder due to psychological causes, with transient alter brain wave activity and functional activation on specific locations of brain.

Traumatization, Loneliness, and Suicidal Ideation among Former Prisoners of War: A Longitudinally Assessed Sequential Mediation Model

Although highly researched among veterans, the underlying mechanisms of suicidal ideation (SI) among former prisoners of war (ex-POWs), especially in the long-term, have rarely been investigated. Furthermore, while posttraumatic stress symptoms (PTSS) and loneliness have been individually associated with veteran SI, and both may be differentially implicated by captivity versus war traumas, the interplay between them has yet to be examined. Filling this gap, the current longitudinal study examined a hypothetical sequential model wherein war captivity, compared with combat-induced trauma, is implicated in worse PTSS, which is then implicated in worse loneliness and PTSS, which together may explain subsequent SI. Two groups of Israeli veterans of the 1973 Yom Kippur War, 163 ex-POWs and 185 matched non-captive veterans were assessed 18 (T1) and 30 (T2) years after the war. Analyses indicated that compared with war, captivity was implicated in worse PTSS, which was implicated in worse loneliness, and these worked in tandem to implicate SI. Loneliness, however, was not directly affected by the type of trauma, nor was its relation to SI linked to its implication in subsequent PTSS. These results may inform future research and clinical practice as the study underscores the importance of both PTSS and loneliness in ex-POWs' long-term SI.

Clinical and socio-demographic correlates of anxious distress in Asian outpatients with major depressive disorder

BACKGROUND

Anxious distress in major depressive disorder (MDD) is common and associated with poor outcomes and management difficulties.

AIMS

This post hoc analysis aimed to examine the socio-demographic and clinical correlates of anxiety distress in Asian outpatients with MDD.

METHODS

Instead of two out of five specifiers defined by the Diagnostic and Statistical Manual Version-5, anxious distress defined in this study was operationalized as the presence of at least two out of four proxy items drawn from the 90-item Symptom Checklist, Revised (SCL-90-R). Other measures included the Montgomery-Asberg Depression Rating Scale (MADRS), the Fatigue Severity Scale, the Sheehan Disability Scale and the Multidimensional Scale of Perceived Social Support.

RESULTS

The data of 496 patients with MDD were included. Anxious distress was found in 371 participants (74.8%). The binary logistic regression analysis found that anxious distress was independently and significantly correlated with working status, higher MADRS scores, severe insomnia and functional impairment.

CONCLUSIONS

Three-fourths of Asian patients with MDD in tertiary care settings may have DSM-5 anxious distress of at least moderate distress. Its prevalence may vary among working groups. The specifier was associated with greater depressive symptom severity, severe insomnia and functional impairment.

The role of dual diagnosis in health-related quality of life among treatment-seeking patients in Spain

PURPOSE

The comorbidity of any substance use disorder and another mental disorder is defined as dual diagnosis. Dual diagnosis is very common and clinical and therapeutic consequences have been described. This cross-sectional study aimed to analyse health-related quality of life (HRQoL) according to clinical characteristics and psychiatric comorbidities in patients with substance dependence.

METHODS

A total of 1276 substance-dependent patients seeking treatment were recruited. HRQoL was evaluated by the Short-Form 36 (SF-36) questionnaire. The SCID-I, SCID-II and Conners' adult ADHD diagnostic interview were used to evaluate dual diagnosis. A visual analogue scale was used to measure craving. Bivariate and multivariate analyses were performed, and correction for multiple tests was conducted.

RESULTS

Substance-dependent patients had impaired quality of life, especially in the mental component. SF-36 physical and mental component scores were 47.7 ± 10.9 and 36.1 ± 14.1, respectively. Furthermore, 65% of the patients had dual diagnosis, 51% had an Axis I DSM-IV-TR mental disorder and 35% had some personality disorder. Impaired physical quality of life was independently associated with medical condition, age, being female, depressive disorder and anxiety disorder. Depression disorder, any personality disorder, active consumption last month, Attention deficit hyperactivity disorder, anxiety disorder, suicide attempt were independently associated with worse mental quality of life.

CONCLUSION

These findings emphasize the significance of dual diagnosis in the impairment of HRQoL in substance-dependent patients, particularly with regard to mental component. In addicted patients with low scores on SF-36, psychiatric comorbidity should be evaluated and treated in an integrated approach.

Severe insomnia is associated with hypertriglyceridemia in women with major depression treated in psychiatry settings

BACKGROUND

Hypertriglyceridemia (HTG) is a cardiovascular risk factor. In the general population, elevated fasting triglyceridemia (TG) is associated with insomnia. Since insomnia is a core symptom of Major Depressive Episodes (MDE), we studied the association of severe insomnia with HTG in major depression.

METHODS

We used the baseline data of the METADAP cohort, comprising 624 patients with a current MDE in a context of Major Depressive Disorder treated in psychiatry settings, without current alcohol use disorders. Patients were screened for severe insomnia, defined by a score of four or more on the three Hamilton Depression Rating Scale (HDRS) sleep items, and for HTG characterised by TG≥200mg/dL.

RESULTS

Severe insomnia was observed in 335(54%) patients with a current MDE, of whom 234(70%) were women; 49(8%) patients had HTG, of whom 25(51%) were women. 69(11%) patients were treated with lipid-lowering drugs. Severe insomnia was associated with a higher frequency of HTG in the whole sample (9.9% vs 5.6%, p=0.046) and in the subgroup of women (9.0% vs 2.0%, p=0.002). Multivariate logistic regression analyses adjusted for age, education levels, BMI and total HDRS scores confirmed the association between severe insomnia and HTG in the whole sample (OR=2.02, 95%CI [1.00-4.08], p=0.05) as well as in the subgroup of women (OR=4.82, 95%CI [1.5-15.5], p=0.008). No association was shown in men.

PERSPECTIVES

HTG should be systematically investigated in depressed patients with severe insomnia and particularly in women. Further studies are needed to explain the association we observed between severe insomnia and HTG.

Efficacy and Safety of Electroacupuncture on Treating Depression Related Sleep Disorders: Study Protocol of a Randomized Controlled Trial

Background. Depression is frequently accompanied by sleep disturbances including insomnia. Insomnia may persist even after mood symptoms have been adequately treated. Acupuncture is considered to be beneficial to adjust the state of body and mind and restore the normal sleep-awake cycle. This trial is aimed at evaluating the efficacy and safety of electroacupuncture on treating insomnia in patients with depression. Methods. We describe a protocol for a randomized, single-blinded, sham controlled trial. Ninety eligible patients will be randomly assigned to one of 3 treatment groups: treatment group (acupuncture), control A group (superficial acupuncture at sham points), and control B group (sham acupuncture). All treatment will be given 3 times per week for 8 weeks. The primary outcome is the Pittsburgh Sleep Quality Index (PSQI). The secondary outcomes are sleep parameters recorded in the Actigraphy, Hamilton Rating Scale for Depression (HAMD), and Self-Rating Depression Scale (SDS). All adverse effects will be accessed by the Treatment Emergent Symptom Scale (TESS). Outcomes will be evaluated at baseline, 4 weeks after treatment, 8 weeks after treatment, and 4 weeks of follow-up. Ethics. This trial has been approved by the Ethics Committee of Shanghai Municipal Hospital of Traditional Chinese Medicine (2015SHL-KY-21) and is registered with ChiCTR-IIR-16008058.

The non-linear association between low-level lead exposure and maternal stress among pregnant women

BACKGROUND

Neuro-developmental impairments in the developing fetus due to exposure to low-level lead have been well documented. However, few studies have investigated the relation between maternal stress levels and low-level lead exposure among pregnant women.

OBJECTIVES

To investigate the relation between maternal blood lead and stress levels during index pregnancy.

METHODS

1931 pregnant women (gestational week 28-36) were investigated using stratified-cluster-sampling in Shanghai in 2010. Maternal life event stress and emotional stress were assessed using "Life-Event-Stress-Scale-for-Pregnant-Women" (LESPW) and "Symptom-Checklist-90-Revised" (SCL-90-R), respectively. Maternal whole blood lead levels were determined, and other data on covariates were obtained from maternal interviews and medical records. Two piecewise linear regression models were applied to assess the relations between blood lead and stress levels using a data-driven approach according to spline smoothing fitting of the data.

RESULTS

Maternal blood lead levels ranged from 0.80 to 14.84μg/dL, and the geometric mean was 3.97μg/dL. The P-values for the two piecewise linear models against the single linear regression models were 0.010, 0.003 and 0.017 for models predicting GSI, depression and anxiety symptom scores, respectively. When blood lead levels were below 2.57μg/dL, each unit increase in log10 transformed blood lead levels (μg/dL) was associated with about 18% increase in maternal GSI, depression and anxiety symptom scores (P_GSI=0.013, P_depression=0.002, P_anxiety=0.019, respectively). However, no significant relation was found when blood lead levels were above 2.57μg/dL (all P-values>0.05).

CONCLUSION

Our findings suggested a nonlinear relationship between blood lead and emotional stress levels among pregnant women. Emotional stress increased along with blood lead levels, and appeared to be plateaued when blood lead levels reached 2.57μg/dL.