Assessing insomnia severity in depression: comparison of depression rating scales and sleep diaries

Impact of sleep disruption on BDD symptoms and treatment response

BACKGROUND

Body dysmorphic disorder (BDD) is severe, undertreated, and relatively common. Although gold-standard cognitive behavioral therapy (CBT) for BDD has strong empirical support, a significant number of patients do not respond. More work is needed to understand BDD's etiology and modifiable barriers to treatment response. Given its high prevalence and impact on the development, maintenance, and treatment of related, frequently comorbid disorders, sleep disruption is a compelling, but not-yet studied factor.

METHODS

Data were drawn from a randomized controlled trial of guided smartphone app-based CBT for BDD. Included participants were offered 12-weeks of treatment, immediately (n = 40) or after a 12-week waitlist (n = 37). Sleep disruption and BDD symptom severity were assessed at baseline, week-6, and week-12.

RESULTS

Hypotheses and analysis plan were pre-registered. Two-thirds of patients reported significant insomnia symptoms at baseline. Baseline severity of sleep disruption and BDD symptoms were not related (r = 0.02). Pre-treatment sleep disruption did not predict BDD symptom reduction across treatment, nor did early sleep improvements predict greater BDD symptom improvement. Early BDD symptom improvement also did not predict later improvements in sleep.

LIMITATIONS

Limitations include the small sample, restricted ranges of BDD symptom severity and treatment response, and few metrics of sleep disruption.

CONCLUSIONS

Although insomnia was disproportionately high in this sample and both BDD symptoms and sleep improved in treatment, results suggest sleep and BDD symptoms may function largely independent of one another. More work is encouraged to replicate and better understand findings as well as potential challenges and benefits of addressing sleep in BDD.

Crime Risk and Depression Differentially Relate to Aspects of Sleep in Patients with Major Depression or Social Anxiety

Individuals with internalizing conditions such as depression or anxiety are at risk of sleep difficulties. Social-ecological models of sleep health propose factors at the individual (e.g., mental health) and neighborhood (e.g., crime risk) levels that contribute to sleep difficulties. However, these relationships have been under-researched in terms of internalizing conditions. Therefore, the current study comprised participants diagnosed with major depression (n = 24) or social anxiety (n = 35). Sleep measures included actigraphic variables (i.e., total sleep time, waking after sleep onset, sleep onset latency) and subjective sleep quality. Geocoding was used to assess nationally-normed crime risk exposure at the person level (e.g., murder, assault) and property level (e.g., robbery, burglary). Analyses consisted of independent t-tests to evaluate potential differences between diagnostic groups. To examine relationships, multiple regressions were used with internalizing symptoms, crime risk, and age as independent variables and sleep measures as the dependent variable. The t-test results revealed that groups differed in symptoms and age but not sleep or neighborhood crime. Regression results revealed crime risk positively corresponded with sleep onset latency but no other sleep measures. Also, only depression positively corresponded with total sleep time. Preliminary findings suggest exposure to crime and depression relate differentially to facets of sleep in individuals with internalizing conditions.

Identifying major depressive disorder with associated sleep disturbances through fMRI regional homogeneity at rest

BACKGROUND

Anomalies in regional homogeneity (ReHo) have been documented in patients with major depressive disorder (MDD) and sleep disturbances (SDs). This investigation aimed to scrutinize changes in ReHo in MDD patients with comorbid SD, and to devise potential diagnostic biomarkers for detecting sleep-related conditions in patients with MDD.

METHODS

Patients with MDD and healthy controls underwent resting-state functional magnetic resonance imaging scans. SD severity was quantified using the 17-item Hamilton Rating Scale for Depression. Subsequent to the acquisition of imaging data, ReHo analysis was performed, and a support vector machine (SVM) method was employed to assess the utility of ReHo in discriminating MDD patients with SD.

RESULTS

Compared with MDD patients without SD, MDD patients with SD exhibited increased ReHo values in the right posterior cingulate cortex (PCC)/precuneus, right median cingulate cortex, left postcentral gyrus (postCG), and right inferior temporal gyrus (ITG). Furthermore, the ReHo values in the right PCC/precuneus and ITG displayed a positive correlation with clinical symptoms across all patients. SVM classification results showed that a combination of abnormal ReHo in the left postCG and right ITG achieved an overall accuracy of 84.21%, a sensitivity of 81.82%, and a specificity of 87.50% in identifying MDD patients with SD from those without SD.

CONCLUSION

We identified disrupted ReHo patterns in MDD patients with SD, and presented a prospective neuroimaging-based diagnostic biomarker for these patients.

Sleep Quality After Quetiapine Augmentation in Patients With Treatment-Resistant Depression and Personality Disorders

PURPOSE/BACKGROUND

Quetiapine is a first-line augmenting agent for treatment-resistant depression (TRD) and is used off-label in insomnia. Quetiapine and its active metabolite norquetiapine act mostly on 5-HT2A, 5-HT2C, H1, and D2 as antagonists and on 5-HT1A as partial agonists. Patients with TRD often have comorbid personality disorder (PD), and evidence suggests an association between sleep disturbance and recovery among patients with PD. Here, we aimed to evaluate the effects of quetiapine on sleep in TRD patients with and without PD (PD+/PD-).

METHODS/PROCEDURES

We reviewed health records of 38 patients with TRD (20 TRD/PD+) who had been treated with a pharmacotherapy regimen including quetiapine. Clinical outcomes were determined by comparing changes in sleep items of the Hamilton Depression Rating Scale at the beginning (T0) and after 3 months of an unchanged treatment (T3).

FINDINGS/RESULTS

Patients with TRD/PD+ and TRD/PD- taking quetiapine showed significant improvement in sleep items from T0 to T3 (P < 0.001, ηp2 ≥ 0.19). There was a significant personality × time interaction for sleep-maintenance insomnia (P = 0.006, ηp2 = 0.23), with TRD/PD+ showing a greater improvement at T3 compared with TRD/PD- (P = 0.01). While exploring other sleep items, no personality × time interaction was found. In the TRD/PD- group, improvement in sleep items was associated with an overall improvement in depressive symptoms (r = 0.55, P = 0.02).

IMPLICATIONS/CONCLUSIONS

Quetiapine induced greater improvements in sleep-maintenance insomnia among TRD/PD+ patients than TRD/PD-. These findings suggest quetiapine could have a therapeutic role for insomnia in PD underscoring a distinct underlying neurobiological mechanism of sleep disturbance in people living with PD.

The Relationship of Early Sleep Improvement With Response to Pharmacotherapy in Unipolar Psychotic Depression

BACKGROUND

Since insomnia and depression are interrelated, improved sleep early in antidepressant pharmacotherapy may predict a positive treatment outcome. We investigated whether early insomnia improvement (EII) predicted treatment outcome in psychotic depression (PD) and examined if there was an interaction effect between EII and treatment type to assess if findings were treatment-specific.

METHODS

This study is a secondary analysis of a randomized trial comparing 7 weeks treatment with the antidepressants venlafaxine, imipramine and venlafaxine plus the antipsychotic quetiapine in PD ( n = 114). Early insomnia improvement, defined as ≥20% reduced insomnia after 2 weeks, was assessed by the Hamilton Rating Scale for Depression (HAM-D-17). Associations between EII and treatment outcome were examined using logistic regressions. Subsequently, we added interaction terms between EII and treatment type to assess interaction effects. The predictive value of EII was compared with early response on overall depression (≥20% reduced HAM-D-17 score after 2 weeks).

RESULTS

EII was associated with response (odds ratio [OR], 7.9; 95% confidence interval [CI], 2.7-23.4; P = <0.001), remission of depression (OR, 6.1; 95% CI, 1.6-22.3; P = 0.009), and remission of psychosis (OR, 4.1; 95% CI, 1.6-10.9; P = 0.004). We found no interaction effects between EII and treatment type on depression outcome. Early insomnia improvement and early response on overall depression had a comparable predictive ability for treatment outcome.

CONCLUSIONS

Early insomnia improvement was associated with a positive outcome in pharmacotherapy of PD, regardless of the medication type. Future studies are needed to confirm our findings and to examine the generalizability of EII as predictor in treatment of depression.

The Relationship between Insomnia and the Pathophysiology of Major Depressive Disorder: An Evaluation of a Broad Selection of Serum and Urine Biomarkers

Insomnia exhibits a clinically relevant relationship with major depressive disorder (MDD). Increasing evidence suggests that insomnia is associated with neurobiological alterations that resemble the pathophysiology of MDD. However, research in a clinical population is limited. The present study, therefore, aimed to investigate the relationship between insomnia and the main pathophysiological mechanisms of MDD in a clinical sample of individuals with MDD. Data were extracted from three cohorts (N = 227) and included an evaluation of depression severity (Quick Inventory of Depressive Symptomatology, QIDS-SR₁₆) and insomnia severity (QIDS-SR₁₆ insomnia items) as well as serum and urine assessments of 24 immunologic (e.g., tumour necrosis factor α receptor 2 and calprotectin), neurotrophic (e.g., brain-derived neurotrophic factor and epidermal growth factor), neuroendocrine (e.g., cortisol and aldosterone), neuropeptide (i.e., substance P), and metabolic (e.g., leptin and acetyl-L-carnitine) biomarkers. Linear regression analyses evaluating the association between insomnia severity and biomarker levels were conducted with and without controlling for depression severity (M = 17.32), antidepressant use (18.9%), gender (59.0% female; 40.5% male), age (M = 42.04), and the cohort of origin. The results demonstrated no significant associations between insomnia severity and biomarker levels. In conclusion, for the included biomarkers, current findings reveal no contribution of insomnia to the clinical pathophysiology of MDD.

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.

Effect of brexanolone on depressive symptoms, anxiety, and insomnia in women with postpartum depression: Pooled analyses from 3 double-blind, randomized, placebo-controlled clinical trials in the HUMMINGBIRD clinical program

BACKGROUND

Brexanolone is currently the only treatment specifically approved for postpartum depression (PPD) in the United States, based on the results from one Phase 2 and two Phase 3 double-blind, randomized, controlled trials in the HUMMINGBIRD program.

METHODS

Adults with PPD randomized to a 60-h infusion of brexanolone 90 μg/kg/h (BRX90) or placebo from the 3 trials were included in these post hoc analyses. Data on change from baseline (CFB) in the 17-item Hamilton Rating Scale for Depression (HAMD-17) total score, HAMD-17 Anxiety/Somatization and Insomnia subscales, and Clinical Global Impression of Improvement (CGI-I) scale were pooled. Response rates for HAMD-17 (≥50 % reduction from baseline) and CGI-I (score of 1 or 2) scales and time to response were analyzed.

RESULTS

Patients receiving BRX90 (n = 102) versus placebo (n = 107) achieved a more rapid HAMD-17 response (median, 24 vs 36 h; p = 0.0265), with an Hour-60 cumulative response rate of 81.4 % versus 67.3 %; results were similar for time to CGI-I response (median, 24 vs 36 h; p = 0.0058), with an Hour-60 cumulative response rate of 81.4 % versus 61.7 %. CFB in HAMD-17 Anxiety/Somatization and Insomnia subscales also favored BRX90 versus placebo, starting at Hour 24 through Day 30 (all p < 0.05), and response rates for both subscales were higher with BRX90.

LIMITATIONS

The study was not powered to assess exploratory outcomes.

CONCLUSIONS

Brexanolone was associated with rapid improvement in depressive symptoms and symptoms of anxiety and insomnia compared with placebo in women with PPD. These data continue to support the use of brexanolone to treat adults with PPD.

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).

Effect of Sleep Disturbance Symptoms on Treatment Outcome in Blended Cognitive Behavioral Therapy for Depression (E-COMPARED Study): Secondary Analysis

Background

Sleep disturbance symptoms are common in major depressive disorder (MDD) and have been found to hamper the treatment effect of conventional face-to-face psychological treatments such as cognitive behavioral therapy. To increase the dissemination of evidence-based treatment, blended cognitive behavioral therapy (bCBT) consisting of web-based and face-to-face treatment is on the rise for patients with MDD. To date, no study has examined whether sleep disturbance symptoms have an impact on bCBT treatment outcomes and whether it affects bCBT and treatment-as-usual (TAU) equally.

Objective

The objectives of this study are to investigate whether baseline sleep disturbance symptoms have an impact on treatment outcomes independent of treatment modality and whether sleep disturbance symptoms impact bCBT and TAU in routine care equally.

Methods

The study was based on data from the E-COMPARED (European Comparative Effectiveness Research on Blended Depression Treatment Versus Treatment-as-Usual) study, a 2-arm, multisite, parallel randomized controlled, noninferiority trial. A total of 943 outpatients with MDD were randomized to either bCBT (476/943, 50.5%) or TAU consisting of routine clinical MDD treatment (467/943, 49.5%). The primary outcome of this study was the change in depression symptom severity at the 12-month follow-up. The secondary outcomes were the change in depression symptom severity at the 3- and 6-month follow-up and MDD diagnoses at the 12-month follow-up, assessed using the Patient Health Questionnaire-9 and Mini-International Neuropsychiatric Interview, respectively. Mixed effects models were used to examine the association of sleep disturbance symptoms with treatment outcome and treatment modality over time.

Results

Of the 943 patients recruited for the study, 558 (59.2%) completed the 12-month follow-up assessment. In the total sample, baseline sleep disturbance symptoms did not significantly affect change in depressive symptom severity at the 12-month follow-up (β=.16, 95% CI –0.04 to 0.36). However, baseline sleep disturbance symptoms were negatively associated with treatment outcome for bCBT (β=.49, 95% CI 0.22-0.76) but not for TAU (β=–.23, 95% CI −0.50 to 0.05) at the 12-month follow-up, even when adjusting for baseline depression symptom severity. The same result was seen for the effect of sleep disturbance symptoms on the presence of depression measured with Mini-International Neuropsychiatric Interview at the 12-month follow-up. However, for both treatment formats, baseline sleep disturbance symptoms were not associated with depression symptom severity at either the 3- (β=.06, 95% CI −0.11 to 0.23) or 6-month (β=.09, 95% CI −0.10 to 0.28) follow-up.

Conclusions

Baseline sleep disturbance symptoms may have a negative impact on long-term treatment outcomes in bCBT for MDD. This effect was not observed for TAU. These findings suggest that special attention to sleep disturbance symptoms might be warranted when MDD is treated with bCBT. Future studies should investigate the effect of implementing modules specifically targeting sleep disturbance symptoms in bCBT for MDD to improve long-term prognosis.

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.

Identifying New Factors Associated With Cognitive Decline and Delirium After Transcatheter Aortic Valve Implantation: A Study Protocol

Background: Transcatheter aortic valve implantation (TAVI) has become the standard-of-care for treatment of severe symptomatic aortic stenosis and is also being increasingly recommended for low-risk patients. While TAVI boasts positive post-procedural outcomes, it is also associated with cognitive complications, namely delirium and cognitive decline. There is a pressing need for accurate risk tools which can identify TAVI patients at risk of delirium and cognitive decline, as risk scores designed for general cardiovascular surgery fall short. The present effect-finding exploratory study will assess the utility of various measures in the context of aging and frailty in predicting who will and who will not develop delirium or cognitive impairment following TAVI. The measures we propose include gait, visual symptoms, voice, swallowing, mood and sleep. Methods: This is an observational prospective cohort study focused on identifying pre-procedural risk factors for the development of delirium and cognitive decline following TAVI. Potential risk factors will be measured prior to TAVI. Primary outcomes will be post-procedure cognitive decline and delirium. Secondary outcomes include activities of daily living, quality of life, and mortality. Delirium presence will be measured on each of the first 2 days following TAVI. All other outcomes will be assessed at 3-, 6-, and 12-months post-operatively. A series of logistic regressions will be run to investigate the relationship between potential predictors and outcomes (presence vs. absence of either delirium or cognitive decline). Discussion: This study will assess the strengths of associations between a range of measures drawn from frailty and aging literature in terms of association with cognitive decline and delirium following TAVI. Identified measures can be used in future development of TAVI risk prediction models, which are essential for the accurate identification of cognitive at-risk patients and successful application of pre-procedural interventions. Clinical Trial Registration: This trial is registered with the Australian New Zealand Clinical Trials Registry. [https://bit.ly/2PAotP5], [ACTRN12618001114235].

Brain structural correlates of insomnia severity in 1053 individuals with major depressive disorder: results from the ENIGMA MDD Working Group

It has been difficult to find robust brain structural correlates of the overall severity of major depressive disorder (MDD). We hypothesized that specific symptoms may better reveal correlates and investigated this for the severity of insomnia, both a key symptom and a modifiable major risk factor of MDD. Cortical thickness, surface area and subcortical volumes were assessed from T1-weighted brain magnetic resonance imaging (MRI) scans of 1053 MDD patients (age range 13-79 years) from 15 cohorts within the ENIGMA MDD Working Group. Insomnia severity was measured by summing the insomnia items of the Hamilton Depression Rating Scale (HDRS). Symptom specificity was evaluated with correlates of overall depression severity. Disease specificity was evaluated in two independent samples comprising 2108 healthy controls, and in 260 clinical controls with bipolar disorder. Results showed that MDD patients with more severe insomnia had a smaller cortical surface area, mostly driven by the right insula, left inferior frontal gyrus pars triangularis, left frontal pole, right superior parietal cortex, right medial orbitofrontal cortex, and right supramarginal gyrus. Associations were specific for insomnia severity, and were not found for overall depression severity. Associations were also specific to MDD; healthy controls and clinical controls showed differential insomnia severity association profiles. The findings indicate that MDD patients with more severe insomnia show smaller surfaces in several frontoparietal cortical areas. While explained variance remains small, symptom-specific associations could bring us closer to clues on underlying biological phenomena of MDD.

Role of persistent and worsening sleep disturbance in depression remission and suicidal ideation among older primary care patients: the PROSPECT study

STUDY OBJECTIVES

We analyzed data from a practice-based randomized controlled trial within 20 primary care practices located in greater New York City, Philadelphia, and Pittsburgh to determine whether persistent or worsening sleep disturbance plays a role in the outcomes of depression and suicidal ideation at 1 year in older adults with depression.

METHODS

The study sample consisted of 599 adults aged 60 years and older meeting criteria for major depression or clinically significant minor depression. Longitudinal analysis via growth curve mixture modeling was carried out to classify patients as having worsening, persistent, or improving sleep over 1 year.

RESULTS

At 1-year follow-up, compared with patients with improving sleep, those with worsening sleep were more likely to have a diagnosis of major depression (adjusted odds ratio (aOR) = 28.60, 95% confidence interval (CI) 12.15 to 67.34), a diagnosis of clinically significant minor depression (aOR = 11.88, 95% CI 5.67 to 24.89), and suicidal ideation (aOR = 1.10, 1.005 to 1.199), and were half as likely to achieve remission (aOR = 0.52, 95% CI 0.46 to 0.57). Patients with persistent sleep disturbance showed similar but attenuated results.

CONCLUSIONS

Older primary care patients with depression who exhibit worsening or persistent sleep disturbance were at increased risk for persistent depression and suicidal ideation 1 year later. The pattern of sleep disturbance over time may be an important signal for exploration by primary care physicians of depression and suicidal ideation among older adults with depression.

CLINICAL TRIAL REGISTRATION

NCT00279682.

Do sleep disturbances contribute to cognitive impairments in schizophrenia spectrum and bipolar disorders?

Sleep disturbances and cognitive impairments are both frequent across psychotic disorders, with debilitating effects on functioning and quality of life. This study aims to investigate if sleep disturbances are related to cognitive impairments in schizophrenia spectrum (SCZ) and bipolar disorders (BD), if this relationship varies between different sleep disturbances (insomnia, hypersomnia or delayed sleep phase (DSP)) and lastly, if this relationship differs between clinical groups and healthy controls (HC). We included 797 patients (SCZ = 457, BD = 340) from the Norwegian Centre for Mental Disorders Research (NORMENT) study in Norway. Sleep disturbances were based on items from the Inventory of Depressive Symptoms-Clinician rated scale (IDS-C). Their relationship with several cognitive domains was tested using separate ANCOVAs. A three-way between-groups ANOVA was conducted to test if the relationship with cognitive impairments varies between different sleep disturbances. These analyses revealed significantly poorer processing speed and inhibition in those with any sleep disturbance versus those without, also after adjusting for several covariates. The relationship between sleep disturbances and cognition was similar across SCZ and BD, and there were significant effects of insomnia and hypersomnia on both processing speed and inhibition. No association between sleep disturbances and cognition was found in HC. Sleep disturbances contribute to cognitive impairments in psychotic disorders. Processing speed and inhibition is poorer in patients with sleep disturbances. Impairments in these domains are related to insomnia and hypersomnia. These findings suggest that treating sleep disturbances is important to protect cognitive functioning, alongside cognitive remediation in psychotic disorders.

Associations of serum chromogranin A with depressive symptoms in men with unipolar depressive disorder

OBJECTIVE

The aim of the present study was to determine the changes of serum chromogranin A (CgA) levels upon depression by investigating the relationship between serum CgA levels and the depressive symptoms assessed by 24-item Hamilton Rating Scale for Depression (HRSD-24).

METHOD

Serum CgA levels were measured by enzyme-linked immunosorbent assay in 133 male patients with major depressive disorder (MDD) and were compared with those of 47 healthy controls. Then generalized linear regression, logistic regression and restricted cubic spline models were performed to examine the association between serum CgA levels and depressive symptoms.

RESULTS

Serum CgA levels were lower in MDD patients than in controls (P < 0.001) and were inversely associated with scores on HRSD-24 in unadjusted, age, smoking, alcohol consumption, traumatic life events and family history of depression-adjusted and fully adjusted linear regression model. The fully adjusted regression coefficient with 95% confidence intervals was -0.028 (-0.045, -0.010) for serum CgA levels and HRSD-24 score. Serum CgA levels were inversely associated with depressive symptoms (HRSD ≥20) in each logistic regression model.

CONCLUSION

Serum CgA decrease was noted in male patients of MDD and may be inversely associated with depressive symptoms.

Severe insomnia is associated with metabolic syndrome in women over 50 years with major depression treated in psychiatry settings: a METADAP report

INTRODUCTION

Major depression is associated with metabolic syndrome and cardiovascular risk. We have previously shown that severe insomnia, a core symptom of major depression episode (MDE), is associated with hypertriglyceridemia, a component of metabolic syndrome, in women but not in men with major depression. Since insomnia is related to cardiovascular morbidity in the general population and major depression also, our objective was to assess the link between insomnia and metabolic syndrome, a marker syndrome of cardiovascular risk, during MDE, in women and in men.

METHODS

In 624 patients with a current MDE cohort, both insomnia and metabolic syndrome were assessed in women and men. Insomnia was rated from 0 to 6 based on the HDRS corresponding items, severe insomnia being defined by a total insomnia score ≥4.

RESULTS

severe insomnia was associated with metabolic syndrome in women but not in men. In multivariate logistic regressions, these results in women were independent from age, educational level, major depressive disorder duration and current smoking. These results were only significant in women aged ≥50 years, a cut-off age for menopausal status but not in women under 50 years.

CONCLUSION

Women aged ≥50 years with a severe insomnia during MDE have an increased risk of metabolic syndrome. Severe insomnia may be a clinical marker of metabolic risk in this population. They should be particularly monitored for metabolic syndrome and may benefit from sleep recommendations and cardiovascular prevention.

Focusing on insomnia symptoms to better understand depression: A STAR*D report

BACKGROUND

Disturbed sleep is a core symptom of major depressive disorder (MDD), with nearly 90% of those with MDD reporting disturbed sleep. However, combining insomnia and hypersomnia into a single diagnostic domain ignores distinct biological differences between those symptom presentations. To better understand depression it may be necessary to explore these symptoms independently, beginning with the more prevalent insomnia.

METHOD

The present study evaluated global insomnia symptom severity in a broad sample of MDD outpatients from the Sequenced Treatment Alternatives to Relieve Depression (STAR*D) trial, excluding patients who reported hypersomnia symptoms. The three insomnia-related symptoms from the 16-item Quick Inventory of Depressive Symptomatology- clinician rated (QIDS-C) were combined to create a global insomnia score to classify baseline insomnia severity. A modified depression severity score was then used to assess depression severity (mQIDS-C), excluding sleep-related items.

RESULTS

A repeated measures ANCOVA revealed a significant improvement in insomnia score over the acute phase treatment (F = 33.1, d.f. = 6, 9897, p < 0.0001). Improvement in insomnia score over the acute phase treatment remained statistically significant even after controlling for change in depression severity (p = 0.0004). Participants with one point higher insomnia score at baseline were significantly less likely to remit at study exit (odds ratio = 0.88, 95% confidence interval = 0.85, 0.92, p < 0.0001) even after controlling for baseline depression severity.

LIMITATIONS

Objective confirmation of sleep profiles was not available.

CONCLUSION

Greater severity of insomnia reduces likelihood of MDD remission, and insomnia symptoms improved independent of depression remission.

A Preliminary Examination of the Effect of Cognitive Processing Therapy on Sleep Disturbance Among Veterans with Military Sexual Trauma-Related Posttraumatic Stress Disorder

Veterans who have experienced military sexual trauma (MST) report numerous psychosocial difficulties including sleep disturbance and posttraumatic stress disorder (PTSD). Cognitive Processing Therapy (CPT) has been shown to effectively reduce total PTSD symptoms among veterans with MST-related PTSD; however, sleep disturbance may persist after successful treatment. Sleep disturbance is associated with suicidal self-directed violence, substance use, and poorer physical health. Identification of if and when CPT can sufficiently address sleep disturbance may help to determine when adjunctive interventions may be indicated. The current study described the rate of sleep disturbance in a sample of veterans with MST-related PTSD before and after CPT. In an exploratory analysis, potential baseline predictors (i.e., sociodemographic, PTSD symptoms, trauma-related cognitions, depression, physical health) of change in sleep disturbance following CPT were assessed. A secondary analysis of 72 male and female veterans enrolled in a randomized clinical trial examining the efficacy of CPT for MST-related PTSD was conducted. Most veterans reported clinically significant sleep disturbance at baseline (100%) and post-treatment (89%). A significant relationship between clinically significant change in PTSD symptoms and resolution of sleep disturbance was not identified. Using hierarchical multiple linear regression, potential predictors of change in sleep severity following CPT were assessed; however, no significant predictors were identified in this exploratory analysis. These results are consistent with previous research describing high residual rates of sleep disturbance in veterans with PTSD, despite reductions in overall PTSD symptoms. Future research should focus on identifying effective augmentation strategies for CPT to specifically address sleep disturbance.

Sleep disturbances in schizophrenia spectrum and bipolar disorders - a transdiagnostic perspective

BACKGROUND

Sleep disturbances are prevalent in severe mental disorders but their type and frequency across diagnostic categories has not been investigated in large scale studies.

METHODS

Participants with Schizophrenia spectrum disorders (SCZ, (N = 617)), Bipolar disorders (BD, (N = 440)), and Healthy Controls (HC, (N = 173)) were included in the study. Sleep disturbances (insomnia, hypersomnia and delayed sleep phase) were identified based on items from the Inventory of Depressive Symptoms - Clinician rated scale. Clinical symptoms were assessed with the Positive and Negative Syndrome scale and level of functioning with the Global assessment of Functioning scale.

RESULTS

The rate of any sleep disturbance was 78% in SZ, 69% in BD and 39% in HC. Insomnia was the most frequently reported sleep disturbance across all groups. Both diagnostic groups reported significantly more of any sleep disturbances than HC (P < 0.001). Having a sleep disturbance was associated with more severe negative and depressive symptoms and with lower functioning across diagnostic groups (P < 0.001, η² = 0.0071). Hypersomnia was the only sleep disturbance associated with previous treatment history.

CONCLUSION

Sleep disturbances, including insomnia, hypersomnia and delayed sleep phase, are frequent in SCZ and BD, and associated with more severe clinical symptomatology across diagnostic groups. This suggests that sleep disturbance is a clinically relevant transdiagnostic phenomenon.

Cognitive Behavioral Therapy for Insomnia in Depression

This article reviews the literature on cognitive-behavioral therapy for insomnia in adults and adolescents with depression. Recent research has expanded on previous research, which established that sleep problems are an important predictor of depression and that sleep problems are associated with more severe depression, more suicidality, and worse outcomes for treatment of depression. The relationship between sleep problems and depression is complex, likely bidirectional, and impactful. To further improve the lives of patients with depression who experience insomnia, it will be important to investigate which patients will do better in a sequential versus concomitant approach.

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.

Glycogen synthase kinase-3β genetic polymorphisms and insomnia in depressed patients: A prospective study

BACKGROUND

80-90% of patients with Major Depressive Episode (MDE) experience insomnia and up-to 50% severe insomnia. Glycogen Synthase Kinase-3β (GSK3B) is involved both in mood regulation and circadian rhythm. Since GSK3B polymorphisms could affect protein levels or functionality, we investigated the association of GSK3B polymorphisms with insomnia in a sample of depressed patients treated with antidepressants.

METHODS

In this 6-month prospective real-world treatment study in psychiatric settings (METADAP), 492 Caucasian patients requiring a new antidepressant treatment were included and genotyped for five GSK3B Single Nucleotide Polymorphisms (SNPs) (rs6808874, rs6782799, rs2319398, rs13321783, rs334558). Insomnia and MDE severity were rated using the Hamilton Depression Rating Scale (HDRS). Bi- and multivariate analyses were performed to assess the association between GSK3B SNPs and insomnia (main objective). We also assessed their association with MDE severity and HDRS response/remission after antidepressant treatment.

RESULTS

At baseline severe insomnia was associated with the GSK3B rs334558 minor allele (C+) [OR=1.81, CI95%(1.17-2.80), p=0.008]. GSK3B rs334558 C+ had greater insomnia improvement after 6 months of antidepressant treatment (p=0.007, β=0.17, t=2.736). No association was found between GSK3B SNPs and MDE baseline severity or 6-month response/remission.

CONCLUSION

GSK3B rs334558 was associated with insomnia but not with MDE severity in depressed patients. Targeting GSK3B in patients with MDE and a severe insomnia could be a way to improve their symptoms with greater efficiency. And it should be further studied whether the GSK3B-insomnia association may fit into the larger picture of mood disorders.

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.

Diffusion Tensor Imaging Tractography Reveals Disrupted White Matter Structural Connectivity Network in Healthy Adults with Insomnia Symptoms

Neuroimaging studies have revealed that insomnia is characterized by aberrant neuronal connectivity in specific brain regions, but the topological disruptions in the white matter (WM) structural connectivity networks remain largely unknown in insomnia. The current study uses diffusion tensor imaging (DTI) tractography to construct the WM structural networks and graph theory analysis to detect alterations of the brain structural networks. The study participants comprised 30 healthy subjects with insomnia symptoms (IS) and 62 healthy subjects without IS. Both the two groups showed small-world properties regarding their WM structural connectivity networks. By contrast, increased local efficiency and decreased global efficiency were identified in the IS group, indicating an insomnia-related shift in topology away from regular networks. In addition, the IS group exhibited disrupted nodal topological characteristics in regions involving the fronto-limbic and the default-mode systems. To our knowledge, this is the first study to explore the topological organization of WM structural network connectivity in insomnia. More importantly, the dysfunctions of large-scale brain systems including the fronto-limbic pathways, salience network and default-mode network in insomnia were identified, which provides new insights into the insomnia connectome. Topology-based brain network analysis thus could be a potential biomarker for IS.

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.

Innovations in Practice: The relationship betweensleep disturbances, depression, and interpersonal functioning in treatment for adolescent depression

BACKGROUND

Sleep disturbance is frequently comorbid with depression and sleep complaints are the most common residual symptoms after treatment among adolescents with depression. The present analyses investigated the effect of sleep disturbance in depressed adolescents treated with Interpersonal Psychotherapy for Adolescents (IPT-A) versus Treatment as Usual (TAU) in school-based mental health clinics.

METHOD

63 adolescents participated in a randomized clinical trial of IPT-A versus TAU for adolescent depression. Participants were diagnosed with a DSM-IV depressive disorder and assessed for symptoms of depression, interpersonal functioning and sleep disturbance. Measures were assessed at baseline, session 4 and 8 of treatment, and session 12 for post-acute treatment follow-up. Hierarchical linear modeling (HLM) was used to model change in depression, interpersonal functioning and sleep disturbance.

RESULTS

Ongoing sleep disturbance was significantly associated with worse depression scores as rated by clinician (γ = 1.04, SE = 0.22, p < .001) and self-report (γ = 1.63, SE = 0.29, p < .001), as well as worse interpersonal functioning across the course of treatment (γ = 0.09, SE = 0.02, p < .001). Treatment condition did not predict change in sleep disturbance (γ = -0.13, SE = 0.14, p = ns).

CONCLUSIONS

For all patients in the study, sleep disturbance was a predictor of depression and interpersonal functioning for depressed adolescents. Sleep disturbance predicted more depression and interpersonal stress across treatments and led to a slower improvement in depression and interpersonal functioning. This data suggests that sleep disturbance should be a target for future treatment development research among depressed adolescents.

Disrupted Topology of Frontostriatal Circuits Is Linked to the Severity of Insomnia

Insomnia is one of the most common health complaints, with a high prevalence of 30~50% in the general population. In particular, neuroimaging research has revealed that widespread dysfunctions in brain regions involved in hyperarousal are strongly correlated with insomnia. However, whether the topology of the intrinsic connectivity is aberrant in insomnia remains largely unknown. In this study, resting-state functional magnetic resonance imaging (rsfMRI) in conjunction with graph theoretical analysis, was used to construct functional connectivity matrices and to extract the attribute features of the small-world networks in insomnia. We examined the alterations in global and local small-world network properties of the distributed brain regions that are predominantly implicated in the frontostriatal network between 30 healthy subjects with insomnia symptoms (IS) and 62 healthy subjects without insomnia symptoms (NIS). Correlations between the small-world properties and clinical measurements were also generated to identify the differences between the two groups. Both the IS group and the NIS group exhibited a small-worldness topology. Meanwhile, the global topological properties didn't show significant difference between the two groups. By contrast, participants in the IS group showed decreased regional degree and efficiency in the left inferior frontal gyrus (IFG) compared with subjects in the NIS group. More specifically, significantly decreased nodal efficiency in the IFG was found to be negatively associated with insomnia scores, whereas the abnormal changes in nodal betweenness centrality of the right putamen were positively correlated with insomnia scores. Our findings suggested that the aberrant topology of the salience network and frontostriatal connectivity is linked to insomnia, which can serve as an important biomarker for insomnia.

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 problems in bipolar disorders: more than just insomnia

OBJECTIVE

Sleep problems in bipolar disorder (BD) are common, but reported rates vary from 10% to 80%, depending on definitions, methodologies and management of potential confounding factors. This multicenter study seeks to address these issues and also compares BD cases with Hypersomnia as well as the more commonly investigated Insomnia and No Sleep Problem groups.

METHOD

A cross-sectional comparison of sleep profiles in 563 BD I and II individuals who participated in a structured assessment of demographic, clinical, illness history and treatment variables.

RESULTS

Over 40% cases met criteria for Insomnia and 29% for Hypersomnia. In univariate analysis, Insomnia was associated with BD II depression whilst Hypersomnia was associated with BD I depression or euthymia. After controlling for confounders and covariates, it was demonstrated that Hypersomnia cases were significantly more likely to be younger, have BD I and be prescribed antidepressants whilst Insomnia cases had longer illness durations and were more likely to be prescribed benzodiazepines and hypnotics.

CONCLUSION

Whilst Insomnia symptoms are common in BD, Hypersomnia is a significant, frequently underexplored problem. Detailed analyses of large representative clinical samples are critical to extending our knowledge of differences between subgroups defined by sleep profile.

Delayed sleep phase: An important circadian subtype of sleep disturbance in bipolar disorders

BACKGROUND

Theoretical models of Bipolar Disorder (BD) highlight that sleep disturbances may be a marker of underlying circadian dysregulation. However, few studies of sleep in BD have reported on the most prevalent circadian sleep abnormality, namely Delayed Sleep Phase (DSP).

METHODS

A cross-sectional study of 404 adults with BD who met published clinical criteria for insomnia, hypersomnia or DSP, and who had previously participated in a study of sleep in BD using a comprehensive structured interview assessment.

RESULTS

About 10% of BD cases with a sleep problem met criteria for a DSP profile. The DSP group was younger and had a higher mean Body Mass Index (BMI) than the other groups. Also, DSP cases were significantly more likely to be prescribed mood stabilizers and antidepressant than insomnia cases. An exploratory analysis of selected symptom item ratings indicated that DSP was significantly more likely to be associated with impaired energy and activity levels.

LIMITATIONS

The cross-sectional design precludes examination of longitudinal changes. DSP is identified by sleep profile, not by diagnostic criteria or objective sleep records such as actigraphy. The study uses data from a previous study to identify and examine the DSP group.

CONCLUSIONS

The DSP group identified in this study can be differentiated from hypersomnia and insomnia groups on the basis of clinical and demographic features. The association of DSP with younger age, higher BMI and impaired energy and activity also suggest that this clinical profile may be a good proxy for underlying circadian dysregulation.

Sense of Coherence and Defense Style Predict Sleep Difficulties in Early Non-metastatic Colorectal Cancer

BACKGROUND

Sleep disturbances are common in cancer patients, but little is known about the complex interplay between the background psychological profile, coping with health stressors capacities and psychological distress in the formation of sleep difficulties in colorectal cancer.

AIMS

To study the course and to identify psychological predictors of sleep difficulties in early non-metastatic colorectal cancer patients over a one-year period.

METHODS

In this 1-year prospective study, we assessed in 84 early non-metastatic colorectal cancer patients the association of psychological distress (SCL-90-R), sense of coherence (SOC-29), and defense styles (Defense Style Questionnaire) with sleep difficulties (SCL-90-R) in multiple regression models. Eighty-two patients with breast cancer and 50 patients with cancer of unknown primary site served as disease controls, and 84 matched for age and sex alleged healthy individuals served as healthy controls.

RESULTS

Colorectal cancer patients presented more sleep difficulties compared to healthy participants but fewer than patients with breast cancer and cancer of unknown primary site. Colorectal cancer patients' trouble falling asleep (p = 0.033) and wakening up early in the morning (p < 0.001) deteriorated over time. Sleep that was restless or disturbed was independently associated with low SOC (p = 0.046) and maladaptive defenses (p = 0.008). Anxiety symptoms (p < 0.001) predicted deterioration in trouble falling asleep, while depressive symptoms (p = 0.022) and self-sacrificing defense style (p = 0.049) predicted deterioration in wakening up early in the morning.

CONCLUSIONS

Psychological parameters and coping with health stressors capacities are independently associated with sleep difficulties in colorectal cancer patients, indicating the need for psychological interventions aiming at improving adjustment to the disease.

IL-1β and BDNF are associated with improvement in hypersomnia but not insomnia following exercise in major depressive disorder

Given the role of sleep in the development and treatment of major depressive disorder (MDD), it is becoming increasingly clear that elucidation of the biological mechanisms underlying sleep disturbances in MDD is crucial to improve treatment outcomes. Sleep disturbances are varied and can present as insomnia and/or hypersomnia. Though research has examined the biological underpinnings of insomnia in MDD, little is known about the role of biomarkers in hypersomnia associated with MDD. This paper examines biomarkers associated with changes in hypersomnia and insomnia and as predictors of improvements in sleep quality following exercise augmentation in persons with MDD. Subjects with non-remitted MDD were randomized to augmentation with one of two doses of aerobic exercise: 16 kilocalories per kilogram of body weight per week (KKW) or 4 KKW for 12 weeks. The four sleep-related items on the clinician-rated Inventory of Depressive Symptomatology (sleep onset insomnia, mid-nocturnal insomnia, early morning insomnia and hypersomnia) assessed self-reported sleep quality. Inflammatory cytokines (tumor necrosis factor-alpha, interleukin (IL)-1β, IL-6) and brain-derived neurotrophic factor (BDNF) were assessed in blood samples collected before and following the 12-week intervention. Reduction in hypersomnia was correlated with reductions in BDNF (ρ = 0.26, P = 0.029) and IL-1β (ρ = 0.37, P = 0.002). Changes in these biomarkers were not associated with changes in insomnia; however, lower baseline levels of IL-1β were predictive of greater improvements in insomnia (F = 3.87, P = 0.050). In conclusion, improvement in hypersomnia is related to reductions in inflammatory markers and BDNF in persons with non-remitted MDD. Distinct biological mechanisms may explain reductions in insomnia.

Pre-treatment insomnia as a predictor of single and combination antidepressant outcomes: a CO-MED report

BACKGROUND

Most patients with major depressive disorder (MDD) report clinically significant sleep problems. Pre-treatment insomnia has been associated with poorer treatment outcomes in some antidepressant trials, leading to suggestions that combined treatment regimens may be more successful in this subgroup. This study investigated this question using data from the CO-MED trial.

METHODS

Adult outpatients with chronic and/or recurrent MDD were randomly assigned in 1:1:1 ratio to 28 weeks of single-blind, placebo-controlled antidepressant treatment with (1) escitalopram+placebo, (2) bupropion-sustained-release+escitalopram, or (3) venlafaxine-extended-release+mirtazapine. We compared baseline characteristics, tolerability, and treatment outcomes at 12 and 28 weeks for patients with and without pre-treatment insomnia.

RESULTS

Of the 665 evaluable patients, the majority (88.3%) reported significant pre-treatment insomnia. Those with pre-treatment insomnia were more likely to be female (69.3% vs. 57.7%) and African-American (29.1% vs. 11.8%). Those with pre-treatment insomnia symptoms reported higher rates of concurrent anxiety disorders, lower rates of alcohol and substance use disorders, and greater impairment in psychosocial functioning. The two groups did not differ in either tolerability or treatment outcomes among the three antidepressant treatments.

CONCLUSIONS

Insomnia symptoms, while common in patients with chronic/recurrent MDD were not predictive of response, remission, or tolerability with either single or combined antidepressant medications.

Prevalence and clinical correlates of co-occurring insomnia and hypersomnia symptoms in depression

BACKGROUND

The aim was to examine the prevalence and consequences of co-occurring insomnia and hypersomnia symptoms in depressed adults drawn from a representative sample of the U.S. population.

METHOD

Data from 687 National Comorbidity Survey Replication (NCS-R) respondents meeting criteria for a major depressive episode (MDE) in the past year were included. Respondents completed clinical interviews that assessed 12-month DSM-IV disorders, impairment, mental health treatment, and depressive symptom severity. Outcomes were compared between respondents who experienced insomnia symptoms-only (N=404), hypersomnia symptoms-only (N=44), both insomnia and hypersomnia symptoms (N=184) and no sleep problems (N=55) during an MDE.

RESULTS

Insomnia and hypersomnia symptoms co-occurred in 27.7% of respondents with past-year MDEs, most frequently in bipolar spectrum disorders and major depressive disorder with dysthymia. Similar to the insomnia-only group, respondents with co-occurring sleep disturbances had more severe depression, and higher rates of past-year impulse control disorders and suicide planning. Similar to the hypersomnia-only group, respondents with co-occurring sleep disturbances had higher rates of past-year drug use disorders and suicide attempts. Compared to the insomnia-only and no sleep problem groups, respondents with both sleep disturbances were more frequently in mental health treatment, seeing a general practitioner, and taking antidepressants.

LIMITATIONS

The NCS-R is cross-sectional and did not evaluate sleep disorder diagnoses.

CONCLUSIONS

Co-occurring insomnia and hypersomnia symptoms were associated with a more severe MDE. Further research is warranted to more fully understand the joint presentation of insomnia and hypersomnia in depression.

Do manualized treatments for depression reduce insomnia symptoms?

OBJECTIVE

Researchers evaluated the effect of manualized treatments for depression on comorbid symptoms of insomnia.

METHOD

Hierarchical linear modeling was used to analyze archival data collected from 14 studies (N = 910) examining the efficacy of psychological treatments for depression in adults.

RESULTS

Participants receiving a psychological treatment for depression experienced significantly more relief from symptoms of insomnia with overall, early-, middle-, and late-night sleep than those not receiving such treatment.

CONCLUSION

Symptoms of insomnia in those with an average (or lower) level of depression can be reduced through psychological treatment for depression. However, more severe depressive symptoms do not receive great relief from sleep disturbance and may require an additional treatment component targeting symptoms of insomnia.

Gonadal hormone levels and platelet tryptophan and serotonin concentrations in perimenopausal women with or without depressive symptoms

INTRODUCTION

The etiology of depressive symptoms associated with the transition to menopause is still unknown; hormonal changes, serotonergic system or insomnia, could be a trigger to depressive symptomatology. The aim of the present study was to evaluate gonadal hormonal levels, platelet serotonin concentrations and platelet tryptophan concentrations in a group of depressed perimenopausal women and their healthy counterparts.

METHODS

A total of 63 perimenopausal women between 45 and 55 years old were evaluated; of these, 44 were depressed patients, and 19 were perimenopausal women without depression. The instruments that were applied included the Center for Epidemiologic Studies Depression Scale (CES-D), the Hamilton Depression Rating Scale (HDRS) and the Green Climacteric Scale (GCS); gonadal hormone levels and platelet tryptophan and serotonin concentrations were measured in all participants. Differences in hormonal levels and tryptophan and serotonin concentrations were evaluated with respect to specific symptoms, such as insomnia, hot flashes, nervousness, depressed mood and loss of interest.

RESULTS

No differences between groups were observed with respect to hormonal levels and tryptophan and serotonin concentrations; mean sleep hours and insomnia were significantly correlated with platelet tryptophan concentrations.

CONCLUSIONS

In this sample, all symptoms of depression could not be explained by platelet tryptophan and serotonin concentrations and hormonal levels; differences were observed only when we evaluated insomnia and hot flashes.

Impact of sleep complaints and depression outcomes among participants in the standard medical intervention and long-term exercise study of exercise and pharmacotherapy for depression

The aim of this study was to examine the effects of exercise and sertraline on disordered sleep in patients with major depressive disorder (MDD). Methods The Standard Medical Intervention and Long-term Exercise study randomized the patients with MDD (n = 202) to one of four arms: a) supervised exercise, b) home-based exercise, c) sertraline therapy, and d) placebo pill. Sleep disturbance was assessed with three sleep-related items from the Hamilton Rating Scale for Depression (HAM-D) before and after 4 months of treatment. The patients were followed for 12 months to assess the prognostic value of sleep disturbance on MDD relapse and recovery.Results Comparison of the active treatment and placebo groups showed no treatment differences in HAM-D sleep complaints after 4 months (p = 0.758). However, residual insomnia symptoms after treatment were strongly associated with elevated depressive symptoms assessed by the HAM-D after 4 months (β = 0.342, p < 0.0001) and MDD relapse (odds ratio, 1.55; 95% confidence interval, 1.15-2.10; p = 0.004) assessed at 1-year follow-up (16 months after randomization). Neither exercise nor sertraline was associated with greater improvements in sleep disturbance compared with the placebo controls. However, residual symptoms of insomnia after successful treatment of MDD predicted relapse, highlighting the clinical importance of addressing insomnia in patients with MDD.

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

OBJECTIVE

To investigate the prevalence, clinical manifestations, and clinical correlates of insomnia in a large cohort of Korean patients with depressive disorders.

METHODS

We recruited 944 patients with depressive disorders from the Clinical Research Center for Depression of South Korea (CRESCEND) study. Psychometric scales were used to assess depression (HAMD), anxiety (HAMA), psychotic symptoms (BPRS), global severity (CGI-S), and functioning (SOFAS). Insomnia levels were determined by adding the scores for all items on the HAMD insomnia subscale. The clinical characteristics of the patients with 'low insomnia' (summed score ≤3 on the HAMD subscale) and 'high insomnia' (score ≥4) were compared using statistical analyses. A logistic regression model was constructed to identify factors associated with 'high insomnia' status.

RESULTS

Symptoms of insomnia were present in 93% of patients, while simultaneous early, middle, and late insomnia affected 64.1%. The high insomnia patients were characterized by significantly greater age, higher symptom levels (including core, gastrointestinal somatic and anxiety symptoms, and suicidal ideation), higher global severity and incidence of physical disorders, and greater insight. Explanatory factors of 'high insomnia' status were older age, higher gastrointestinal somatic and anxiety symptom levels, higher global severity, and greater insight.

CONCLUSION

In clinical psychiatry, insomnia has been significantly underdiagnosed and undertreated. It affects most patients with depressive disorders, and is indicative of the global severity of depression. Active efforts to diagnose and treat insomnia in patients with depressive disorders should be strongly encouraged. Further research is needed to improve the diagnosis and treatment of insomnia in depressive patients.

Can sleep disturbance in depression predict repetitive transcranial magnetic stimulation (rTMS) treatment response?

Treatment for depression is not effective in all patients and it is therefore important to identify factors that can be used to tailor treatments. One potential factor is insomnia. Several repetitive transcranial magnetic stimulation (rTMS) studies have reported on this symptom, however, they did not take into account the presence of hypersomnia or that insomnia was related to their outcome measure. Our aim was to investigate whether baseline sleep disruption was related to rTMS treatment response. We pooled data from four clinical trials using rTMS to treat depression, including 139 subjects in data analysis. Insomnia was measured using the Hamilton Depression Rating Scale (HamD) sleep questions and hypersomnia from the Beck Depression Inventory (BDI). To reduce the possible impact of insomnia on our treatment response outcome we created an adjusted HamD score which omitted sleep items. Sleep disturbances were common in our study: 66% had insomnia and 38% hypersomnia. Using regression analysis with our adjusted HamD score we found no relation between baseline insomnia or hypersomnia and rTMS treatment response. Our data are consistent with previous studies; however, this is the first rTMS study to our knowledge that has attempted to dissociate baseline insomnia from the HamD outcome measure and to report no relationship between hypersomnia and rTMS outcome.

The role of sleep problems in the development of depression in those with persistent pain: a prospective cohort study

STUDY OBJECTIVES

One theoretical model suggests a pathway between pain and the development of depression through sleep problems. Here, we prospectively test the hypothesis that incident sleep problems, in those with persistent pain, increase risk of new onset probable depression, and investigate the role of "pain that interferes with daily life" (pain interference) on this pathway.

DESIGN

Prospective cohort study.

SETTING

Community based population study within UK.

PARTICIPANTS

Participants with persistent pain nested within a larger longitudinal community study.

MEASUREMENTS

Participants were mailed health questionnaires at baseline (time 1) with follow-up at 3 years (time 2) and 6 years from baseline (time 3). Questionnaires at baseline and at follow up contained measures of sleep problems (Jenkins Sleep Questionnaire), depressive symptoms (Hospital Anxiety and Depressive Scale), and pain interference.

RESULTS

In total, 2,622 participants returned health questionnaires at all time points and indicated the presence of pain at each time point. After adjustment for age, gender, marital status, employment status, alcohol intake, smoking status, and body mass index, having a new period of sleep problems at year 3 more than trebled the risk of a new period of probable depression at year 6 (relative risk 3.47, 95% CI 1.97 to 6.03). Mediation analysis showed that pain interference played a significant but relatively minor role in the pathway.

CONCLUSION

Clinicians treating patients with persistent pain may wish to consider options that involve addressing the prevention or treatment of sleep problems, in addition to their primary focus of pain management.

The role of beliefs and attitudes about sleep in seasonal and nonseasonal mood disorder, and nondepressed controls

BACKGROUND

Unhelpful sleep-related cognitions play an important role in insomnia and major depressive disorder, but their role in seasonal affective disorder has not yet been explored. Therefore, the purpose of this study was to determine if individuals with seasonal affective disorder (SAD) have sleep-related cognitions similar to those with primary insomnia, and those with insomnia related to comorbid nonseasonal depression.

METHODS

Participants (n=147) completed the Dysfunctional Beliefs and Attitudes about Sleep 16-item scale (DBAS-16) and the Structured Interview Guide for the Hamilton Depression Rating Scale, Seasonal Affective Disorder Version (SIGH-SAD), which assesses self reported sleep problems including early, middle, or late insomnia, and hypersomnia in the previous week. All participants were assessed in winter, and during an episode for those with a depressive disorder.

RESULTS

Individuals with SAD were more likely to report hypersomnia on the SIGH-SAD, as well as a combined presentation of hypersomnia and insomnia on the Pittsburgh Sleep Quality Index (PSQI). The SAD group reported DBAS-16 scores in the range associated with clinical sleep disturbance, and DBAS-16 scores were most strongly associated with reports of early insomnia, suggesting circadian misalignment.

LIMITATIONS

Limitations include the self-report nature of the SIGH-SAD instrument on which insomnia and hypersomnia reports were based.

CONCLUSIONS

Future work could employ sleep- or chronobiological-focused interventions to improve clinical response in SAD.

Pre-deployment daytime and nighttime sleep complaints as predictors of post-deployment PTSD and depression in National Guard troops

There is growing evidence that disturbed sleep is a risk factor for the development of a number of psychiatric diagnoses including depression, PTSD and substance use. The goal of this study was to use a subset of participants from a larger prospective longitudinal study to examine whether preexisting daytime and nighttime sleep disturbances predict depression, PTSD and substance use in US National Guard Soldiers deployed to Iraq. Data on daytime and nighttime sleep complaints, baseline symptoms and personality variables were gathered prior to deployment to Iraq. Measures of psychopathology were collected at three time points post-deployment over the course of two years using both questionnaires and interviews. Multiple regressions were used to predict diagnoses and symptoms of depression, PTSD and substance use. Pre-deployment daytime and nighttime sleep complaints contributed significantly to the prediction of PTSD and depression up to two years after deployment, but not substance use. This study suggests that daytime and nighttime sleep complaints are a risk factor for internalizing disorders including PTSD and depression.

Cognitive training improves sleep quality and cognitive function among older adults with insomnia

Study Objectives

To investigate the effect of an eight-week, home-based, personalized, computerized cognitive training program on sleep quality and cognitive performance among older adults with insomnia.

Design

Participants (n = 51) were randomly allocated to a cognitive training group (n = 34) or to an active control group (n = 17). The participants in the cognitive training group completed an eight-week, home-based, personalized, computerized cognitive training program, while the participants in the active control group completed an eight-week, home-based program involving computerized tasks that do not engage high-level cognitive functioning. Before and after training, all participants' sleep was monitored for one week by an actigraph and their cognitive performance was evaluated.

Setting

Community setting: residential sleep/performance testing facility.

Participants

Fifty-one older adults with insomnia (aged 65–85).

Interventions

Eight weeks of computerized cognitive training for older adults with insomnia.

Results

Mixed models for repeated measures analysis showed between-group improvements for the cognitive training group on both sleep quality (sleep onset latency and sleep efficiency) and cognitive performance (avoiding distractions, working memory, visual memory, general memory and naming). Hierarchical linear regressions analysis in the cognitive training group indicated that improved visual scanning is associated with earlier advent of sleep, while improved naming is associated with the reduction in wake after sleep onset and with the reduction in number of awakenings. Likewise the results indicate that improved “avoiding distractions” is associated with an increase in the duration of sleep. Moreover, the results indicate that in the active control group cognitive decline observed in working memory is associated with an increase in the time required to fall asleep.

Conclusions

New learning is instrumental in promoting initiation and maintenance of sleep in older adults with insomnia. Lasting and personalized cognitive training is particularly indicated to generate the type of learning necessary for combined cognitive and sleep enhancements in this population.

Trial Registration

ClinicalTrials.gov NCT00901641

Left dorsolateral prefrontal transcranial magnetic stimulation (TMS): sleep factor changes during treatment in patients with pharmacoresistant major depressive disorder

As they alleviate major depressive disorder, antidepressant therapies may improve associated sleep disturbances, but may also have inherent sedating or activating properties. We examined sleep changes during a multicenter, sham-controlled, trial of transcranial magnetic stimulation (TMS) therapy for pharmacoresistant MDD. Medication-free outpatients (N=301) were randomized to receive active (N=155) or sham (N=146) TMS for 6 weeks. Depression severity was rated with the Montgomery-Asberg Depression Rating Scale, the 24-item Hamilton Depression Scale (HAMD), and the Inventory of Depressive Symptoms-Self Report (IDS-SR). Assessments were performed at baseline, 2, 4, and 6 week time points. Sleep was assessed using the HAMD and IDS-SR sleep factors; comparison between treatment groups employed ANCOVA model. No significant differences were identified between the active and sham treatment groups in either the HAMD or IDS-SR sleep factor scores at any time during treatment. Sleep difficulty as an adverse event over the length of the study did not differ between active and sham treatment. Stratified by end of acute treatment responder status, there was a statistically significant improvement in both the HAMD sleep factor score and the IDS-SR sleep factor during acute treatment in both the active and sham treatment conditions. TMS exerts no intrinsic effect upon sleep in patients with MDD.

Sleep Difficulties Are Correlated with Emotional Problems following Loss and Residual Symptoms of Effective Prolonged Grief Disorder Treatment

There is preliminary evidence that poor sleep quality is associated with emotional problems following loss, including symptoms of prolonged grief disorder (PGD) and depression. We conducted two studies to improve existing knowledge about the role of sleep difficulties in recovery from loss. Study 1 that relied on self-reported data from a heterogeneous sample of 177 bereaved individuals replicated prior findings of a linkage between increased sleep difficulties and increased PGD severity. This study also suggested that sleep difficulties are more strongly associated with depression than with PGD. In Study 2, we examined whether prior evidence that sleep complaints are a residual symptom of PGD treatment could be replicated in a sample of 43 bereaved individuals who underwent cognitive behavioural therapy for PGD. Outcomes showed that, although sleep difficulties declined significantly during this cognitive behavioural therapy, after this therapy, over half of all patients still had sleep difficulties above the average sleep difficulties observed in the general Dutch population.

Are you Sleeping? Pilot Comparison of Self-Reported and Objective Measures of Sleep Quality and Duration in an Inpatient Alcoholism Treatment Program

Sleep disturbances are common among alcohol-dependent individuals and can increase risk of relapse. The current study compares subjective and objective measures of sleep quality and duration and describes the prevalence of baseline sleep disturbances in an inpatient population of alcoholics undergoing their first week of detoxification. At baseline, the PSQI revealed that 79% of participants were above the cutoff score (≥5) for clinically meaningful sleep disturbances (mean = 12.57, SD = 4.38). Actigraphy results revealed that average sleep efficiency was 75.89%. Sleep efficiency scores were significantly correlated with self-reported sleep efficiency (P = 0.04, r = 0.47). Sleep duration measured by the actigraphy watches was not significantly correlated with self-reported sleep duration (P = 0.65, r = 0.10). Ongoing assessment of sleep disturbances may be a valuable tool for informing the development of customized sleep interventions in a similar inpatient alcohol treatment sample.

Postpartum maternal sleep and mothers’ perceptions of their attachment relationship with the infant among women with a history of depression during pregnancy

This study assessed the links between maternal sleep and mothers’ perceptions of their attachment relationship with their infant among women at risk for postpartum depression by virtue of having been depressed during pregnancy. Sixty-two mothers completed sleep diaries and questionnaires at 3 and 6 months postpartum. Regression analyses, controlling for depression severity and infant temperament, revealed significant prospective correlation between maternal shorter total sleep time at 3 months and lower scores on a mother–infant attachment questionnaire at 6 months. At 6 months, the longer time mothers were awake tending to their infants the lower were their attachment scores. The findings suggest that improving sleep of mothers who suffered from prenatal depression may have a positive effect on mothers’ self-reported relationship with their infants.

Evaluation of melatonin on the precocious puberty: a pilot study

OBJECTIVE

To evaluate the effect of 6-sulphatoxymelatonin on the sleep quality of girls with precocious puberty.

STUDY DESIGN

Ninety-nine girls were divided into three groups: GI, precocious puberty; GII, normal prepubescent; GIII, normal puberty. Questionnaires containing demographic and clinical data were applied. Blood was collected for hormonal evaluation for 6-sulphatoxymelatonin. The modified Rush Sleep Diary was used.

RESULTS

The levels of 6-sulphatoxymelatonin were highest in the group without pubertal development (75.23 ± 10.84 ng/ml), second highest in the group with normal puberty (45.66 ± 3.87 ng/ml, p < 0.001) and lowest in the group with true precocious puberty (37.04 ± 5.47 ng/ml). The amount of day sleep was greater in the group without pubertal development compared to other groups.

CONCLUSION

Despite the sleep data, melatonin may be involved in the precocious puberty process.