Circadian depression: A mood disorder phenotype

Evening Chronotypes With Depression Report Poorer Outcomes of Selective Serotonin Reuptake Inhibitors: A Survey-Based Study of Self-Ratings

BACKGROUND

Preliminary evidence suggests that evening chronotype is related to poorer efficacy of selective serotonin reuptake inhibitors. It is unknown whether this is specific to particular medications, self-rated chronotype, or efficacy.

METHODS

In the Australian Genetics of Depression Study (n = 15,108; 75% women; 18-90 years; 68% with ≥1 other lifetime diagnosis), a survey recorded experiences with 10 antidepressants, and the reduced Morningness-Eveningness Questionnaire was used to estimate chronotype. A chronotype polygenic score was calculated. Age- and sex-adjusted regression models (Bonferroni-corrected) estimated associations among antidepressant variables (how well the antidepressant worked [efficacy], duration of symptom improvement, side effects, discontinuation due to side effects) and self-rated and genetic chronotypes.

RESULTS

The chronotype polygenic score explained 4% of the variance in self-rated chronotype (r = 0.21). Higher self-rated eveningness was associated with poorer efficacy of escitalopram (odds ratio [OR] = 1.04; 95% CI, 1.02 to 1.06; p = .000035), citalopram (OR = 1.03; 95% CI, 1.01 to 1.05; p = .004), fluoxetine (OR = 1.03; 95% CI, 1.01 to 1.05; p = .001), sertraline (OR = 1.02; 95% CI, 1.01 to 1.04; p = .0008), and desvenlafaxine (OR = 1.03; 95% CI, 1.01 to 1.05; p = .004), and a profile of increased side effects (80% of those recorded; ORs = 0.93-0.98), with difficulty getting to sleep the most common. Self-rated chronotype was unrelated to duration of improvement or discontinuation. The chronotype polygenic score was only associated with suicidal thoughts and attempted suicide (self-reported). While our measures are imperfect, and not of circadian phase under controlled conditions, the model coefficients suggest that dysregulation of the phenotypic chronotype relative to its genetic proxy drove relationships with antidepressant outcomes.

CONCLUSIONS

The idea that variation in circadian factors influences response to antidepressants was supported and encourages exploration of circadian mechanisms of depressive disorders and antidepressant treatments.

Circadian photoentrainment varies by season and depressed state: associations between light sensitivity and sleep and circadian timing

STUDY OBJECTIVES

Altered light sensitivity may be an underlying vulnerability for disrupted circadian photoentrainment. The photic information necessary for circadian photoentrainment is sent to the circadian clock from melanopsin-containing intrinsically photosensitive retinal ganglion cells (ipRGCs). The current study tested whether the responsivity of ipRGCs measured using the post-illumination pupil response (PIPR) was associated with circadian phase, sleep timing, and circadian alignment, and if these relationships varied by season or depression severity.

METHODS

Adult participants (N = 323, agem = 40.5, agesd = 13.5) with varying depression severity were recruited during the summer (n = 154) and winter (n = 169) months. Light sensitivity was measured using the PIPR. Circadian phase was assessed using Dim Light Melatonin Onset (DLMO) on Friday evenings. Midsleep was measured using actigraphy. Circadian alignment was calculated as the DLMO-midsleep phase angle. Multilevel regression models covaried for age, gender, and time since wake of PIPR assessment.

RESULTS

Greater light sensitivity was associated with later circadian phase in summer but not in winter (β = 0.23; p = 0.03). Greater light sensitivity was associated with shorter DLMO-midsleep phase angles (β = 0.20; p = 0.03) in minimal depression but not in moderate depression (SIGHSAD < 6.6; Johnson-Neyman region of significance).

CONCLUSIONS

Light sensitivity measured by the PIPR was associated with circadian phase during the summer but not in winter, suggesting ipRGC functioning in humans may affect circadian entrainment when external zeitgebers are robust. Light sensitivity was associated with circadian alignment only in participants with minimal depression, suggesting circadian photoentrainment, a possible driver of mood, may be decreased in depression year-round, similar to decreased photoentrainment in winter.

Actigraphic monitoring of sleep and circadian rest-activity rhythm in individuals with major depressive disorder or depressive symptoms: A meta-analysis

BACKGROUND

Disrupted sleep and rest-activity pattern are common clinical features in depressed individuals. This meta-analysis compared sleep and circadian rest-activity rhythms in people with major depressive disorder (MDD) or depressive symptoms and healthy controls.

METHODS

Eligible studies were identified in five databases up to December 2023. The search yielded 53 studies with a total of 11,115 participants, including 4000 depressed participants and 7115 healthy controls.

RESULTS

Pooled meta-analyses demonstrated that depressed individuals have significantly longer sleep latency (SMD = 0.23, 95 % CI: 0.12 to 0.33) and wake time after sleep onset (SMD = 0.37, 95 % CI: 0.22 to 0.52), lower sleep efficiency (SMD = -0.41, 95 % CI: -0.56 to -0.25), more nocturnal awakenings (SMD = 0.58, 95 % CI: 0.29 to 0.88), lower MESOR (SMD = -0.54, 95 % CI: -0.81 to -0.28), amplitude (SMD = -0.33, 95 % CI: -0.57 to -0.09), and interdaily stability (SMD = -0.17, 95 % CI: -0.28 to -0.05), less daytime (SMD = -0.79, 95 % CI: -1.08 to -0.49) and total activities (SMD = -0.89, 95 % CI: -1.28 to -0.50) when compared with healthy controls.

LIMITATIONS

Most of the included studies reported separate sleep and activity parameters instead of 24-hour rest-activity rhythms. The variabilities among actigraphy devices and the types of participants recruited also impede precise comparisons.

CONCLUSIONS

The findings emerging from this study offered a better understanding of sleep and rest-activity rhythm in individuals with MDD or depressive symptoms. Future studies could advocate for deriving objective, distinctive 24-hour rest-activity profiles contributing to the risk of depression.

PROSPERO REGISTRATION NUMBER

CRD42021259780.

The rhythm of mental health: the relationship of chronotype with psychiatric trait dimensions and diurnal variation in psychiatric symptoms

To advance the emergence of circadian-based therapies, this study characterized how psychiatric symptoms fluctuate across the day and vary between individuals. Using a dimensional approach, we determined how chronotype relates to 13 psychiatric traits, and modeled the temporal development of symptoms throughout the day using generalized additive mixed effects models. In this preregistered study, a subclinical sample completed 13 psychiatric trait scales and a chronotype scale at baseline (N = 515, n = 404 women, 109 men, n = 2 non-binary, M age = 32.4 years, range 18-77), followed by 22 psychiatric symptoms and behaviors rated repeatedly between ~08:00-00:00 (n = 410). Key findings are that 11 out of 13 psychiatric traits were associated with being an evening-type, ranging from depression to obsessive comulsive disorder, social anxiety, and delusional ideation, while only mania was associated with being a morning-type. Four distinct psychiatric trait factors were identified, each predicting worse symptom levels throughout the day. Fatigue-related symptoms exhibited strong time-of-day changes with evening-types experiencing worse fatigue in the morning and morning-types in the evening. Evening-types had considerably lower drive and motivation than morning-types from morning to early evening. Evening-types also had more pronounced negative emotional symptoms and ADHD-type symptoms in the evening, particularly among those high in psychiatric trait factors. These findings identified important research targets that hold promise for improving mental health outcomes, such as strategies to boost morning motivation. Furthermore, the results emphasize the relevance of incorporating circadian factors, including chronotype, into translational psychiatric research and interventions.

Chronotype and subjective sleep quality predict white matter integrity in young people with emerging mental disorders

Protecting brain health is a goal of early intervention. We explored whether sleep quality or chronotype could predict white matter (WM) integrity in emerging mental disorders. Young people (N = 364) accessing early-intervention clinics underwent assessments for chronotype, subjective sleep quality, and diffusion tensor imaging. Using machine learning, we examined whether chronotype or sleep quality (alongside diagnostic and demographic factors) could predict four measures of WM integrity: fractional anisotropy (FA), and radial, axial, and mean diffusivities (RD, AD and MD). We prioritised tracts that showed a univariate association with sleep quality or chronotype and considered predictors identified by ≥80% of machine learning (ML) models as 'important'. The most important predictors of WM integrity were demographics (age, sex and education) and diagnosis (depressive and bipolar disorders). Subjective sleep quality only predicted FA in the perihippocampal cingulum tract, whereas chronotype had limited predictive importance for WM integrity. To further examine links with mood disorders, we conducted a subgroup analysis. In youth with depressive and bipolar disorders, chronotype emerged as an important (often top-ranking) feature, predicting FA in the cingulum (cingulate gyrus), AD in the anterior corona radiata and genu of the corpus callosum, and RD in the corona radiata, anterior corona radiata, and genu of corpus callosum. Subjective quality was not important in this subgroup analysis. In summary, chronotype predicted altered WM integrity in the corona radiata and corpus callosum, whereas subjective sleep quality had a less significant role, suggesting that circadian factors may play a more prominent role in WM integrity in emerging mood disorders.

Familial risk for depression is associated with reduced physical activity in young adults: evidence from a wrist-worn actigraphy study

Depression is characterized by reduced physical activity and sleep-wake cycle disturbances, often considered important features of the disease. While a few studies have suggested that self-reported reduced physical activity and sleep-wake cycle disturbances might both be linked to depression vulnerability, actigraphy-based measures in vulnerable samples remain largely unexplored. This study relied on actigraphy-based parameters to test whether these disturbances characterize depression vulnerability. Seven-day actigraphy data were collected from 20 (13 female) university students with a high vulnerability to depression, which was determined by the presence of a family history of the condition but no current symptoms, and 32 (21 female) controls with neither a family history of depression nor current depressive symptoms. Daily physical activity, namely gross motor activity, was quantified as average daily acceleration and time spent engaging in moderate-vigorous physical activity (MVPA). The sleep-wake cycle and circadian rhythms were assessed as total sleep duration per night (in hours), sleep within sleep period time (in hours), sleep efficiency (%), and relative amplitude (i.e., the difference between the activity during the day and the night, which reflects circadian rhythms amplitude). Results showed that individuals with a familial risk for depression exhibited reduced daily acceleration and time spent in MVPA relative to the control group, particularly on the weekend during their free time away from scheduled activities. On the other hand, the two groups were comparable in terms of sleep estimates. Taken together, reduced physical activity, but not sleep-wake disturbances, seem to be associated with vulnerability to depression and might be a viable target for identification and prevention efforts.

Temporal pathways between circadian rhythm, depression and anxiety in the transition from adolescence to early adulthood

BACKGROUND

Sleep and circadian rhythm problems intertwine with affective disorders. Adolescents are particularly vulnerable to developing sleep and affective problems. Yet, the temporal pathways between circadian rhythm, depression and anxiety in the transition phase from adolescence to early adulthood are not fully understood.

METHODS

233 adolescents (76 % females) participated at two time points (T1 and T2) at an interval of 19-months (aged 16.8 and 18.4 years). We used The Beck Depression Inventory-II, Generalized Anxiety Disorder Assessment, GENEActiv actigraphy across 8 days (delayed sleep phase (DSP), sleep duration, midpoint, and regularity), and iButton 1922L thermologgers across 3 days (intrinsic circadian period length, amplitude, and mesor).

RESULTS

A shorter sleep duration at T1 associated with an increase in affective problems at T2, and affective problems at T1 associated with an increase in sleep irregularity at T2. A longer circadian period at T1 associated with an increase in males' affective problems at T2. Moderate to severe depression and anxiety at T1 associated with a 2.69-fold risk (95 % CI 1.38-5.26, p = 0.004) and 2.11-fold risk (95 % CI 1.04-4.25, p = 0.038) of poor sleep quality at T2. Moderate to severe generalized anxiety associated with a 3.17-fold risk (95 % CI 1.35-7.41, p = 0.008) of DSP at T2.

LIMITATIONS

The follow-up period is short.

CONCLUSIONS

The results revealed bidirectional temporal links between sleep and affective problems. Novel observations include a heightened risk of future DSP following a current anxiety disorder and a heightened risk of affective problems following a longer circadian period measured from the 24-hour temperature variation in males.

Multimodal digital assessment of depression with actigraphy and app in Hong Kong Chinese

There is an emerging potential for digital assessment of depression. In this study, Chinese patients with major depressive disorder (MDD) and controls underwent a week of multimodal measurement including actigraphy and app-based measures (D-MOMO) to record rest-activity, facial expression, voice, and mood states. Seven machine-learning models (Random Forest [RF], Logistic regression [LR], Support vector machine [SVM], K-Nearest Neighbors [KNN], Decision tree [DT], Naive Bayes [NB], and Artificial Neural Networks [ANN]) with leave-one-out cross-validation were applied to detect lifetime diagnosis of MDD and non-remission status. Eighty MDD subjects and 76 age- and sex-matched controls completed the actigraphy, while 61 MDD subjects and 47 controls completed the app-based assessment. MDD subjects had lower mobile time (P = 0.006), later sleep midpoint (P = 0.047) and Acrophase (P = 0.024) than controls. For app measurement, MDD subjects had more frequent brow lowering (P = 0.023), less lip corner pulling (P = 0.007), higher pause variability (P = 0.046), more frequent self-reference (P = 0.024) and negative emotion words (P = 0.002), lower articulation rate (P < 0.001) and happiness level (P < 0.001) than controls. With the fusion of all digital modalities, the predictive performance (F1-score) of ANN for a lifetime diagnosis of MDD was 0.81 and 0.70 for non-remission status when combined with the HADS-D item score, respectively. Multimodal digital measurement is a feasible diagnostic tool for depression in Chinese. A combination of multimodal measurement and machine-learning approach has enhanced the performance of digital markers in phenotyping and diagnosis of MDD.

Delivery of bright light therapy within the Veterans Health Administration

BACKGROUND

Bright light therapy (BLT) is efficacious for seasonal and non-seasonal depression. However, the current state of BLT use in practice is unknown, impeding efforts to identify and address utilization gaps. This study's objective was to investigate BLT delivery in a nationwide U.S. healthcare system.

METHODS

This was a retrospective observational study of electronic medical records from all veterans who received outpatient mood disorder-related care in the Veterans Health Administration (VHA) from October 2008 through September 2020. BLT delivery was measured through the placement of light box consults.

RESULTS

Of the 3,442,826 veterans who received outpatient mood disorder care, only 57,908 (1.68 %) received a light box consult. Consults increased by 548.44 % (99.9 % credible interval: 467.36 %, 638.74 %) over the timeframe and displayed a robust yearly cycle that peaked on either December 21st or December 22nd. Past mental health treatment for a mood disorder was associated with a higher probability of a consult (relative risk = 4.79, 99.9 % CI: 4.21, 5.60). There was low representation related to veteran age, gender, race, and ethnicity.

LIMITATIONS

No information on patients who declined light boxes or actual light box use following consult placement.

CONCLUSIONS

Outpatient BLT delivery for mood disorders in the VHA remains low, despite significant growth over the past decade. It also displays a strong seasonal rhythm that peaks on the winter solstice, suggesting a limited focus on seasonal depression and a suboptimal reactive approach to changing sunlight. Overall, there exists ample opportunity for novel implementation efforts aimed at increasing utilization of BLT.

Disruptions to sleep and circadian rhythms are associated with poorer athlete mental health in female, but not male, elite Australian Rules footballers

Elite athletes are vulnerable to sleep and circadian disruption and associated mental health symptoms. This study aimed to investigate sex differences in sleep, circadian rhythms, and mental health, as well as the moderating role of sex in the prediction of mental health, among male professional and female semi-professional elite athletes. Participants were 87 elite Australian Rules football (ARF) athletes (43% female; mean [standard deviation] age 24.0 [4.1] years). Participants completed baseline questionnaires, 2 weeks of sleep/wake monitoring via actigraphy, and a circadian phase assessment (dim-light melatonin onset [DLMO]). Cross-sectional data were collected in training-only Australian Football League (AFL) Men's and Women's pre-season periods, with 53 providing data in two pre-seasons. Female athletes, relative to males, reported poorer mental health (a higher athlete psychological strain score), had a later mid-sleep time (by 28 min), reported a greater preference towards eveningness, and displayed a later circadian phase (by 33 min). For female athletes, lower sleep efficiency and lower sleep regularity were associated with poorer mental health. For female athletes, there were U-shaped relationships between both morningness-eveningness and phase angle (interval between sleep onset and DLMO time) and mental health. No significant relationships were found for male athletes. In summary, elite female ARF athletes reported poorer mental health, relative to males, especially when experiencing sleep or circadian disruption. Lifestyle factors associated with sex differences in ARF professionalism (scheduling, finances, supports) may contribute to these findings. Programmes to improve sleep, circadian alignment, and mental health among female semi-professional elite athletes should be strongly considered.

The sleep-circadian interface: A window into mental disorders

Sleep, circadian rhythms, and mental health are reciprocally interlinked. Disruption to the quality, continuity, and timing of sleep can precipitate or exacerbate psychiatric symptoms in susceptible individuals, while treatments that target sleep-circadian disturbances can alleviate psychopathology. Conversely, psychiatric symptoms can reciprocally exacerbate poor sleep and disrupt clock-controlled processes. Despite progress in elucidating underlying mechanisms, a cohesive approach that integrates the dynamic interactions between psychiatric disorder with both sleep and circadian processes is lacking. This review synthesizes recent evidence for sleep-circadian dysfunction as a transdiagnostic contributor to a range of psychiatric disorders, with an emphasis on biological mechanisms. We highlight observations from adolescent and young adults, who are at greatest risk of developing mental disorders, and for whom early detection and intervention promise the greatest benefit. In particular, we aim to a) integrate sleep and circadian factors implicated in the pathophysiology and treatment of mood, anxiety, and psychosis spectrum disorders, with a transdiagnostic perspective; b) highlight the need to reframe existing knowledge and adopt an integrated approach which recognizes the interaction between sleep and circadian factors; and c) identify important gaps and opportunities for further research.

Potential Role of Bmal1 in Lipopolysaccharide-Induced Depression-Like Behavior and its Associated "Inflammatory Storm"

Inflammation plays an important role in the pathogenesis of depression; however, the underlying mechanisms remain unclear. Apart from the disordered circadian rhythm in animal models and patients with depression, dysfunction of clock genes has been reported to be involved with the progress of inflammation. This study aimed to investigate the role of circadian clock genes, especially brain and muscle ARNT-like 1 (Bmal1), in the linkage between inflammation and depression. Lipopolysaccharide (LPS)-challenged rats and BV2 cells were used in the present study. Four intraperitoneal LPS injections of 0.5 mg/kg were administered once every other day to the rats, and BV2 cells were challenged with LPS for 24 h at the working concentration of 1 mg/L, with or without the suppression of Bmal1 via small interfering RNA. The results showed that LPS could successfully induce depression-like behaviors and an "inflammatory storm" in rats, as indicated by the increased immobility time in the forced swimming test and the decreased saccharin preference index in the saccharin preference test, together with hyperactivity of the hypothalamic-pituitary-adrenal axis, hyperactivation of astrocyte and microglia, and increased peripheral and central abundance of tumor necrosis factor-α, interleukin 6, and C-reactive protein. Moreover, the protein expression levels of brain-derived neurotrophic factor, triggering receptor expressed on myeloid cells 1, Copine6, and Synaptotagmin1 (Syt-1) decreased in the hippocampus and hypothalamus, whereas the expression of triggering receptor expressed on myeloid cells 2 increased. Interestingly, the fluctuation of temperature and serum concentration of melatonin and corticosterone was significantly different between the groups. Furthermore, protein expression levels of the circadian locomotor output cycles kaput, cryptochrome 2, and period 2 was significantly reduced in the hippocampus of LPS-challenged rats, whereas Bmal1 expression was significantly increased in the hippocampus but decreased in the hypothalamus, where it was co-located with neurons, microglia, and astrocytes. Consistently, apart from the reduced cell viability and increased phagocytic ability, LPS-challenged BV2 cells presented a similar trend with the changed protein expression in the hippocampus of the LPS model rats. However, the pathological changes in BV2 cells induced by LPS were reversed after the suppression of Bmal1. These results indicated that LPS could induce depression-like pathological changes, and the underlying mechanism might be partly associated with the imbalanced expression of Bmal1 and its regulated dysfunction of the circadian rhythm.

Circadian light therapy and light dose for depressed young people: a systematic review and meta-analysis

Background

Empirical evidence has shown that light therapy (LT) can reduce depression symptoms by stimulating circadian rhythms. However, there is skepticism and inconclusive results, along with confusion regarding dosing. The purpose of this study is to quantify light as a stimulus for the circadian system and create a dose-response relationship that can help reduce maladies among adolescents and young adults (AYAs). This will provide a reference for light exposure and neural response, which are crucial in the neuropsychological mechanism of light intervention. The study also aims to provide guidance for clinical application.

Methods

The latest quantitative model of CLA (circadian light) and CSt,f (circadian stimulus) was adopted to quantify light dose for circadian phototransduction in youth depression-related light therapy. Articles published up to 2023 through Web of Science, Cochrane Library, Medline (OVID), CINAHL, APA PsycINFO, Embase, and Scholars were retrieved. A meta-analysis of 31 articles (1,031 subjects) was performed using Stata17.0, CMA3.0 (comprehensive meta-analysis version 3.0) software, and Python 3.9 platform for light therapy efficacy comparison and dose-response quantification.

Results

Under various circadian stimulus conditions (0.1 < CSt,f < 0.7) of light therapy (LT), malady reductions among AYAs were observed (pooled SMD = -1.59, 95%CI = -1.86 to -1.32; z = -11.654, p = 0.000; I2 = 92.8%), with temporal pattern (p = 0.044) and co-medication (p = 0.000) suggested as main heterogeneity sources. For the efficacy advantage of LT with a higher circadian stimulus that is assumed to be influenced by visualization, co-medication, disease severity, and time pattern, sets of meta-analysis among random-controlled trials (RCTs) found evidence for significant efficacy of circadian-active bright light therapy (BLT) over circadian-inactive dim red light (SMD = -0.65, 95% CI = -0.96 to -0.34; z = -4.101, p = 0.000; I2 = 84.9%) or circadian-active dimmer white light (SMD = -0.37, 95% CI = -0.68 to -0.06; z = -2.318, p = 0.02; I2 = 33.8%), whereas green-blue, circadian-active BLT showed no significant superiority over circadian-inactive red/amber light controls (SMD = -0.21, 95% CI = -0.45 to 0.04; z = -2.318, p = 0.099; I2 = 0%). Overall, circadian-active BLT showed a greater likelihood of clinical response than dim light controls, with increased superiority observed with co-medication. For pre-to-post-treatment amelioration and corresponding dose-response relationship, cumulative duration was found more influential than other categorical (co-medication, severity, study design) or continuous (CSt,f) variables. Dose-response fitting indicated that the therapeutic effect would reach saturation among co-medicated patients at 32-42 days (900-1,000 min) and 58-59 days (1,100-1,500 min) among non-medicated AYAs. When exerting high circadian stimulus of light therapy (0.6 < CSt,f < 0.7), there was a significantly greater effect size in 1,000-1,500 min of accumulative duration than <1,000 or >1,500 min of duration, indicating a threshold for practical guidance.

Limitations

The results have been based on limited samples and influenced by a small sample effect. The placebo effect could not be ignored.

Conclusions

Although the superiority of LT with higher circadian stimulus over dimmer light controls remains unproven, greater response potentials of circadian-active BLT have been noticed among AYAs, taking co-medication, disease severity, time pattern, and visual characteristics into consideration. The dose-response relationship with quantified circadian stimulus and temporal pattern had been elaborated under various conditions to support clinical depression treatment and LT device application in the post-pandemic era.

Sleep/wake regularity and cognition in college students using antidepressants

The current project examined sleep, sleep/wake regularity, and cognition in college students diagnosed with depression and using serotonergic antidepressants and in those without a depression diagnosis. Forty participants either using antidepressants (n = 20, 24.75 ± 6.82 years) or without a depression diagnosis (n = 20, 21.70 ± 2.74 years) wore actigraphs for two consecutive weeks (14 days). Cognitive tasks were completed on day 1 (along with demographic surveys) and day 14. Effect sizes indicated that compared to non-clinically depressed peers, participants using antidepressants exhibited slightly greater wake after sleep onset (d = 0.36) and lower sleep efficiency (d = 0.40); however, these differences were likely not noticed by the sleeper. No sleep regularity or cognitive differences were present between groups. Within the antidepressant group, higher dosage predicted greater time in bed (R2 = 0.77), but less total sleep time (R2 = 0.86). The time of day that participants took their antidepressant exhibited differential effects on certain cognitive parameters, such as procedural reaction time and spatial processing, and interactions with years of antidepressant use were found. Self-reported wake episodes also predicted better reaction time and inhibition in the antidepressant group. This study is the first to demonstrate that sleep/wake regularity is comparable between people using antidepressants and non-clinically depressed human samples. For individuals using antidepressants, years of use, dosage, and time of day of use have predictive qualities for reaction times, spatial processing, and inhibition.

Research Review: The internalizing paradox - youth anxiety and depression symptoms, psychotherapy outcomes, and implications for research and practice

BACKGROUND

Youth anxiety and depression have long been combined within the empirically derived internalizing syndrome. The two conditions show substantial comorbidity, symptom co-occurrence, and overlap in treatment procedures, but paradoxically diverge in psychotherapy outcomes: strong, positive effects for anxiety and weak effects for depression.

METHODS

Drawing on recent research, we examine candidate explanations for this paradox to help identify strategies for addressing it by improving outcomes for youth depression.

RESULTS

Candidate explanations include that youth depression, compared with youth anxiety, has more varied comorbidities and more heterogeneous symptom combinations, has greater uncertainty regarding mediators and mechanisms of change, is treated with more complex and potentially confusing protocols, and has characteristics that may impede client engagement. Candidate strategies for shrinking the psychotherapy effectiveness gap include personalizing through transdiagnostic modular treatment, simplifying therapy by focusing on empirically supported principles of change, developing effective strategies for engaging family members as intervention allies, using shared decision-making to inform clinical decisions and boost client engagement, capitalizing on youth-friendly technological advances, and shortening and digitizing treatments to enhance their accessibility and appeal.

CONCLUSIONS

Recent advances suggest explanations for the internalizing paradox, which in turn suggest strategies for shrinking the youth anxiety-depression psychotherapy outcome gap; these form an agenda for a promising new era of research.

Report from a randomized control trial: improved alignment between circadian biology and sleep-wake behavior as a mechanism of depression symptom improvement in evening-type adolescents with depressive symptoms

STUDY OBJECTIVES

An evening circadian preference is common among adolescents. It is characterized by a behavioral predilection for later sleep and wake timing and is associated with higher rates of Major Depressive Disorder (MDD). The present study aims to (a) test the effectiveness of a cognitive behavioral sleep intervention (Transdiagnostic Sleep and Circadian Intervention; TranS-C) in a sample of adolescents with an evening circadian preference and clinically significant depressive symptoms and (b) evaluate improved alignment between circadian biology and sleep-wake behavior as a potential mechanism in the relationship between sleep and depression symptom improvement.

METHODS

Adolescents with an evening circadian preference and clinically significant depressive symptoms were randomized to receive TranS-C (n = 24) or a psychoeducation condition (PE; n = 18). Alignment between circadian biology and sleep-wake behavior was measured using objective biological measurement. Measures of sleep and circadian rhythm were taken at pre- and posttreatment, and depression symptoms were measured at pre- and posttreatment and 6- and 12-month follow-up.

RESULTS

Mixed effects modeling revealed that compared with an active control condition, TranS-C resulted in a significant reduction in MDD severity at 12-month follow-up. A MacArthur mediation analysis conducted to explore alignment between circadian biology and sleep-wake behavior as a mediator of depression severity reduction through 12-month follow-up revealed a significant interaction between change in alignment between circadian biology and sleep-wake behavior and treatment arm, indicating that improved alignment between circadian biology and sleep-wake behavior at posttreatment was associated with improvements in depression outcomes at 12-month follow-up under the treatment condition.

CONCLUSIONS

These results provide novel evidence for improved alignment between circadian biology and sleep-wake behavior as a specific mechanism of depression improvement, provide key clues into the complex relationship between sleep and depression, and have significant clinical implications for adolescents with depression.

Objective and subjective sleep in patients with non-seasonal major depressive disorder and eveningness - Results from a randomized controlled trial of bright light therapy

STUDY OBJECTIVES

This study examines the (dis)agreement between objective and subjective sleep and their prospective changes in a randomized controlled trial of bright light therapy (BLT) in patients with major depressive disorder (MDD) and eveningness.

METHODS

A total of 93 adults were randomized to receive either 30-min daily of 10,000 lux BLT or 50lux placebo dim red light therapy (DRL group) for a total of 5 weeks. Actigraphic data were collected at the baseline and during the last week of treatment. (Dis)Concordance of diary and actigraphic sleep parameters were assessed by partial correlations and Bland-Altman plots, and the associations between these discrepancies to depression severity was assessed by linear regression models. Changes of sleep parameters were assessed by linear mixed models.

RESULTS

Significant correlations were found between subjective sleep timings and chronotype to actigraphic parameters. Discrepancies between diary- and actigraphic-measures were observed, and patients with more severe depressive symptoms were associated with a greater under-estimation of total sleep time (TST). A greater advance in the diary-based time to fall sleep and rise time were achieved in the BLT group as compared to the DRL group, while diary-based wake after sleep onset (WASO), TST and sleep efficiency (SE) comparably improved with time in both groups. There was no significant difference between the two groups in the actigraphic parameters after treatment.

CONCLUSIONS

In this study, we found that depression severity influenced subjective report of sleep. BLT led to a greater advance in subjective sleep timings when compared to the placebo group.

The blues and rhythm

Most organisms, including humans, show daily rhythms in many aspects of physiology and behavior, and abnormalities in the rhythms are potential risk factors for various diseases. Mood disorders such as depression are no exception. Accumulating evidence suggests strong associations between circadian disturbances and the development of depression. Numerous studies have shown that interventions to circadian rhythms trigger depression-like phenotypes in human cases and animal models. Conversely, mood changes can affect circadian rhythms as symptoms of depression. Our preliminary data suggest that the phosphorylation signal pathway of the clock protein may act as a common pathway for mood and clock regulation. We hypothesize that mood regulation and circadian rhythms may influence each other and may share a common regulatory mechanism. This review provides an overview of circadian disturbances in animal models and human patients with depression.

An association study of clock genes with major depressive disorder

OBJECTIVE

To study the relationship between clock genes and Major Depressive Disorder (MDD).

METHODS

GEO database was used to obtain the chip data and clinical information of datasets GSE98793, GSE39653 and GSE52790. The differentially expressed clock genes were found through the analysis of the differentially expressed genes between MDD and healthy controls. Gene Ontology (GO) and Kyoto Encyclopedia of Genes and Genomes Pathway (KEGG) enrichment analysis were performed on the differential expressed clock genes. Lasso Regression and Support Vector Machine (SVM) method were used for screening the differential expressed clock genes. Logistic regression was used to establish a diagnostic model for depression with the screened genes. Receiver Operating Characteristic (ROC) Curve was used to verify the model. Gene differential expression analysis was performed for MDD with high scores and MDD with low scores in the diagnostic model. Gene Set Enrichment Analysis (GSEA) enrichment analysis was performed for differentially expressed genes. Single-gene GSEA was used to analyze each gene in the model separately. Cibersort method was used to analyze the immune infiltration of MDD and healthy controls, and the correlation between immune cells and clock genes was analyzed. Cytoscape was used to analyze the clock gene interaction network. The DGIdb website was used to predict potentially effective therapeutic drugs for clock genes closely related to MDD.

RESULTS

Six genes were identified by differential expression analysis of clock genes between MDD and healthy controls. GO and KEGG enrichment analysis of 6 genes showed that their pathways were concentrated such as circadian rhythm, rhythmic process, TGF - beta signaling pathway, longevity regulating pathway-multiple species, adipocytokine signaling pathway and so on. Lasso regression and SVM were used to screen out 5 clock genes (HDAC1, ID3, NFIL3, PRKAA1, TNF) for MDD. The diagnostic model of depression was established according to the 5 clock genes. The area under the curve (AUC) of the established depression diagnostic model was 0.686. Gene difference analysis was performed between MDD patients with high score of clock gene diagnostic model and MDD patients with low score. GSEA was performed for the differential genes showed that the most enriched pathways were:adipocytokine signaling pathway, TGF beta signaling pathway, oxidative phosphorylation, primary immunodeficiency, and so on. The single gene GSEA showed that the most enriched pathways were Toll like receptor signaling pathway, glucolipid metabolism, amino acid metabolism, neuroactive ligand receptor interaction, and so on. The results of immune infiltration analysis showed that NK cells resting and Macrophages M2 were different between MDD and control groups. In MDD, the gene closely related to NK cells resting was HDAC1, and the genes closely related to Macrophages M2 were HDAC1 and NFIL3. The RNA interactions network of clock genes shows that the regulation process is complex, which can provide a reference for subsequent related research. Potential therapeutic drugs predict display, among the 5 clock genes, TNF, HDAC1, and PRKAA1 may have potential effective therapeutic drugs.

CONCLUSION

Among all CLOCK genes, HDAC1, ID3, NFIL3, PRKAA1, TNF are closely related to MDD. Among them, TNF, HDAC1, and PRKAA1 may have potential effective therapeutic drugs.

Longitude-based time zone partitions and rates of suicide

BACKGROUND

Increasing evidence suggests that conditions with decreased morning and increased evening light exposure, including shift work, daylight-saving time, and eveningness, are associated with elevated mortality and suicide risk. Given that the alignment between the astronomical, biological, and social time varies across a time zone, with later-shifted daylight exposure in the western partition, we hypothesized that western time zone partitions would have higher suicide rates than eastern partitions.

METHODS

United States (U.S.) county-level suicide and demographic data, from 2010 to 2018, were obtained from a Centers for Disease Control database. Using longitude and latitude, counties were sorted into the western, middle, or eastern partition of their respective time zones, as well as the northern and southern halves of the U.S. Linear regressions were used to estimate the associations between suicide rates and time zone partitions, adjusting for gender, race, ethnicity, age group, and unemployment rates.

RESULTS

Data were available for 2872 counties. Across the U.S., western partitions had statistically significantly higher rates of suicide compared to eastern partitions and averaged up to two additional yearly deaths per 100,000 people (p < .001).

LIMITATIONS

Ecological design and limited adjustment for socioeconomic factors.

CONCLUSIONS

To our knowledge, this is the first study of the relationship between longitude-based time zone partitions and suicide. The results were consistent with the hypothesized elevated suicide rates in the western partitions, and concordant with previous reports on cancer mortality and transportation fatalities. The next step is to retest the hypothesis with individual-level data, accounting for latitude, photoperiodic changes, daylight-saving time, geoclimatic variables, physical and mental health indicators, as well as socioeconomic adversity and protection.

Circadian biology to advance therapeutics for mood disorders

Mood disorders account for a significant global disease burden, and pharmacological innovation is needed as existing medications are suboptimal. A wide range of evidence implicates circadian and sleep dysfunction in the pathogenesis of mood disorders, and there is growing interest in these chronobiological pathways as a focus for treatment innovation. We review contemporary evidence in three promising areas in circadian-clock-based therapeutics in mood disorders: targeting the circadian system informed by mechanistic molecular advances; time-tailoring of medications; and personalizing treatment using circadian parameters. We also consider the limitations and challenges in accelerating the development of new circadian-informed pharmacotherapies for mood disorders.

Chronic jet lag reduces motivation and affects other mood-related behaviors in male mice

Introduction: The circadian system regulates various physiological processes such as sleep-wake cycles, hormone secretion, metabolism, and the reaction to both natural and drug-based rewards. Chronic disruption of the circadian system caused by unsteady synchronization with light-dark (LD) schedules, such as advancing chronic jet lag (CJL), leads to adverse physiological effects and pathologies, and is linked with changes in mood and depressive behaviors in humans and rodent models. Methods: C57BL/6J male mice were subjected to circadian disruption through phase advances of 6 h every 2 days (CJL +6/2). Mice under 12:12-h LD cycle were used as controls. After 8 weeks under these conditions, a battery of behavioral tests was performed to assess if mood-related behaviors were affected. Results: Compared to controls under 24 h LD cycles, mice under CJL presented desynchronization of activity-rest rhythms that led to several behavioral impairments, including a decrease in motivation for food reward, and an increase in anxiety, anhedonia, and depressive-like behavior. Conclusion: Chronic circadian disruption, caused by an experimental CJL protocol, affects mood-related and reward-related behaviors in mice. Understanding the importance of the circadian system and its potential role for disruption due to CJL is important for maintaining good health and well-being.

Potential links between brown adipose tissue, circadian dysregulation, and suicide risk

Circadian desynchronizations are associated with psychiatric disorders as well as with higher suicidal risk. Brown adipose tissue (BAT) is important in the regulation of body temperature and contributes to the homeostasis of the metabolic, cardiovascular, skeletal muscle or central nervous system. BAT is under neuronal, hormonal and immune control and secrets batokines: i.e., autocrine, paracrine and endocrine active substances. Moreover, BAT is involved in circadian system. Light, ambient temperature as well as exogen substances interact with BAT. Thus, a dysregulation of BAT can indirectly worsen psychiatric conditions and the risk of suicide, as one of previously suggested explanations for the seasonality of suicide rate. Furthermore, overactivation of BAT is associated with lower body weight and lower level of blood lipids. Reduced body mass index (BMI) or decrease in BMI respectively, as well as lower triglyceride concentrations were found to correlate with higher risk of suicide, however the findings are inconclusive. Hyperactivation or dysregulation of BAT in relation to the circadian system as a possible common factor is discussed. Interestingly, substances with proven efficacy in reducing suicidal risk, like clozapine or lithium, interact with BAT. The effects of clozapine on fat tissue are stronger and might differ qualitatively from other antipsychotics; however, the significance remains unclear. We suggest that BAT is involved in the brain/environment homeostasis and deserves attention from a psychiatric point of view. Better understanding of circadian disruptions and its mechanisms can contribute to personalized diagnostic and therapy as well as better assessment of suicide risk.

Kullback-Leibler Divergence of Sleep-Wake Patterns Related with Depressive Severity in Patients with Epilepsy

(1) Objective: Whether abnormal sleep-wake rhythms were associated with depressive symptoms in patents with epilepsy had remained unclear. Our study aimed to establish relative entropy for the assessment of sleep-wake patterns and to explore the relationship between this index and the severity of depressive symptoms in patients with epilepsy. (2) Methods: We recorded long-term scalp electroencephalograms (EEGs) and Hamilton Depression Rating Scale-17 (HAMD-17) questionnaire scores from 64 patients with epilepsy. Patients with HAMD-17 scores of 0-7 points were defined as the non-depressive group, while patients with scores of 8 or higher were defined as the depression group. Sleep stages were firstly classified based on EEG data. We then quantified sleep-wake rhythm variations in brain activity using the Kullback-Leibler divergence (KLD) of daytime wakefulness and nighttime sleep. The KLD at different frequency bands in each brain region was analyzed between the depression and non-depression groups. (3) Results: Of the 64 patients with epilepsy included in our study, 32 had depressive symptoms. It was found that patients with depression had significantly decreased KLD for high-frequency oscillations in most brain areas, especially the frontal lobe. A detailed analysis was conducted in the right frontal region (F4) because of the significant difference in the high-frequency band. We found that the KLDs at the gamma bands were significantly decreased in the depression groups compared to the non-depression group (KLD_D = 0.35 ± 0.05, KLD_ND = 0.57 ± 0.05, p = 0.009). A negative correlation was displayed between the KLD of gamma band oscillation and HAMD-17 score (r = -0.29, p = 0.02). (4) Conclusions: Sleep-wake rhythms can be assessed using the KLD index calculated from long-term scalp EEGs. Moreover, the KLD of high-frequency bands had a negative correlation with HAMD-17 scores in patients with epilepsy, which indicates a close relationship between abnormal sleep-wake patterns and depressive symptoms in patients with epilepsy.

Subjective and objective sleep and circadian parameters as predictors of depression-related outcomes: A machine learning approach in UK Biobank

BACKGROUND

Sleep and circadian disruption are associated with depression onset and severity, but it is unclear which features (e.g., sleep duration, chronotype) are important and whether they can identify individuals showing poorer outcomes.

METHODS

Within a subset of the UK Biobank with actigraphy and mental health data (n = 64,353), penalised regression identified the most useful of 51 sleep/rest-activity predictors of depression-related outcomes; including case-control (Major Depression (MD) vs. controls; postnatal depression vs. controls) and within-case comparisons (severe vs. moderate MD; early vs. later onset, atypical vs. typical symptoms; comorbid anxiety; suicidality). Best models (of lasso, ridge, and elastic net) were selected based on Area Under the Curve (AUC).

RESULTS

For MD vs. controls (n_(MD) = 24,229; n_(control) = 40,124), lasso AUC was 0.68, 95 % confidence interval (CI) 0.67-0.69. Discrimination was reasonable for atypical vs. typical symptoms (n_(atypical) = 958; n_(typical) = 18,722; ridge: AUC 0.74, 95 % CI 0.71-0.77) but poor for remaining models (AUCs 0.59-0.67). Key predictors across most models included: difficulty getting up, insomnia symptoms, snoring, actigraphy-measured daytime inactivity and lower morning activity (~8 am). In a distinct subset (n = 310,718), the number of these factors shown was associated with all depression outcomes.

LIMITATIONS

Analyses were cross-sectional and in middle-/older aged adults: comparison with longitudinal investigations and younger cohorts is necessary.

DISCUSSION

Sleep and circadian measures alone provided poor to moderate discrimination of depression outcomes, but several characteristics were identified that may be clinically useful. Future work should assess these features alongside broader sociodemographic, lifestyle and genetic features.

Does circadian dysrhythmia drive the switch into high- or low-activation states in bipolar I disorder?

OBJECTIVES

Emerging evidence suggests a role of circadian dysrhythmia in the switch between "activation" states (i.e., objective motor activity and subjective energy) in bipolar I disorder.

METHODS

We examined the evidence with respect to four relevant questions: (1) Are natural or environmental exposures that can disrupt circadian rhythms also related to the switch into high-/low-activation states? (2) Are circadian dysrhythmias (e.g., altered rest/activity rhythms) associated with the switch into activation states in bipolar disorder? (3) Do interventions that affect the circadian system also affect activation states? (4) Are associations between circadian dysrhythmias and activation states influenced by other "third" factors?

RESULTS

Factors that naturally or experimentally alter circadian rhythms (e.g., light exposure) have been shown to relate to activation states; however future studies need to measure circadian rhythms contemporaneously with these natural/experimental factors. Actigraphic measures of circadian dysrhythmias are associated prospectively with the switch into high- or low-activation states, and more studies are needed to establish the most relevant prognostic actigraphy metrics in bipolar disorder. Interventions that can affect the circadian system (e.g., light therapy, lithium) can also reduce the switch into high-/low-activation states. Whether circadian rhythms mediate these clinical effects is an unknown but valuable question. The influence of age, sex, and other confounders on these associations needs to be better characterised.

CONCLUSION

Based on the reviewed evidence, our view is that circadian dysrhythmia is a plausible driver of transitions into high- and low-activation states and deserves prioritisation in research in bipolar disorders.

Dynamic association of the first identifiable symptom with rapidity of progression to first-episode psychosis

BACKGROUND

Rapid progression from the first identifiable symptom to the onset of first-episode psychosis (FEP) allows less time for early intervention. The aim of this study was to examine the association between the first identifiable symptom and the subsequent speed of illness progression.

METHODS

Data were available for 390 patients attending a catchment-based early intervention service for FEP. Exposure to non-psychotic and subthreshold psychotic symptoms was retrospectively recorded using semi-structured interviews. Outcomes following the onset of the first identifiable symptom were (1) time to onset of FEP and (2) symptom incidence rate (i.e. number of symptoms emerging per person-year until FEP onset). These outcomes were respectively analyzed with Cox proportional hazards and negative binomial regressions.

RESULTS

After Bonferroni correction, having a subthreshold psychotic (v. non-psychotic) symptom as the first symptom was not associated with time to FEP onset [hazard ratio (HR) = 1.39; 95% CI 0.94-2.04] but was associated with higher symptom incidence [incidence rate ratio (IRR) = 1.92; 95% CI 1.10-3.48]. A first symptom of suspiciousness was associated with shorter time to FEP onset (HR = 2.37; 95% CI 1.38-4.08) and higher symptom incidence rate (IRR = 3.20; 95% CI 1.55-7.28) compared to other first symptoms. In contrast, a first symptom of self-harm was associated with lower symptom incidence rate (IRR = 0.06; 95% CI 0.01-0.73) compared to other first symptoms. Several associations between symptoms and illness progression were moderated by the age at symptom onset.

CONCLUSIONS

Appreciating the content and timing of early symptoms can identify windows and treatment targets for early interventions in psychosis.

Bright light therapy for mental and behavioral illness: A systematic umbrella review

Bright light therapy (BLT) is a promising non-pharmacological treatment for a range of psychiatric conditions. The goal of this review was to provide a comprehensive overview of the efficacy of BLT across mental and behavioral illnesses. Using systematic umbrella review methodology, we searched Ovid MEDLINE, Embase, PsycInfo, Web of Science, and Google Scholar for systematic reviews of randomized controlled trials (RCTs) evaluating BLT for any mental or behavioral illness from the date of inception until March 2021. Review quality was assessed using the AMSTAR 2 tool and summary efficacy data were extracted from recent reviews. Of 792 unique records, 67 systematic reviews were included which targeted a range of disorders related to mood, neurocognition, sleep, and eating. Recent meta-analyses targeting seasonal or non-seasonal depression found that BLT outperformed light-related control conditions. Reviews of other disorders identified few RCTs and generally did not support the efficacy of BLT for various outcomes. Overall, the extant literature supports the efficacy of BLT for seasonal and non-seasonal depression, although higher quality systematic reviews are needed to increase confidence in these findings. There was no specific funding for this review, and it was preregistered on Prospero (ID: CRD42021240751).

Multidimensional self-rating biological rhythm disorder and its association with depression and anxiety symptoms among adolescents aged 11-23 years: a school-based cross-sectional study from China

BACKGROUND

Depression and anxiety are topical concerns worldwide, especially among adolescents. Besides, biological rhythm disorder as a candidate mechanism for mood disorders is highly prevalent, but relevant research among adolescents in China is presently limited. We conducted the present study to investigate the distribution of multi-dimensional self-rating biological rhythm disorder and the association of self-rating biological rhythm disorders with depression and anxiety symptoms among Chinese adolescents in different academic stages.

METHODS

In the cross-sectional study, 3693 students aged 11-23 from Zhengzhou City, Henan Province, China were included. The Patient Health Questionnaire (PHQ-9) and General Anxiety Disorder (GAD-7) were used to evaluate symptoms of depression and anxiety, respectively. Additionally, the Self-Rating of Biological Rhythm Disorder for Adolescents (SBRDA) was used to assess status of biological rhythm disorders. Multivariate logistic regression was developed to explore factors potentially associated with symptoms of depression and anxiety stratified by academic stages.

RESULTS

Among all participants, 44.14 and 36.15% suffered from depression and anxiety symptoms, respectively. On average, participants scored 74.66 ± 19.37 on the measure of total biological rhythm disorder. Adjusted for demographic confounding factors, the logistic regression analysis showed higher scores of total biological rhythm disorder were associated with more severe depression (OR = 14.38, 95%CI: 11.38-18.16) and anxiety symptoms (OR = 11.63, 95%CI: 9.14-14.81). The similar results were also found in the stratified analysis by academic stages.

CONCLUSIONS

Self-rating biological rhythm disorders are significantly associated with depression and anxiety symptoms among adolescents. Discrepancy across academic stages should also be taken into account in establishing public health strategies.

Depression and bipolar disorder subtypes differ in their genetic correlations with biological rhythms

Major Depression and Bipolar Disorder Type I (BIP-I) and Type II (BIP-II), are characterized by depressed, manic, and hypomanic episodes in which specific changes of physical activity, circadian rhythm, and sleep are observed. It is known that genetic factors contribute to variation in mood disorders and biological rhythms, but unclear to what extent there is an overlap between their underlying genetics. In the present study, data from genome-wide association studies were used to examine the genetic relationship between mood disorders and biological rhythms. We tested the genetic correlation of depression, BIP-I, and BIP-II with physical activity (overall physical activity, moderate activity, sedentary behaviour), circadian rhythm (relative amplitude), and sleep features (sleep duration, daytime sleepiness). Genetic correlations of depression, BIP-I, and BIP-II with biological rhythms were compared to discover commonalities and differences. A gene-based analysis tested for associations of single genes and common circadian genes with mood disorders. Depression was negatively correlated with overall physical activity and positively with sedentary behaviour, while BIP-I showed associations in the opposite direction. Depression and BIP-II had negative correlations with relative amplitude. All mood disorders were positively correlated with daytime sleepiness. Overall, we observed both genetic commonalities and differences across mood disorders in their relationships with biological rhythms: depression and BIP-I differed the most, while BIP-II was in an intermediate position. Gene-based analysis suggested potential targets for further investigation. The present results suggest shared genetic underpinnings for the clinically observed associations between mood disorders and biological rhythms. Research considering possible joint mechanisms may offer avenues for improving disease detection and treatment.

Effects of adjunctive brexpiprazole on sleep-wake and circadian parameters in youth with depressive disorders: study protocol for a clinical trial

INTRODUCTION

Sleep-wake and circadian disturbance is a key feature of mood disorders with a potential causal role and particular relevance to young people. Brexpiprazole is a second-generation antipsychotic medication with demonstrated efficacy as an adjunct to antidepressant treatment for major depressive disorder (MDD) in adults, with preliminary evidence suggesting greater effectiveness in subgroups of depressed patients with sleep disturbances. This clinical trial aims to evaluate the relationships between changes in sleep-wake and circadian parameters and changes in depressive symptoms following adjunctive brexpiprazole treatment in young adults with MDD and sleep-wake disturbance.

METHODS AND ANALYSIS

This study is designed as a 16 week (8 weeks active treatment, 8 weeks follow-up) mechanistic, open-label, single-arm, phase IV clinical trial and aims to recruit 50 young people aged 18-30 with MDD and sleep-wake cycle disturbance through an early intervention youth mental health clinic in Sydney, Australia. At baseline, participants will undergo multidimensional outcome assessment and subsequently receive 8 weeks of open-label treatment with brexpiprazole as adjunctive to their stable psychotropic medication. Following 4 weeks of treatment, clinical and self-report measures will be repeated. Ambulatory sleep-wake monitoring will be conducted continuously for the duration of treatment. After 8 weeks of treatment, all multidimensional outcome assessments will be repeated. Follow-up visits will be conducted 4 and 8 weeks after trial completion (including sleep-wake, clinical and self-report assessments). Circadian rhythm biomarkers including salivary melatonin, cortisol and core body temperature will be collected during an in-lab assessment. Additionally, metabolic, inflammatory and genetic risk markers will be collected at baseline and after 8 weeks of treatment.

ETHICS AND DISSEMINATION

This trial protocol has been approved by the Human Research Ethics Committee of the Sydney Local Health District (X19-0417 and 2019/ETH12986, Protocol Version 1-3, dated 25 February 2021). The results of this study, in deidentified form, will be disseminated through publication in peer-reviewed journals, scholarly book chapters, presentation at conferences and publication in conference proceedings.

TRIAL REGISTRATION NUMBER

ACTRN12619001456145.

Association between polarity of first episode and solar insolation in bipolar I disorder

OBJECTIVE

Circadian rhythm disruption is commonly observed in bipolar disorder (BD). Daylight is the most powerful signal to entrain the human circadian clock system. This exploratory study investigated if solar insolation at the onset location was associated with the polarity of the first episode of BD I. Solar insolation is the amount of electromagnetic energy from the Sun striking a surface area of the Earth.

METHODS

Data from 7488 patients with BD I were collected at 75 sites in 42 countries. The first episode occurred at 591 onset locations in 67 countries at a wide range of latitudes in both hemispheres. Solar insolation values were obtained for every onset location, and the ratio of the minimum mean monthly insolation to the maximum mean monthly insolation was calculated. This ratio is largest near the equator (with little change in solar insolation over the year), and smallest near the poles (where winter insolation is very small compared to summer insolation). This ratio also applies to tropical locations which may have a cloudy wet and clear dry season, rather than winter and summer.

RESULTS

The larger the change in solar insolation throughout the year (smaller the ratio between the minimum monthly and maximum monthly values), the greater the likelihood the first episode polarity was depression. Other associated variables were being female and increasing percentage of gross domestic product spent on country health expenditures. (All coefficients: P ≤ 0.001).

CONCLUSION

Increased awareness and research into circadian dysfunction throughout the course of BD is warranted.

Transdiagnostic Clinical Staging for Childhood Mental Health: An Adjunctive Tool for Classifying Internalizing and Externalizing Syndromes that Emerge in Children Aged 5-11 Years

Clinical staging is now recognized as a key tool for facilitating innovation in personalized and preventative mental health care. It places a strong emphasis on the salience of indicated prevention, early intervention, and secondary prevention of major mental disorders. By contrast to established models for major mood and psychotic syndromes that emerge after puberty, developments in clinical staging for childhood-onset disorders lags significantly behind. In this article, criteria for a transdiagnostic staging model for those internalizing and externalizing disorders that emerge in childhood is presented. This sits alongside three putative pathophysiological profiles (developmental, circadian, and anxious-arousal) that may underpin these common illness trajectories. Given available evidence, we argue that it is now timely to develop a transdiagnostic staging model for childhood-onset syndromes. It is further argued that a transdiagnostic staging model has the potential to capture more precisely the dimensional, fluctuating developmental patterns of illness progression of childhood psychopathology. Given potential improvements in modelling etiological processes, and delivering more personalized interventions, transdiagnostic clinical staging for childhood holds much promise for assisting to improve outcomes. We finish by presenting an agenda for research in developments of transdiagnostic clinical staging for childhood mental health.

Persistence of Anxiety/Depression Symptoms in Early Adolescence: A Prospective Study of Daily Life Stress, Rumination, and Daytime Sleepiness in a Genetically Informative Cohort

In this prospective study of mental health, we examine the influence of three interrelated traits - perceived stress, rumination, and daytime sleepiness - and their association with symptoms of anxiety and depression in early adolescence. Given the known associations between these traits, an important objective is to determine the extent to which they may independently predict anxiety/depression symptoms. Twin pairs from the Queensland Twin Adolescent Brain (QTAB) project were assessed on two occasions (N = 211 pairs aged 9-14 years at baseline and 152 pairs aged 10-16 years at follow-up). Linear regression models and quantitative genetic modeling were used to analyze the data. Prospectively, perceived stress, rumination, and daytime sleepiness accounted for 8-11% of the variation in later anxiety/depression; familial influences contributed strongly to these associations. However, only perceived stress significantly predicted change in anxiety/depression, accounting for 3% of variance at follow-up after adjusting for anxiety/depression at baseline, although it did not do so independently of rumination and daytime sleepiness. Bidirectional effects were found between all traits over time. These findings suggest an underlying architecture that is shared, to some degree, by all traits, while the literature points to hypothalamic-pituitary-adrenal (HPA) axis and/or circadian systems as potential sources of overlapping influence and possible avenues for intervention.

Dynamic networks of psychological symptoms, impairment, substance use, and social support: The evolution of psychopathology among emerging adults

BACKGROUND

Subthreshold/attenuated syndromes are established precursors of full-threshold mood and psychotic disorders. Less is known about the individual symptoms that may precede the development of subthreshold syndromes and associated social/functional outcomes among emerging adults.

METHODS

We modeled two dynamic Bayesian networks (DBN) to investigate associations among self-rated phenomenology and personal/lifestyle factors (role impairment, low social support, and alcohol and substance use) across the 19Up and 25Up waves of the Brisbane Longitudinal Twin Study. We examined whether symptoms and personal/lifestyle factors at 19Up were associated with (a) themselves or different items at 25Up, and (b) onset of a depression-like, hypo-manic-like, or psychotic-like subthreshold syndrome (STS) at 25Up.

RESULTS

The first DBN identified 11 items that when endorsed at 19Up were more likely to be reendorsed at 25Up (e.g., hypersomnia, impaired concentration, impaired sleep quality) and seven items that when endorsed at 19Up were associated with different items being endorsed at 25Up (e.g., earlier fatigue and later role impairment; earlier anergia and later somatic pain). In the second DBN, no arcs met our a priori threshold for inclusion. In an exploratory model with no threshold, >20 items at 19Up were associated with progression to an STS at 25Up (with lower statistical confidence); the top five arcs were: feeling threatened by others and a later psychotic-like STS; increased activity and a later hypo-manic-like STS; and anergia, impaired sleep quality, and/or hypersomnia and a later depression-like STS.

CONCLUSIONS

These probabilistic models identify symptoms and personal/lifestyle factors that might prove useful targets for indicated preventative strategies.

A network analysis of rest-activity rhythms in young people with emerging bipolar disorders

AIMS

Actigraphy studies of individuals with bipolar disorders (BD) suggest that illness progression may be associated with a range of progressive disruptions in 24-hour rest-activity rhythms (RAR). However, those longitudinal studies were undertaken in older adults with extended histories or illness and treatment rather than young people with emerging BD. To our knowledge, this is the first study to use network modelling to examine the statistical associations between clinical phenotypes of BD and different subsets of RAR markers.

METHODS

This study of adolescents and young adults (mean age 22 years; 69% female) uses network modelling to examine which self-rated or actigraphic markers of RAR are more strongly associated with full threshold BD (referred to as Stage 2; N = 15) compared with BD-at risk syndromes (subthreshold presentations referred to as Stage 1; N = 25).

RESULTS

Network analysis demonstrated that some RAR are associated with both stage of BD and a family history of BD (such as longer sleep duration and higher levels of daytime impairment). Markers of circadian rhythmicity indicated that regulation of this system is weaker in Stage 2 compared with Stage 1 of BD.

LIMITATIONS

The small subgroup samples may have undermined the ability to detect some associations between phenotypes and RAR.

CONCLUSIONS

Network modelling may offer a useful strategy for visualizing and analysing patterns of association between RAR and clinical phenotypes defined by stage of illness, familial loading or symptom profile. This could prove useful in understanding the underlying pathophysiology of sleep-wake cycle and circadian rhythm disturbances in BD.

Neurobiological and behavioral mechanisms of circadian rhythm disruption in bipolar disorder: A critical multi-disciplinary literature review and agenda for future research from the ISBD task force on chronobiology

AIM

Symptoms of bipolar disorder (BD) include changes in mood, activity, energy, sleep, and appetite. Since many of these processes are regulated by circadian function, circadian rhythm disturbance has been examined as a biological feature underlying BD. The International Society for Bipolar Disorders Chronobiology Task Force (CTF) was commissioned to review evidence for neurobiological and behavioral mechanisms pertinent to BD.

METHOD

Drawing upon expertise in animal models, biomarkers, physiology, and behavior, CTF analyzed the relevant cross-disciplinary literature to precisely frame the discussion around circadian rhythm disruption in BD, highlight key findings, and for the first time integrate findings across levels of analysis to develop an internally consistent, coherent theoretical framework.

RESULTS

Evidence from multiple sources implicates the circadian system in mood regulation, with corresponding associations with BD diagnoses and mood-related traits reported across genetic, cellular, physiological, and behavioral domains. However, circadian disruption does not appear to be specific to BD and is present across a variety of high-risk, prodromal, and syndromic psychiatric disorders. Substantial variability and ambiguity among the definitions, concepts and assumptions underlying the research have limited replication and the emergence of consensus findings.

CONCLUSIONS

Future research in circadian rhythms and its role in BD is warranted. Well-powered studies that carefully define associations between BD-related and chronobiologically-related constructs, and integrate across levels of analysis will be most illuminating.

Rapid-acting antidepressants and the circadian clock

A growing number of epidemiological and experimental studies has established that circadian disruption is strongly associated with psychiatric disorders, including major depressive disorder (MDD). This association is becoming increasingly relevant considering that modern lifestyles, social zeitgebers (time cues) and genetic variants contribute to disrupting circadian rhythms that may lead to psychiatric disorders. Circadian abnormalities associated with MDD include dysregulated rhythms of sleep, temperature, hormonal secretions, and mood which are modulated by the molecular clock. Rapid-acting antidepressants such as subanesthetic ketamine and sleep deprivation therapy can improve symptoms within 24 h in a subset of depressed patients, in striking contrast to conventional treatments, which generally require weeks for a full clinical response. Importantly, animal data show that sleep deprivation and ketamine have overlapping effects on clock gene expression. Furthermore, emerging data implicate the circadian system as a critical component involved in rapid antidepressant responses via several intracellular signaling pathways such as GSK3β, mTOR, MAPK, and NOTCH to initiate synaptic plasticity. Future research on the relationship between depression and the circadian clock may contribute to the development of novel therapeutic strategies for depression-like symptoms. In this review we summarize recent evidence describing: (1) how the circadian clock is implicated in depression, (2) how clock genes may contribute to fast-acting antidepressants, and (3) the mechanistic links between the clock genes driving circadian rhythms and neuroplasticity.

Preliminary Evidence That Circadian Alignment Predicts Neural Response to Monetary Reward in Late Adolescent Drinkers

Background

Robust evidence links sleep and circadian rhythm disturbances to alcohol use and alcohol-related problems, with a growing literature implicating reward-related mechanisms. However, the extant literature has been limited by cross-sectional designs, self-report or behavioral proxies for circadian timing, and samples without substantive alcohol use. Here, we employed objective measures of sleep and circadian rhythms, and an intensive prospective design, to assess whether circadian alignment predicts the neural response to reward in a sample of late adolescents reporting regular alcohol use.

Methods

Participants included 31 late adolescents (18–22 y/o; 19 female participants) reporting weekly alcohol use. Participants completed a 14-day protocol including pre- and post-weekend (Thursday and Sunday) circadian phase assessments via the dim light melatonin onset (DLMO), in counterbalanced order. Sleep-wake timing was assessed via actigraphy. Circadian alignment was operationalized as the DLMO-midsleep interval; secondary analyses considered social jet lag based on weekday-weekend differences in midsleep or DLMO. Neural response to reward (anticipation and outcome) was assessed via a monetary reward fMRI task (Friday and Monday scans). Alcohol use was assessed at baseline and via ecological momentary assessment. Mean BOLD signal was extracted from two regions-of-interest (striatum and medial prefrontal cortex, mPFC) for analyses in regression models, accounting for age, sex, racial identity, and scan order.

Results

In primary analyses, shorter DLMO-midsleep intervals (i.e., greater misalignment) on Thursday predicted lower striatal and mPFC responses to anticipated reward, but not reward outcome, on Friday. Lower neural (striatum and mPFC) responses to anticipated reward on Friday correlated with more binge-drinking episodes at baseline, but were not associated with alcohol use in the post-scan weekend. In secondary analyses, greater social jet lag (particularly larger weekend delays in midsleep or DLMO) was associated with lower neural responses to reward anticipation on Monday.

Conclusion

Findings provide preliminary evidence of proximal associations between objectively determined circadian alignment and the neural response to anticipated monetary reward, which is linked in turn to patterns of problematic drinking. Replication in a larger sample and experimental designs will be important next steps to determining the extent to which circadian misalignment influences risk for alcohol involvement via alterations in reward function.

Change in circadian preference predicts sustained treatment outcomes in patients with unipolar depression and evening preference

STUDY OBJECTIVES

Eveningness is associated with worse outcomes in depression. It remained unclear if eveningness could be altered with chronobiological therapy and whether such a change would predict long-term outcomes of depression.

METHODS

Data from a randomized controlled trial of 5-week adjunctive bright light therapy with a gradual advance protocol conducted in 91 adult patients with nonseasonal unipolar depression and eveningness (Morningness-Eveningness Questionnaire, score ≤ 41) was examined. "Change of eveningness" was defined by Morningness-Eveningness Questionnaire score over 41 at posttreatment week 5 and "persistent change of eveningness" was defined as maintenance of Morningness-Eveningness Questionnaire score > 41 throughout the follow-up period from week 5 to posttreatment 5 months.

RESULTS

Thirty-three participants (36%) had change of eveningness at week 5. Generalized estimating equations models showed that a change of eveningness at week 5 predicted a 2-fold increase in remission of depression over the 5-month follow up (odds ratio = 2.61 95% confidence interval 1.20-5.71, P = .016). Twenty-five participants (75.7%) had a persistent change and were more likely to achieve a remission of depression over the 5-month follow up (odds ratio = 3.18, 95% confidence interval: 1.35-7.50, P = .008).

CONCLUSIONS

One-third of the patients with depression changed their evening-preference after 5-week of chronotherapeutic treatment, and such change predicted a higher likelihood of depression remission over 5 months of follow-up.

CLINICAL TRIAL REGISTRATION

Registry: Chinese Clinical Trial Registry; Name: Adjunctive light treatment in major depressive disorder patients with evening chronotype-A randomized controlled trial; URL: https://www.chictr.org.cn/showprojen.aspx?proj=11672; Identifier: ChiCTR-IOR-15006937.

CITATION

Chan JWY, Chan NY, Li SX, et al. Change in circadian preference predicts sustained treatment outcomes in patients with unipolar depression and evening preference. J Clin Sleep Med. 2022;18(2):523-531.

Circadian rhythm disruptions: A possible link of bipolar disorder and endocrine comorbidities

Epidemiological studies have demonstrated an association between bipolar disorder (BP) and endocrine diseases. Further, circadian rhythm disruptions may be a potential common pathophysiological mechanism of both disorders. This review provides a brief overview of the molecular mechanisms of circadian rhythms, as well as roles circadian rhythms play in BP and common endocrine comorbidities such as diabetes and thyroid disease. Treatments targeting the circadian system, both pharmacological and non-pharmacological, are also discussed. The hope is to elicit new interest to the importance of circadian system in BP and offer new entry points and impetus to the development of medicine.

Circadian disruption and human health

Circadian disruption is pervasive and can occur at multiple organizational levels, contributing to poor health outcomes at individual and population levels. Evidence points to a bidirectional relationship, in that circadian disruption increases disease severity and many diseases can disrupt circadian rhythms. Importantly, circadian disruption can increase the risk for the expression and development of neurologic, psychiatric, cardiometabolic, and immune disorders. Thus, harnessing the rich findings from preclinical and translational research in circadian biology to enhance health via circadian-based approaches represents a unique opportunity for personalized/precision medicine and overall societal well-being. In this Review, we discuss the implications of circadian disruption for human health using a bench-to-bedside approach. Evidence from preclinical and translational science is applied to a clinical and population-based approach. Given the broad implications of circadian regulation for human health, this Review focuses its discussion on selected examples in neurologic, psychiatric, metabolic, cardiovascular, allergic, and immunologic disorders that highlight the interrelatedness between circadian disruption and human disease and the potential of circadian-based interventions, such as bright light therapy and exogenous melatonin, as well as chronotherapy to improve and/or modify disease outcomes.

Circadian rhythm sleep-wake disturbances and depression in young people: implications for prevention and early intervention

A rate-limiting step in the prevention and early intervention of depressive disorders in young people is our insufficient understanding of causal mechanisms. One plausible pathophysiological pathway is disturbance in the 24 h sleep-wake cycle and the underlying circadian system. Abnormalities in circadian rhythms are well documented in adults with various depressive disorders and have been linked to core clinical features, including unstable mood, daytime fatigue, non-restorative sleep, reduced motor activity, somatic symptoms, and appetite and weight change. In this Review, we summarise four areas of research: basic circadian biology and animal models of circadian disturbances; developmental changes in circadian rhythms during adolescence and implications for the emergence of adolescent-onset depressive syndromes; community and clinical studies linking 24 h sleep-wake cycle disturbances and depressive disorders; and clinical trials of circadian-based treatments. We present recommendations based on a highly personalised, early intervention model for circadian-linked depression in young people.

Neurobiology Youth Follow-up Study: protocol to establish a longitudinal and prospective research database using multimodal assessments for current and past mental health treatment-seeking young people within an early intervention service

INTRODUCTION

Approximately 75% of major mental illness occurs before the age of 25 years. Despite this, our capacity to provide effective, early and personalised interventions is limited by insufficient evidence for characterising early-stage, and less specific, presentations of major mental disorders in youth populations. This article describes the protocol for setting up a large-scale database that will collect longitudinal, prospective data that incorporate clinical, social and occupational function, neuropsychological, circadian, metabolic, family history and genetic metrics. By collecting data in a research-purposed, standardised manner, the 'Neurobiology Youth Follow-up Study' should improve identification, characterisation and profiling of youth attending mental healthcare, to better inform diagnosis and treatment at critical time points. The overall goal is enhanced long-term clinical and functional outcomes.

METHODS AND ANALYSIS

This longitudinal clinical cohort study will invite participation from youth (12-30 years) who seek help for mental health-related issues at an early intervention service (headspace Camperdown) and linked services. Participants will be prospectively tracked over 3 years with a series of standardised multimodal assessments at baseline, 6, 12, 24 and 36 months. Evaluations will include: (1) clinician-administered and self-report assessments determining clinical stage, pathophysiological pathways to illness, diagnosis, symptomatology, social and occupational function; (2) neuropsychological profile; (3) sleep-wake patterns and circadian rhythms; (4) metabolic markers and (5) genetics. These data will be used to: (1) model the impact of demographic, phenomenological and treatment variables, on clinical and functional outcomes; (2) map neurobiological profiles and changes onto a transdiagnostic clinical stage and pathophysiological mechanisms framework.

ETHICS AND DISSEMINATION

This study protocol has been approved by the Human Research Ethics Committee of the Sydney Local Health District (2020/ETH01272, protocol V.1.3, 14 October 2020). Research findings will be disseminated through peer-reviewed journals and presentations at scientific conferences and to user and advocacy groups. Participant data will be de-identified.

Days out of role and somatic, anxious-depressive, hypo-manic, and psychotic-like symptom dimensions in a community sample of young adults

Improving our understanding of the causes of functional impairment in young people is a major global challenge. Here, we investigated the relationships between self-reported days out of role and the total quantity and different patterns of self-reported somatic, anxious-depressive, psychotic-like, and hypomanic symptoms in a community-based cohort of young adults. We examined self-ratings of 23 symptoms ranging across the four dimensions and days out of role in >1900 young adult twins and non-twin siblings participating in the "19Up" wave of the Brisbane Longitudinal Twin Study. Adjusted prevalence ratios (APR) and 95% confidence intervals (95% CI) quantified associations between impairment and different symptom patterns. Three individual symptoms showed significant associations with days out of role, with the largest association for impaired concentration. When impairment was assessed according to each symptom dimension, there was a clear stepwise relationship between the total number of somatic symptoms and the likelihood of impairment, while individuals reporting ≥4 anxious-depressive symptoms or five hypomanic symptoms had greater likelihood of reporting days out of role. Furthermore, there was a stepwise relationship between the total number of undifferentiated symptoms and the likelihood of reporting days out of role. There was some suggestion of differences in the magnitude and significance of associations when the cohort was stratified according to sex, but not for age or twin status. Our findings reinforce the development of early intervention mental health frameworks and, if confirmed, support the need to consider interventions for subthreshold and/or undifferentiated syndromes for reducing disability among young people.