The effects of nefazodone on sleep architecture in depression

Insomnia and related mental health conditions: Essential neurobiological underpinnings towards reduced polypharmacy utilization rates

Insomnia represents a significant public health burden, with a 10% prevalence in the general population. Reduced sleep affects social and working functioning, productivity, and patient's quality of life, leading to a total of $100 billion per year in direct and indirect healthcare costs. Primary insomnia is unrelated to any other mental or medical illness; secondary insomnia co-occurs with other underlying medical, iatrogenic, or mental conditions. Epidemiological studies found a 40-50% comorbidity prevalence between insomnia and psychiatric disorders, suggesting a high relevance of mental health in insomniacs. Sleep disturbances also worsen the outcomes of several psychiatric disorders, leading to more severe psychopathology and incomplete remission, plausibly contributing to treatment-resistant conditions. Insomnia and psychiatric disorder coexistence can lead to polypharmacy, namely, the concurrent use of two or more medications in the same patient, regardless of their purpose or rationale. Polypharmacy increases the risk of using unnecessary drugs, the likelihood of drug interactions and adverse events, and reduces the patient's compliance due to regimen complexity. The workup of insomnia must consider the patient's sleep habits and inquire about any medical and mental concurrent conditions that must be handled to allow insomnia to be remitted adequately. Monotherapy or limited polypharmacy should be preferred, especially in case of multiple comorbidities, promoting multipurpose molecules with sedative properties and with bedtime administration. Also, non-pharmacological interventions for insomnia, such as sleep hygiene, relaxation training and Cognitive Behavioral Therapy may be useful in secondary insomnia to confront behaviors and thoughts contributing to insomnia and help optimizing the pharmacotherapy. However, insomnia therapy should always be patient-tailored, considering drug indications, contraindications, and pharmacokinetics, besides insomnia phenotype, clinical picture, patient preferences, and side effect profile.

Telemedicine-delivered cognitive-behavioral therapy for insomnia in alcohol use disorder (AUD): study protocol for a randomized controlled trial

BACKGROUND

Alcohol use disorder (AUD) is a leading preventable cause of morbidity and mortality, but relapse rates are high even with available treatments. Insomnia is a robust predictor of relapse and pilot studies have shown that CBT for insomnia improves insomnia and daytime functioning in adults with AUD and insomnia. The impact of CBT for insomnia on relapse, however, is unclear. This trial will compare telemedicine-delivered CBT for insomnia (CBT-TM) with sleep hygiene education (SHE-TM) on improving insomnia/sleep, daytime symptom, and drinking outcomes in treatment-seeking AUD adults with insomnia. The study will also determine the effects of treatment on sleep mechanisms and their association with clinical outcomes.

METHODS

This is a single-site randomized controlled trial with planned enrollment of 150 adults meeting criteria for both AUD and chronic insomnia. Eligible participants will be randomized 1:1 to 6 sessions of telemedicine-delivered Cognitive Behavioral Therapy for Insomnia (CBT-TM) or Sleep Hygiene Education (SHE-TM) with clinical assessments conducted at pre-treatment, post- treatment, and at 3, 6, and 12 months post-treatment. Overnight polysomnography will be conducted before and after treatment. Primary clinical outcomes will include post-treatment scores on the Insomnia Severity Index and the General Fatigue subscale of the Multidisciplinary Fatigue Inventory, and the percent of days abstinent (PDA) on the interview-administered Time Line Follow Back. EEG delta activity, derived from overnight polysomnography, will be the primary endpoint to assess the sleep homeostasis mechanism.

DISCUSSION

This adequately powered randomized controlled trial will provide clinically relevant information about whether targeting insomnia is effective for improving treatment outcomes among treatment-seeking adults with AUD. Additionally, the study will offer new scientific insights on the impact of an evidence-based non-medication treatment for insomnia on a candidate mechanism of sleep dysfunction in this population - sleep homeostasis.

TRIAL REGISTRATION

CClinicalTrials.gov NCT # 04457674 . Registered on 07 July 2020.

Adverse Effects of Psychotropic Medications on Sleep

Psychotropic medications such as antidepressants, antipsychotics, stimulants, and benzodiazepines are widely prescribed. Most of these medications are thought to exert their effects through modulation of various monoamines as well as interactions with receptors such as histamine and muscarinic cholinergic receptors. Through these interactions, psychotropics can also have a significant impact on sleep physiology, resulting in both beneficial and adverse effects on sleep.

Sleep-disordered breathing in major depressive disorder

Individuals with major depressive disorder often experience obstructive sleep apnea. However, the relationship between depression and less severe sleep-disordered breathing is unclear. This study examined the rate of sleep-disordered breathing in depression after excluding those who had clinically significant sleep apnea (>5 apneas∙h⁻¹). Archival data collected between 1991 and 2005 were used to assess the prevalence of sleep-disordered breathing events in 60 (31 depressed; 29 healthy controls) unmedicated participants. Respiratory events were automatically detected using a program developed in-house measuring thermal nasal air-flow and chest pressure. Results show that even after excluding participants with clinically significant sleep-disordered breathing, individuals with depression continue to exhibit higher rates of sleep-disordered breathing compared with healthy controls (depressed group: apnea-hypopnea index mean = 0.524, SE = 0.105; healthy group: apnea-hypopnea index mean = 0.179, SE = 0.108). Exploratory analyses were also conducted to assess for rates of exclusion in depression studies due to sleep-disordered breathing. Study exclusion of sleep-disordered breathing was quantified based on self-report during telephone screening, and via first night polysomnography. Results from phone screening data reveal that individuals reporting depression were 5.86 times more likely to report a diagnosis of obstructive sleep apnea than presumptive control participants. Furthermore, all of the participants excluded for severe sleep-disordered breathing detected on the first night were participants with depression. These findings illustrate the importance of understanding the relationship between sleep-disordered breathing and depression, and suggest that screening and quantification of sleep-disordered breathing should be considered in depression research.

Effects of a 3-hour sleep delay on sleep homeostasis in alcohol dependent adults

OBJECTIVES

This study evaluated slow wave activity homeostatic response to a mild sleep challenge in alcohol-dependent adults compared to healthy controls.

DESIGN

Participants maintained a 23:00-06:00 schedule for 5 days verified by actigraphy and diary, followed by 3 nights in the lab: adaptation, baseline, and a sleep delay night with an 02:00-09:00 schedule.

SETTING

Sleep ' Chronophysiology laboratory.

PARTICIPANTS

48 alcohol-dependent adults (39 men, 9 women) who were abstinent for at least 3 weeks and 16 healthy control adults (13 men, 3 women), 21-55 years of age participated in study.

INTERVENTIONS

N/A.

MEASUREMENTS AND RESULTS

Slow wave EEG activity (SWA) in consecutive NREM periods was compared between baseline and sleep delay nights and between AD and HC groups, using age and sex as statistical covariates. The AD group showed a blunted SWA response to sleep delay with significantly lower SWA power than the HC group. Exponential regression analyses confirmed lower asymptotic SWA with a slower decay rate over NREM sleep time in the AD group. Results were similar for raw SWA and %SWA on the delay night expressed relative to baseline SWA.

CONCLUSIONS

Alcohol dependence is associated with impaired SWA regulation and a blunted response to a mild homeostatic sleep challenge.

The effect of melatonergic and non-melatonergic antidepressants on sleep: weighing the alternatives

In DSM-IV the occurrence of disturbed sleep is one of the principal diagnostic criteria for major depressive disorder (MDD). Further, there is evidence of reciprocity between the two conditions such that, even in the absence of current depressive symptoms, disturbed sleep often predicts their development. The present review discusses the effects of antidepressants on sleep and evaluates the use of the recently developed melatonin agonist-selective serotonin antagonists on sleep and depression. Although many antidepressants such as the tricyclics, monoamine oxidase inhibitors, serotonin-norepinephrine reuptake inhibitors, several serotonin receptor antagonists and selective serotonin reuptake inhibitors (SSRIs) have all been found successful in treating depression, their use is often associated with a disruptive effect on sleep. SSRIs, currently the most widely prescribed of the antidepressants, are well known for their instigation or exacerbation of insomnia. The recently introduced novel melatonin agonist and selective serotonin antagonist antidepressant, agomelatine, which has melatonin MT(1) and MT(2) receptor agonist and 5-HT(2c) antagonist properties, has been useful in treating patients with MDD. Its rapid onset of action and effectiveness in improving the mood of depressed patients has been attributed to its ability to improve sleep quality. These properties underline the use of melatonin analogues as a promising alternative for the treatment of depression.

Management of chronic insomnia in elderly persons

BACKGROUND

Chronic insomnia is common among the elderly These elderly patients are often viewed as difficult to treat, yet they are among the groups with the greatest need of treatment.

OBJECTIVE

This article reviews the literature on the management of chronic insomnia in elderly persons.

METHODS

A search of MEDLINE was conducted for articles published in English between January 1966 and March 2006 using the terms insomnia, behavioral therapy, estsazolsam, fluvsazepsam, qusazepsam, teMsazepsam, tvisazolsam, eszopiclone, zaleplon, zolpidem, mirtazapine, nefazodone, trazodone, and ramelteon. Articles were selected if they were meta-analyses or evidence-based reviews of therapeutic modalities; randomized controlled trials of nonpharmacologic or pharmacologic treatment; or review articles covering the characteristics and management of insomnia. Preference was given to meta-analyses, evidence-based reviews, and articles that included relevant new information.

RESULTS

Available options for the treatment of insomnia include nonpharmacologic approaches, foremost among them cognitive behavioral therapy, and pharmacotherapies, including chloral hydrate, barbiturates, over-the-counter (OTC) and prescription antihistamines, OTC dietary supplements (including melatonin), sedating antidepressants, benzodiazepine and nonbenzodiazepine sedative-hypnotics, and melatonin agonists. There is considerable evidence to support the effectiveness and durability of nonpharmacologic interventions for insomnia in adults of all ages, yet these interventions are underutilized. With some recent exceptions, the majority of identified studies of pharmacotherapy were of short duration (< or =6 weeks) and did not exclusively enroll older adults. Compared with the benzodiazepines, the nonbenzodiazepine sedative-hypnotics appeared to offer few, if any, significant clinical advantages in efficacy or tolerability in elderly persons. Newer agents with novel mechanisms of action and improved safety profiles, such as the melatonin agonists, hold promise for the management of chronic insomnia in elderly people.

CONCLUSIONS

Long-term use of sedative-hypnotics for insomnia lacks an evidence base and has traditionally been discouraged for reasons that include concerns about such potential adverse drug effects as cognitive impairment (anterograde amnesia), daytime sedation, motor incoordination, and increased risk of motor vehicle accidents and falls. In addition, the effectiveness and safety of long-term use of these agents remain to be determined. More research is needed to evaluate the long-term effects of treatment and the most appropriate management strategy for elderly persons with chronic insomnia.

Future antidepressants: what is in the pipeline and what is missing?

Monoamine reuptake inhibitors still reign in the treatment of major depression, but possibly not for long. While medicinal chemists have been able to reduce the side effects of these drugs, their delayed onset of action and considerable non-response rate remain problematic. Of late, serious questions have been raised regarding the efficacy of monoamine reuptake inhibitors. The present review presents an inventory of what is (and until recently was) in the antidepressant pipeline of pharmaceutical companies. Novel antidepressant compounds can be categorised into four groups depending on their target(s): (i) monoamine receptors; (ii) non-monoamine receptors; (iii) neuropeptide receptors; and (iv) hormone receptors. Other possible targets include components of post-receptor intracellular processes and elements of the immune system; to date, however, compounds specifically aimed at these targets have not been the subject of clinical trials. Development of several compounds targeted at monoamine receptors has recently been discontinued. At least five neurokinin-1 (NK(1)) receptor antagonists were until recently in phase II of clinical testing. However, the apparent interest in the NK(1) receptor should not be interpreted as representing a departure from the monoamine hypothesis since neurokinins also modulate monoaminergic systems. In the authors' view, development of future antidepressants will continue to rely on the serendipity-based monoamine hypothesis. However, an alternative approach, based on the hypothesis that chronic stress precipitates depressive symptoms, might be more productive. Unfortunately, clinical results using drugs targeted at components of the HPA axis have not been very encouraging to date. In the short run, the authors believe that augmentation strategies offer the best hope for improving the efficacy of antidepressant treatment. Several approaches to improve the efficacy of SSRIs are conceivable, such as concurrent blockade of monoamine autoreceptors and the addition of antipsychotics, neuromodulators or hormones (HPA axis and gender related). In the long-term, however, construction of a scientifically verified conceptual framework will be needed before more effective antidepressants can be developed. It can be argued that it is not depression itself that should be treated, but rather that its duration should be reduced by pharmacological means. Animal models that take this concept into consideration and identify mechanisms for acceleration of recovery from the effects of stress need to be developed.

Nefazodone in primary insomnia: an open pilot study

The present study is the first to investigate the effect of the antidepressant nefazodone on sleep in patients with primary (psychophysiological) insomnia. Following baseline assessment of sleep (polysomnography and subjective sleep parameters), 32 patients received initially 100 mg nefazodone in a single dose at bedtime; according to efficacy and tolerability, the dose could be increased up to 400 mg. Polysomnography and assessment of subjective sleep parameters were repeated after 4 weeks' administration. 12 patients dropped out, 11 of them due to lack of efficiency or intolerable side effects. In 20 patients who completed, the authors observed a lengthened sleep onset latency, decreases in stage 1 and slow wave sleep, and increases in stages 2 and REM under nefazodone. Subjective measures of sleep mirrored a clearer improvement: there was a significant reduction of the PSQI total score and all subscores except sleep latency. We suppose that the dose range chosen was too high for this patient population, thus accounting for the high proportion of dropouts and the partly unfavorable effects on objective sleep parameters. For a definite evaluation of the possible role of nefazodone in the treatment of primary (psychophysiological) insomnia, double-blind, placebo-controlled, randomized studies with lower doses are needed.

Effects of clozapine on sleep in bipolar and schizoaffective disorders

OBJECTIVE

Sleep disturbances are strongly associated with mood disorders, although the majority of data have been obtained in patients with major depressive disorder. Studies reporting results in bipolar disorder are few, and results have not been consistent. Clozapine is a prototype of atypical antipsychotics, which is effective in improving symptoms of manic episodes in patients with bipolar disorder, or schizoaffective disorder, bipolar type and has been shown to influence sleep in other psychiatric disorders. The present study evaluated the sleep effects of clozapine in bipolar and schizoaffective disorders.

METHODS

Participants were 11 women and 4 men (range:28-53 years of age, mean 40.9+/-8.6 years), all with a history of mania by DSM-IV criteria for either bipolar I disorder or schizoaffective disorder, bipolar type. They participated in a sleep study at baseline and again after 6 months initiation of clozapine add-on therapy.

RESULTS

Sleep latency was longer on clozapine and the number of awakenings were increased, whereas time in bed (TIB) and total sleep period (TSP) were increased (range: F=6.2-17.9; df=l,12; p<0.05). Although none of the individual sleep stage showed significant treatment changes, both Stage 2 and slow-wave sleep were increased and Stage 2 decreased on clozapine. Subjective sleep measures improved on clozapine with a small but significant improvement in how rested patients felt upon awakening (t=-2.1; df=26; p<0.05).

CONCLUSION

Clozapine prolonged sleep latency, improved restedness, and increased total sleep time. Although lack of a control group limits interpretation of these results, they are in general agreement with studies in other psychiatric populations, and support the view that clozapine is primarily a NREM sleep enhancer. The improvement in restedness may be of positive clinical consequence.

Comparison of nefazodone and sertraline for the treatment of posttraumatic stress disorder

Posttraumatic stress disorder (PTSD) is a prevalent condition that has been shown to be responsive to pharmacotherapy. Few head-to-head comparisons of medications used in the treatment of PTSD have been published. This 12-week, randomized, double-blind study compares the effectiveness, safety, and tolerability of nefazodone and sertraline for the treatment of PTSD. Thirty-seven male and female outpatients meeting DSM-IV criteria for PTSD were randomly assigned to receive nefazodone (maximum dose 600 mg/day; average dose 463 mg/day) or sertraline (maximum dose 200/day; average dose 153 mg/day). The primary outcome measures were the 17-item total severity score of the Clinician Administered PTSD Scale, Part 2 (CAPS-2) and the Clinical Global Impression Improvement Scale (CGI-I). Other assessments included the Davidson Trauma Scale (DTS), the Top-8 PTSD Rating Scale, Sheehan Disability Scale (SDS), Montgomery-Asberg Depression Rating Scale (MADRS), Hamilton Anxiety Scale (HAM-A), and Pittsburgh Sleep Quality Index (PSQI). Twenty-six subjects had at least one post-randomization CAPS-2 assessment and were therefore included in the data analysis. There were no statistically significant differences between treatment groups on any of the outcome measures. There was a significant effect for time in both groups, indicating an improvement in PTSD symptoms, depression, sleep, and quality of life over time. CAPS-2 scores for all of the PTSD symptom clusters decreased significantly over time. This study did not find significant differences in the effectiveness of nefazodone and sertraline for the treatment of PTSD. Larger trials are warranted.

Effects of reboxetine on sleep and nocturnal cardiac autonomic activity in patients with dysthymia

Antidepressants may have sleep and autonomic side-effects. The acute and long-term effect of reboxetine (2 mg b.i.d.) on sleep and cardiac autonomic activity was compared with that of placebo in a single-blind study. Twelve patients affected by dysthymia underwent four polysomnographic studies at baseline (placebo); at night 3 (reboxetine; acute effect); at night 9 (reboxetine; intermediate-term effect); and at night 122 (reboxetine; chronic effect). After the first administration, reboxetine increased time awake after sleep onset, number of awakenings, percentage of stages 1 and 2 non-rapid eye movement (REM), and reduced the amount of stages 3-4 non-REM, but all these effects disappeared by continuing treatment. However, reboxetine caused a persistent suppression of REM sleep, which was accompanied by an increase of REM sleep latency. The spectral analysis of heart rate variability showed a trend towards an increase in sympathetic activity with both acute and intermediate reboxetine use. Long-term treatment with 4 mg reboxetine does not cause significant changes in cardiac autonomic function.

Pediatric psychopharmacology for the major psychiatric disorders found in the residential treatment setting

Intensive measures of rehabilitation are effective for treating the chronic course of the major pediatric psychiatric diagnoses. The treatment of these dis-orders in a residential treatment setting involves a coordinated team approach with components individually tailored to meet patient needs. Whereas milieu,group, and individual psychotherapy are important aspects of treatment, along with educational programming and behavior management, psychopharmacology currently plays an integral role in the treatment of children and adolescents with chronic mental illness in the residential treatment setting. Pharmacologic interventions in chronic psychiatric illnesses have decreased suffering and improved the quality of life for countless children and adolescents. In many cases, we still do not know what kind of pharmacologic treatment is best for each individual patient. Despite the progress of the past decade, further clinical research is needed with well-designed clinical trials for chronic psychiatric illnesses in children and adolescents.

REM sleep effects as a biomarker for the effects of antidepressants in healthy volunteers

The potential use of rapid eye movement (REM) sleep effects as a biomarker for the therapeutic effects of antidepressants in healthy volunteers is reviewed. A literature search was performed to select studies investigating the effects of antidepressants on REM sleep. To assess the specificity of REM sleep effects as a biomarker, the effects of other central nervous system drugs on REM sleep were also investigated. A significant REM sleep reduction was shown for 16 of 21 investigated antidepressants after single-dose (mean reduction 34.1%) and for 11/13 drugs after multiple-dose administration (mean reduction 29.2%). The median increase in REM latency was approximatety 60% after single- or multiple-dose administration. REM sleep effects were linearly normalized to therapeutic doses, by dividing the REM sleep effect by the investigated dose and multiplying by the therapeutic dose. Normalized REM sleep effects were highly variable (range -27.0% to 81.8% for REM sleep; range -17.0% to 266.3% for REM latency) and demonstrated no relationship with relevant pharmacological properties of the investigated drugs. No quantifiable dose-response relationship could be constructed after single and multiple dose administration. REM sleep effects were not specific for antidepressants. Benzodiazepines, for example, caused an average dose normalized REM sleep reduction of 8.7% and a median 8.6% increase of REM latency. This review demonstrates that although REM sleep effects occur with most of the antidepressants, it is by itself of limited value as a biomarker for antidepressant action. The specificity for antidepressants is limited, and it does not show a quantitative dose-response relationship to antidepressant agents. This is at least partly due to the complex relationships between drug pharmacokinetics and the variable time course of REM and other sleep stages throughout the night. Models that take these complex relationships into account may provide more comprehensive and quantifiable results.

Non-dreamers

OBJECTIVE

Assess incidence and clarify whether diagnostic correlates exist for sleep laboratory patients reporting a lack of dream recall. To awaken, during polysomnographically defined sleep including rapid eye movement (REM) sleep, individuals reporting never having experienced a dream, and determine whether they report dreaming.

METHODS

Study # 1 - Incidence and polysomnographic correlates of sleep lab patients responding on questionnaire that they had never experienced dreaming. Study # 2 - Phone interviews with those individuals reporting non-dreaming on questionnaire to reassess incidence. Study # 3 - After reassessment, individuals (non-dreamers - # 16) are awakened during polysomnographic defined sleep (including REM sleep) and queried about dream recall. This group is compared statistically to a group (rare-dreamers - # 12) that reported dreaming as an extremely rare occurrence (mean dream recall latency - 13.5 years).

RESULTS

Study # 1: Incidence of questionnaire reported non-dreaming in this sleep laboratory population is 6.5% (N=534) and is associated with the diagnosis of obstructive sleep apnea (specificity 95.6% for respiratory disturbance index >15). Study # 2 - Individuals who report after interview to have never experienced dreaming are more unusual (0.38% of this sleep laboratory population). Study # 3 - None of the non-dreamers (# 16) reported dream recall after waking in the sleep laboratory (36 awakenings in total for this group). This group does not differ, based on polysomnographic, clinical, or demographic variables, from the rare-dreaming group that occasionally reported dreams when awakened (3/12 patients, 3/32 awakenings) - a finding consistent with the reports of previous studies.

CONCLUSION

The experience of dreaming may not be as ubiquitous as generally accepted. The group of non-dreamers evaluated in this study reports never having recalled a dream and reports no dreams when awakened during polysomnographicly defined sleep. These individuals might not experience dreaming.

The effects of vagus nerve stimulation on sleep EEG in depression: a preliminary report

OBJECTIVE

The present study evaluated the effects of vagus nerve stimulation (VNS) on sleep in seven treatment-resistant depressed outpatients.

METHODS

Sleep studies were conducted in the laboratory at baseline and 10-12 weeks after VNS implantation while the concomitant psychotropic medication regimen was unchanged. Standard sleep macroarchitecture based on visual stage and assessment of ultradian sleep electroencephalographic (EEG) rhythms were measured on all nights.

RESULTS

An overall significant treatment effect on sleep macroarchitecture was obtained by MANOVA. Decreased awake time, decreased Stage 1 sleep and increased Stage 2 sleep were evident post-VNS, although univariate analyses did not reach significance. In addition, the strength or amplitude of ultradian sleep EEG rhythms more than doubled on VNS and was restored to within normal range.

CONCLUSION

VNS improved the clinical symptoms of depression and sleep architecture. Results suggest that treatment-resistant depressed patients have dampened sleep EEG rhythms that are restored to near-normal amplitudes with VNS treatment.

An open pilot study of nefazodone in depression with anger attacks: relationship between clinical response and receptor binding

Nefazodone has been widely used as an antidepressant, but it has not been tested for depression with anger attacks. In an open study, we administered nefazodone (maximum 600 mg/day) for 12 weeks to 16 outpatients who had major depression with anger attacks. Assessment instruments comprised the Structured Clinical Interview for DSM-IV (SCID), Anger Attacks Questionnaire (AAQ), 17-item Hamilton Rating Scale for Depression (HAM-D-17), Clinician Global Impression Scale (CGI), Symptom Questionnaire (SQ), Modified Overt Aggression Scale (MOAS), and MOAS-Self-Rated. Three subjects underwent positron emission tomography (PET) with [18F]-setoperone for 5-HT2 binding potential (BP) and [11C]-SCH-23,390 for D1 BP, both at baseline and after 6 weeks of treatment. Eight subjects underwent PET with [18F]-setoperone and with [11C]-SCH-23,390 at baseline only. In an examination of whether D1 and 5HT2 (data available in six subjects) receptor BP predicted treatment response, we found significant decreases in the HAM-D-17, CGI-S, weighted MOAS, MOAS verbal scale, OAS Self-Rated verbal, SQ Depression and Anger/Hostility scales after nefazodone; 50% responded to nefazodone (defined as >or=50% decrease in HAM-D-17 score), and 44% reported disappearance of anger attacks. A statistically significant percentage decrease in 5HT2 BP was observed for the right mesial frontal and left parietal regions after 6 weeks of treatment. No significant change was observed in D1 BP in any region. Although CGI-I scores correlated significantly with D1 BP in the left thalamic region, the correlation was not significant after Bonferroni correction. The effectiveness of nefazodone for depression with anger attacks may be related to widespread changes in 5HT2 receptor BP.

Depression, sleep physiology, and antidepressant drugs

This review summarizes current findings regarding effects of antidepressant compounds on sleep architecture and interprets their clinical relevance. Effects of the major classes of antidepressant drugs on sleep properties are presented, with the antidepressant compounds organized into categories based primarily on their putative mechanism of action. The majority of antidepressant compounds, across several different categories, exhibit robust suppression of REM sleep. Others, such as bupropion and nefazodone, lack REM suppressant effects. Such findings support the idea that critical neurochemical mechanisms involved in the regulation of discrete sleep stages can be elucidated by means of polysomnographic investigations utilizing pharmacologically targeted agents. Clinicians have appreciated the importance of antidepressant drug effects on sleep when considering therapeutic options for patients. While such decisions in the past were based on empirical observations, an increasing amount of information regarding specific effects of different antidepressant drugs on sleep continuity and sleep architecture is available. Thus, clinicians may choose to consider profiles of sleep effects for different antidepressant drugs in the initial selection of an antidepressant compound.

Treatment of insomnia in patients with mood disorders

Mood disorders and chronic insomnia share complex theoretical and clinical relationships. This article reviews the subjective symptoms and polysomnographic findings of subjects with mood and insomnia syndromes. The polysomnographic findings reviewed include macro-architectural and micro-architectural data. Various treatments of patients with insomnia and mood disorders will be presented, including both behavioral and pharmacological interventions.

A randomized, double-blind controlled comparison of nefazodone and paroxetine in the treatment of depression: safety, tolerability and efficacy in continuation phase treatment

We investigated the safety, tolerability and efficacy of nefazodone and paroxetine in the continuation phase of treatment of depression. The study comprised a double-blind, parallel-group comparison over 4 months, of patients who had previously improved following random allocation to nefazodone or paroxetine during an 8-week acute treatment study. Assessments included Clinical Global Impression Scales, Hamilton Rating Scales for Depression and Anxiety, Montgomery-Asberg Depression Rating Scale and the Patient Global Assessment Scale, in addition to a review of reported adverse events, vital sign measurements, electrocardiograms and clinical laboratory tests. One hundred and eight patients participated in the continuation study (53 received paroxetine, 55 nefazodone) and 73 completed treatment. No clinically relevant differences in antidepressant efficacy were seen. Headache and somnolence were the most common reported adverse events in both treatment groups. Both nefazodone and paroxetine maintain their efficacy in continuation treatment, and both are generally well tolerated.

A double-blind, randomized, prospective evaluation of the efficacy and safety of risperidone versus haloperidol in the treatment of schizoaffective disorder

The relative efficacy and safety of risperidone versus haloperidol in the treatment of schizoaffective disorder was studied. Sixty-two patients (29 depressed type; 33 bipolar type) entered a three-site, randomized, double-blind, 6-week trial of risperidone (up to 10 mg/day) or haloperidol (up to 20 mg/day). Trained raters assessed baseline, weekly, and end-of-study levels of psychopathology with the Positive and Negative Syndrome Scale (PANSS), the 24-item Hamilton Rating Scale for Depression (HAM-D-24) and the Clinician-Administered Rating Scale for Mania (CARS-M). The authors were unable to statistically distinguish between risperidone and haloperidol in the amelioration of psychotic and manic symptoms. In addition, there was no difference in worsening of mania between the two agents in either subgroup (i.e., depressed or bipolar subgroups). For the total PANSS, risperidone produced a mean decrease of 16 points from baseline compared with a 14-point decrease with haloperidol. For the total CARS-M scale, risperidone and haloperidol produced mean change scores of 5 and 8 points, respectively, and for the CARS-M Mania subscale, 3 and 7 points, respectively. Additionally, risperidone produced a mean decrease of 13 points from the baseline 24-item HAM-D, compared with an 8-point decrease with haloperidol. In those patients who had more severe depressive symptoms (i.e., HAM-D baseline score >20), risperidone produced at least a 50% mean improvement in 12 (75%) of 16 patients in comparison to 8 (38%) of 21 patients receiving haloperidol. Haloperidol produced significantly more extrapyramidal side effects and resulted in more dropouts caused by any side effect. There was no difference between risperidone and haloperidol in reducing both psychotic and manic symptoms in this group of patients with schizoaffective disorder. Risperidone did not demonstrate a propensity to precipitate mania and was better tolerated than haloperidol. In those subjects with higher baseline HAM-D scores (i.e., >20), risperidone produced a greater improvement in depressive symptoms than haloperidol.

Open trial of nefazodone for combat veterans with posttraumatic stress disorder

Fourteen combat veterans completed a 9-week open trial of nefazodone for treatment of posttraumatic stress disorder (PTSD). Overall PTSD symptoms as measured by the Clinician-Administered PTSD Scale (CAPS) showed a modest but statistically significant decrease with nefazodone treatment. Decreases in CAPS reexperiencing and avoidance, but not hyperarousal symptoms, approached statistical significance. Anxiety decreased significantly, and there were trends toward decreased depression and anger on structured assessments. This study adds to the clinical evidence that nefazodone may be helpful for the management of PTSD symptoms.

The effects of antidepressants on sleep in patients with depression

This paper reviews sleep disturbances in patients with major depressive disorders and the effects of different classes of antidepressants on sleep. It is clear from the studies reviewed that not all antidepressants improve sleep, and, indeed, some worsen sleep disturbances in patients with depression. Whether sleep is improved or further disrupted is of high clinical significance, because persistent sleep problems elevate the risk of relapse, recurrence, or suicide, as well as the need for augmenting medications.

Slow-wave activity in NREM sleep: sex and age effects in depressed outpatients and healthy controls

The amplitude and time course of slow-wave activity (SWA) during NREM sleep were compared in 76 outpatients with depression and 55 healthy control subjects. Lower SWA amplitude was evident in the depressed group, especially among depressed men. For the most part, significant differences between patients and control subjects were restricted to the first NREM period and only in those 20-30 years of age. Significant age-related declines in SWA amplitude were evident in control subjects but not in depressed patients. In addition, sex differences in the depressed group were twice as large as those seen in control subjects. The time course of SWA amplitude, presumed to reflect homeostatic sleep regulation of SWA, was only abnormal in depressed men with lower accumulation and slower dissipation over NREM sleep. Depressed women showed no evidence of an abnormal SWA time course. Furthermore, no sex differences in the time course of SWA were evident in control subjects, and age-related changes in this aspect of regulation were not striking in any group. Thus, the amplitude of SWA showed strong age effects in healthy individuals but not in those with MDD whereas the time course showed very subtle age effects. It was suggested that men, but not women, with MDD show impaired SWA regulation that is evident from 20 to 40 years of age. These findings provide further support that the pathophysiology of depression differs for men and women and suggest that maturational effects on SWA in depression differ from those observed in healthy individuals.

Increased rate of trazodone prescribing with bupropion and selective serotonin-reuptake inhibitors versus tricyclic antidepressants

OBJECTIVE

To determine whether trazodone is prescribed significantly more often with selective serotonin-reuptake inhibitors (SSRIs) and bupropion than with tricyclic antidepressants (TCAs).

METHODS

A retrospective analysis of Iowa City Department of Veteran's Affairs prescription records from March 1, 1995, to March 1, 1998, was performed. Antidepressants prescribed only by psychiatrists were included. Concomitant use was defined as trazodone prescribed on the same date or up to 42 days after the fill date of the primary antidepressant.

STATISTICS

All comparisons used 2 x 2 chi 2 contingency table. Significance level was set at p < 0.05.

RESULTS

Significantly more patients were prescribed trazodone concurrently with bupropion and SSRI antidepressants than with TCAs. Trazodone was prescribed significantly more often for patients receiving an SSRI (p = 0.0001, chi 2 = 14.59) or bupropion (p = 0.0295, chi 2 = 4.74) than for patients receiving a TCA. There was no significant difference in trazodone use between the patients taking SSRIs or bupropion. The percent of patients that received an SSRI, bupropion, or a TCA in combination with trazodone was 27%, 23%, and 13%, respectively. Overall, 23.7% of patients received trazodone concomitantly with a primary antidepressant.

DISCUSSION

The effects of antidepressants on sleep and on sleep scores of depression rating scales are reviewed. The clinical implications of these findings are discussed. The literature addressing the effects of antidepressants on sleep and on sleep scores of depression rating scales is summarized. Although sleep studies suggest that SSRIs may not improve sleep as well as a TCA, clinical studies do not often support these findings. Several studies report that bupropion may not improve sleep parameters as well as doxepin or trazodone. The clinical implications of these findings are discussed.

CONCLUSIONS

We have demonstrated that our clinicians prescribe trazodone at a significantly higher rate with an SSRI or bupropion than with a TCA. The exact reason for this difference is not known. If trazodone is used during the first six weeks of an initial antidepressant treatment trial, it should be discontinued to determine whether the patient's sleep disturbance has responded to the primary antidepressant. More comparison studies among the newer antidepressants and between classes of antidepressants concerning their effects on sleep in the depressed patient need to be performed.

Ultradian rhythms and temporal coherence in sleep EEG in depressed children and adolescents

BACKGROUND

It has been suggested that a primary ultradian (80-120 minute) rhythm disturbance in EEG underlies sleep abnormalities in adults with depression. The present study evaluated ultradian rhythm disturbances in childhood and adolescent depression.

METHODS

Sleep macroarchitecture and temporal coherence in quantitative EEG rhythms were investigated in 50 medication-free outpatients with major depression (25 children and 25 adolescents) and 15 healthy normal controls (5 children and 10 adolescents).

RESULTS

Few of the macroarchitectural measures showed significant group effects. In fact, age and sex effects were stronger than disease-dependent components. Temporal coherence of EEG rhythms during sleep did differentiate those with MDD from controls. Both depressed children and adolescents had lower intrahemispheric coherence, whereas interhemispheric was only lower in depressed adolescents in comparison with controls. Gender differences were evident in adolescents, but not children, with MDD with lowest interhemispheric coherence in adolescent girls.

CONCLUSIONS

These findings are in keeping with increased risk for depression in females beginning at adolescence and extending throughout adulthood. It was suggested that low temporal coherence in depression reflects a disruption in the fundamental basic rest-activity cycle of arousal and organization in the brain that is strongly influenced by gender.

Depression in epilepsy: etiology, phenomenology, and treatment

A history of depression or depressive symptomatology has been reported in up to two-thirds of patients with medically intractable epilepsy, whereas community studies have demonstrated affective disorder only in a quarter of these patients. Depression has been reported peri- and interictally. However, differentiation may be difficult in patients with frequent seizures. Most authors have found no correlation between depression and epilepsy variables. However, complex partial seizures, especially of temporal lobe origin, appear to be etiologic factors, particularly in men with left-sided foci. Depression is also more common in patients treated with polytherapy especially with barbiturates, phenytoin, and vigabatrin. Depression has also been described de novo after temporal lobectomy. Psychosocial factors also play a part, but underlying risk factors (e.g., genetic, endocrine and metabolic) may explain the increased rates of depression in people with epilepsy compared to those with other neurologic and chronic medical conditions. The depression appears to be endogenous. Patients tend to exhibit fewer neurotic traits and more psychotic symptoms such as paranoia, delusions, and persecutory auditory hallucinations. Treatment approaches include psychotherapy, rationalization of antiepileptic drug medication, antidepressant treatment, and ECT. The tricyclic and related antidepressants appear to be epileptogenic, especially in people at high risk (personal or family history of seizures, abnormal pretreatment EEG, brain damage, alcohol or substance abuse/withdrawal and concurrent use of CNS-active medication). Seizures tend to occur early in treatment or after dose increments, especially if rapidly titrated. There is little evidence that the newer antidepressants, e.g., selective serotonin reuptake inhibitors, moclobemide, venlafaxine, or nefazodone are more epileptogenic than placebo.

Nontricyclic antidepressants: current trends in children and adolescents

OBJECTIVES

First, to review the extant data on the safety and efficacy of the use of nontricyclic antidepressants in children and adolescents; second, to identify the main limitations of our current knowledge in this area; and third, to point to future research directions.

METHOD

A Medline search and a review of previous scientific meetings were conducted; all available reports on the efficacy and safety of nontricyclic antidepressants in children and adolescents were critically reviewed.

RESULTS

As in adults, also in children nontricyclic antidepressants are potentially useful in treating a variety of psychiatric disorders. The data supporting their efficacy, however, are quite limited. Obsessive-compulsive disorder is the only psychiatric diagnosis for which pediatric use of selective serotonin reuptake inhibitors has been approved. One placebo-controlled study in children and adolescents with major depression supports the efficacy of fluoxetine. Other clinical trials of nontricyclic antidepressants in depressed adolescents are in progress. Available data indicate that the safety of these medications is good, at least in the short term.

CONCLUSIONS

The potential usefulness of nontricyclic antidepressants for children and adolescents suffering from a range of disorders is considerable. While information from adults can suggest potential areas of possible efficacy in pediatric patients suffering from similar psychopathology, further research is essential to provide the necessary information on the efficacy, safety, and pharmacokinetics of these medications in children and adolescents.

Effects of drugs on sleep

Many commonly prescribed medications and substances of abuse can have significant effects on sleep and wakefulness. Chronic use or abuse of certain drugs may lead to the development of substance-related sleep disorders. Primary sleep disorders, such as apnea, periodic movement disorders, and parasomnias, may be exacerbated by various drugs. This article summarizes the effects of widely used medications and recreational drugs on sleep.

Nefazodone for patients with chronic fatigue syndrome

OBJECTIVE

Patients with chronic fatigue syndrome (CFS) present with a variety of musculoskeletal, neurocognitive, sleep disturbance and mood symptoms. An open evaluation of the clinical utility of the novel antidepressant compound, nefazodone, was completed.

METHOD

Ten patients with CFS presenting for assessment by a specialist psychiatrist were treated with nefazodone. Patients treated within this specialist service are also advised to engage in appropriate behavioural and sleep-wake cycle strategies to improve their level of functioning.

RESULTS

Of the 10 patients, eight (80%) reported at least some improvement in the key symptom of fatigue, with four (40%) reporting moderate or marked symptom relief. Additionally, sleep disturbance and mood were both moderately or markedly improved in seven (70%) and eight (80%) of the patients, respectively. Five of the patients (50%) achieved at least a moderate improvement in overall functional outcome and were able to return to work or their previous level of role function. The mean dose of nefazodone was 370 mg/day (range = 200-800 mg), with a strong preference for nocturnal dosing. Seven of the patients had previously failed to respond to moclobemide, while seven had previously failed to respond to conventional antidepressant therapy.

CONCLUSION

Nefazodone appears to be worthy of further systematic investigation in patients with CFS. Given its effects on sleep, mood and anxiety symptoms, it may have particular advantages in patients with this disorder.

The effects of nefazodone on sleep in depressed patients and healthy controls

This paper briefly reviews the effects of antidepressants on sleep, and highlights recent studies on the effects of nefazodone on sleep in healthy adults and those with major depressive disorders. Studies indicate significant improvement in sleep quality, decreased light sleep, and a reduction in nocturnal awakenings on nefazodone with minimal effect on REM sleep. The clinical relevance of these sleep findings is also discussed.

Comparative effects of nefazodone and fluoxetine on sleep in outpatients with major depressive disorder

BACKGROUND

Sleep disturbances are common in major depressive disorder. In previous open-label trials, nefazodone improved sleep continuity and increased rapid eye movement (REM) sleep, while not affecting stage 3/4 sleep or REM latency: in contrast, fluoxetine suppressed REM sleep. This study compared the objective and subjective effects of nefazodone and fluoxetine on sleep.

METHODS

This paper reports combined results of three identical, multisite, randomized, double-blind, 8-week, acute-phase trials comparing nefazodone (n = 64) with fluoxetine (n = 61) in outpatients with nonpsychotic major depressive disorder and insomnia. Sleep electroencephalographic (EEG) recordings were gathered at baseline and weeks 2, 4, and 8. Clinical ratings were obtained at weeks 1-4, 6, and 8.

RESULTS

Nefazodone and fluoxetine were equally effective in reducing depressive symptoms; however, nefazodone differentially and progressively increased (while fluoxetine reduced) sleep efficiency and reduced (while fluoxetine increased) the number of awakenings in a linear fashion over the 8-week trial. Fluoxetine, but not nefazodone, prolonged REM latency and suppressed REM sleep. Nefazodone significantly increased total REM sleep time. Clinical evaluations of sleep quality were significantly improved with nefazodone compared with fluoxetine.

CONCLUSIONS

Nefazodone and fluoxetine were equally effective antidepressants. Nefazodone was associated with normal objective, and clinician- and patient-rated assessments of sleep when compared with fluoxetine. These differential sleep EEG effects are consistent with the notion that nefazodone and fluoxetine may have somewhat different modes and spectra of action.

Psychobiology of sleep disturbances in posttraumatic stress disorder

Sleep disturbances are prominent complaints of PTSD patients. Some, but not all, of the polysomnographic studies support the occurrence of sleep disruption. The main dimensions of sleep disturbance in the disorder relate to arousal regulation and REM-related functions of dreaming and memory processing. Both of these issues are relevant to the pathogenesis of PTSD and manifestations of the disorder during wake states. Studies elucidating the effects of treatment on sleep parameters are an important direction for future research.

A multicenter, double-blind comparison of the effects of nefazodone and fluoxetine on sleep architecture and quality of sleep in depressed outpatients

This study was an 8-week, randomized, double-blind, parallel-group investigation that compared the effects of nefazodone and fluoxetine on sleep architecture and on clinician- and patient-rated sleep measures in 43 outpatients with moderate to severe, nonpsychotic major depressive disorder and insomnia. Twenty-two patients received nefazodone 200 mg daily for 1 week, followed by 400 mg daily for 7 weeks. Twenty-one patients received fluoxetine 20 mg daily. Dosage increases (to 500 mg/day for nefazodone and 40 mg/day for fluoxetine) were available after day 29, depending on clinician judgement. Sleep parameters were measured during baseline phase, while patients were unmeasured and symptomatic, and at weeks 2, 4, and 8 of treatment. Nefazodone and fluoxetine were equally effective as antidepressants. However, compared with baseline, nefazodone increased sleep efficiency and reduced the number of awakenings and percent awake and movement time, whereas fluoxetine increased the number of awakenings and did not significantly alter sleep efficiency or percent awake and movement time. Although fluoxetine increased stage 1 sleep and rapid eye movement (REM) latency and reduced total percent REM sleep, nefazodone increased REM sleep, decreased REM latency, and did not alter stage 1 sleep. Differences between treatment groups, based on change from baseline, revealed greater sleep efficiency, fewer awakenings, less percent awake and movement time, less percent stage 1 and more REM sleep, and shorter REM latency for nefazodone compared with fluoxetine. Significantly greater improvement in clinician- and patient-rated sleep disturbance was found with nefazodone compared with fluoxetine. Nefazodone was associated with better sleep quality.

Nefazodone. A review of its pharmacology and clinical efficacy in the management of major depression

Nefazodone hydrochloride is a phenylpiperazine antidepressant with a mechanism of action that is distinct from those of other currently available drugs. It potently and selectively blocks postsynaptic serotonin (5-hydroxytryptamine; 5-HT) 5-HT2A receptors and moderately inhibits serotonin and noradrenaline (norepinephrine) reuptake. In short term clinical trials of 6 or 8 weeks' duration, nefazodone produced clinical improvements that were significantly greater than those with placebo and similar to those achieved with imipramine, and the selective serotonin reuptake inhibitors (SSRIs) fluoxetine, paroxetine and sertraline. The optimum therapeutic dosage of nefazodone appears to be between 300 and 600 mg/day. Limited long term data suggest that nefazodone is effective in preventing relapse of depression in patients treated for up to 1 year. Analyses of pooled clinical trial results indicate that nefazodone and imipramine produces similar and significant improvements on anxiety- and agitation-related rating scales compared with placebo in patients with major depression. Short term tolerability data indicate that nefazodone has a lower incidence of adverse anticholinergic, antihistaminergic and adrenergic effects than imipramine. Compared with SSRIs, nefazodone causes fewer activating symptoms, adverse gastrointestinal effects (nausea, diarrhoea, anorexia) and adverse effects on sexual function, but is associated with more dizziness, dry mouth, constipation, visual disturbances and confusion. Available data also suggest that nefazodone is not associated with abnormal weight gain, seizures, priapism or significant sleep disruption, and appears to be relatively safe in overdosage. Nefazodone inhibits the cytochrome P450 3A4 isoenzyme and thus has the potential to interact with a number of drugs. Further long term and comparative studies will provide a more accurate assessment of the relative place of nefazodone in the management of major depression. Nonetheless, available data suggest that nefazodone is a worthwhile treatment alternative to tricyclic antidepressants and SSRIs in patients with major depression.

Sleep in psychiatric disorders

Psychiatric disorders are some of the most common causes of sleep-related complaints, particularly insomnia. Sleep abnormalities may be caused by CNS abnormalities associated with psychiatric illnesses as well as by accompanying behavioral disturbances. Although sleep patterns are not necessarily diagnostic of particular psychiatric disorders, there are relationships between certain sleep abnormalities and categories of psychiatric disorders. Sleep disturbances associated with psychiatric disorders and general approaches to treatment are reviewed.

Effects of drugs on sleep

Many commonly prescribed medications and substances of abuse can have significant effects on sleep and wakefulness. Chronic use or abuse of certain drugs may lead to the development of substance-related sleep disorders. Primary sleep disorders, such as apnea, periodic movement disorders, and parasomnias, may be exacerbated by various drugs. This article summarizes the effects of widely used medications and recreational drugs on sleep.

Nefazodone: its place among antidepressants

OBJECTIVE

To review the pharmacology, pharmacokinetics, efficacy, adverse effects, and drug interactions of nefazodone as well as to determine its place among currently available antidepressants.

DATA SOURCES

A search of European and American literature using EMBASE and MEDLINE was completed. Nefazodone was the search term.

DATA SYNTHESIS

Nefazodone is an antidepressant that blocks serotonin type 2 (5-HT2) receptors in addition to inhibiting the reuptake of serotonin and norepinephrine. In double-blind, placebo-controlled studies, nefazodone demonstrates antidepressant activity at dosages ranging from 400 to 600 mg/d. Sedation, dry mouth, nausea, and dizziness are the more common adverse effects of nefazodone. Nefazodone, an analog of trazodone, has not been associated with priapism at this time, and may have fewer sexual adverse effects than other antidepressants. More studies are needed to determine the potential role of nefazodone in treating anxiety, pain, and premenstrual syndrome.

STUDY SELECTION

Only double-blind, placebo-controlled studies designed to establish the efficacy of nefazodone as an antidepressant were reviewed.

CONCLUSIONS

Based on placebo-controlled, double-blind, comparative trials, nefazodone demonstrates greater efficacy than placebo, and equivalent efficacy to imipramine. Somnolence, dry mouth, nausea, dizziness, and constipation are the most common adverse effects. Nefazodone appears to have a milder adverse effect profile than the tricyclic antidepressants, causes fewer sexual dysfunctions than the serotonin selective reuptake inhibitors, and may cause less dizziness than trazodone. Nefazodone at dosages of at least 300 mg/d provides another option for the treatment of depression.

The effects of paroxetine and nefazodone on sleep: a placebo controlled trial

We studied the effect of acute (1 day) and subacute (16 days) administration of the new antidepressant, nefazodone (400 mg daily), and the selective serotonin re-uptake inhibitor (SSRI), paroxetine (30 mg daily), on the sleep polysomnogram of 37 healthy volunteers using a random allocation, double-blind, placebo-controlled design. Compared to placebo, paroxetine lowered rapid eye movement (REM) sleep and increased REM latency. In addition, paroxetine increased awakenings and reduced Actual Sleep Time and Sleep Efficiency. In contrast, nefazodone did not alter REM sleep and had little effect on measures of sleep continuity. We conclude that in contrast to typical SSRIs, nefazodone administration has little effect on sleep architecture in healthy volunteers.

Antidepressant options: venlafaxine in perspective

Depression is often related to disturbances of norepinephrine and serotonin neurochemical systems within the brain that affect functional neurobehavioral systems. Classes of antidepressant agents have been developed that directly affect proposed brain neurochemical alterations. Many of the differences among antidepressant agents, particularly in safety and tolerability, can be attributed to their differing effects on receptor blockade and neurotransmitter reuptake. The overall goal of antidepressant treatment is complete recovery, and three phases of treatment have been delineated. Because of the recurrent and potentially chronic nature of depression, safety and tolerability of available treatments are especially important. An overview of antidepressant options is presented, with a particular focus on venlafaxine.

Estimation of the time course of slow-wave sleep over the night in depressed patients: effects of clomipramine and clinical response

The distribution of slow-wave activity during sleep has been analyzed using a method related to the two-process model of sleep regulation. This method is applied to the analyses of data collected from 21 inpatients with unipolar depression who received the antidepressant clomipramine (CMI) in a pulse-loading protocol. CMI infusion was found to redistribute slow-wave activity, producing more concentration in the early part of the night, and also significantly reduced the fluctuation in slow-wave power as a function of time. These measures also distinguished clinical responders from the nonresponders. Drug responders had a significant redistribution of slow-wave activity to the earlier part of the night as compared to nonresponders. This suggests that measures of the distribution of slow-wave activity over the night may represent a good measure of clinical response to antidepressant therapy and have implications for the interpretation of the two-process model and sleep in depression.