Clinical features of circadian rhythm sleep disorders in outpatients

Decrease in Social Zeitgebers Is Associated With Worsened Delayed Sleep-Wake Phase Disorder: Findings During the Pandemic in Japan

BACKGROUND

Delay in sleep-wake rhythms was observed in the general population during the coronavirus disease 2019 (COVID-19) pandemic. Patients with delayed sleep-wake phase disorder (DSWPD) may have also experienced exacerbation of symptoms, but no studies have investigated this topic. In this study, we aimed to retrospectively examine the changes in symptoms of outpatients with DSWPD both before and during the pandemic and to identify the factors associated with the exacerbation of sleep-wake rhythms.

METHODS

We included outpatients with DSWPD aged 16 years or older who visited the outpatient clinic due to sleep disorders between January and September 2020. Decreased social zeitgebers was defined as a reduction of 50% or more in the frequency of commuting to school or work during the COVID-19 pandemic. The severity of DSWPD was assessed using the clinical global impressions - severity of illness (CGI-S) at two points: before and during the pandemic. We defined the worsened, unchanged, and improved groups as those whose CGI-S scores worsened by at least one point, remained unchanged, and improved by at least one point, respectively. Multivariate logistic regression analysis was performed to determine the factors associated with worsened DSWPD symptoms.

RESULTS

Sixty patients with DSWPD were eligible for this study. Even before the pandemic, patients who were unemployed or did not attend school tended to show more severe DSWPD symptoms. During the pandemic, 27 patients belonged to the worsened group; 28 patients, unchanged group; and 5 patients, improved group. Decreased social zeitgebers (odds ratio [OR] = 6.668, 95% confidence interval [CI]: 1.653-26.891, p < 0.05) and comorbid mood disorders (OR = 8.876, 95% CI: 1.714-45.974, p < 0.05) showed independent significant associations with the worsening of DSWPD symptoms.

CONCLUSIONS

During the pandemic, the symptoms of DSWPD tended to worsen. The obtained findings emphasize the importance of social zeitgebers, suggesting the need for external motivation in DSWPD treatment.

Non‐24‐hour sleep‐wake disorder successfully treated with the combination of ramelteon and suvorexant in a case of autism spectrum disorder

Introduction

Non‐24‐hour sleep‐wake disorder (N24SWD) is often observed in the visually impaired and those who isolate indoors. Melatonin receptor agonists may be used for treatment, but there is currently no evidence that they are effective in patients without visual impairment.

Case

We report a case of a 23‐year‐old woman who withdrew from her social life owing to autism spectrum disorder and experienced an unusual sleep rhythm. She presented with N24SWD. The N24SWD cycle averaged 25.6 days but was extended to 42 days using ramelteon. However, this was not enough. We prescribed the addition of suvorexant and the sleep cycle returned to normal.

Conclusion

N24SWD is a disease that seriously impairs social life and productivity. We propose a possible treatment strategy for N24SWD using ramelteon and suvorexant.

We present a case in which the combination therapy of ramelteon and suvorexant was effective for a patient with autism spectrum disorder with non‐24‐hour sleep‐wake disorder (N24SWD) owing to social withdrawal. Here, we discussed the pharmacological mechanism of the combination of ramelteon and suvorexant as a possible therapeutic strategy for patients with N24SWD.

Adherence and acceptability of light therapies to improve sleep in intrinsic circadian rhythm sleep disorders and neuropsychiatric illness: a systematic review

Sleep problems and circadian misalignment affect health and well-being and are highly prevalent in those with co-morbid neuropsychiatric disorders. Interventions altering light exposure patterns of affected individuals are a promising non-pharmacological treatment option, shown by previous meta-analyses to improve sleep, and often described as minimally invasive. To best translate laboratory-based mechanistic research into effective treatments, acceptability and barriers to adherence should be understood, but these have not yet been systematically evaluated. Here, we examined evidence regarding adherence and acceptability in studies of light or dark interventions using various delivery devices and protocols to improve sleep in intrinsic circadian rhythm sleep-wake disorders and neuropsychiatric illness. Attrition during intervention was low, and reported experiences were largely positive, but measurement and reporting of self-reported experiences, expectations, and adverse effects were poor. Approaches to management and measurement of adherence were varied, and available light monitoring technology appeared under-exploited, as did mobile technology to prompt or track adherence. Based on these findings we suggest recommended reporting items on acceptability and adherence for future investigations. Few studies assessed baseline light exposure patterns, and few personalised interventions. Overall, many applied studies exhibited an approach to light schedule interventions still reminiscent of laboratory protocols; this is unlikely to maximise acceptability and clinical effectiveness. For the next phase of translational research, user acceptability and adherence should receive increased attention during intervention design and study design. We suggest framing light therapies as complex interventions, and emphasise the occupationally embedded (daily activity routine embedded) context in which they occur.

Agomelatine treatment corrects impaired sleep-wake cycle and sleep architecture and increases MT1 receptor as well as BDNF expression in the hippocampus during the subjective light phase of rats exposed to chronic constant light

RATIONALE

Exposure to chronic constant light (CCL) has a detrimental impact on circadian rhythms of motor activity and sleep/wake cycles. Agomelatine is an atypical antidepressant showing a chronotropic activity.

OBJECTIVES

In this study, we explored the role of melatonin (MT) receptors and brain-derived neurotrophic factor (BDNF) in the brain in the mechanism underlying the effects of agomelatine on diurnal variations of motor activity, sleep/wake cycle, and sleep architecture in a rat model of CCL.

METHODS

In Experiment #1, home cage activity was monitored automatically with cameras for a period of 24 h. The diurnal rhythm of MT_1, MT₂ receptors, and BDNF expression in the hippocampus and frontal cortex (FC), was tested using the ELISA test. In Experiment #2, rats were equipped with electroencephalographic (EEG) and electromyographic (EMG) electrodes and recordings were made under basal conditions (12:12 LD cycle + vehicle), LL + vehicle and LL + agomelatine (40 mg/kg/day for 21 days).

RESULTS

The rats exposed to CCL showed an impaired diurnal rhythm of motor activity and sleep/wake cycle with reduced NREM sleep and delta power and increased REM sleep and theta power. The duration and number of episodes of the wake were diminished during the subjective dark phase in this group. The circadian rhythm of MT₁ and MT₂ receptors and their expression did not change in the hippocampus and FC under CCL exposure, while the BDNF levels in the hippocampus decreased during the subjective light phase. Agomelatine restored the diurnal rhythm of motor activity, disturbed sleep/wake cycle, and sleep architecture, which effect was accompanied by an increase in MT₁ receptor and BDNF expression in the hippocampus at 10:00 in CCL rats.

CONCLUSIONS

These findings support the value of agomelatine as an antidepressant that can adjust circadian homeostasis of motor activity and sleep/wake cycle in a CCL model.

Attention-deficit hyperactivity disorder symptoms add risk to circadian rhythm sleep problems in depression and anxiety

BACKGROUND

Comorbid ADHD symptoms may partly account for circadian rhythm disturbances in depression and anxiety disorders.

METHODS

Self-reported sleep characteristics of 2090 participants in the Netherlands Study of Depression and Anxiety were assessed using the Munich Chronotype Questionnaire. We defined 3 groups: healthy controls (HC), persons with lifetime depression and/or anxiety disorders (LDA), and those with both LDA and high ADHD symptoms (LDA+ADHD), using the Conner's Adult ADHD Rating Scale.

RESULTS

Sleep characteristics were least favorable in the LDA+ADHD group. Important group differences between LDA+ADHD, LDA and HC were found for extremely late chronotype (12% vs. 5% vs. 3%; p<.001), sleep duration <6h (15% vs. 5% vs. 4%; p<.001), and for an indication of the Delayed Sleep Phase Syndrome (DSPS; 16% vs. 8% vs. 5%; p<.001). After adjustment for covariates, including depression and anxiety, presence of ADHD symptoms increased the odds ratio for late chronotype (OR=2.6; p=.003), indication of DSPS (OR=2.4; p=.002), and sleep duration <6h (OR=2.7; p=.007).

LIMITATIONS

ADHD conceptually overlaps with symptom presentation of depression and anxiety. We used a cross-sectional study design, and used self reported sleep characteristics.

CONCLUSIONS

High ADHD symptoms were associated with an increased rate of circadian rhythm sleep disturbances in an already at-risk population of people with depression and/or anxiety disorders. Circadian rhythm sleep disorders, as often seen in ADHD are not entirely due to any comorbid depression and/or anxiety disorder. Adequate treatment of such sleep problems is needed and may prevent serious health conditions in the long term.

Systematic evaluation of Axis-I DSM diagnoses in delayed sleep phase disorder and evening-type circadian preference

BACKGROUND

Alterations in circadian rhythms can have profound effects on mental health. High co-morbidity for psychiatric disorders has been observed in patients with circadian rhythm disorders, such as delayed sleep phase disorder (DSPD), and in those with an evening-type circadian preference. The aim of this study was to systematically determine the prevalence and type of Diagnostic and Statistical Manual of Mental Disorders fourth edition (DSM IV) Axis-I disorders in those with DSPD compared to evening-type controls.

METHODS

Forty-eight DSPD and 25 evening-type participants took part in this study. Sleep and wake parameters were assessed with actigraphy, diary and questionnaires (Pittsburgh Sleep Quality Index (PSQI) and Functional Outcomes of Sleep Questionnaire (FOSQ). Evening-type preference was defined by the Horne-Ostberg questionnaire. DSPD was determined by an interview according to International Classification of Sleep Disorders criteria. Current and past diagnoses of psychiatric disorders were assessed with a Structured Clinical Interview for DSM-IV disorders.

RESULTS

DSPD was associated with a later wake time, longer sleep time, higher PSQI score and lower Horne-Ostberg and FOSQ scores compared to evening-types. There were no significant differences in the prevalence or type of Axis-I disorders between those with DSPD or evening-type preference. Over 70% of participants met criteria for at least one past Axis-I disorder. Approximately 40% of both the DSPD and evening-types met criteria for a past diagnosis of mood, anxiety (most frequently phobia) or substance-use disorders. Evening types were more likely to have a past diagnosis of more than one Axis-I disorder.

CONCLUSIONS

These results highlight the important link between circadian rhythms and mental disorders. Specifically, an evening circadian chronotype regardless of DSPD status is associated with a risk for anxiety, depressive or substance-use disorders.

Circadian rhythm sleep disorders: part I, basic principles, shift work and jet lag disorders. An American Academy of Sleep Medicine review

OBJECTIVE

This the first of two articles reviewing the scientific literature on the evaluation and treatment of circadian rhythm sleep disorders (CRSDs), employing the methodology of evidence-based medicine. In this first part of this paper, the general principles of circadian biology that underlie clinical evaluation and treatment are reviewed. We then report on the accumulated evidence regarding the evaluation and treatment of shift work disorder (SWD) and jet lag disorder (JLD).

METHODS

A set of specific questions relevant to clinical practice were formulated, a systematic literature search was performed, and relevant articles were abstracted and graded.

RESULTS

A substantial body of literature has accumulated that provides a rational basis the evaluation and treatment of SWD and JLD. Physiological assessment has involved determination of circadian phase using core body temperature and the timing of melatonin secretion. Behavioral assessment has involved sleep logs, actigraphy and the Morningness-Eveningness Questionnaire (MEQ). Treatment interventions fall into three broad categories: 1) prescribed sleep scheduling, 2) circadian phase shifting ("resetting the clock"), and 3) symptomatic treatment using hypnotic and stimulant medications.

CONCLUSION

Circadian rhythm science has also pointed the way to rational interventions for the SWD and JLD, and these treatments have been introduced into the practice of sleep medicine with varying degrees of success. More translational research is needed using subjects who meet current diagnostic criteria.

Circadian rhythm sleep disorders: part II, advanced sleep phase disorder, delayed sleep phase disorder, free-running disorder, and irregular sleep-wake rhythm. An American Academy of Sleep Medicine review

OBJECTIVE

This the second of two articles reviewing the scientific literature on the evaluation and treatment of circadian rhythm sleep disorders (CRSDs), employing the methodology of evidence-based medicine. We herein report on the accumulated evidence regarding the evaluation and treatment of Advamced Sleep Phase Disorder (ASPD), Delayed Sleep Phase Disorder (DSPD), Free-Running Disorder (FRD) and Irregular Sleep-Wake Rhythm ISWR).

METHODS

A set of specific questions relevant to clinical practice were formulated, a systematic literature search was performed, and relevant articles were abstracted and graded.

RESULTS

A substantial body of literature has accumulated that provides a rational basis the evaluation and treatment of CRSDs. Physiological assessment has involved determination of circadian phase using core body temperature and the timing of melatonin secretion. Behavioral assessment has involved sleep logs, actigraphy and the Morningness-Eveningness Questionnaire (MEQ). Treatment interventions fall into three broad categories: 1) prescribed sleep scheduling, 2) circadian phase shifting ("resetting the clock"), and 3) symptomatic treatment using hypnotic and stimulant medications.

CONCLUSION

Circadian rhythm science has also pointed the way to rational interventions for CRSDs and these treatments have been introduced into the practice of sleep medicine with varying degrees of success. More translational research is needed using subjects who meet current diagnostic criteria.

Behavioral and psychiatric consequences of sleep-wake schedule disorders

Circadian rhythm sleep disorders (CRSDs) arise when an individual's sleep-wake rhythm mismatches the environmental 24-h schedule. Physiological data and genetic studies in patients with CRSDs suggest that these disorders result from abnormal functioning of the circadian timing system. Diagnosis involves recognition of the characteristics of CRSDs, which can be achieved by clinical interview and actigraphic monitoring of rest-activity patterns. Bright-light therapy and melatonin administration have proved to be the most effective treatment modalities of CRSDs. In psychiatric practice, CRSDs can be encountered on various occasions. Some evidence indicates that a deviant sleep-wake schedule might be a predisposing factor to personality disorders. CRSDs can emerge as an iatrogenic effect of certain psychoactive drugs, such as haloperidol and fluvoxamine. It is not uncommon that the daytime functional difficulties that accompany CRSDs are misinterpreted as symptoms of psychopathology. Recognition and awareness of these disorders should prevent years of erroneous diagnosis and treatment in these patients.