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Appiah CB, Gardner JJ, Farmer GE, Cunningham RL, Cunningham JT. Chronic intermittent hypoxia-induced hypertension: the impact of sex hormones. Am J Physiol Regul Integr Comp Physiol 2024; 326:R333-R345. [PMID: 38406843 DOI: 10.1152/ajpregu.00258.2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2023] [Revised: 02/12/2024] [Accepted: 02/15/2024] [Indexed: 02/27/2024]
Abstract
Obstructive sleep apnea, a common form of sleep-disordered breathing, is characterized by intermittent cessations of breathing that reduce blood oxygen levels and contribute to the development of hypertension. Hypertension is a major complication of obstructive sleep apnea that elevates the risk of end-organ damage. Premenopausal women have a lower prevalence of obstructive sleep apnea and cardiovascular disease than men and postmenopausal women, suggesting that sex hormones play a role in the pathophysiology of sleep apnea-related hypertension. The lack of protection in men and postmenopausal women implicates estrogen and progesterone as protective agents but testosterone as a permissive agent in sleep apnea-induced hypertension. A better understanding of how sex hormones contribute to the pathophysiology of sleep apnea-induced hypertension is important for future research and possible hormone-based interventions. The effect of sex on the pathophysiology of sleep apnea and associated intermittent hypoxia-induced hypertension is of important consideration in the screening, diagnosis, and treatment of the disease and its cardiovascular complications. This review summarizes our current understanding of the impact of sex hormones on blood pressure regulation in sleep apnea with a focus on sex differences.
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Affiliation(s)
- Cephas B Appiah
- Department of Physiology and Anatomy, School of Biomedical Sciences, University of North Texas Health Science Center at Fort Worth, Fort Worth, Texas, United States
| | - Jennifer J Gardner
- Department of Physiology and Anatomy, School of Biomedical Sciences, University of North Texas Health Science Center at Fort Worth, Fort Worth, Texas, United States
| | - George E Farmer
- Department of Physiology and Anatomy, School of Biomedical Sciences, University of North Texas Health Science Center at Fort Worth, Fort Worth, Texas, United States
| | - Rebecca L Cunningham
- Department of Pharmaceutical Sciences, System College of Pharmacy, University of North Texas Health Science Center at Fort Worth, Fort Worth, Texas, United States
| | - J Thomas Cunningham
- Department of Physiology and Anatomy, School of Biomedical Sciences, University of North Texas Health Science Center at Fort Worth, Fort Worth, Texas, United States
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Tabata H, Kinoshita M, Taniguchi M, Ooi M. Clinical application of headache impact test (HIT)-6 and epworth sleepiness scale (ESS) for sleep apnea headache. SLEEP SCIENCE AND PRACTICE 2023. [DOI: 10.1186/s41606-023-00084-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/25/2023] Open
Abstract
Abstract
Background
Sleep apnea headache is a major symptom accompanying obstructive sleep apnea (OSA), but relatively little evidence has been reported on the magnitude of its negative effects on patients or the evaluation of therapeutic effects. We quantitatively assessed sleep apnea headache using the Epworth sleepiness scale (ESS) and headache impact test (HIT)-6.
Methods
The first part of this study enrolled 86 patients (72 male; mean [± standard deviation] age 53.2 ± 13.8 years) who had been diagnosed with OSA by polysomnography in our sleep center and investigated the prevalence and characteristics of sleep apnea headache. The second part enrolled 21 patients (12 male; mean age, 47.5 ± 13.0 years) diagnosed with sleep apnea headache by polysomnography and/or peripheral arterial tonometry and evaluated the effects of OSA therapy on headache. Medical records including ESS, HIT-6, and polysomnographic data were retrospectively analyzed.
Results
The prevalence of sleep apnea headache among OSA patients was 22.1%, and was higher in female (50.0%) than in male (16.7%). The proportion of N3 and HIT-6 score showed a significant negative correlation (Pearson’s R = -0.51, p < 0.05). In female, median apnea–hypopnea index (AHI) was significantly lower in patients with headache (26.1 /h [interquartile range 21.4–29.6 /h]) than in patients without (54.2 /h [41.3–73.9 /h], p < 0.05, Wilcoxon rank-sum test). HIT-6 and ESS scores improved from 56.4 ± 9.7 to 45.9 ± 8.4 and from 9.0 ± 4.4 to 5.3 ± 4.2 in patients with oral appliance (OA), and from 54.3 ± 10.7 to 44.6 ± 6.1 and from 10.0 ± 4.0 to 4.9 ± 2.9 with continuous positive airway pressure (CPAP). In patients with good CPAP adherence, these scores improved from 58.1 ± 10.8 to 44.0 ± 6.0 and from 9.6 ± 3.8 to 3.6 ± 1.7.
Conclusion
Among patients with OSA, prevalence of sleep apnea headache was higher in female than in male. In female, headache was associated with relatively mild OSA. OA showed substantial effects on headache in mild to moderate OSA patients. CPAP adherence was important for improving the headache. HIT-6 score appears useful for the diagnosis and management of sleep apnea headache.
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3
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Schlafbezogene Atmungsstörungen und Gynäkologie – Teil 2. SOMNOLOGIE 2022. [DOI: 10.1007/s11818-022-00384-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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4
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Pigeon WR, Funderburk JS, Cross W, Bishop TM, Crean HF. Brief CBT for insomnia delivered in primary care to patients endorsing suicidal ideation: a proof-of-concept randomized clinical trial. Transl Behav Med 2020; 9:1169-1177. [PMID: 31271210 DOI: 10.1093/tbm/ibz108] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Insomnia co-occurs frequently with major depressive disorder (MDD) and posttraumatic stress disorder (PTSD); all three conditions are prevalent among primary care patients and associated with suicidal ideation (SI). The purpose of the article was to test the effects of a brief cognitive behavioral therapy for insomnia (bCBTi) and the feasibility of delivering it to primary care patients with SI and insomnia in addition to either MDD and/or PTSD. Fifty-four patients were randomized to receive either bCBTi or treatment-as-usual for MDD and/or PTSD. The primary outcome was SI intensity as measured by the Columbia-Suicide Severity Rating Scale; secondary clinical outcomes were measured by the Insomnia Severity Index, Patient Health Questionnaire for depression, and PTSD Symptom Checklist. Effect sizes controlling for baseline values and sample size were calculated for each clinical outcome comparing pre-post differences between the two conditions with Hedge's g. The effect size of bCBTi on SI intensity was small (0.26). Effects were large on insomnia (1.91) and depression (1.16) with no effect for PTSD. There was a marginally significant (p = .069) effect of insomnia severity mediating the intervention's effect on SI. Findings from this proof-of-concept trial support the feasibility of delivering bCBTi in primary care and its capacity to improve mood and sleep in patients endorsing SI. The results do not support bCBTi as a stand-alone intervention to reduce SI, but this or other insomnia interventions may be considered as components of suicide prevention strategies.
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Affiliation(s)
- Wilfred R Pigeon
- VISN 2 Center of Excellence for Suicide Prevention, Canandaigua VA Medical Center, Canandaigua, NY, USA.,Department of Psychiatry, University of Rochester Medical Center, Rochester, NY, USA.,Center for Integrated Healthcare, Syracuse VA Medical Center, Syracuse, NY, USA
| | - Jennifer S Funderburk
- Department of Psychiatry, University of Rochester Medical Center, Rochester, NY, USA.,Center for Integrated Healthcare, Syracuse VA Medical Center, Syracuse, NY, USA.,Department of Psychology, Syracuse University, Syracuse, NY, USA
| | - Wendi Cross
- VISN 2 Center of Excellence for Suicide Prevention, Canandaigua VA Medical Center, Canandaigua, NY, USA.,Department of Psychiatry, University of Rochester Medical Center, Rochester, NY, USA
| | - Todd M Bishop
- VISN 2 Center of Excellence for Suicide Prevention, Canandaigua VA Medical Center, Canandaigua, NY, USA.,Department of Psychiatry, University of Rochester Medical Center, Rochester, NY, USA.,Center for Integrated Healthcare, Syracuse VA Medical Center, Syracuse, NY, USA
| | - Hugh F Crean
- VISN 2 Center of Excellence for Suicide Prevention, Canandaigua VA Medical Center, Canandaigua, NY, USA.,Department of Psychiatry, University of Rochester Medical Center, Rochester, NY, USA
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Lee J, Han Y, Cho HH, Kim MR. Sleep Disorders and Menopause. J Menopausal Med 2019; 25:83-87. [PMID: 31497577 PMCID: PMC6718648 DOI: 10.6118/jmm.19192] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2019] [Revised: 03/22/2019] [Accepted: 04/17/2019] [Indexed: 01/18/2023] Open
Abstract
Sleep disorders are one of the main symptoms of menopause. Symptoms of sleep disorders that menopausal women complain about include falling asleep, frequent awakening and/or early morning awakening. There are many possible causes of sleep disorders in postmenopausal women, including vasomotor symptoms, ovarian hormone changes, restless legs syndrome, periodic leg movement syndrome, and obstructive sleep apnea. In this review, we discuss the relationship between menopause and sleep disorders.
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Affiliation(s)
- Jinju Lee
- Department of Obstetrics and Gynecology, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Youngsin Han
- Department of Obstetrics and Gynecology, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Hyun Hee Cho
- Department of Obstetrics and Gynecology, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Mee-Ran Kim
- Department of Obstetrics and Gynecology, College of Medicine, The Catholic University of Korea, Seoul, Korea
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Dunlop BW, Polychroniou PE, Rakofsky JJ, Nemeroff CB, Craighead WE, Mayberg HS. Suicidal ideation and other persisting symptoms after CBT or antidepressant medication treatment for major depressive disorder. Psychol Med 2019; 49:1869-1878. [PMID: 30207254 DOI: 10.1017/s0033291718002568] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND Persisting symptoms after treatment for major depressive disorder (MDD) contribute to ongoing impairment and relapse risk. Whether cognitive behavior therapy (CBT) or antidepressant medications result in different profiles of residual symptoms after treatment is largely unknown. METHODS Three hundred fifteen adults with MDD randomized to treatment with either CBT or antidepressant medication in the Predictors of Remission in Depression to Individual and Combined Treatments (PReDICT) study were analyzed for the frequency of residual symptoms using the Montgomery Asberg Depression Rating Scale (MADRS) item scores at the end of the 12-week treatment period. Separate comparisons were made for treatment responders and non-responders. RESULTS Among treatment completers (n = 250) who responded to CBT or antidepressant medication, there were no significant differences in the persistence of residual MADRS symptoms. However, non-responders treated with medication were significantly less likely to endorse suicidal ideation (SI) at week 12 compared with those treated with CBT (non-responders to medication: 0/54, 0%, non-responders to CBT: 8/30, 26.7%; p = .001). Among patients who terminated the trial early (n = 65), residual MADRS item scores did not significantly differ between the CBT- and medication-treated groups. CONCLUSIONS Depressed adults who respond to CBT or antidepressant medication have similar residual symptom profiles. Antidepressant medications reduce SI, even among patients for whom the medication provides little overall benefit.
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Affiliation(s)
- Boadie W Dunlop
- Department of Psychiatry and Behavioral Sciences,Emory University School of Medicine,Atlanta, GA,USA
| | | | - Jeffrey J Rakofsky
- Department of Psychiatry and Behavioral Sciences,Emory University School of Medicine,Atlanta, GA,USA
| | - Charles B Nemeroff
- Department of Psychiatry and Behavioral Sciences,University of Miami Miller School of Medicine,Miami, FL,USA
| | - W Edward Craighead
- Department of Psychiatry and Behavioral Sciences,Emory University School of Medicine,Atlanta, GA,USA
| | - Helen S Mayberg
- Department of Psychiatry,Mount Sinai School of Medicine,New York, NY,USA
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Lastra AC, Attarian HP. The Persistent Gender Bias in the Diagnosis of Obstructive Sleep Apnea. GENDER AND THE GENOME 2018. [DOI: 10.1177/2470289718787107] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023] Open
Abstract
Prevalence estimates of obstructive sleep apnea (OSA) continue to rise, partially due to better recognition of and screening for the disease, in part due to increase in obesity and in part due to changes in definitions of obstructive hypopneas. Despite increasing knowledge of the deleterious impact of OSA on health, underrecognition continues to be a major concern, especially in women. A middle-aged man that snores and is sleepy has been the accepted “textbook” picture of OSA; women may present with more atypical symptoms and excessive sleepiness that are not reflected on sleepiness scale questionnaires. Even when presenting with snoring and sleepiness, and in the presence of comorbidities, women are less likely to be evaluated for OSA. Symptom burden and poor health outcomes have been documented in women with OSA and treatment improves their health. In this article, we explore possible causes for this underrecognition of OSA in women, including gender bias and healthcare inequity, and propose solutions.
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Affiliation(s)
- Alejandra Carolina Lastra
- Internal Medicine, Pulmonary, Critical Care and Sleep Medicine, Sleep Disorders Service & Research Center, Rush University Medical Center, Chicago, IL, USA
| | - Hrayr Pierre Attarian
- Circadian Rhythms and Sleep Research Lab, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
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The gender difference of snore distribution and increased tendency to snore in women with menopausal syndrome: a general population study. Sleep Breath 2016; 21:543-547. [PMID: 28012067 PMCID: PMC5399062 DOI: 10.1007/s11325-016-1447-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2016] [Revised: 11/27/2016] [Accepted: 12/15/2016] [Indexed: 11/25/2022]
Abstract
Purpose Sleep-disordered breathing (SDB) is a prevalent disorder with a major impact in women, especially postmenopausal women. However, few studies have investigated the prevalence of a specific SDB, snoring, among women especially those with menopausal syndrome. Methods Computer-assisted telephone interviews were conducted in Taiwan. Adults over 20 years of age were interviewed. The number of successful interviews was calculated based on the population prior to the study. Demographic data and information about snoring, menopausal syndrome, and medical conditions were obtained. Results In total, 3624 adults, 1473 males and 2151 females, completed the interviews. Both men and women shows an increase in snoring until age 50 to 59 years, followed by a decline in snoring that is less steep among women. The prevalence of snoring increased significantly in females after age 50 years, which is the mean menopausal age in our country (p < 0.05). After adjusting for age, body mass index, and other major diseases, the percentage of women with snoring was significantly higher among those with menopausal syndrome than those without menopausal syndrome (p = 0.021, odds ratio = 1.629). Conclusions This population-based study revealed different snoring percentages among men and women and diminishing differences in the older population. Additionally, the percentage of women with snoring was increased among those women who were older than 50 years and those with menopausal syndrome.
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Chen HH, Lu J, Guan YF, Li SJ, Hu TT, Xie ZS, Wang F, Peng XH, Liu X, Xu X, Zhao FP, Yu BL, Li XP. Estrogen/ERR-α signaling axis is associated with fiber-type conversion of upper airway muscles in patients with obstructive sleep apnea hypopnea syndrome. Sci Rep 2016; 6:27088. [PMID: 27250523 PMCID: PMC4890001 DOI: 10.1038/srep27088] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2015] [Accepted: 05/10/2016] [Indexed: 12/20/2022] Open
Abstract
Estrogen is related with the low morbidity associated with obstructive sleep apnea hypopnea syndrome (OSAS) in women, but the underlying mechanisms remain largely unknown. In this study, we examined the relationship between OSAS and estrogen related receptor-α (ERR-α). We found that the expression levels of ERR-α and Myh7 were both downregulated in palatopharyngeal tissues from OSAS patients. In addition, we report that ERR-α is dynamically expressed during differentiation of C2C12 myoblasts. Knockdown of ERR-α via instant siRNA resulted in reduced expression of Myh7, but not Myh4. Furthermore, differentiation of C2C12 cells under 3% chronic intermittent hypoxia, a model resembling human OSAS, was impaired and accompanied by a obvious reduction in Myh7 expression levels. Moreover, activation of ERR-α with 17β-estradiol (E2) increased the expression of Myh7, whereas pretreatment with the ERR-α antagonist XCT790 reversed the E2-induced slow fiber-type switch. A rat ovariectomy model also demonstrated the switch to fast fiber type. Collectively, our findings suggest that ERR-α is involved in estrogen-mediated OSAS by regulating Myhc-slow expression. The present study illustrates an important role of the estrogen/ERR-α axis in the pathogenesis of OSAS, and may represent an attractive therapeutic target, especially in postmenopausal women.
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Affiliation(s)
- H H Chen
- Department of Otolaryngology-Head and Neck Surgery, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - J Lu
- Department of Otolaryngology-Head and Neck Surgery, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Y F Guan
- Department of Neurobiology, Southern Medical University, Guangzhou, China
| | - S J Li
- Department of Neurobiology, Southern Medical University, Guangzhou, China
| | - T T Hu
- Department of Anatamy, Southern Medical University, Guangzhou, China
| | - Z S Xie
- Department of Neurology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - F Wang
- Department of Otolaryngology-Head and Neck Surgery, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - X H Peng
- Department of Otolaryngology-Head and Neck Surgery, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - X Liu
- Department of Otolaryngology-Head and Neck Surgery, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - X Xu
- Department of Otolaryngology-Head and Neck Surgery, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - F P Zhao
- Department of Otolaryngology-Head and Neck Surgery, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - B L Yu
- Department of Otolaryngology-Head and Neck Surgery, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - X P Li
- Department of Otolaryngology-Head and Neck Surgery, Nanfang Hospital, Southern Medical University, Guangzhou, China
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Jobst A, Brakemeier EL, Buchheim A, Caspar F, Cuijpers P, Ebmeier KP, Falkai P, Jan van der Gaag R, Gaebel W, Herpertz S, Kurimay T, Sabaß L, Schnell K, Schramm E, Torrent C, Wasserman D, Wiersma J, Padberg F. European Psychiatric Association Guidance on psychotherapy in chronic depression across Europe. Eur Psychiatry 2016; 33:18-36. [PMID: 26854984 DOI: 10.1016/j.eurpsy.2015.12.003] [Citation(s) in RCA: 71] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2015] [Accepted: 12/12/2015] [Indexed: 01/07/2023] Open
Abstract
PURPOSE Patients with chronic depression (CD) by definition respond less well to standard forms of psychotherapy and are more likely to be high utilizers of psychiatric resources. Therefore, the aim of this guidance paper is to provide a comprehensive overview of current psychotherapy for CD. The evidence of efficacy is critically reviewed and recommendations for clinical applications and research are given. METHODS We performed a systematic literature search to identify studies on psychotherapy in CD, evaluated the retrieved documents and developed evidence tables and recommendations through a consensus process among experts and stakeholders. RESULTS We developed 5 recommendations which may help providers to select psychotherapeutic treatment options for this patient group. The EPA considers both psychotherapy and pharmacotherapy to be effective in CD and recommends both approaches. The best effect is achieved by combined treatment with psychotherapy and pharmacotherapy, which should therefore be the treatment of choice. The EPA recommends psychotherapy with an interpersonal focus (e.g. the Cognitive Behavioural Analysis System of Psychotherapy [CBASP]) for the treatment of CD and a personalized approach based on the patient's preferences. DISCUSSION The DSM-5 nomenclature of persistent depressive disorder (PDD), which includes CD subtypes, has been an important step towards a more differentiated treatment and understanding of these complex affective disorders. Apart from dysthymia, ICD-10 still does not provide a separate entity for a chronic course of depression. The differences between patients with acute episodic depression and those with CD need to be considered in the planning of treatment. Specific psychotherapeutic treatment options are recommended for patients with CD. CONCLUSION Patients with chronic forms of depression should be offered tailored psychotherapeutic treatments that address their specific needs and deficits. Combination treatment with psychotherapy and pharmacotherapy is the first-line treatment recommended for CD. More research is needed to develop more effective treatments for CD, especially in the longer term, and to identify which patients benefit from which treatment algorithm.
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Affiliation(s)
- A Jobst
- Department of Psychiatry und Psychotherapy, Ludwig Maximilian University, Munich, Germany
| | - E-L Brakemeier
- Department of Clinical Psychology and Psychotherapy, Berlin University of Psychology, Berlin, Germany
| | - A Buchheim
- Department of Psychology, Clinical Psychology, University of Innsbruck, Innsbruck, Austria
| | - F Caspar
- Institute of Psychology, University of Bern, Bern, Switzerland
| | - P Cuijpers
- Department of Clinical Psychology, VU University, Amsterdam, The Netherlands
| | - K P Ebmeier
- Department of Psychiatry, Division of Clinical Medicine, University of Oxford, Oxford, United Kingdom
| | - P Falkai
- Department of Psychiatry und Psychotherapy, Ludwig Maximilian University, Munich, Germany
| | | | - W Gaebel
- Department of Psychiatry und Psychotherapy, Heinrich Heine University Düsseldorf, Medical Faculty, Düsseldorf, Germany
| | - S Herpertz
- Department of Psychiatry and Psychotherapy, University of Heidelberg, Heidelberg, Germany
| | - T Kurimay
- Institute of Behaviour Sciences, Semmelweis University, Budapest, Hungary
| | - L Sabaß
- Department of Psychiatry und Psychotherapy, Ludwig Maximilian University, Munich, Germany
| | - K Schnell
- Department of Psychiatry and Psychotherapy, University of Freiburg, Freiburg, Germany
| | - E Schramm
- Department of Psychiatry and Psychotherapy, University of Freiburg, Freiburg, Germany
| | - C Torrent
- Clinical Institute of Neuroscience, Hospital Clinic Barcelona, CIBERSAM, IDIBAPS, University of Barcelona, Barcelona, Spain
| | - D Wasserman
- National Centre for Suicide Research and Prevention of Mental lll-Health (NASP), Karolinska Institutet, Stockholm, Sweden
| | - J Wiersma
- Department of Psychiatry, GGZinGeest, Amsterdam, The Netherlands
| | - F Padberg
- Department of Psychiatry und Psychotherapy, Ludwig Maximilian University, Munich, Germany.
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11
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Pigeon WR, Heffner KL, Crean H, Gallegos AM, Walsh P, Seehuus M, Cerulli C. Responding to the need for sleep among survivors of interpersonal violence: A randomized controlled trial of a cognitive-behavioral insomnia intervention followed by PTSD treatment. Contemp Clin Trials 2015; 45:252-260. [PMID: 26343743 DOI: 10.1016/j.cct.2015.08.019] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2015] [Revised: 08/27/2015] [Accepted: 08/30/2015] [Indexed: 02/03/2023]
Abstract
Sleep disturbance is a common feature of posttraumatic stress disorder (PTSD), but is not a focus of standard PTSD treatments. Psychological trauma exposure is associated with considerable physical and mental health morbidity, possibly due to the alterations in neuroendocrine function and inflammation observed in trauma exposed individuals. Although PTSD treatments are efficacious, they are associated with high drop-out rates in clinical trials and clinical practice. Finally, individuals with PTSD stemming from exposure to interpersonal violence represent an especially under-treated population with significant sleep disturbance. Community-based participatory research was utilized to design and prepare a clinical trial that randomizes recent survivors of interpersonal violence who have PTSD, depression, and insomnia to receive either: (1) Cognitive Behavioral Therapy for Insomnia (CBTi) followed by Cognitive Processing Therapy (CPT) for trauma, or (2) attention control followed by CPT. Outcome measures include subjective and objective measures of sleep, clinician-administered PTSD and depression scales, inflammatory cytokines, and salivary cortisol. Assessments are conducted at baseline, following the sleep or control intervention, and again following CPT. The design allows for: (1) the first test of a sleep intervention in this population; (2) the comparison of sequenced CBTi and CPT to attention control followed by CPT, and (3) assessing the roles of neuroendocrine function, inflammatory processes, and objective sleep markers in mediating treatment outcomes. The study's overarching hypothesis is that treating insomnia will produce reduction in insomnia, PTSD, and depression severity, allowing patients to more fully engage in, and derive optimal benefits from, cognitive processing therapy.
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Affiliation(s)
- Wilfred R Pigeon
- Sleep and Neurophysiology Research Laboratory, Department of Psychiatry, University of Rochester Medical Center, Rochester, NY USA; U.S. Department of Veterans Affairs Center of Excellence for Suicide Prevention, Canandaigua VA Medical Center, Canandaigua, NY USA.
| | - Kathi L Heffner
- Sleep and Neurophysiology Research Laboratory, Department of Psychiatry, University of Rochester Medical Center, Rochester, NY USA
| | - Hugh Crean
- School of Nursing, University of Rochester Medical Center, Rochester, NY USA
| | - Autumn M Gallegos
- Sleep and Neurophysiology Research Laboratory, Department of Psychiatry, University of Rochester Medical Center, Rochester, NY USA
| | - Patrick Walsh
- Sleep and Neurophysiology Research Laboratory, Department of Psychiatry, University of Rochester Medical Center, Rochester, NY USA
| | - Martin Seehuus
- Sleep and Neurophysiology Research Laboratory, Department of Psychiatry, University of Rochester Medical Center, Rochester, NY USA
| | - Catherine Cerulli
- Susan B. Anthony Center and Laboratory of Interpersonal Violence and Victimization, University of Rochester Medical Center, Rochester, NY USA
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Watson NF, Badr MS, Belenky G, Bliwise DL, Buxton OM, Buysse D, Dinges DF, Gangwisch J, Grandner MA, Kushida C, Malhotra RK, Martin JL, Patel SR, Quan SF, Tasali E. Joint Consensus Statement of the American Academy of Sleep Medicine and Sleep Research Society on the Recommended Amount of Sleep for a Healthy Adult: Methodology and Discussion. J Clin Sleep Med 2015; 11:931-52. [PMID: 26235159 DOI: 10.5664/jcsm.4950] [Citation(s) in RCA: 225] [Impact Index Per Article: 25.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2015] [Accepted: 07/03/2015] [Indexed: 12/19/2022]
Abstract
The American Academy of Sleep Medicine and Sleep Research Society recently released a Consensus Statement regarding the recommended amount of sleep to promote optimal health in adults. This paper describes the methodology, background literature, voting process, and voting results for the consensus statement. In addition, we address important assumptions and challenges encountered during the consensus process. Finally, we outline future directions that will advance our understanding of sleep need and place sleep duration in the broader context of sleep health.
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13
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Watson NF, Badr MS, Belenky G, Bliwise DL, Buxton OM, Buysse D, Dinges DF, Gangwisch J, Grandner MA, Kushida C, Malhotra RK, Martin JL, Patel SR, Quan SF, Tasali E. Joint Consensus Statement of the American Academy of Sleep Medicine and Sleep Research Society on the Recommended Amount of Sleep for a Healthy Adult: Methodology and Discussion. Sleep 2015; 38:1161-83. [PMID: 26194576 DOI: 10.5665/sleep.4886] [Citation(s) in RCA: 420] [Impact Index Per Article: 46.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2015] [Accepted: 07/03/2015] [Indexed: 12/24/2022] Open
Abstract
The American Academy of Sleep Medicine and Sleep Research Society recently released a Consensus Statement regarding the recommended amount of sleep to promote optimal health in adults. This paper describes the methodology, background literature, voting process, and voting results for the consensus statement. In addition, we address important assumptions and challenges encountered during the consensus process. Finally, we outline future directions that will advance our understanding of sleep need and place sleep duration in the broader context of sleep health.
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14
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Won C, Guilleminault C. Gender differences in sleep disordered breathing: implications for therapy. Expert Rev Respir Med 2015; 9:221-31. [PMID: 25739831 DOI: 10.1586/17476348.2015.1019478] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
There are gender differences in the upper airway function and respiratory stability in obstructive sleep apnea (OSA). Hormones are implicated in some gender-related differences, and these differences between men and women appear to mitigate as age increases. In addition, changes in the airway and lung function during pregnancy can contribute to snoring and OSA that might have an adverse effect on the mother and fetus. The limited data available suggest that although the prevalence and severity of OSA may be lower in women, the consequences of the disease are similar, if not worse. Women with OSA may have greater risk for hypertension and endothelial dysfunction, be more likely to develop comorbid conditions such as anxiety and depression and have increased mortality. Therefore, treatment options specifically targeting female presentations and pathophysiology of sleep-disordered breathing (SDB) are expected to result in improved outcomes in women.
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Affiliation(s)
- Christine Won
- Yale University School of Medicine, New Haven, CT, USA
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15
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Application of Cognitive Behavioral Therapies for Comorbid Insomnia and Depression. Sleep Med Clin 2015; 10:77-84. [DOI: 10.1016/j.jsmc.2014.11.006] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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16
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Abad VC, Guilleminault C. Pharmacological treatment of sleep disorders and its relationship with neuroplasticity. Curr Top Behav Neurosci 2015; 25:503-53. [PMID: 25585962 DOI: 10.1007/7854_2014_365] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Sleep and wakefulness are regulated by complex brain circuits located in the brain stem, thalamus, subthalamus, hypothalamus, basal forebrain, and cerebral cortex. Wakefulness and NREM and REM sleep are modulated by the interactions between neurotransmitters that promote arousal and neurotransmitters that promote sleep. Various lines of evidence suggest that sleep disorders may negatively affect neuronal plasticity and cognitive function. Pharmacological treatments may alleviate these effects but may also have adverse side effects by themselves. This chapter discusses the relationship between sleep disorders, pharmacological treatments, and brain plasticity, including the treatment of insomnia, hypersomnias such as narcolepsy, restless legs syndrome (RLS), obstructive sleep apnea (OSA), and parasomnias.
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Affiliation(s)
- Vivien C Abad
- Psychiatry and Behavioral Science-Division of Sleep Medicine, Stanford University School of Medicine, Palo Alto, CA, USA
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17
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Pigeon WR, Funderburk J. Delivering a Brief Insomnia Intervention to Depressed VA Primary Care Patients. COGNITIVE AND BEHAVIORAL PRACTICE 2014. [DOI: 10.1016/j.cbpra.2013.10.007] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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18
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Yon A, Scogin F, DiNapoli EA, McPherron J, Arean PA, Bowman D, Jamison CS, Karpe JA, Latour D, Reynolds CF, Rohen N, Pardini JEL, Thompson LW. Do manualized treatments for depression reduce insomnia symptoms? J Clin Psychol 2014; 70:616-30. [PMID: 24596077 DOI: 10.1002/jclp.22062] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
OBJECTIVE Researchers evaluated the effect of manualized treatments for depression on comorbid symptoms of insomnia. METHOD Hierarchical linear modeling was used to analyze archival data collected from 14 studies (N = 910) examining the efficacy of psychological treatments for depression in adults. RESULTS Participants receiving a psychological treatment for depression experienced significantly more relief from symptoms of insomnia with overall, early-, middle-, and late-night sleep than those not receiving such treatment. CONCLUSION Symptoms of insomnia in those with an average (or lower) level of depression can be reduced through psychological treatment for depression. However, more severe depressive symptoms do not receive great relief from sleep disturbance and may require an additional treatment component targeting symptoms of insomnia.
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Robillard R, Naismith SL, Smith KL, Rogers NL, White D, Terpening Z, Ip TKC, Hermens DF, Whitwell B, Scott EM, Hickie IB. Sleep-wake cycle in young and older persons with a lifetime history of mood disorders. PLoS One 2014; 9:e87763. [PMID: 24586290 PMCID: PMC3934865 DOI: 10.1371/journal.pone.0087763] [Citation(s) in RCA: 57] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2013] [Accepted: 12/30/2013] [Indexed: 11/19/2022] Open
Abstract
Considering the marked changes in sleep and circadian rhythms across the lifespan, age may contribute to the heterogeneity in sleep-wake profiles linked to mood disorders. This study aimed to investigate the contributions of age and depression severity to sleep-wake disturbances. The Hamilton Depression Rating Scale (HDRS) was administered to assess current symptoms severity in 238 persons with a history of a mood disorder between 12 and 90 years of age (y.o.). Actigraphy was recorded over five to 22 days. Regression analyses and analyses of variance [age (12–19 y.o., 20–39 y.o., 40–59 y.o., and ≥60 y.o.) by depression severity (HDRS< and ≥8)] were conducted. The 12–19 y.o. and 20–39 y.o. groups had a delayed sleep schedule and acrophase compared to all other groups. The ≥60 y.o. group had a lower rhythmicity and amplitude (p≤.006) than the 12–19 y.o. group (p≤.046). Participants with a HDRS≥8 spent longer time in bed, had later sleep offset times and had lower circadian rhythmicity than those with a HDRS<8 (p≤.036). Younger age and higher HDRS score correlated with later sleep onset and offset times, longer time in bed, higher WASO, lower sleep efficiency and later acrophase (p≤.023). Age was a significant predictor of delayed sleep and activity schedules (p≤.001). The profile of sleep-wake cycle disturbances associated with mood disorders changes with age, with prominent sleep phase delay during youth and reduced circadian strength in older persons. Conversely, disruptions in sleep consolidation seem more stable across age.
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Affiliation(s)
- Rébecca Robillard
- Clinical Research Unit, Brain & Mind Research Institute, The University of Sydney, Camperdown, New South Wales, Australia
| | - Sharon L. Naismith
- Clinical Research Unit, Brain & Mind Research Institute, The University of Sydney, Camperdown, New South Wales, Australia
- Healthy Brain Ageing Clinic, Brain & Mind Research Institute, The University of Sydney, Camperdown, New South Wales, Australia
| | - Kristie Leigh Smith
- Clinical Research Unit, Brain & Mind Research Institute, The University of Sydney, Camperdown, New South Wales, Australia
| | - Naomi L. Rogers
- Concord Clinical School, The University of Sydney, Concord, New South Wales, Australia
| | - Django White
- Clinical Research Unit, Brain & Mind Research Institute, The University of Sydney, Camperdown, New South Wales, Australia
| | - Zoe Terpening
- Clinical Research Unit, Brain & Mind Research Institute, The University of Sydney, Camperdown, New South Wales, Australia
- Healthy Brain Ageing Clinic, Brain & Mind Research Institute, The University of Sydney, Camperdown, New South Wales, Australia
| | - Tony K. C. Ip
- Clinical Research Unit, Brain & Mind Research Institute, The University of Sydney, Camperdown, New South Wales, Australia
| | - Daniel F. Hermens
- Clinical Research Unit, Brain & Mind Research Institute, The University of Sydney, Camperdown, New South Wales, Australia
| | - Bradley Whitwell
- Clinical Research Unit, Brain & Mind Research Institute, The University of Sydney, Camperdown, New South Wales, Australia
| | - Elizabeth M. Scott
- Clinical Research Unit, Brain & Mind Research Institute, The University of Sydney, Camperdown, New South Wales, Australia
| | - Ian B. Hickie
- Clinical Research Unit, Brain & Mind Research Institute, The University of Sydney, Camperdown, New South Wales, Australia
- * E-mail:
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Tsai YL, Chen CW, Cheng HC, Chang CH, Chen CY, Yang CM. Cognitive and behavioral factors in insomnia comorbid with depression and anxiety. Sleep Biol Rhythms 2013. [DOI: 10.1111/sbr.12030] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Yun-Lin Tsai
- Department of Health; Tsaotun Psychiatric Center; Nantou Taiwan
| | - Chang-Wei Chen
- Department of Psychology; National Chengchi University; Taipei Taiwan
| | - Hsiu-Chu Cheng
- Department of Health; Tsaotun Psychiatric Center; Nantou Taiwan
| | | | - Chung-Ying Chen
- Department of Health; Tsaotun Psychiatric Center; Nantou Taiwan
| | - Chien-Ming Yang
- Research Center for Mind, Brain & Learning; National Chengchi University; Taipei Taiwan
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21
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Hovland A, Pallesen S, Hammar A, Hansen AL, Thayer JF, Sivertsen B, Tarvainen MP, Nordhus IH. Subjective sleep quality in relation to inhibition and heart rate variability in patients with panic disorder. J Affect Disord 2013; 150:152-5. [PMID: 23347472 DOI: 10.1016/j.jad.2012.12.017] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2012] [Revised: 12/19/2012] [Accepted: 12/21/2012] [Indexed: 11/25/2022]
Abstract
BACKGROUND Patients with panic disorder (PD) are known to report impaired sleep quality and symptoms of insomnia. PD is an anxiety disorder characterised by deficient physiological regulation as measured by heart rate variability (HRV), and reduced HRV, PD and insomnia have all been related to impaired inhibitory ability. The present study aimed to investigate the interrelationships between subjectively reported sleep impairment, cognitive inhibition and vagally mediated HRV in a sample characterised by variability on measures of all these constructs. METHODS Thirty-six patients with PD with or without agoraphobia were included. Cognitive inhibition was assessed with the Color-Word Interference Test from the Delis-Kaplan Executive Function System (D-KEFS), HRV was measured using high frequency (HF) power (ms(2)), and subjectively reported sleep quality was measured with the Pittsburgh Sleep Quality Index (PSQI). RESULTS Cognitive inhibition was related to both Sleep latency and Sleep disturbances, whereas HRV was only related to Sleep disturbances. These relationships were significant also after controlling for depression. LIMITATIONS Correlational design. CONCLUSION Cognitive inhibition is related to key insomnia symptoms: sleep initiation and sleep maintenance. The data supports the psychobiological inhibition model of insomnia, and extends previous findings. Possible clinical implications of these findings are discussed.
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Affiliation(s)
- Anders Hovland
- Department of Clinical Psychology, University of Bergen, Norway.
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22
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Manglick M, Rajaratnam SM, Taffe J, Tonge B, Melvin G. Persistent sleep disturbance is associated with treatment response in adolescents with depression. Aust N Z J Psychiatry 2013; 47:556-63. [PMID: 23508680 DOI: 10.1177/0004867413481630] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Sleep disturbances are highly prevalent in adolescents with depressive disorders. To date there is limited evidence of the extent to which sleep disturbances are associated with treatment response in adolescents. This study aimed to examine the extent to which self-reported sleep disturbances are associated with treatment response in adolescents with depression. METHOD Sleep data were gathered from a sample of 166 adolescents (aged 12-18 years) with a diagnosis of a DSM-IV depressive disorder who underwent 3 months of treatment (psychosocial and/or pharmacotherapy (sertraline)) in community-based research programs. The subjective report of sleep disturbance within depressive disorders was assessed using the Kiddie Schedule for Affective Disorders and Schizophrenia for School Age Children at three time points: pre-treatment, post-treatment and 6-month follow-up. RESULTS Sixty-nine percent of participants had a sleep disturbance pre-treatment and approximately 75% of these participants had threshold symptoms. Threshold sleep disturbances that persisted from pre- to post-treatment assessments were positively associated with depression at the 6-month follow-up. An ordered logistic regression model controlling for gender, treatment group and comorbid anxiety estimated a 70% risk of depression or partial remission for those with persistent sleep disturbance. Treatment group, anxiety and gender generally had no significant effect on the relationship between sleep and depression. CONCLUSION Sleep disturbances were highly related to depressive state and were associated with poorer treatment response in adolescents with depression. These results provide a rationale for further exploration of sleep-related treatments for adolescents with depression. Knowledge of patient-reported persistent sleep disturbances can help clinicians to predict treatment outcomes and may direct them to augment treatment or focus on sleep-related treatment strategies.
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Affiliation(s)
- Maneesha Manglick
- Centre for Developmental Psychiatry and Psychology, School of Psychology and Psychiatry, Monash University, Notting Hill, Australia.
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23
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Plante DT, Frankenburg FR, Fitzmaurice GM, Zanarini MC. Relationship between sleep disturbance and recovery in patients with borderline personality disorder. J Psychosom Res 2013; 74:278-82. [PMID: 23497827 PMCID: PMC3603271 DOI: 10.1016/j.jpsychores.2013.01.006] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2012] [Revised: 01/14/2013] [Accepted: 01/15/2013] [Indexed: 12/01/2022]
Abstract
OBJECTIVE Patients with borderline personality disorder (BPD) frequently experience sleep disturbance, however, the role of sleep quality in the course of BPD is unknown. The purpose of this study was to evaluate the cross-sectional association between sleep quality and recovery status (symptomatic remission plus good concurrent psychosocial functioning) in a well-characterized cohort of patients with BPD to examine the role of sleep disturbance in the course of the disorder. METHODS 223 patients with BPD participating in the McLean Study of Adult Development (MSAD) were administered the Pittsburgh Sleep Quality Index (PSQI) as part of the 16-year follow-up wave. Sleep quality was compared between recovered (n=105) and non-recovered (n=118) BPD participants, including adjustment for age, sex, depression, anxiety, and primary sleep disorders. RESULTS Non-recovered BPD patients had significantly worse sleep quality than recovered BPD participants as measured by the global PSQI score (adjusted means 12.01 vs. 10.73, p=0.03). In addition, non-recovered BPD participants had longer sleep onset latency (adjusted means 39.20 vs. 28.11minutes, p=0.04), as well as increased odds of using sleeping medication (adjusted OR 1.49, p=0.009) and experiencing daytime dysfunction as a result of their sleep disturbance (adjusted OR 1.48, p=0.008). CONCLUSION These results demonstrate an association between subjective sleep disturbance and recovery status among BPD patients. Further research is indicated to evaluate the mechanisms underlying sleep disturbance in BPD, and whether treatment of sleep complaints improves the symptomatic and psychosocial course of the disorder.
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Affiliation(s)
- David T. Plante
- Department of Psychiatry, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Frances R. Frankenburg
- Laboratory for the Study of Adult Development, McLean Hospital, Belmont, MA
,Boston University School of Medicine
,Edith Nourse Rogers Memorial Veterans Hospital, Bedford, MA
| | - Garrett M. Fitzmaurice
- Department of Psychiatry, Harvard Medical School
,Laboratory for Psychiatric Biostatistics, McLean Hospital, Belmont, MA
,Department of Biostatistics, Harvard School of Public Health, Boston, MA
| | - Mary C. Zanarini
- Laboratory for the Study of Adult Development, McLean Hospital, Belmont, MA
,Department of Psychiatry, Harvard Medical School
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St-Amand J, Provencher MD, Bélanger L, Morin CM. Sleep disturbances in bipolar disorder during remission. J Affect Disord 2013; 146:112-9. [PMID: 22884237 DOI: 10.1016/j.jad.2012.05.057] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2012] [Revised: 05/29/2012] [Accepted: 05/30/2012] [Indexed: 11/29/2022]
Abstract
BACKGROUND While sleep disturbances associated with bipolar disorder's depression and mania phases are well documented, the literature regarding sleep during remission phases is less consistent. The present study's aim was to describe the nature and severity of sleep difficulties in individuals with bipolar disorder (BD) during remission phases. METHODS Fourteen participants with BD were compared to 13 participants with primary insomnia and 13 without mental health disorders or insomnia on different sleep and daytime functioning parameters using actigraphy, sleep diaries and self-report measures. RESULTS Results suggest that sleep of individuals with BD was similar to that of individuals without mental health disorders or insomnia, but differed from that of individuals with insomnia. Nevertheless, participants with BD still presented sleep complaints and, like individuals with insomnia, were less active in the daytime, carried on their daily activities at more variable times from day to day, and reported more daytime sleepiness. LIMITATIONS Patients were taking medications and the limited sample size did not permit comparison of sleep parameters between bipolar I and bipolar II patients. CONCLUSIONS Psychological interventions aimed at encouraging the adoption of more stable sleep and daily routines might be helpful in helping individuals with BD cope more efficiently with some of these complaints.
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Affiliation(s)
- Julie St-Amand
- École de psychologie, 2325, rue des Bibliothèques, Université Laval, Québec, Canada G1V 0A6
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Abstract
Sleep disorders in the menopause are common. Although these disorders may be due to the menopause itself and/or the associated vasomotor symptoms, the etiology is multifactorial and includes a number of other associated conditions. They may simply arise as part of the aging process and not be specifically related to the decrease in estrogen levels or, alternatively, because of breathing or limb movement syndromes, depression, anxiety, co-morbid medical diseases, medication, pain and/or psychosocial factors. The most commonly encountered sleep disorders in menopausal women include insomnia, nocturnal breathing disturbances and the associated sleep disorders that accompany the restless leg syndrome, periodic leg movement syndrome, depression and anxiety. This review article addresses sleep and the sleep disorders associated with menopause and briefly the role that hormone therapy may play in alleviating these disorders.
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Affiliation(s)
- F Guidozzi
- Department of Obstetrics and Gynaecology, Charlotte Maxeke Johannesburg Academic Hospital, University of the Witwatersrand, Johannesburg, South Africa
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Abstract
Insomnia is one of the most common sleep disorders, which is characterized by nocturnal symptoms of difficulties initiating and/or maintaining sleep, and by daytime symptoms that impair occupational, social, or other areas of functioning. Insomnia disorder can exist alone or in conjunction with comorbid medical and/or psychiatric conditions. The incidence of insomnia is higher in women and can increase during certain junctures of a woman's life (e.g., pregnancy, postpartum, and menopause). This article will focus on an overview of cognitive behavioral therapy for insomnia, evidence of effectiveness for this treatment when insomnia disorder is experienced alone or in parallel with a comorbidity, and a review with promising data on the use of cognitive behavioral therapy for insomnia when present during postpartum and menopause.
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Affiliation(s)
- Allison T Siebern
- Stanford University School of Medicine, Sleep Medicine Center, Redwood City, California 94063, USA.
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27
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Chan AS, Wong QY, Sze SL, Kwong PPK, Han YMY, Cheung MC. A Chinese chan-based mind-body intervention improves sleep on patients with depression: a randomized controlled trial. ScientificWorldJournal 2012; 2012:235206. [PMID: 22623888 PMCID: PMC3353275 DOI: 10.1100/2012/235206] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2011] [Accepted: 12/25/2011] [Indexed: 11/17/2022] Open
Abstract
Sleep disturbance is a common problem associated with depression, and cognitive-behavioral therapy (CBT) is a more common behavioral intervention for sleep problems. The present study compares the effect of a newly developed Chinese Chan-based intervention, namely Dejian mind-body intervention (DMBI), with the CBT on improving sleep problems of patients with depression. Seventy-five participants diagnosed with major depressive disorder were randomly assigned to receive 10 weekly sessions of CBT or DMBI, or placed on a waitlist. Measurements included ratings by psychiatrists who were blinded to the experimental design, and a standardized questionnaire on sleep quantity and quality was obtained before and after the 10-week intervention. Results indicated that both the CBT and DMBI groups demonstrated significantly reduced sleep onset latency and wake time after sleep onset (effect size range = 0.46-1.0, P ≤ 0.05) as compared to nonsignificant changes in the waitlist group (P > 0.1). Furthermore, the DMBI group, but not the CBT or waitlist groups, demonstrated significantly reduced psychiatrist ratings on overall sleep problems (effect size = 1.0, P = 0.00) and improved total sleep time (effect size = 0.8, P = 0.05) after treatment. The present findings suggest that a Chinese Chan-based mind-body intervention has positive effects on improving sleep in individuals with depression.
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Affiliation(s)
- Agnes S Chan
- Department of Psychology, The Chinese University of Hong Kong, Shatin, New Territories, Hong Kong.
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Schuman CC, Attarian HP. Integrating Sleep Management into Clinical Practice. J Clin Psychol Med Settings 2012; 19:65-76. [DOI: 10.1007/s10880-012-9297-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
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Lin CM, Huang YS, Guilleminault C. Pharmacotherapy of obstructive sleep apnea. Expert Opin Pharmacother 2012; 13:841-57. [DOI: 10.1517/14656566.2012.666525] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Pigeon WR, Cerulli C, Richards H, He H, Perlis M, Caine E. Sleep disturbances and their association with mental health among women exposed to intimate partner violence. J Womens Health (Larchmt) 2011; 20:1923-9. [PMID: 21988551 DOI: 10.1089/jwh.2011.2781] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022] Open
Abstract
BACKGROUND Intimate partner violence puts the victim at risk for substantial medical and psychiatric morbidity. As with other stress- and trauma-related experiences, intimate partner violence is associated with sleep disturbance, particularly insomnia and nightmares. This association, however, has not been well characterized in terms of general prevalence or its further relationship with depression, suicidality, and posttraumatic stress disorder (PTSD). METHODS The present study used validated instruments to characterize insomnia and nightmares among 121 women exposed to intimate partner violence. Participants with and without depression were compared on demographic, abuse, and sleep characteristics as were those with and without suicidality. Logistic regression models were constructed to test sleep variables as independent predictors of depression controlling for demographic factors, abuse severity, and PTSD severity. RESULTS Clinically significant insomnia and nightmares were observed in 46% and 32% of participants, respectively. Depressed women had more severe PTSD and were more likely to have insomnia and to have nightmares than nondepressed women. In models controlling for PTSD severity, the presence of insomnia was associated with an approximately eightfold greater risk of being depressed; nightmares were associated with a twofold increase in risk. CONCLUSIONS Sleep disturbances were prevalent among women experiencing intimate partner violence, with both insomnia and nightmares predicting the presence of depression even after controlling for PTSD severity. In addition to the need to address common mental health issues such as depression, given that sleep problems are modifiable and potentially less stigmatizing than mental health problems, assessing and addressing insomnia and nightmares in survivors of interpersonal violence warrants strong clinical consideration and further investigation.
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Affiliation(s)
- Wilfred R Pigeon
- Center of Excellence for Suicide Prevention, Canandaigua VA Medical Center, Canandaigua, New York, USA.
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Belleville G, Cousineau H, Levrier K, St-Pierre-Delorme MÈ. Meta-analytic review of the impact of cognitive-behavior therapy for insomnia on concomitant anxiety. Clin Psychol Rev 2011; 31:638-52. [PMID: 21482322 DOI: 10.1016/j.cpr.2011.02.004] [Citation(s) in RCA: 130] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2010] [Revised: 02/07/2011] [Accepted: 02/08/2011] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Concomitant anxiety and insomnia is a frequent problem encountered by mental health professionals. PRIMARY OBJECTIVE To assess the impact of cognitive-behavior therapy for insomnia (CBT-I) on associated anxiety. METHOD Systematic search for clinical trials of CBT-I in PsycInfo, Medline, and Proquest Dissertations and Theses. RESULTS Of the 216 CBT-I trials reviewed, 72 (33.3%) reported data on anxiety. The combined effect size (ES) of CBT-I on anxiety was 0.406 [95% CI 0.318-0.493], indicating a small to moderate effect of CBT-I on concomitant anxiety. Anxiety and anxiety-related constructs were measured with 31 different questionnaires or questionnaire subscales, the majority of which were used only once in the sample of studies. CONCLUSIONS CBT-I has only a moderate impact on anxiety in individuals who present insomnia with or without a comorbid anxiety disorder. A careful evaluation of residual anxiety should be conducted subsequent to CBT-I. Further research should focus on standardizing the assessment of anxiety in insomnia research.
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Affiliation(s)
- Geneviève Belleville
- École de Psychologie, Université Laval, Pavillon Félix-Antoine-Savard, Québec, Canada .
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Abstract
INTRODUCTION Insomnia symptoms, which are common in depression, have a significant impact on function and quality of life. However, little is known about the prevalence and associated features of insomnia symptoms in representative treatment-seeking patients with depression. METHODS Data from the Sequenced Treatment Alternatives to Relieve Depression (STAR*D) trial were analyzed. STAR*D recruited 3,743 adult outpatients diagnosed with nonpsychotic major depressive disorder (MDD) from primary (n=18) and psychiatric care (n=23) clinics across the United States. Baseline sociodemographic and clinical features were compared between those with insomnia symptoms (84.7%) and those without (15.3%). RESULTS The most common presentation was the simultaneous presence of sleep onset, mid-nocturnal, and early morning insomnia symptoms (27.1%). Of these three types of insomnia symptoms, mid-nocturnal insomnia symptoms were the most commonly found alone (13.5%) and in combination with one or more other types (82.3%). Insomnia symptoms were associated with several indicators of a more severe depressive illness. Only a small proportion of participants with insomnia symptoms were receiving treatment for sleep disturbances at study initiation, and the vast majority of those receiving treatment still reported having insomnia symptoms. CONCLUSION In outpatients who seek treatment for nonpsychotic MDD in typical clinical settings, insomnia symptoms are very common, undertreated, and indicative of a more severe depression.
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Tranah GJ, Parimi N, Blackwell T, Ancoli-Israel S, Ensrud KE, Cauley JA, Redline S, Lane N, Paudel ML, Hillier TA, Yaffe K, Cummings SR, Stone KL. Postmenopausal hormones and sleep quality in the elderly: a population based study. BMC WOMENS HEALTH 2010; 10:15. [PMID: 20441593 PMCID: PMC2876067 DOI: 10.1186/1472-6874-10-15] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 07/28/2009] [Accepted: 05/04/2010] [Indexed: 11/10/2022]
Abstract
Background Sleep disturbance and insomnia are commonly reported by postmenopausal women. However, the relationship between hormone therapy (HT) and sleep disturbances in postmenopausal community-dwelling adults is understudied. Using data from the multicenter Study of Osteoporotic Fractures (SOF), we tested the relationship between HT and sleep-wake estimated from actigraphy. Methods Sleep-wake was ascertained by wrist actigraphy in 3,123 women aged 84 ± 4 years (range 77-99) from the Study of Osteoporotic Fractures (SOF). This sample represents 30% of the original SOF study and 64% of participants seen at this visit. Data were collected for a mean of 4 consecutive 24-hour periods. Sleep parameters measured objectively included total sleep time, sleep efficiency (SE), sleep latency, wake after sleep onset (WASO), and nap time. All analyses were adjusted for potential confounders (age, clinic site, race, BMI, cognitive function, physical activity, depression, anxiety, education, marital status, age at menopause, alcohol use, prior hysterectomy, and medical conditions). Results Actigraphy measurements were available for 424 current, 1,289 past, and 1,410 never users of HT. Women currently using HT had a shorter WASO time (76 vs. 82 minutes, P = 0.03) and fewer long-wake (≥ 5 minutes) episodes (6.5 vs. 7.1, P = 0.004) than never users. Past HT users had longer total sleep time than never users (413 vs. 403 minutes, P = 0.002). Women who never used HT had elevated odds of SE <70% (OR,1.37;95%CI,0.98-1.92) and significantly higher odds of WASO ≥ 90 minutes (OR,1.37;95%CI,1.02-1.83) and ≥ 8 long-wake episodes (OR,1.58;95%CI,1.18-2.12) when compared to current HT users. Conclusions Postmenopausal women currently using HT had improved sleep quality for two out of five objective measures: shorter WASO and fewer long-wake episodes. The mechanism behind these associations is not clear. For postmenopausal women, starting HT use should be considered carefully in balance with other risks since the vascular side-effects of hormone replacement may exceed its beneficial effects on sleep.
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Matteson-Rusby SE, Pigeon WR, Gehrman P, Perlis ML. Why treat insomnia? PRIMARY CARE COMPANION TO THE JOURNAL OF CLINICAL PSYCHIATRY 2010; 12:PCC.08r00743. [PMID: 20582296 PMCID: PMC2882812 DOI: 10.4088/pcc.08r00743bro] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/11/2008] [Accepted: 03/06/2009] [Indexed: 10/19/2022]
Abstract
OBJECTIVE To make the case that insomnia is better conceptualized, not as a symptom, but as a primary disorder. DATA SOURCES PubMed was searched from 1975-2009 using the search terms insomnia, insomnia and treatment, insomnia and cost, and insomnia and treatment and safety. STUDY SELECTION English-language articles and other materials were selected to address the following claims: insomnia is unremitting, insomnia is disabling, insomnia is costly, insomnia is pervasive, insomnia is pernicious, and insomnia treatment is safe and effective. DATA EXTRACTION/SYNTHESIS Insomnia, at least when chronic, should be conceptualized as a comorbid condition, one for which effective interventions are available. CONCLUSIONS It is speculated that treatment for insomnia will only become the norm when it has been demonstrated that treatment not only addresses the problem of insomnia but also serves to reduce medical and psychiatric morbidity. At that time, the question will no longer be "Why treat insomnia?" but instead "When isn't insomnia treatment indicated?"
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Affiliation(s)
- Sara E Matteson-Rusby
- Sleep and Neurophysiology Research Laboratory, Department of Psychiatry, University of Rochester, New York and Behavioral Sleep Medicine, Department of Psychiatry, University of Pennsylvania, Philadelphia
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Pigeon WR, May PE, Perlis ML, Ward EA, Lu N, Talbot NL. The effect of interpersonal psychotherapy for depression on insomnia symptoms in a cohort of women with sexual abuse histories. J Trauma Stress 2009; 22:634-8. [PMID: 19885874 PMCID: PMC2798908 DOI: 10.1002/jts.20456] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Insomnia frequently occurs with trauma exposure and depression, but can ameliorate with improvements in depression. Insomnia was assessed by the insomnia subscale of the Hamilton Rating Scale for Depression in 106 women with childhood sexual abuse (CSA) and major depression receiving interpersonal psychotherapy (IPT) in an uncontrolled pilot (n = 36) and an immediately subsequent randomized controlled trial (n = 70) comparing IPT to treatment as usual. Depression improved in each study and in both treatment conditions; insomnia had smaller, nonsignificant improvements. Overall, 95 women (90%) endorsed insomnia on the Structured Clinical Interview for DSM-IV at baseline and, of those, 90% endorsed insomnia following treatment. Despite improvements in depression, insomnia persists for most women with CSA.
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Affiliation(s)
- Wilfred R. Pigeon
- Department of Psychiatry, University of Rochester Medical Center, Rochester, New York, USA
| | - Pamela E. May
- Department of Psychiatry, University of Rochester Medical Center, Rochester, New York, USA
| | - Michael L. Perlis
- Department of Psychiatry, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Erin A. Ward
- Department of Psychiatry, University of Rochester Medical Center, Rochester, New York, USA
| | - Naiji Lu
- Department of Psychiatry, University of Rochester Medical Center, Rochester, New York, USA
| | - Nancy L. Talbot
- Department of Psychiatry, University of Rochester Medical Center, Rochester, New York, USA
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Staner L. Comorbidity of insomnia and depression. Sleep Med Rev 2009; 14:35-46. [PMID: 19939713 DOI: 10.1016/j.smrv.2009.09.003] [Citation(s) in RCA: 301] [Impact Index Per Article: 20.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2009] [Revised: 09/08/2009] [Accepted: 09/09/2009] [Indexed: 12/18/2022]
Abstract
During the last decade, several studies have shown that insomnia, rather than a symptom of depression, could be a medical condition on its own, showing high comorbidity with depression. Epidemiological research indicates that insomnia could lead to depression and/or that common causalities underlie the two disorders. Neurobiological and sleep EEG studies suggest that a heightened level of arousal may play a common role in both conditions and that signs of REM sleep disinhibition may appear in individuals prone to depression. The effects of antidepressant drugs on non-REM and REM sleep are discussed in relation to their use in insomnia comorbid with depression. Empirical treatment approaches are behavioral management of sleep combined with prescription of a sedative antidepressant alone, co-prescription of two antidepressants, or of an antidepressant with a hypnotic drug.
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Affiliation(s)
- Luc Staner
- Sleep Laboratory, Forenap, Centre Hospitalier de Rouffach, 27 rue du 4ème R.S.M. F-68250 Rouffach, France.
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Parikh SV, Segal ZV, Grigoriadis S, Ravindran AV, Kennedy SH, Lam RW, Patten SB. Canadian Network for Mood and Anxiety Treatments (CANMAT) clinical guidelines for the management of major depressive disorder in adults. II. Psychotherapy alone or in combination with antidepressant medication. J Affect Disord 2009; 117 Suppl 1:S15-25. [PMID: 19682749 DOI: 10.1016/j.jad.2009.06.042] [Citation(s) in RCA: 124] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2009] [Accepted: 06/23/2009] [Indexed: 11/24/2022]
Abstract
BACKGROUND In 2001, the Canadian Psychiatric Association and the Canadian Network for Mood and Anxiety Treatments (CANMAT) partnered to produce evidence-based clinical guidelines for the treatment of depressive disorders. A revision of these guidelines was undertaken by CANMAT in 2008-2009 to reflect advances in the field. This article, one of five in the series, reviews new studies of psychotherapy in the acute and maintenance phase of MDD, including computer-based and telephone-delivered psychotherapy. METHODS The CANMAT guidelines are based on a question-answer format to enhance accessibility to clinicians. Evidence-based responses are based on updated systematic reviews of the literature and recommendations are graded according to the Level of Evidence, using pre-defined criteria. Lines of Treatment are identified based on criteria that included evidence and expert clinical support. RESULTS Cognitive-Behavioural Therapy (CBT) and Interpersonal Therapy (IPT) continue to have the most evidence for efficacy, both in acute and maintenance phases of MDD, and have been studied in combination with antidepressants. CBT is well studied in conjunction with computer-delivered methods and bibliotherapy. Behavioural Activation and Cognitive-Behavioural Analysis System of Psychotherapy have significant evidence, but need replication. Newer psychotherapies including Acceptance and Commitment Therapy, Motivational Interviewing, and Mindfulness-Based Cognitive Therapy do not yet have significant evidence as acute treatments; nor does psychodynamic therapy. LIMITATIONS Although many forms of psychotherapy have been studied, relatively few types have been evaluated for MDD in randomized controlled trials. Evidence about the combination of different types of psychotherapy and antidepressant medication is also limited despite widespread use of these therapies concomitantly. CONCLUSIONS CBT and IPT are the only first-line treatment recommendations for acute MDD and remain highly recommended for maintenance. Both computer-based and telephone-delivered psychotherapy--primarily studied with CBT and IPT--are useful second-line recommendations. Where feasible, combined antidepressant and CBT or IPT are recommended as first-line treatments for acute MDD.
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Abstract
Sleep complaints are a common occurrence in pregnancy that are in part due to pregnancy-associated anatomic and physiological changes but may also be due to pathological causes. In the non-pregnant population, sleep deprivation has been associated with physical and cognitive issues; poor sleep may even be associated with adverse maternal outcomes. Maternal obesity, one of the most prevalent risk factors in obstetric practices, together with physiologic changes of pregnancy predispose to the development of sleep disordered breathing. Symptoms of sleep disordered breathing have also been associated with poor maternal outcomes. Management options of restless legs syndrome and narcolepsy pose a challenge in pregnancy; benefits of therapy need to be weighed against the potential harm to the fetus. This article briefly reviews the normal changes in pregnancy affecting sleep, gives an overview of certain sleep disorders occurring in pregnancy, and suggests management options specific for this population.
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Affiliation(s)
- Ghada Bourjeily
- Warren Alpert Medical School of Brown University , Pulmonary and Critical Care Medicine, Women & Infants Hospital, Providence, RI 02905 , USA
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Abstract
The almost ubiquitous sleep disturbances in patients with depression commonly, but not always, subside with the remission of depression. Evidence linking insomnia with the risk of relapses in recurrent depression, as well as suicide, makes optimization of the treatment of insomnia associated with depression a priority. However, most antidepressant agents do not adequately address the sleep complaints in depression: their effects on sleep range from sizeable improvement to equally significant worsening. One approach to the management of insomnia associated with depression is to choose a sedating antidepressant agent such as trazodone, mirtazapine or agomelatine. A second approach is to start with a non-sedating antidepressant (e.g. the selective serotonin reuptake inhibitors, bupropion, venlafaxine or duloxetine); those with a persistent or treatment-emergent insomnia can be switched to a more sedating antidepressant, or offered a hypnotic or cognitive-behavioural therapy as adjunctive treatment. The review discusses the advantages and disadvantages of all treatment options, pharmacological and otherwise.
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Affiliation(s)
- Ripu D Jindal
- University of Ottawa School of Medicine, Ottawa, Ontario, Canada.
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Frenette E, Guilleminault C. NEUROHORMONES AND SLEEP. Continuum (Minneap Minn) 2009. [DOI: 10.1212/01.con.0000300027.22909.c4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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Franzen PL, Buysse DJ. Sleep disturbances and depression: risk relationships for subsequent depression and therapeutic implications. DIALOGUES IN CLINICAL NEUROSCIENCE 2009. [PMID: 19170404 PMCID: PMC3108260 DOI: 10.31887/dcns.2008.10.4/plfranzen] [Citation(s) in RCA: 423] [Impact Index Per Article: 28.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The majority of individuals with depression experience sleep disturbances. Depression is also over-represented among populations with a variety of sleep disorders. Although sleep disturbances are typical features of depression, such symptoms sometimes appear prior to an episode of depression. The bidirectional associations between sleep disturbance (especially insomnia) and depression increase the difficulty of differentiating cause-and-effect relationships between them. Longitudinal studies have consistently identified insomnia as a risk factor for the development of a new-onset or recurrent depression, and this association has been identified in young, middle-aged, and older adults. Studies have also observed that the combination of insomnia and depression influences the trajectory of depression, increasing episode severity and duration as well as relapse rates. Fortunately, recent studies have demonstrated that both pharmacological and nonpharmacological interventions for insomnia may favorably reduce and possibly prevent depression. Together, these findings suggest that sleep-related symptoms that are present before, during, andlor after a depressive episode are potentially modifiable factors that may play an important role in achieving and maintaining depression remission.
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Affiliation(s)
- Peter L Franzen
- Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
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Jayaraman G, Sharafkhaneh H, Hirshkowitz M, Sharafkhaneh A. Pharmacotherapy of obstructive sleep apnea. Ther Adv Respir Dis 2009; 2:375-86. [PMID: 19124383 DOI: 10.1177/1753465808098225] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Obstructive sleep apnea (OSA) is associated with serious comorbid illnesses and diminished quality of life. At this time, continuous positive airway pressure (CPAP) therapy is the treatment of choice. However, only half of those individuals who accept CPAP are still using it at the end of one year. Furthermore, efficacy for improving self-reported sleepiness appears to be greater for patients with severe sleep apnea and severe sleepiness than other patient groups. Some patients, notwithstanding optimized therapy and therapeutic adherence continue experiencing excessive daytime somnolence. Consequently, other treatment modalities have developed, including oral appliances, surgery and pharmacotherapy. It is widely believed, albeit not empirically demonstrated, that an effective medication to treat OSA would elicit better acceptance and adherence than having to use a machine for many hours on a nightly basis. Nonetheless, paucity of data (i.e. lack of large-scale randomized controlled trials), variability of perceived and actual benefits, and adverse side-effects of the drugs thus far tested have prevented the use of pharmacotherapy until now. In this paper we review the outcome data from published trials designed to evaluate efficacy and safety of various medications proposed for treating obstructive sleep apnea.
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Affiliation(s)
- Gnananadh Jayaraman
- Department of Medicine, Baylor College of Medicine and Michael E. DeBakey VA Medical Center, Houston, TX, USA
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Manber R, Edinger JD, Gress JL, San Pedro-Salcedo MG, Kuo TF, Kalista T. Cognitive behavioral therapy for insomnia enhances depression outcome in patients with comorbid major depressive disorder and insomnia. Sleep 2008; 31:489-95. [PMID: 18457236 DOI: 10.1093/sleep/31.4.489] [Citation(s) in RCA: 560] [Impact Index Per Article: 35.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
STUDY OBJECTIVE Insomnia impacts the course of major depressive disorder (MDD), hinders response to treatment, and increases risk for depressive relapse. This study is an initial evaluation of adding cognitive behavioral therapy for insomnia (CBTI) to the antidepressant medication escitalopram (EsCIT) in individuals with both disorders. DESIGN AND SETTING A randomized, controlled, pilot study in a single academic medical center. PARTICIPANTS 30 individuals (61% female, mean age 35 +/- 18) with MDD and insomnia. INTERVENTIONS EsCIT and 7 individual therapy sessions of CBTI or CTRL (quasi-desensitization). MEASUREMENTS AND RESULTS Depression was assessed with the HRSD17 and the depression portion of the SCID, administered by raters masked to treatment assignment, at baseline and after 2, 4, 6, 8, and 12 weeks of treatment. The primary outcome was remission of MDD at study exit, which required both an HRSD17 score < or =7 and absence of the 2 core symptoms of MDD. Sleep was assessed with the insomnia severity index (ISI), daily sleep diaries, and actigraphy. EsCIT + CBTI resulted in a higher rate of remission of depression (61.5%) than EsCIT + CTRL (33.3%). EsCIT + CBTI was also associated with a greater remission from insomnia (50.0%) than EsCIT + CTRL (7.7%) and larger improvement in all diary and actigraphy measures of sleep, except for total sleep time. CONCLUSIONS This pilot study provides evidence that augmenting an antidepressant medication with a brief, symptom focused, cognitive-behavioral therapy for insomnia is promising for individuals with MDD and comorbid insomnia in terms of alleviating both depression and insomnia.
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Affiliation(s)
- Rachel Manber
- Department of Psychiatry and Behavioral Sciences, Stanford University, 401 Quarry Rd., Stanford, CA 94305, USA.
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Pigeon WR, Hegel M, Unützer J, Fan MY, Sateia MJ, Lyness JM, Phillips C, Perlis ML. Is insomnia a perpetuating factor for late-life depression in the IMPACT cohort? Sleep 2008; 31:481-8. [PMID: 18457235 DOI: 10.1093/sleep/31.4.481] [Citation(s) in RCA: 189] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
STUDY OBJECTIVES Insomnia and depressive disorders are significant health problems in the elderly. Persistent insomnia is a risk factor for the development of new-onset and recurrent major depressive disorder (MDD). Less clear is whether persistent insomnia may perpetuate MDD andlor dysthymia. The present longitudinal study examines the relationship of insomnia to the continuation of depression in the context of an intervention study in elderly subjects. DESIGN Data were drawn from Project IMPACT, a multisite intervention study, which enrolled 1801 elderly patients with MDD and/or dysthymia. In the current study, subjects were assigned to an insomnia-status group (Persistent, Intermediate, and No Insomnia) based on insomnia scores at both baseline and 3-month time points. Logistic regressions were conducted to determine whether Persistent Insomnia was prospectively associated with increased risk of remaining depressed and/or achieving a less than 50% clinical improvement at 6 and at 12 months compared with the No Insomnia reference group. The Intermediate Insomnia group was compared with the other 2 groups to determine whether a dose-response relationship existed between insomnia type and subsequent depression. SETTING Eighteen primary clinics in 5 states. PARTICIPANTS Older adults (60+) with depression. MEASUREMENTS AND RESULTS Overall, patients with persistent insomnia were 1.8 to 3.5 times more likely to remain depressed, compared with patients with no insomnia. The findings were more robust in patients receiving usual care for depression than in patients receiving enhanced care. Findings were also more robust in subjects who had MDD as opposed to those with dysthymia alone. CONCLUSIONS These findings suggest that, in addition to being a risk factor for a depressive episode, persistent insomnia may serve to perpetuate the illness in some elderly patients and especially in those receiving standard care for depression in primary care settings. Enhanced depression care may partially mitigate the perpetuating effects of insomnia on depression.
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Affiliation(s)
- Wilfred R Pigeon
- Department of Psychiatry, University of Rochester Medical Center, Rochester NY, USA.
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Dombrovski AY, Cyranowski JM, Mulsant BH, Houck PR, Buysse DJ, Andreescu C, Thase ME, Mallinger AG, Frank E. Which symptoms predict recurrence of depression in women treated with maintenance interpersonal psychotherapy? Depress Anxiety 2008; 25:1060-6. [PMID: 18781665 PMCID: PMC2705944 DOI: 10.1002/da.20467] [Citation(s) in RCA: 87] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
BACKGROUND Even low levels of residual symptoms are known to increase the risk of relapse and early recurrence of major depression. It is not known if ongoing psychotherapy lessens this risk. We therefore examined the impact of persistent symptoms, including mood, insomnia, and anxiety symptoms, on time to recurrence in women receiving maintenance interpersonal psychotherapy (IPT-M) for recurrent depression. METHODS We analyzed data on 131 women aged 20-60 from a 2-year randomized trial of weekly versus twice-monthly versus monthly IPT-M. Participants achieved remission with IPT alone (n=99) or IPT plus sequential antidepressant medication (n=32). Medications were tapered before starting maintenance treatment. Residual symptoms were assessed with the Hamilton Rating Scale for Depression (HRSD; total score and subscales); insomnia was also assessed in 76 women with the Pittsburgh Sleep Quality Index (PSQI). Data analyses used Cox proportional hazards regression models. RESULTS Neither overall burden of residual symptoms (HRSD total score), nor HRSD mood and anxiety subscale scores predicted recurrence during ongoing IPT-M. In contrast, persistent insomnia measured both by the HRSD-17 insomnia subscale and the PSQI predicted recurrence. Women with persistent insomnia who required sequential pharamacotherapy had the highest recurrence rate (65%) compared to women requiring sequential treatment without insomnia (13%), or women who had recovered with IPT alone but had persistent insomnia (21%) or no insomnia (18%). CONCLUSIONS Persistent insomnia following the recovery from an episode of recurrent major depression is associated with increased risk of recurrence despite maintenance psychotherapy, particularly for those withdrawn from antidepressant medication.
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Affiliation(s)
- Alexandre Y. Dombrovski
- Western Psychiatric Institute and Clinic, Department of Psychiatry, University of Pittsburgh School of Medicine
| | - Jill M. Cyranowski
- Western Psychiatric Institute and Clinic, Department of Psychiatry, University of Pittsburgh School of Medicine
| | - Benoit H. Mulsant
- Western Psychiatric Institute and Clinic, Department of Psychiatry, University of Pittsburgh School of Medicine,Centre for Addictions and Mental Health, and Department of Psychiatry, University of Toronto
| | - Patricia R. Houck
- Western Psychiatric Institute and Clinic, Department of Psychiatry, University of Pittsburgh School of Medicine
| | - Daniel J. Buysse
- Western Psychiatric Institute and Clinic, Department of Psychiatry, University of Pittsburgh School of Medicine
| | - Carmen Andreescu
- Western Psychiatric Institute and Clinic, Department of Psychiatry, University of Pittsburgh School of Medicine
| | - Michael E. Thase
- Western Psychiatric Institute and Clinic, Department of Psychiatry, University of Pittsburgh School of Medicine,Department of Psychiatry, University of Pennsylvania School of Medicine,Philadelphia Veterans Affairs Medical Center
| | - Alan G. Mallinger
- Western Psychiatric Institute and Clinic, Department of Psychiatry, University of Pittsburgh School of Medicine,Mood and Anxiety Disorders Program, National Institutes of Health Intramural Research Program, Bethesda, Maryland
| | - Ellen Frank
- Western Psychiatric Institute and Clinic, Department of Psychiatry, University of Pittsburgh School of Medicine
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Dombrovski AY, Mulsant BH, Houck PR, Mazumdar S, Lenze EJ, Andreescu C, Cyranowski JM, Reynolds CF. Residual symptoms and recurrence during maintenance treatment of late-life depression. J Affect Disord 2007; 103:77-82. [PMID: 17321595 PMCID: PMC2680091 DOI: 10.1016/j.jad.2007.01.020] [Citation(s) in RCA: 103] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2006] [Revised: 12/07/2006] [Accepted: 01/04/2007] [Indexed: 10/23/2022]
Abstract
BACKGROUND Many older patients who recover from an episode of major depression continue to suffer from depressed mood, anxiety, and sleep problems. Our study assesses the impact of these residual symptoms on the risk of recurrence during maintenance treatment of late-life depression. METHOD We analyzed data from a randomized clinical trial of maintenance treatment in patients with unipolar depression aged > or =70, 116 of whom remitted and remained stable during open pharmacotherapy and interpersonal psychotherapy (IPT) and were randomized to clinical management/pharmacotherapy; clinical management/placebo; monthly maintenance IPT/ pharmacotherapy; or monthly maintenance IPT/placebo. We assessed the impact of overall residual symptoms (based on the Hamilton Depression Rating Scale (HAM-D) total score) and of specific residual symptom clusters - mood symptoms (depressed mood, guilt, suicidality, energy/interests), sleep disturbance (early, middle, late insomnia), and anxiety (agitation, psychic and somatic anxiety, hypochondriasis) measured at randomization. Sleep disturbance was also assessed with the Pittsburgh Sleep Quality Index (PSQI). We used Cox proportional hazards regression models controlling for assignment to antidepressant medication versus placebo to identify predictors of recurrence. RESULTS Residual anxiety and residual sleep disturbance (as measured by the PSQI but not the HAM-D) independently predicted early recurrence. LIMITATIONS Use of HAM-D clusters to define residual symptoms; analysis limited to completers of acute and continuation treatment. CONCLUSIONS In patients with late-life depression who have remitted with pharmacotherapy and psychotherapy, the deleterious effect of residual symptoms is due to persisting anxiety and, possibly, residual sleep disturbance.
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Affiliation(s)
- Alexandre Y. Dombrovski
- Western Psychiatric Institute and Clinic, Department of Psychiatry, University of Pittsburgh School of Medicine
| | - Benoit H. Mulsant
- Western Psychiatric Institute and Clinic, Department of Psychiatry, University of Pittsburgh School of Medicine
- Centre for Addictions and Mental Health, and Department of Psychiatry, University of Toronto
| | - Patricia R. Houck
- Western Psychiatric Institute and Clinic, Department of Psychiatry, University of Pittsburgh School of Medicine
| | - Sati Mazumdar
- Department of Biostatistics, Graduate School of Public Health, University of Pittsburgh
| | - Eric J. Lenze
- Western Psychiatric Institute and Clinic, Department of Psychiatry, University of Pittsburgh School of Medicine
| | - Carmen Andreescu
- Western Psychiatric Institute and Clinic, Department of Psychiatry, University of Pittsburgh School of Medicine
| | - Jill M. Cyranowski
- Western Psychiatric Institute and Clinic, Department of Psychiatry, University of Pittsburgh School of Medicine
| | - Charles F. Reynolds
- Western Psychiatric Institute and Clinic, Department of Psychiatry, University of Pittsburgh School of Medicine
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Chakraborti A, Gulati K, Ray A. Estrogen Actions on Brain and Behavior: Recent Insights and Future Challenges. Rev Neurosci 2007; 18:395-416. [DOI: 10.1515/revneuro.2007.18.5.395] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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Abstract
This review examines the relationship between sleep and depression. Most depressive disorders are characterized by subjective sleep disturbances, and the regulation of sleep is intricately linked to the same mechanisms that are implicated in the pathophysiology of depression. After briefly reviewing the physiology and topography of normal sleep, the disturbances revealed in studies of sleep in depression using polysomnographic recordings and neuroimaging assessments are discussed. Next, treatment implications of the disturbances are reviewed at both clinical and neuro-biologic levels. Most antidepressant medications suppress rapid eye movement (REM) sleep, although this effect is neither necessary nor sufficient for clinical efficacy. Effects on patients' difficulties initiating and maintaining sleep are more specific to particular types of antidepressants. Ideally, an effective antidepressant will result in normalization of disturbed sleep in concert with resolution of the depressive syndrome, although few interventions actually restore decreased slow-wave sleep. Antidepressants that block central histamine 1 and serotonin 2 tend to have stronger effects on sleep maintenance, but are also prone to elicit complaints of daytime sedation. Adjunctive treatment with sedative hypnotic medications-primarily potent, shorter-acting benzodiazepine and γ-aminobutyric acid (GABA A)-selective compounds such as zolpidem-are often used to treat associated insomnia more rapidly. Cognitive behavioral therapy and other nonpharmacologic strategies are also helpful.
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Abstract
Obstructive sleep apnea (OSA) is a highly significant condition based both on the high prevalence in community and significant consequences. Obstructive sleep apnea syndrome (OSAS), OSA together with hypersomnolence, is seen in 4% of middle-aged men and 2% of middle-aged women. OSA is associated with impaired quality of life and increased risks of motor vehicle accidents, cardiovascular disease (including hypertension and coronary artery disease), and metabolic syndrome. There is some evidence for the use of conservative interventions such as weight loss and position modification. CPAP remains the mainstay of treatment in this condition with high-level evidence supporting its efficacy. Continuous positive airway pressure (CPAP) is an intrusive therapy, with long-term adherence rates of less than 70%. Dental appliances have been shown to be effective therapy in some subjects but are limited by the inability to predict treatment responders. Alternative treatments are discussed but there is little role for upper airway surgery (except in a select few experienced institutions) or pharmacological treatment. The current levels of evidence for the different treatment regimens are reviewed.
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Affiliation(s)
- Craig A Hukins
- Sleep Disorders Centre, Department of Respiratory and Sleep Medicine, Princess Alexandra Hospital, Woolloongabba, Australia.
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