Kupfer Dj

Symptoms of stress and depression as correlates of sleep in primary insomnia.

Objective: Previous studies have not evaluated the clinical correlates of the electroencephalographic spectral profile in patients with insomnia. In the preliminary study described here, we evaluated the extent to which symptoms of stress and depression are associated with subjective sleep complaints and quantitative measures of sleep in individuals with chronic insomnia. Methods: Subjects were 14 healthy adults who met criteria for primary insomnia as specified in the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders. Measures of stress, depression, and subjective sleep quality were collected before subjects participated in a two-night laboratory sleep series. We hypothesized that elevated symptoms of stress and depression would be associated with subjective sleep complaints and electroencephalographic evidence of hyperarousal during sleep. Hyperarousal during sleep was defined as decreases in delta power and elevations in alpha and beta power throughout non–rapid eye movement sleep, and symptoms of stress were defined as the tendency to experience stress-related intrusive thoughts and the interaction between intrusion tendency and the number of recent stressful events (subjective stress burden). Results: A stronger tendency to experience stress-related intrusive thoughts was associated with greater sleep complaints and a trend toward higher beta power, whereas increases in subjective stress burden were associated with decreases in delta power. In addition, elevations in subclinical symptoms of depression were associated with greater sleep complaints and elevations in alpha power. Conclusions: Observed relationships among symptoms of stress, depression, subjective sleep complaints, and electroencephalographic power may be relevant to the discrepancy between subjective and objective measures of sleep in patients with insomnia and may be more broadly applicable to sleep complaints in association with stressful life events and major depression.

Predictors and moderators of time to remission of major depression with interpersonal psychotherapy and SSRI pharmacotherapy.

BACKGROUND Although many studies suggest that, on average, depression-specific psychotherapy and antidepressant pharmacotherapy are efficacious, we know relatively little about which patients are more likely to respond to one versus the other. We sought to determine whether measures of spectrum psychopathology are useful in deciding which patients with unipolar depression should receive pharmacotherapy versus depression-specific psychotherapy. METHOD A total of 318 adult out-patients with major depression were randomly assigned to escitalopram pharmacotherapy or interpersonal psychotherapy (IPT) at academic medical centers at Pittsburgh, Pennsylvania and Pisa, Italy. Our main focus was on predictors and moderators of time to remission on monotherapy at 12 weeks. RESULTS Participants with higher scores on the need for medical reassurance factor of the Panic-Agoraphobic Spectrum Self-Report (PAS-SR) had more rapid remission with IPT and those with lower scores on the psychomotor activation factor of the Mood Spectrum Self-Report (MOODS-SR) experienced more rapid remission with selective serotonin reuptake inhibitor (SSRI) pharmacotherapy. Non-specific predictors of longer time to remission with monotherapy included several panic spectrum and mood spectrum factors and the Social Phobia Spectrum (SHY) total score. Higher baseline scores on the 17- and 25-item Hamilton Depression Rating Scales (HAMD-17 and HAMD-25) and the Work and Social Adjustment Scale (WSAS) also predicted a longer time to remission, whereas being married predicted a shorter time to remission. CONCLUSIONS This exploratory study identified several non-specific predictors but few moderators of psychotherapy versus pharmacotherapy outcome. It offers useful indicators of the characteristics of patients that are generally difficult to treat, but only limited guidance as to who benefits from IPT versus SSRI pharmacotherapy.

Personality pathology and outcome in recurrently depressed women over 2 years of maintenance interpersonal psychotherapy

BACKGROUND Empirical data on the impact of personality pathology on acute treatment outcome for depression are mixed, in part because of challenges posed by assessing trait-like personality patterns while patients are in an active mood episode. To our knowledge, no previous study has examined the effect of personality pathology on maintenance treatment outcome. By maintenance treatment we refer to long-term treatment provided to prevent depression recurrence among remitted patients. METHOD Structured Clinical Interviews for the DSM-III-R Personality Disorders (SCID-II) were obtained on a sample of 125 recurrently depressed women following sustained remission of the acute mood episode and prior to entering maintenance treatment. SCID-II interviews were then repeated following 1 and 2 years of maintenance interpersonal psychotherapy. RESULTS At the pre-maintenance assessment, 21.6% of the sample met SCID-II personality disorder criteria. Co-morbid personality pathology was related to an earlier age of onset, more previous depressive episodes, and a greater need for adjunctive pharmacotherapy to achieve remission of the acute mood episode. Co-morbid personality pathology predicted both higher rates of depression recurrence and a shorter time to recurrence over the 2-year course of maintenance treatment. Notably, among those patients who remained depression-free, continuous levels of personality pathology steadily declined over the 2-year course of maintenance therapy. CONCLUSIONS Results highlight the need for early and effective intervention of both episodic mood disorder and inter-episode interpersonal dysfunction inherent to the personality disorders. Future maintenance treatment trials are needed to clarify the relationship between episodic mood disorder and personality function over time.

Prevalence of sleep apnea and nocturnal myoclonus in major affective disorders: clinical and polysomnographic findings.

We performed screening polysomnography on 86 inpatients with affective disorders and found that 13 (15.1 per cent) had sleep apnea and one had nocturnal myoclonus. The apnea tended to be extremely mild, with an average of 27.8 episodes per patient and with a mean duration of 15.0 seconds. No clinically significant cardiac arrhythmia accompanied the apnea. The apnea was predominantly obstructive or mixed, not central. Only four patients (4.7 per cent) had apnea indices greater than five, and even here the total apnea was considered mild. Much of the apnea (68.3 per cent) occurred during rapid eye movement sleep. While there was no association of apnea with gender or with type of sleep-wake complaint, a significant relationship with age emerged. On the basis of these data, we suggest that routine polysomnographic screening for sleep apnea and nocturnal myoclonus in affective disorders is not indicated. On occasion, however, both an affective disorder and a sleep-apnea syndrome co-exist in the same patient. In such cases, the sleep-wake complaint is usually very prominent and/or long-standing in relation to other psychopathology and requires appropriate polysomnographic evaluation.

Effects of positive and negative life events on time to depression onset: an analysis of additivity and timing.

While the relationship of life events to depression onset has occupied researchers for almost a quarter of a century, few studies have attempted to account for either the temporal patterning of events relative to episode onset, or, the effect of multiple events in a study period. In this report, we attempt to address the issues of timing of events, multiple events (both positive and negative) and multiple aspects (both positivity and negativity) of single events on latency time to depression onset, while simultaneously accounting for possible decay in the effects of events over time. We use the proportional hazards approach to model the effects of life events and consider modelling the change in impact of events with the passage of time. After interviewing 142 recurrent unipolar patients using the Life Events and Difficulties Schedule, we rated severity and positivity of life events reported during the 6-month period prior to onset. As we hypothesized, additional life events occurring after an initial provoking agent level event significantly alter the risk of illness onset. Additional severely threatening events decrease the time to onset, but positive events do not appear to delay onset. Interestingly, seemingly neutral events had a highly significant effect in shortening the time to onset. We note the many limitations imposed on the interpretation of these findings related to the selected group of subjects studied and encourage those who have more generalizable data to apply these methods of analysis.

Sleep duration is associated with dyslipidemia in patients with bipolar disorder in clinical remission

BACKGROUND The pathways to increased cardiovascular risk in bipolar disorder include health behaviors, psychosocial stress and long-term medication exposure. However, the evidence that the association between cardiovascular risk factors and bipolar disorder remains significant after controlling for these co-factors suggests that additional important risk factors have yet to be identified. Our hypothesis is that disturbances in the sleep-wake cycle are an important and under-recognized pathway through which affective disorders lead to increased cardiovascular risk. METHODS In patients with bipolar disorder type 1 in clinical remission, we: 1) explored whether sleep disturbance predicted the endorsement of NCEP ATP-III criteria for dyslipidemia, independent of other lifestyle factors and 2) tested the association between low HDL (NCEP-ATP III) and sleep duration measured with actigraphy over an eight-day period. RESULTS Median sleep duration is significantly associated with low HDL. The risk of having low HDL increases by 1.23 with every 30 minutes of reduced sleep time. LIMITATIONS Since sleep patterns in patients with bipolar disorder are variable and irregular, it is possible that other sleep characteristics, not present during the span of our study, or the variability itself may be what drives the increased cardiovascular risk. CONCLUSIONS Sleep characteristics of patients with bipolar disorder in clinical remission are associated with cardiovascular risk. More specifically, sleep duration was associated with low HDL. Clinicians should pay special attention to sleep hygiene in treating individuals with bipolar disorder, even when they are in clinical remission.

Self-reported cognitive problems predict employment trajectory in patients with bipolar I disorder

BACKGROUND Cognitive impairment in bipolar disorder has been associated with poor functional outcomes. We examined the relation of self-reported cognitive problems to employment trajectory in patients diagnosed with bipolar I disorder. METHODS 154 bipolar I disorder patients were followed for 15-43months at the Bipolar Disorders Center for Pennsylvanians. Using a multinomial logistic regression we examined predictors of employment group including self-reported cognitive problems, mood symptoms, education and age. Cognitive functioning was measured via 4 self-report items assessing memory/concentration at baseline and termination. Employment status was recorded at baseline and termination. Employment was categorized as working (full-time, part-time, homemaker, volunteer) or not working (leave of absence, disability, unemployed, no longer volunteering) at each time point. Patients were categorized as good stable, improving, worsening and poor stable. RESULTS Baseline self-reported concentration problems and years of education significantly predicted employment trajectory. LIMITATIONS Post-hoc analyses of existing clinical data. CONCLUSIONS Self-reported concentration problems assessed in the context of specific areas of functioning may serve as a sensitive predictor of functional outcome in patients diagnosed with bipolar I disorder.

Pretreatment systolic orthostatic blood pressure (PSOP) and treatment response in elderly depressed inpatients.

This study evaluated the utility of morning pretreatment systolic orthostatic blood pressure (PSOP) in predicting clinical response to treatment with nortriptyline (N = 11) or electroconvulsive therapy (N = 6) in 17 depressed geriatric inpatients (mean age, 70.4 +/- 5.1). Morning PSOP showed a significant inverse correlation with percent change in Hamilton depression ratings (rho = -0.59, p less than 0.01; r = -0.52, p less than 0.02). In nortriptyline-treated patients (N = 10, excluding one outlier), PSOP was significantly correlated with percent change in Hamilton ratings (rho = -0.55, p less than 0.05); a similar association was also found in the subsample of electroconvulsive therapy-treated patients (N = 6, rho = -0.77, p less than 0.05). Patients with PSOP less than or equal to 10 mm Hg averaged 83% improvement in Hamilton depression ratings versus 64% improvement in patients with PSOP less than or equal to 10 mm Hg (p less than 0.05). In an age-equated contrast group of 15 inpatients with mixed clinical pictures of depression and cognitive impairment (11 with primary degenerative dementia with depressive features and four with major depressive disorder with cognitive impairment), no relation between PSOP and treatment response (as measured by Hamilton ratings) was found. The current findings extend earlier work in medically healthy, nonsuicidal geriatric depressed outpatients and suggest that PSOP may also be useful in predicting treatment response in older, cognitively intact depressed inpatients (many with concurrent medical illness and/or suicidal) but not in mixed depression-dementia.

The association between meal timing and frequency with cardiometabolic profile in patients with bipolar disorder

The goal of this study was to explore the association of timing of and frequency of meals with markers of cardiometabolic risk in patients with bipolar disorder in out‐patient maintenance treatment.

Can clinical features of bipolar-I disorder be assessed reliably on the telephone?

BACKGROUND The reliability of telephone interviews for rating 25 selected individual items of the Diagnostic Interview for Genetic Studies (DIGS) was assessed among persons with remitted bipolar disorder I (BPD I, n = 20). METHODS The Diagnostic Interview for Genetic Studies (DIGS) was administered directly (with two raters present) and by telephone in random order to 20 adults with bipolar disorder I. RESULTS Telephone interviews achieved reliability comparable to direct interviews for 16 items (64%), but were considered unsatisfactory for seven others (28%). Two other items, which evaluated the overlap between substance abuse and mood disorder, were considered unreliable for both methods of interview. LIMITATIONS The presence of two interviewers for the in-person interview may have led to over-estimation of in-person reliability. Investigator bias in favor of phone interviews and a relatively small sample may have confounded the results. CONCLUSIONS Telephone interviews may be used to evaluate individuals with BPD I in remission, provided the limitations of this method are recognized. They have limited reliability for dissecting overlap between mood abnormalities and psychotic phenomena or substance abuse.