Vivekananda Lahan

A study examining depression in restless legs syndrome

BACKGROUND Distress is known to occur in RLS subjects consequent to symptoms. However, studies regarding prevalence of depression in RLS are scarce. This study was conducted to find out prevalence of depression in RLS patients and to explore possible underlying factors. METHOD 112 consecutive RLS subjects presenting to sleep-clinic were included in this study. History regarding RLS, depression and sleep-disturbances was sought. Depression and insomnia were diagnosed using DSM-IV-TR criteria. Subjects were specifically asked whether they had depressive episodes in past one year. Severity of RLS and insomnia was measured using Hindi versions of IRLS and ISI, respectively. Family history of depression and RLS was also asked. RESULTS One year prevalence of depression was 41.8%. MDD was reported by 33% and dysthymia by 8.8%. Both the groups were comparable with respects to demographic and clinical features, viz., age, gender, duration, severity and family history of RLS. Duration, number of episodes and severity of insomnia were comparable between groups, so was the family history of depression. In 37.8% of the subjects with MDD, depressive symptoms preceded RLS while in 51.4% of them, they followed onset of RLS. Total duration of RLS symptoms did not correlate with total duration of depression (r(2)=0.07; P=0.64). CONCLUSION Clinical depression is seen in more than a third of RLS patients. Depression is not affected by clinical picture of RLS and it is not consequent to sleep disturbance. Perhaps, it is a co-morbid condition.

Restless Legs Syndrome: A common disorder, but rarely diagnosed and barely treated - an Indian experience

OBJECTIVE Restless Legs Syndrome is a common problem that is under-diagnosed. This disorder has a significant socio-economic impact as it worsens quality of life. There is either no or little data available in terms of the Indian context. METHODS Patients who presented with insomnia or leg pain were screened for Restless Legs Syndrome (RLS) in the Psychiatry and Neurology departments of a tertiary care teaching institution from June 2011 to October 2011. One hundred consecutive patients diagnosed with RLS were included. Duration of symptoms, previous medical consultation history, and treatment received were scrutinized and recorded. Severity of RLS was assessed using the IRLS Hindi version. For statistical analysis, descriptive analysis and independent sample t-test were used. RESULTS Out of 653 subjects with insomnia or leg pain, 15.31% of the subjects had RLS. Females outnumbered males by a ratio of 2:1. Ninety-four percent of subjects had a moderate to very severe form of the illness. Only 32% of subjects reported leg symptoms to their physician on each visit. The rest of the patients sought an opinion for other symptoms like insomnia, daytime-fatigue, memory impairment, irritability, etc. Eighty percent of patients visited a general Physician or a primary care Physician. On average, five consultations were made before patients came to see us. None of the patients were diagnosed with RLS by any of their general Physicians or by specialists like neurologists, psychiatrists, etc. Common misdiagnoses (available in just 8% of cases) for legs symptoms were arthritis, calcium deficiency, worms in the stomach, depression, anxiety, stress, and vitamin deficiency. All the patients were prescribed medicines. Benzodiazepines were the most frequently prescribed drugs (97%), followed by injectable vitamin B-Complex (95% cases), calcium tablets (62% cases), selective-serotonin-reuptake-inhibitors (30%), and tri-cyclic antidepressants (25%). Proton pump inhibitors or NSAIDs were prescribed to almost all the patients along with previously mentioned drugs. CONCLUSION Diagnosis of RLS was missed not only by general physicians, but also by specialists like neurologists and psychiatrists. Most of the time diagnosis could not be established, yet medicines were prescribed. Many of these medicines were either ineffective or deleterious to RLS.

Translation and validation of the insomnia severity index in hindi language

Aims and Objectives: Translation of the Insomnia Severity Index from English to Hindi and Validation of the Hindi version. Materials and Methods: The translation process of the Insomnia Severity Index was initiated after obtaining due permission from the author of the original version of the same. Translation was carried out by using standard translation procedures, such as combined translation, decentering, and pretest method. The final version of the Insomnia Severity Index in Hindi was finally validated. A randomly selected sample size of 65 subjects was enrolled for the purpose of validation and testing the reliability of Hindi version of the Insomnia Severity Index. Insomnia was present in 45 subjects and they constituted the insomnia group. The rest 20 subjects did not have insomnia and were included in the control group. The Hindi version of the Insomnia Severity Index was applied to both the groups. Results: The total sample constituted of 50.8% males and 49.2% females. The mean age in the control group was 30.8±8.3 years and that in the insomnia group was 40.3±4 years (t=3.04; P=0.001). The translated version of the Insomnia Severity Index showed a reliability of 0.91 (Cronbachs α=0.91). This was not just simple translation, but many of the words were changed to adapt it for the local population. Conclusion: The Hindi version of the Insomnia Severity Index is a valid and reliable tool that can be administered for the assessment of severity of insomnia.

Primary headaches in restless legs syndrome patients

Earlier studies conducted among migraineurs have shown an association between migraine and restless legs syndrome (RLS). We chose RLS patients and looked for migraine to exclude sample bias. Materials and Methods: 99 consecutive subjects of idiopathic RLS were recruited from the sleep clinic during four months period. Physician diagnosis of headache and depressive disorder was made with the help of ICHD-2 and DSM-IV-TR criteria, respectively. Sleep history was gathered. Severity of RLS and insomnia was measured using IRLS (Hindi version) and insomnia severity index Hindi version, respectively. Chi-square test, one way ANOVA and t-test were applied to find out the significance. Results: Primary headache was seen in 51.5% cases of RLS. Migraine was reported by 44.4% subjects and other types of ‘primary headaches’ were reported by 7.1% subjects. Subjects were divided into- RLS; RLS with migraine and RLS with other headache. Females outnumbered in migraine subgroup (χ2=16.46, P<0.001). Prevalence of depression (χ2=3.12, P=0.21) and family history of RLS (χ2=2.65, P=0.26) were not different among groups. Severity of RLS (P=0.22) or insomnia (P=0.43) were also similar. Conclusion: Migraine is frequently found in RLS patients in clinic based samples. Females with RLS are prone to develop migraine. Depression and severity of RLS or insomnia do not affect development of headache.

Insomnia associated with depressive disorder: primary, secondary, or mixed?

Background: Insomnia is a common problem that is known to occur during depression. However, literature still debates whether insomnia is part of depression or a separate entity. Materials and Methods: Subjects presenting with depressive disorder according to DSM-IV-Text Revision criteria were recruited after seeking informed consent. Clinical interview was performed with the help of Mini International Neuropsychiatric Interview Plus. Their demographic data and depression related history were recorded. Depression severity was assessed by using Hamilton Rating Scale for Depression. Diagnosis of insomnia was made with the help of International Classification of Sleep Disorders-2 criteria. Type of insomnia, its duration, and its relationship with depressive illness were specifically asked. If any subject fulfilled criteria for more than one type of insomnia, both were recorded. Statistical analysis was done with the help of statistical package for social sciences (SPSS) version 17.0. χ2 test, independent sample t test, and Pearsons correlation were performed. Results: A total of 54 subjects were enrolled in this study. Primary insomnia was seen in 40.7% cases and secondary insomnia in 58.8% cases; 27.3% subjects did not experience insomnia along with depressive disorder. In the primary insomnia category, adjustment insomnia was most prevalent (63.6%), and in secondary insomnia group, insomnia due to depressive disorder was most frequent (59.3%). Interestingly, primary insomnia often followed an onset of depressive illness (P=0.04), while secondary insomnia preceded it (c2 =11.1; P=0.004). The presence of either type of insomnias was not influenced by duration of depressive illness, number of depressive episodes, and duration of current depressive episode. On the other hand, duration of insomnia was positively correlated with total duration of depressive illness (P=0.003), number of episodes (P=0.04), and duration of current depressive episode (P<0.001). Conclusion: Primary insomnia is common in subjects with depression, and it usually follows depressive illness. On the other hand, secondary insomnia often precedes the onset of depressive illness. Duration of insomnia positively correlates with duration and frequency of depressive episodes.

Prevalence of restless leg syndrome in subjects with depressive disorder.

Background: Restless legs syndrome (RLS) is known to be associated with depression. We hypothesized that RLS in depression is linked to the severity, duration, and frequency of depressive episodes. Materials and Methods: Subjects fulfilling DSM-IV-TR criteria of depressive disorders were included in this study after seeking informed consent. Using structured interview of MINI-Plus their demographic data and history were recorded. Severity of depression was assessed with the help of HAM-D. Insomnia was diagnosed following ICSD-2 criteria. RLS was diagnosed according to IRLSSG criteria. Descriptive statistics, Chi-square test, independent sample t test and MANOVA were computed with the help of SPSS v 17.0. Results: RLS was reported by 31.48% of sample. There was no gender difference in prevalence of RLS (X2 =0.46; P=0.33). There was no difference in the age , total duration of depressive illness and number of depressive episodes between RLS and non-RLS groups (F=0.44; P=0.77; Wilks Lambda=0.96). The HAM-D score was higher in the non-RLS group (P=0.03). Onset of RLS symptoms was not related to onset of depressive symptoms. Conclusion: RLS is prevalent in depressive disorder. However, onset of RLS is unrelated to age and number or duration of depressive disorders.

Translation and validation of International Restless Leg Syndrome Study Group rating scale in Hindi language

Objectives: The objective of this study is to translate and validate the International Restless Leg Syndrome Study Group rating scale (IRLS) in Hindi language. Materials and Methods: Thirty one consecutive patients diagnosed of Restless Leg Syndrome (RLS) were included in the study. Control group comprised of 31 subjects not having any symptom of RLS. The scale was procured from MAPI research trust; and, permission for the translation was sought. The translation was done according to the guidelines provided by the publisher. After translation, final version of the scale was applied in both the groups to find out the reliability and clinical validity. Results: RLS group had a predominance of females, and they were younger than the male counterparts (Age=36.80 ± 10.46 years vs 45.18 ± 8.34 years; t=2.28; P=0.03). There was no difference in the mean age between groups (RLS=39.77 ± 10.44 years vs Non RLS=38.29 ± 11.29 years; t=-0.53; P=0.59). IRLS scores were significantly different between both groups on all items (P<0.001). Translated version showed high reliability (Cronbachs alpha=0.86). IRLS scores were significantly different between both groups on all items (P<0.001). Conclusion: Hindi version of IRLS is reliable and a clinically valid tool that can be applied in Hindi speaking population.

Subjective sleep problems in young women suffering from premenstrual dysphoric disorder.

Premenstrual syndrome (PMS) is a common disorder that affects nearly 9–72% women across studies.[1–3] Premenstrual dysphoric disorder (PMDD) is the more severe form of the PMS and its prevalence ranges between 3% and 30%.[2,4] Sleep problems form an integral part of the problem as they are included in the diagnostic criteria for PMDD.[5] A number of studies have tried to find association between PMS or PMDD with sleep pattern and quality of sleep in the past. Sleep was examined using subjective as well as objective measures.[6–10] Majority of the studies have recorded sleep using a polysomnograph across various phases of menstrual cycle.[6–10] However, many of the patients experience first-night effect while sleeping in a sleep laboratory and this may adversely affect polysomnographic data.[11,12] Subjective perception of sleep-related parameters may not match the objective data, and resultantly the patient often complains of subjectively poor-quality sleep despite a good sleep on polysomnograph.[13] The common example is the paradoxical insomnia. Subjective perception of sleep which affects the clinical picture to a greater extent was examined by only a handful of these studies.[6,10] Though as scientists we rely more on objective evidences, still the subjective parameters cannot be overlooked as they are stronger determinants of quality of life. Hence, the present study was planned to assess subjective sleep problems in PMDD subjects and to compare them with the non-PMDD group. We further hypothesized that subjective sleep parameters would also affect the daytime functioning. This questionnaire-based study was done in a nursing college after seeking approval of the institutional ethics committee and permission of college administration. All the female students were invited to participate in the study. Female teachers who took the responsibility to get the questionnaires filled were explained the purpose of the study beforehand. They were also explained what kind of information was intended from each question in a training session. The questionnaire was distributed among the girls with the help of female teachers. Hence, the authors were blinded regarding the identity of participants. This blinding helped to motivate the participants. Teachers then explained the purpose of study to all students and encouraged them to volunteer the information. Verbal informed consent was taken from the participants and those who were not interested in participating in the study were excluded. The girls who were taking any kind of psychotropic drug or hormonal therapy were also advised not to participate in this study. The survey questionnaire was designed in Hindi language. It contained instructions regarding intended information. First part of the questionnaire contained instructions and the exclusion criteria as mentioned above. The next part contained questions regarding participants’ demographic data and changes observed in their sleep patterns prior to 1 week of onset of menstruation as compared to other days of the month during past 3 months. These questions included: “change in total sleep time” (responses were increased, as usual, decreased); “time to bed” (advanced, as usual, or delayed); “quality of sleep” (poor, as usual, better); etc. Subjects were supposed to choose the response that best described their condition. Screening for the PMDD was based upon DSM-IV-TR criteria.[5] The question was as follows: “Did you notice any change in your mood (depressed, as usual, better) 1 week prior to onset of your menstruation as compared to other days of the month?”. Similar questions were asked regarding other symptoms e.g. irritability (increased, as usual, worse); ability to concentrate (better, as usual, poor) etc.” In this manner, all the 11 criteria mentioned in DSM-IV-TR were changed in the question form. Subjects responded by marking the option that best explained their condition on that item. As per the DSM-IV-TR criteria, subjects who fulfilled 5 of the 11 criteria with at least 1 from the first 4 criteria during past 3 months were considered PMDD. However, DSM requires prospective charting of symptoms for the diagnosis of PMDD; hence, these cases were termed as possible-PMDD. Students were provided explanation if they had any difficulty in understanding the meaning of any of the items. The questionnaires were then collected and analyzed. Statistical analysis was done with the help of SPSS version 17.0. Cohort was divided into two groups – those with PMDD and those not fulfilling the criteria of PMDD. Chi-square test was used to compare non-parametric variables. The study sample consisted of 269 subjects. The average age of students was 19.06 years (±1.56 years). 37.5% students met the criteria for possible-PMDD. Possible-PMDD subjects reported that their sleep quality was worse before the onset of their menstruation, as compared to subjects who did not fulfill the criteria for PMDD. Table 1 depicts the other details of sleep-related variables. Table 1 Comparison of sleep-related variables between possible-PMDD and no PMDD groups No difference was reported in dream frequency between these groups. However, emotions associated with dreams were reported to differ between the two groups. Possible-PMDD group reported higher frequency of anxiety and anger in their dreams, as compared to the other group (χ2 = 24.93, df = 3, P < 0.001). However, no difference was observed in the frequency of parasomnia (sleep talking, sleepwalking) and snoring between these groups. Possible-PMDD group complained of fatigue during the day (χ2 = 36.68, df = 3, P < 0.001) and daytime sleepiness (χ2 = 18.16, df = 3, P < 0.001). Our study found that possible-PMDD group had poor sleep as compared to non-PMDD group on several measures of sleep including bed time, sleep quality, sleep-onset latency, sleep maintenance, and wake time. Similarly, daytime fatigue and daytime sleepiness was also reported by possible-PMDD group. This is in concordance with the results of earlier studies. Mauri et al.[10] have reported that women with severe PMS complain of increased sleepiness and fatigue before menstruation as compared to other periods of their own menstrual cycle as well as with reference to the control group. An increase in daytime sleepiness was the only factor that was able to differentiate between women with and without PMS in another study.[14] Severe PMS has been known to worsen the sleep quality, increase the daytime sleepiness, and is associated with reduced alertness during the day.[9] Thus, these studies reported that the fatigue, sleepiness, and alertness during the day may be used to differentiate PMDD group from non-PMDD group. However, unlike the present study, these studies failed to find any difference in nocturnal sleep. This association between PMS and disturbed subjective sleep parameters (increased nocturnal awakenings, unpleasant dreams, delayed wake time, and morning tiredness) was reported by only one study which was conducted long back.[10] As the quest for the objectivity has increased, most of the work in this area during past decade was done using objective parameters, which may not find any difference despite subjective symptoms.[15] Thus, as a clinician, it is important to consider patients’ symptoms rather than just look for the laboratory reports. Further, as a scientist, these results promote us to search for the factors that are responsible for the difference between subjective and objective quality of sleep in this specialized group. We also found an increased frequency of daytime symptoms in possible–PMDD group, which could have been an influence of nocturnal sleep. Considering the example of paradoxical insomnia, in future, it will be interesting to examine the relationship between PMDD, subjective sleep quality, objective sleep parameters, and daytime symptoms. This may guide us in the management of PMDD. We would like to mention that in this study, subjects without possible PMDD also reported sleep problems. This suggests that sleep problems are not governed by PMDD; rather, they are related to menstrual cycle. In the past, one study reported that poor sleep quality was seen not only in PMDD group but also among non-PMDD women; however; other factors remained unaffected.[6] Manber et al.[14] also reported that sleep disturbance, e.g. increased sleep latency, reduced sleep efficiency, and poor sleep quality, was not limited to PMS group; rather, it was found in all women before menstruation. One reason for these results could be fluctuation in plasma melatonin level and sleep–wake rhythms across menstrual cycle, even in healthy females.[7] These evidences suggest that poor sleep could be a trait marker of premenstrual period rather than a state marker of PMS or PMDD. In other words, sleep changes may be an inherent property of menstrual cycle and PMDD sufferers could have an exaggeration of sleep-related problems during late luteal phase. Like any other study, this study also had some methodological limitations. First, it was a survey and questionnaire can be used to screen only. Secondly, surveys are always associated with recall bias. Thirdly, DSM-IV-TR suggests that PMDD should be diagnosed prospectively, which was not done in the present study. Nonetheless, this study shows important findings in this area and is probably the first Indian study to address this important but yet unrecognized issue. In addition, this study adds up to the scarcely available literature that has examined subjective sleep parameters in PMDD subjects. In conclusion, possible-PMDD sufferers have problems with their night sleep and also bear daytime symptoms. These symptoms negatively affect their ability to accomplish daily chores.

What patients do to counteract the symptoms of Willis-Ekbom disease (RLS/WED): Effect of gender and severity of illness

Objectives: This study was carried out to assess different counteracting strategies used by patients with idiopathic Willis-Ekbom disease (RLS/WED). Whether these strategies were influenced by gender or disease severity was also assessed. Materials and Methods: A total of 173 patients of idiopathic RLS/WED were included in this study. Their demographic data was recorded. Details regarding the RLS/WED and strategies that they used to counteract the symptoms were asked. The severity of RLS/WED was measured with the help of the Hindi version of international restless legs syndrome severity rating scale. They were asked to provide the details regarding the relief obtained from all the strategies they used on three-point scale: no relief, some relief, and complete relief. Results: Of the patients, 72% were females. Mean age of the subjects in this study was 39.6 ± 12.6 years, and male subjects were older than females. Four common strategies were reported by the patients to counter the sensations of RLS/WED: moving legs while in bed (85.5%), asking somebody to massage their legs or massaging legs themselves (76.9%), walking (53.2%), and tying a cloth/rope tightly on the legs (39.3%). Of all the patients who moved their legs, 6.7% did not experience any relief, 64.2% reported some relief, and 28.4% reported complete relief. Similarly, of all the patients who used “walking” to counteract symptoms, 50% reported complete relief, 44.5% reported some relief, and the rest did not experience any relief. Many of these patients reported that massage and tying a cloth/rope on legs brought greater relief than any of these strategies. Tying cloth on the leg was more common among females as compared to males (45.9% females vs. 23.5% males; χ2 = 7.54; P = 0.006), while patients with moderately severe to severe RLS/WED reported “moving legs in bed” (79.3% in mild to moderate RLS/WED; 91.8% in severe to very severe RLS; χ2 = 5.36; P = 0.02). Conclusion: Patients with RLS/WED use a variety of strategies to counteract symptoms. These strategies may be influenced by gender, disease severity, and cultural practices.

RLS relieved by tobacco chewing: paradoxical role of nicotine

Restless leg syndrome (RLS) is a sensorimotor disorder manifested as an urge to move legs which is alleviated by movement [1, 2]. It is more common in females, elderly and is a common cause of sleep disturbance [1]. The pathogenesis of RLS is unclear; however, the alleviation of RLS with dopaminergic drugs implicates D2 receptors [2]. Caffeine, nicotine and chocolate may aggravate RLS [2]. We are presenting a case who reported paradoxical relief in RLS after chewing tobacco. To best of our knowledge only one such case has been reported earlier [3]. A 70-year-old lady presented with sleep disturbance since 1 year. She revealed feeling restlessness in lower limbs at bed-time that interfered with either falling asleep or caused terminal insomnia. She would often hit one leg with the other to get relief and on occasions she would tie a piece of cloth to get relief. Abolition of symptoms was observed at 7.00 a.m. and she could get 3–4 h sleep thereafter. She felt tired and disinterested during day. Symptoms were gradually progressive. The lady had been taking tobacco mixed with betel-leaf for many years without any apparent effect on leg symptoms. However, on few occasions she chewed tobacco-leaves without betel-leaves during nocturnal awakenings and found a decrement in her leg symptoms. Since then, she started using it as a therapy to relieve her RLS. Hematological investigations revealed presence of iron deficiency anemia (Hemoglobin = 7.1 g/dl; serum TIBC = 517 lg/dl; serum ferritin = 24 ng/ml). Past medical or psychiatric history was non-contributory. Family history was nonremarkable. A clinical diagnosis of RLS was made. Two issues need special mention in this case, first, immediate relief (although partial but noticeable) in RLS by tobacco chewing and second, absence of effect while chewing tobacco with betel-leaf. Smoking, and thus nicotine is thought to relieve RLS symptoms by acting on acetylcholine receptors [3]. Interaction between nicotine and dopamine is known for a long time. Smoking has been reported to relieve symptoms of Parkinson’s disease during drug off period [4]. Not only smoking, but also the nicotine chewing gum has been found to increase dopamine level in striatum [5]. However, nicotine gum has less pronounced effect on symptoms of PD as compared to smoking [4]. Since, PD and RLS both respond to dopamine agonsits, it seems possible that beneficial effect of nicotine observed in PD would be seen in RLS also. In a study, RLS patients were found to have higher prevalence of nocturnal smoking; however, it was attributed to presence of psychopathology instead of therapeutic benefit [6]. However, total amelioration of symptoms of RLS was not attained with tobacco in this case and a number of factors might be responsible for it. First, it might be related to amount of tobacco since, tobacco in betel-leaf (which was smaller in quantity) was unable to produce relief, while tobacco chewed directly (larger quantity) had pronounced effect; second, co-morbid iron deficiency might play a role; third, smoking and tobacco chewing might produce different effects on brain dopamine [4]. Better relief reported in earlier case could be attributed to reasons mentioned above [3]. V. Lahan R. Gupta (&) Department of Psychiatry and Sleep Clinic, Himalayan Institute of Medical Sciences, Swami Ram Nagar, Doiwala, Dehradun 248140, India e-mail: sleepdoc.ravi@gmail.com