Motor activity in depressed patients during therapeutic sleep deprivation.

PROBLEM: Both sleep and motor activity have a bidirectional relationship with depression. The existing literature on motor activity during therapeutic sleep deprivation in depressed patients is inconsistent and fragmentary. In the present study we measured motor activity continuously during 40 hours of sleep deprivation in depressed patients. METHOD: Thirty-four inpatients suffering from a major depression (DSM-IV) underwent sleep deprivation with a continuous waking period of 40 hours. Motor activity of the patients was continuously recorded using an actigraph on the non-dominant wrist. The effect of sleep deprivation was assessed by the Hamilton Depression Scale (six-item version), thus separating the group into responders and non-responders to sleep deprivation. RESULTS: We found no significant differences in motor activity between responders and non-responders on the day before sleep deprivation. During the night, responders to sleep deprivation exhibited a higher motor activity and less periods of rest. On the day after sleep deprivation, responders exhibited a higher activity, too. CONCLUSIONS: Motor activity levels differ between the two groups, thus giving more insight into possible mechanisms of action of the therapeutic sleep deprivation. We suggest that higher motor activity during the night prevents naps and leads to better response to sleep deprivation.

[Basic diagnostics of sleep disorders: possibilities of the family physician]. / Basisdiagnostik der Schlafstörungen. Schlüsselrolle für den Hausarzt.

Many sleep disorders can be definitively diagnosed using basic diagnostics in the family practice. Important elements of the diagnosis are the patient's general medical history and acquiring a description of the current phenomenology of the disorder. The use of sleep diaries and information provided by a third party are also helpful. For chronic sleep disorders, patient habits that are not in line with the rules of good sleep hygiene should be regarded as potential perpetuating causes of the disorder. In some cases, simple test procedures can also be useful. The identification or the exclusion of a primary physical or mental disease whose symptom may be the sleep disorder (example: insomnia for underlying depression) is important. In some cases, referral to a specialist or to a sleep medicine centre is necessary.

[Drug treatment of sleep disorders in the elderly]. / Arzneimittelbehandlung von Schlafstörungen im Alter.

Changes in the pattern of sleep, e.g. more frequent nocturnal awakenings, are normal in the elderly. There is also a greater incidence of medical and psychiatric sleep disorders (depression, dementia). Initially, a thorough diagnostic assessment should be performed in order to identify disorders which can be treated specifically. For the symptomatic drug treatment of insomnias, the specific metabolic and pharmacokinetic, as well as possible interactions, should be considered. The new benzodiazepine receptor agonists (zopiclone, zolpidem and zaleplone), with their favourable risk-benefit profile, can be considered as first-choice treatments in elderly patients; in general, they should be preferred to the classical benzodiazepines. When a longer treatment is necessary, certain (non-anticholinergic) antidepressants and neuroleptics can be considered (the latter especially in cases of abnormal nocturnal behaviour). Herbal drugs and other hypnotically active compounds play a secondary role. Drug treatment of insomnia should always be carried out in the context of a general treatment plan which also includes non-pharmacological elements. In elderly patients, "chronotherapeutic" methods, which accentuate the sleep-wake rhythm, are of crucial importance.

Trimipramine in primary insomnia: results of a polysomnographic double-blind controlled study.

In recent years, sedating antidepressants have been increasingly used to treat primary insomnia. Up to now, only one open pilot study with trimipramine and one double-blind placebo-controlled study with doxepin have provided scientific support for this approach in treating primary insomnia. In order to test the hypothesis that sedating antidepressants are useful in the treatment of primary insomnia, the effect of trimipramine on objectively and subjectively measured parameters of sleep was investigated in a double-blind placebo- and lormetazepam-controlled study in a sample of 55 patients with primary insomnia attending outpatient sleep-disorder clinics. Trimipramine was selected since it has shown positive effects on sleep continuity with a lack of REM sleep suppression in studies on depressed patients and in one pilot study on patients with primary insomnia. Trimipramine at an average dose of 100 mg over a period of 4 weeks significantly enhanced sleep efficiency, but not total sleep time (which had been the primary target variable) compared to placebo as measured by polysomnography. Changes in objective sleep parameters were paralleled by changes in subjective sleep parameters. Trimipramine did not suppress REM sleep. Lormetazepam decreased wake time and sleep stage 3 and increased REM sleep compared to placebo. After switching trimipramine to placebo, sleep parameters returned to baseline. There was no evidence of any rebound effect from trimipramine. Side effects from trimipramine were only marginal. This first double-blind placebo-controlled study with trimipramine suggests its efficacy in the treatment of primary insomnia. However, due to the large intra- and interindividual variance in the parameters of interest before and during treatment a larger sample size would have been necessary to strengthen the validity of our findings.

Sleep and sleep-wake cycle in an 81-year-old patient with de novo ultra-rapid cycling bipolar disorder.

This is a case report of an 81-year-old man who developed de novo bipolar disorder with ultrarapid cycling at the age of 80. Mood was self-rated daily over a period of ten weeks; in addition, polysomnographic and motor activity recordings were performed during a drug-free baseline period. Both depressive and hypomanic episodes had an average duration of about 30 hours; the affective cycle was thus independent from the sleep-wake cycle. When mood shifts occurred during nighttime, sleep was different in nights following depression than in nights following hypomania. Positron emission tomography revealed a moderate bilateral frontal hypermetabolism in the hypomanic phase and yielded normal findings for the depressive stage. In contrast to what is usually expected in ultra-rapid cycling bipolar disorder, this case demonstrates an unusual sleep-unrelated cycle duration in the oldest reported patient so far.

Patterns of response to repeated total sleep deprivations in depression.

BACKGROUND: Patterns of response and nonresponse in repeated sleep deprivation (SD) are of both clinical and scientific interest; as yet, studies have yielded inconsistent results. METHODS: Eighteen inpatients suffering from a major depression were subjected to a series of six scheduled total sleep deprivations within 3 weeks; 12 of them completed the whole protocol. All were under a constant antidepressant medication with amitriptyline. SD effects were measured using observer and self rating scales. RESULTS: Each single SD led to a significant improvement. Of the 12 patients who completed the protocol, seven were classified as responders at endpoint (i.e., 1 week after the sixth TSD). The majority of patients exhibited a pattern of responses and nonresponses randomly distributed over time. There was no temporal trend. The initial effect did not predict the average response to the following SDs. LIMITATIONS: One third of patients dropped out before completing the protocol which limits the scope of the study. CONCLUSIONS: Response to a single SD is not generalizable on a series of following SDs in an individual. The mechanism of action of SD does probably not involve mechanisms subjected to habituation or sensitization.

[Effectiveness of zopiclone in disorders of initiating and maintaining sleep. Results of a drug monitoring study in 811 general practices]. / Die Effektivität von Zopiclon bei Ein- und Durchschlafstörungen. Ergebnisse einer Anwendungsbeobachtung in 811 Hausarztpraxen.

BACKGROUND AND METHOD: In a drug monitoring study with 811 participating general practitioners, safety and tolerability of zopiclone were studied in 2416 patients with disorders of initiating and maintaining sleep. RESULTS: In general, zopiclone was efficient in all forms of insomnia; the subjective sleep duration was prolonged for 2 hours on average. Patients without somatic complaints or comorbidity showed the greatest benefit. Daytime well-being and vigilance were in general not impaired. Drug related adverse events occurred rarely; the great majority of the participating physicians rated the treatment with zopiclone as efficient and acceptable. CONCLUSION: In this drug monitoring study, zopiclone proved an efficient hypnotic for the treatment of disorders of initiating and maintaining sleep.

[Kufs-disease; a rare cause of early-onset dementia]. / Die Kufs-Erkrankung. Seltene Ursache einer früh beginnenden Demenz.

The case of a 35-year-old man with progressive dementia from the age of 17 is presented. Clinical examination showed mild extrapyramidal and cerebellar signs and rare myoclonus. Neuropsychological evaluation disclosed severe cognitive deficits. Magnetic resonance imaging (MRI) revealed moderate generalized atrophy with abnormal iron deposition in the basal ganglia. Positron emission tomography (PET) with 18-fluorodeoxyglucose (18-FDG) demonstrated clear temporoparietal hypometabolism. The clinical symptoms and course are typical for the rare adult type of neuronal ceroid lipofuscinoses (Kufs' disease). The diagnosis is supported by the electron microscope detection of an abnormal accumulation of lipid vacuoles and lipofuscin in the eccrine sweat glands and the rectal ganglia cells.

Double-blind, placebo-controlled safety and efficacy trial with yohimbine hydrochloride in the treatment of nonorganic erectile dysfunction.

This double-blind, placebo-controlled clinical trial of yohimbine hydrochloride included 86 patients with erectile dysfunction and without clearly detectable organic or psychologic causes. The patient group fulfilled all entry criteria; 85 of these could be considered for the Safety-respectively 83 for the Intention-to-treat (ITT)-analysis. Yohimbine was administered orally in a dosage of 30 mg a day (two 5 mg tablets three times daily) for eight weeks. Patients were seen for follow-up after four weeks' treatment, and for a final visit after eight weeks. Efficacy evaluation was based on both subjective and objective criteria. Subjective criteria included improvement in sexual desire, sexual satisfaction, frequency of sexual contacts, and quality of erection (penile rigidity) during sexual contact/intercourse. Objective criteria of outcome were based on improvement in penile rigidity determined by use of polysomnography in the sleep laboratory. Overall Yohimbine was found significantly more effective than placebo in terms of response rate: 71 vs 45%. Yohimbine was well-tolerated: Only 7% of patients rated tolerability fair or poor, and most adverse experiences were mild. There was no serious adverse event.