Depression and survival of glioma patients: A systematic review and meta-analysis.

INTRODUCTION: There is currently a lack of a well-formed consensus regarding the effects of depression on the survival of glioma patients. A more thorough understanding of such effects may better highlight the importance of recognizing depressive symptoms in this patient population and guide treatment plans in the future. OBJECTIVE: The aim of this meta-analysis was to study the effect of depression on glioma patients' survival. METHODS: A meta-analysis was conducted according to the PRISMA guidelines. PubMed, Embase, and Cochrane databases were searched for studies that reported depression and survival among glioma patients through 11/06/2016. Both random-effects (RE) and fixed-effect (FE) models were used to compare survival outcomes in glioma patients with and without depression. RESULTS: Out of 619 identified articles, six were selected for the meta-analysis. Using RE model, the various measures for survival outcomes displayed worsened outcomes for both high and low-grade glioma patients with depression compared to those without depression. For binary survival outcomes, the overall pooled risk ratio for survival was 0.70 (95% CI: 0.47, 1.04; 6 studies; I2 = 54.9%, P-heterogeneity = 0.05) for high grade gliomas (HGG) and 0.28 (95% CI: 0.04, 1.78; I2 = 0%, P-heterogeneity = 1.00; one study) for low grade gliomas (LGG) was. A sub-group analysis in the HGG group by depression timing (pre- versus post-operative) revealed no differences between depression and survival outcomes (P-interaction = 0.47). For continuous survival outcomes, no statistically significant difference was found among the high and low-grade glioma groups (P-interaction = 0.31). The standardized mean difference (SMD) in survival outcomes was -0.56 months (95%CI: -1.13, 0.02; 4 studies, I2 = 89.4%, P-heterogeneity < 0.01) for HGG and -1.69 months (95%CI: -3.26, -0.13; one study; I2 = 0%, P-heterogeneity = 1.00) for LGG. In patients with HGG, the pooled HR of death also showed a borderline significant increased risk of death among depressive patients (HR 1.42, 95% CI: 1.00, 2.01). Results using the FE model were not materially different. CONCLUSIONS: Depression was associated with significantly worsened survival regardless of time of diagnosis, especially among patients with high-grade glioma.

Neuropsychological effects of methyltestosterone in women using menopausal hormone replacement.

To observe the effects of androgen replacement on neuropsychological measures in menopausal women, healthy menopausal women already using replacement estrogen were studied in a randomized, double-blind, active placebo-controlled, crossover comparison between two 8-week periods of treatment with (1) 0.625 mg oral esterified estrogen (E) alone and (2) in combination with 1.25 mg oral methyltestosterone (meT). After an initial baseline session, data were gathered at the end of two treatment periods. Scores on standardized psychological tests and computerized reaction times were compared between treatments, as was an overall outcome score that combined all measures. Added meT significantly improved scores on a test of complex information processing, the Switching Attention Test, but not on other tests. Mean outcome score showed no net change and wide variation. Fourteen subjects had outcome scores >1 SD from the mean, and 21 had no change. In the estrogen alone condition, three measures predicted favorable outcome with added meT: surgically compromised ovarian function, fewer physical symptoms, and higher score on a self-image measure of creativity. Added meT treatment may improve complex information processing. Despite wide disparities in outcome, an increased chance of overall improvement may be predicted by specific pretreatment measures.

Preliminary observations on differing psychological effects of conjugated and esterified estrogen treatments.

During a double-blind comparison of menopausal replacement therapy with estrogen alone compared with estrogen plus methyltestosterone (meT), subjects who had been on conjugated equine estrogen (CEE) said they felt better when placed on esterified estrogen (EE). We, therefore, tested whether these estrogen treatments differed in their neuropsychological effects. Subjects were 34 healthy menopausal respondents to advertisements younger than age 66 who were on CEE at baseline. Each was randomized into the EE condition, either immediately after baseline or after they first took EE plus added meT for 8 weeks. We compared neuropsychological measures between these two conditions. Data included cognitive performance test results and symptom self-ratings. Multivariate techniques were used to adjust for the effects of treatment order. Compared with prior CEE treatment, EE treatment was associated with significantly improved scores on the Zung Self-Rated Depression Scale and on Switching Attention Test performance. Further investigation is warranted to determine if different forms of estrogen replacement induce different neuropsychological effects.

Correlation between somatic sensation inventory scores and hyperarousal scale scores.

Somatization mechanisms are poorly understood. The authors tested whether somatization might involve altered central nervous system information processing. They measured somatization using the Somatization Sensation Inventory (SSI) and information processing style using the Hyperarousal Scale, scores of which correlate with electroencephalogram(EEG) measures of cortical electrical responsiveness. SSI scores correlated highly with Hyperarousal scores. On logistic regression, two SSI items and two Hyperarousal items accounted for most of this correlation. These specific hyperarousal items had previously been found to covary with EEG activity and cortical evoked potential amplitudes. The authors concluded that somatization may involve altered CNS processing of somatic stimuli.

Psychiatrists' views of managed care and the future of psychiatry.

Managed care aims to insure the health of a population rather than that of an individual. This paper compiles opinions of psychiatrists and others on managed care and lists ways managed care potentially affects psychiatry. Managed care reverses the economic incentives indemnity insurance gave doctors to prolong treatment. It encourages psychiatrists to spend less time on empathic discussion and to use more standardized, less costly treatments. Many psychiatrists feel distressed about how managed care has changed their practices. Capitation care will change it further. Current trends suggest the U. S. will use and train fewer psychiatrists. Psychiatrists will spend less time with individual patients and more time planning and guiding the treatment of severely impaired patients. Many more psychiatrists will likely have unprecedented changes imposed on their careers.

Excessive daytime sleepiness associated with idiopathic alterations of consciousness.

Sleep/wake patterns were recorded by continuous 24-hour ambulatory polysomnography in 339 patients, who had episodes of altered consciousness. Patients were recorded while they were outside the hospital. From a seven-channel montage of electrodes affixed below the hairline, sleep polygraphic EEG was easily read from T3-T4, EOG from F2-F8 and EMG from T3-T6. Sleep was staged by analysis of aural signals on 60 times real time playback, augmented by continuous visual display and selected frozen frames. Patient major sleep period patterns reflected those reported for general populations. Unexpectedly, 47% of the patients took daytime naps and 44% of the nappers took more than one nap. Naps had a mean duration of 71 minutes. Those who took no naps slept significantly longer at night by 23 min. Napping reduced night sleep much more in patients who did not take CNS-acting medications. We conclude that excessive sleepiness may in part explain complaints of episodically altered consciousness.

Treatment of delayed sleep phase syndrome.

Delayed sleep phase syndrome (DSPS) is a common but little reported cause of severe insomnia. Affected individuals complain of difficulty falling asleep and difficulty awaking at socially acceptable hours. It results from a dysregulation of the circadian sleep-wake cycle. DSPS presents in clinically heterogenous ways as modulated by motivation, psychopathology, drug status, and treatment compliance factors. Patients respond variably to the range of possible treatments. Bright light treatment potentially corrects the circadian abnormality of DSPS. Other treatments reported to relieve some DSPS patients include schedule shifts, drugs, and vitamin and hormone treatments. The safety and efficacy of light treatment have not been conventionally defined, but available information suggests that it is ophthalmologically safe. At present, DSPS must be managed empirically by various methods.

Delayed sleep phase syndrome: a review of its clinical aspects.

OBJECTIVE: Delayed sleep phase syndrome is a common but little reported cause of severe insomnia. Since it was first described, few detailed reports of delayed sleep phase syndrome have appeared, and treatment methods have not been reviewed. From the literature, the authors provide diagnostic descriptions and review treatment methods, and from their sleep disorder clinic, they describe the management and outcome of the largest series of patients with delayed sleep phase syndrome thus far reported. METHOD: The authors reviewed all articles with primary data on delayed sleep phase syndrome published through 1993 and add data from a group of 33 patients at their sleep disorder clinic. RESULTS: Delayed sleep phase syndrome involves undesirably late bedtimes and arising times, early night insomnia, and poor morning alertness but lack of insomnia on vacations. The mean bedtime and arising time for the 33 patients were 4:00 a.m. and 10:38 a.m., respectively. Twenty-five patients were, or had been, depressed. Individual responses to treatments varied widely. Seventeen patients showed little treatment response. Delayed sleep phase syndrome had a worse treatment outcome than other sleep disorders. CONCLUSIONS: Delayed sleep phase syndrome presents in a heterogeneous manner. In the sleep disorder clinic population, it was often associated with major depression and was more resistant to treatment than other sleep disorders. Multiple and varied treatments are required.

Daytime alertness in patients with primary insomnia.

OBJECTIVE: In the absence of clear distinctions in alertness between patients with primary insomnia and normal subjects, the goal of this study was to identify psychometric and electrophysiological measures that would distinguish these two groups. METHOD: The daytime alertness of 20 primary insomnia patients and 20 normal subjects was investigated through their scores on a 26-item hyperarousal scale and measurement of auditory evoked potentials and alpha and nonalpha band EEG activity. Statistical analysis of the data included correlation of the hyperarousal scores and the electrophysiological measures. RESULTS: The hyperarousal scores showed clearly higher daytime alertness in the insomnia patients compared with the normal subjects. In addition, during wakefulness, the insomnia patients showed greater amplitudes of P1N1, a durable, intrinsic, late (cortical) component of the auditory evoked potential, as well as greater EEG activity across the frequency spectrum. The hyperarousal scores correlated positively with the amplitude of P1N1 at each of three sound intensities. CONCLUSIONS: To the authors' knowledge, this is the first study to offer evidence that patients with primary insomnia have objectively definable features during wakefulness that clearly distinguish them from normal subjects. The measurement of hyperarousal might be used to refine descriptions of insomnia populations in experimental studies.

Is the poor sleep of shift workers a disorder?

OBJECTIVE: The purpose of this article is to describe the impact of shift work on sleep, as recently acknowledged in official nosologies of sleep disorders, and to discuss whether sleep altered by shift work actually constitutes a disorder. METHOD: The authors review subjective responses to recent survey questions about sleep and polygraphic measurements of sleep in shift workers and describe sleep clinic experiences with complaints related to shift work. FINDINGS: Shift work entails wide variation in work schedules, sleep quality, and worker tolerance and a high prevalence of night-shift sleepiness. It probably affects rates of drug use, health status, and family organization. Clinical presentations were rare, highly varied, and empirically treated. The United States, unlike other countries, has no legal restrictions on shift work. CONCLUSIONS: As a clinical phenomenon, sleep altered by shift work is common and varied, probably expresses nonphysiological sleep-wake scheduling, and is little treated. Further study of its health effects and consideration of whether it is a "disorder" or a "problem" seem warranted.

Relief of sleep apnea by revision of the adult upper airway. A review of clinical experience.

Surgical revision of the upper airway for obstructive sleep apnea has repeatedly improved subjective more than objective laboratory outcome measures. To examine this disparity, we obtained subjective sleepiness questionnaire scores, Continuous Performance test, and polysomnography (PSG) in 40 patients with mild to moderate obstructive sleep apnea (mean apnea index, 33.9; mean minimum oxygen saturation during sleep, 75.4%). Continuous Performance test confirmed abnormal daytime sleepiness and correlated with minimum oxygen saturation and number of transitions between stages. Postoperatively, questionnaire scores fell a mean of 62%, indicating a marked improvement in subjective sleepiness. Changes in questionnaire score correlated with changes in minimum oxygen saturation. Mean PSG indexes showed no change. Individual patients without PSG improvement reported long-term improvement in daytime functioning, as confirmed by family members. These results suggest that measures in addition to PSG, including patient subjective response, would more fully characterize the outcome of revision of the upper airway for sleep apnea.

Specific effects of sedative/hypnotic drugs in the treatment of incapacitating chronic insomnia.

Sedative/hypnotic drugs for the treatment of chronic insomnia are generally considered ineffective by most experts but helpful by many patients. Occasionally, insomnia-induced debilitations may be remedied by long-term use of sedative/hypnotic drugs; some examples are given. The present discrepancy between expert and patient opinion may be derived from current research practices. The improbability that series of sedative/hypnotic drug trials will be carried out for patients with insomnia further biases against observation of rarer but clinically significant distinctions among these drugs.

Daily sleep patterns observed among institutionalized elderly residents.

The sleep/wake patterns of 16 institutionalized demented women were visually monitored hourly for 14 consecutive days. Individual mean total sleep time varied markedly from 5.0 to 12.1 hours per 24 hours. Unexpectedly, amounts of day sleep and night sleep correlated positively, suggesting a general sleep tendency manifested throughout the 24-hour day. Consistent individual sleep patterns and high inter-day correlations were found. A high degree of individuality in the sleep/wake patterns was also found, contrary to expectations that elderly obtain less sleep than others. Night sleep in the institutionalized elderly was not lessened by daytime sleep. Visual monitoring of sleep/wake patterns generated reliable data.