Residual sleep disturbances in patients remitted from major depressive disorder: a 4-year naturalistic follow-up study.

STUDY OBJECTIVES: To investigate the prevalence and clinical, psychosocial, and functional correlates of residual sleep disturbances in remitted depressed outpatients. DESIGN: A 4-yr prospective observational study in a cohort of psychiatric outpatients with major depressive disorder was conducted with a standardized diagnostic psychiatric interview and a packet of questionnaires, including a sleep questionnaire, Hospital Anxiety and Depression Scale, NEO personality inventory, and Short Form-12 Health Survey. SETTINGS: A university-affiliated psychiatric outpatient clinic. INTERVENTIONS: N/A MEASUREMENTS AND RESULTS: Four hundred twenty-one depressed outpatients were recruited at baseline, and 371 patients (mean age 44.6 ± 10.4 yr, female 81.8%; response rate 88.1%) completed the reassessments, in which 41% were classified as remitted cases. One year prevalence of frequent insomnia at baseline and follow-up in remitted patients was 38.0% and 19.3%, respectively. One year prevalence of frequent nightmares at baseline and follow-up was 24.0% and 9.3%, respectively. Remitted patients with residual insomnia were more likely to be divorced (P < 0.05) and scored higher on the anxiety subscale (P < 0.05). Remitted patients with residual nightmares were younger (P < 0.05) and scored higher on neuroticism (P < 0.05) and anxiety subscales (P < 0.01). Residual insomnia and nightmares were associated with various aspects of impaired quality of life. Residual nightmares was associated with suicidal ideation (odds ratio = 8.40; 95% confidence interval 1.79-39.33). CONCLUSIONS: Residual sleep disturbances, including insomnia and nightmares, were commonly reported in remitted depressed patients with impaired quality of life and suicidal ideation. A constellation of psychosocial and personality factors, baseline sleep disturbances, and comorbid anxiety symptoms may account for the residual sleep disturbances. Routine assessment and management of sleep symptoms are indicated in the integrated management of depression.

Nocturnal sleep disturbances as a predictor of suicide attempts among psychiatric outpatients: a clinical, epidemiologic, prospective study.

OBJECTIVE: Nocturnal sleep disturbances, including insomnia and recurrent nightmares, represent common distressing sleep complaints that might have important prognostic and therapeutic implications in psychiatric patients. The present study aimed at investigating nocturnal sleep disturbances in relation to the risk of suicide attempts in a consecutive cohort of psychiatric outpatients. METHOD: Participants attending a psychiatric outpatient clinic in Hong Kong were recruited into the study with a detailed sleep questionnaire assessment. The questionnaire was distributed between May and June 2006. Relevant clinical information, with a comprehensive clinical history of patients since their attendance at psychiatric services and 1 year after completion of their questionnaires, was reviewed. RESULTS: The final study population consisted of 1,231 psychiatric outpatients with a mean age of 42.5 years (SD = 11.3; range, 18-65). Both frequent insomnia and recurrent nightmares were significantly and independently associated with an increased incidence of suicide attempts 1 year after questionnaire assessment (insomnia: OR = 6.96; 95% CI, 1.21-39.97; recurrent nightmares: OR = 8.17; 95% CI, 1.06-63.13) and an increase in lifetime prevalence of suicide attempts (insomnia: OR = 1.55; 95% CI, 1.06-2.25; recurrent nightmares: OR = 2.43; 95% CI, 1.51-3.91). Comorbid insomnia and nightmares had increased odds of lifetime prevalence (OR = 2.43; 95% CI, 1.53-3.85) and 1-year incidence of suicidal risk (OR = 17.08; 95% CI, 2.64-110.40). Antidepressants, particularly selective serotonin reuptake inhibitors (OR = 1.52; 95% CI, 1.02-2.25), serotonin-norepinephrine reuptake inhibitors (OR = 2.10; 95% CI, 1.15-3.83), heterocyclics (OR = 2.78; 95% CI, 1.21-6.42), and non-benzodiazepine hypnotics (OR = 1.54; 95% CI, 1.02-2.33) were independently associated with recurrent nightmares after adjustment for confounding variables. CONCLUSIONS: Nocturnal sleep disturbances, particularly frequent insomnia and recurrent nightmares, were independently associated with enhanced suicidal risk among psychiatric patients. Future studies are warranted to investigate the underlying pathophysiologic mechanism and interventional responses.

Parasomnia among psychiatric outpatients: a clinical, epidemiologic, cross-sectional study.

OBJECTIVE: Epidemiologic studies from general population and clinical case series suggest association of parasomnias with mental illnesses and psychotropic medications. This cross-sectional study aimed at determining the prevalence rate of sleepwalking, sleep-related eating disorder (SRED), rapid eye movement sleep behavior-like disorder (RSBD-like disorder), and sleep-related injury (SRI) and their associated factors in an adult psychiatric outpatient clinic. METHOD: Subjects aged 18 to 65 years who were attending an outpatient clinic in Hong Kong from May 2006 through June 2006 were included in this cross-sectional study. A 3-phase design was employed, including a structured questionnaire on parasomnias, followed by clinical interviews of both questionnaire-positive and -negative groups, and polysomnography for subjects having active parasomnias in recent 1 year. In addition, the principal psychiatric diagnoses, medical illnesses, and detailed drug history over recent 1 year were retrieved from the computerized records. RESULTS: Twelve hundred thirty-five subjects completed the phase 1 interview. The estimated prevalence of the lifetime diagnoses of sleepwalking, SRED, SRI, sleep violence, and RSBD-like disorder were 8.5%, 4.0%, 21.0%, 3.6%, and 5.8%, respectively, while the 1-year prevalence of these conditions were 2.9%, 2.4%, 8.8%, 2.5%, and 3.8%, respectively. These conditions were associated with depression and a constellation of sleep disturbances. Specific combinations of psychotropics were found to pose risk in particular parasomnias: sedative antidepressants and nonbenzodiazapine hypnotics in sleepwalking, regular zolpidem and antidepressants in SRED, and selective serotonin reuptake inhibitors in RSBD-like disorder. CONCLUSIONS: Sleepwalking, SRED, RSBD-like disorder, and SRI were common and underrecognized among the psychiatric population in this study. Their occurrences were likely contributed by interacting effect of mental illnesses, sleep disturbances, and specific psychotropic medications. Further prospective study is warranted for clarification of the etiology and clinical management of these potentially dangerous and "hidden" parasomnias.