Understanding fatigue in medicine

Even in ancient times, it was understood that rest and sleep are vital processes, as essential as breathing, eating, and other bodily functions. However, only in recent decades science has demonstrated that sleep is an active process involving neuronal network stabilization, restoration of brain and whole-body energy reserves, proper protein structure formation, promotion of macromolecule synthesis, processing and long-term retention of information, emotional regulation, reduction of oxidative stress-induced cellular damage, regulation of immune responses, and the clearance of toxic metabolites and protein degradation products. In cases of mental and sleep disorders, these processes are disrupted. The aim of this review article is to analyze the relationship between sleep and mental disorders, while focusing on different groups of psychiatric conditions. We also discuss the comorbidity of sleep and mental disorders, explore how sleep disturbances may trigger relapses or worsen psychiatric symptoms, and characterize core changes in sleep architecture for various mental disorders. Additionally, we review the effects of psychotropic medications on sleep, therapeutic considerations for their usage, and present combined psychotherapeutic and pharmacological treatment strategies that can optimize the treatment outcomes for both sleep and mental disorders.

To evaluate the effects of adjunctive pregabalin 300 mg/day versus placebo on polysomnographic (PSG) variables in patients with well controlled partial seizures and subjectively reported sleep disturbance. An exploratory, 4-week, double-blind, randomized study in patients with well controlled partial seizures on AED monotherapy and subjective sleep disturbance over the previous 6 months. Mean changes from baseline to endpoint in PSG and subjective sleep variables (MOS Sleep Scale, Groningen Sleep Questionnaire) in patients on adjunctive pregabalin 300 mg/day (n=8) were compared with patients on placebo (n=7). Baseline PSGs showed sleep fragmentation. Mean sleep efficiency improved significantly in both treatment groups in the mean baseline to endpoint change; there was no significant between-group difference. Pregabalin treatment was associated with a significant reduction in number of awakenings (p = 0.02), and improvement in wake time after sleep onset approached significance (p = 0.055), suggesting improvement in sleep continuity that was not observed in the placebo group. Pregabalin was also associated with significant improvements in the MOS sleep disturbance and sleep quantity subscales compared with placebo (p < or =0.03). There were no changes in self-reported seizure control. This exploratory pilot study suggests that pregabalin may improve sleep continuity in patients with clinically relevant sleep disturbance. The effect on disturbed sleep appears independent of seizure control. The effects of pregabalin on disturbed sleep and seizures and their interrelationships warrant further study.

Introduction: Sleep and psychiatric disorders are common, and often co-morbid. Sleep disorders may predispose to development or exacerbation of psychiatric disorders. Authors hypothesized that treatment of sleep disorders improve outcomes in psychiatric illnesses. Methods: Charts of patients diagnosed with sleep disorders from October 2007 to December 2007 were reviewed. Outcomes in patients with co-morbid psychiatric disorders were recorded at 6, 12 and 24 months after initiation of sleep disorder treatment. These patients received a baseline psychiatric status score of 0. Change in status at each subsequent time point was scored as: ?2 (marked worsening), ?1 (mild worsening), 0 (no change), +1 (mild improvement) or +2 (marked improvement). We individually compared change in average score at each time point to baseline using the signed rank test. We compared provider documented compliance to sleep therapies between patients with and without psychiatric disorders using Fisher’s exact test. Results: Of 127 charts reviewed, 10 were excluded as patients died within follow-up period. No death was reported as suicide. Of 117 patients, 97.64% were men, 2.36% were women. Age range: 21 - 40: 7.69%, 41 - 60: 42.74%, 61 - 80: 47.87%, >81: 1.70%. 58 patients (45.67%) had coexistent psychiatric diagnoses. There was no difference in provider documented compliance rate to sleep therapies between patients with and without psychiatric disorders at 6, 12 and 24 months, (Fisher’s p value 0.1031, 0.2290 and 0.2248 respectively). Psychiatric status progressively improved compared to baseline (Change in average score by +0.45, +0.56, and +0.79 at 6, 12, and 24 months, respectively, p < 0.0001). Conclusion: Psychiatric disorders did not affect compliance to sleep related treatment. Treatment of co-morbid sleep disorders is associated with improvement in psychiatric disorders. Authors recommend need for prospective study with more subjects.

Clinical Guidelines for the Use of Unattended Portable Monitors in the Diagnosis of Obstructive Sleep Apnea in Adult Patients

Don’t Let Your Patients Lose Sleep Over Insomnia

This is a narrative review of sleep disorders, especially chronic insomnia, as a primary diagnosis or as a comorbid diagnosis associated with different psychiatric and organic diseases. The epidemiological evidence is reviewed, the diagnostic criteria most frequently used in clinical practice are examined, and a series of therapeutic recommendations for the correct treatment of this pathology is presented. Sleep disorders are very prevalent in the general population (one-third experiences difficulty with sleep ini- tiation/maintenance at least once a week, and about 6-15% meet the criteria for insomnia disorders), but remain rel-atively poorly understood and frequently overlooked by healthcare professionals. Prevalence estimates of insom-nia disorder vary between 5% and 20%. Sleep disorders co-exist with psychiatric and medical conditions with an in-teractive and bidirectional relationship. About 70-80% of psychiatric patients show some sleep disturbance and there is a correlation between the severity of the sleep disturbance and the severity of the psychopathology. Untreated sleep disorders increase the risk of cardiovascular events, cognitive impairment, motor vehicle accidents, obesity, diabetes, and efficiency and safety at work, leading to increased all-cause healthcare utilization and being a strong predictor of sick leave or disability pension and poor quality of life. Sleep disorders can cause drowsiness or excessive daytime sleepiness, which can lead to functional impairment in 15% of the general adult population. Sleep quality should be a routine target in the evaluation of patients with psychiatric and non-psychiatric diseases to ensure sleep health based on early diagnosis and adequate therapeutic approaches.

Psychiatric correlates in deficit of immunoglobulins

The human body has adapted to daily changes in dark and light such that it anticipates periods of sleep and activity. Deviations from this circadian rhythm come with functional consequences. Thus, 17 hours of sustained wakefulness in adults leads to a decrease in performance equivalent to a blood alcohol-level of 0.05%;[1] the legal level for drink driving in many countries.[2] Rats deprived of sleep die after 32 days,[3] and, with longer periods of sleep deprivation, this would also be the case in human beings. Indeed, sleep deprivation is a common form of torture.[4] Given the readily observable effects of sleep in everyday life, it is not surprising that there has been scholarly interest in sleep since the beginning of recorded history.[5] Sleep epidemiology as a subject in its own right has a recognisable history of just over 30 years,[6] with the first modern epidemiological studies of sleep disturbances appearing around 1980.[7;8] Nevertheless, a PubMed search for terms “sleep/insomnia” and “epidemiology” shows that the cumulative number of papers on the subject over the past 10 years is already about 10,000. Although this is less than for standard risk factors, such as obesity (>60,000) and smoking (50,000)(Figure 1), the annual number of papers on sleep epidemiology is rising rapidly (Figure 2). This issue of IJE includes a review[9] of the first comprehensive textbook of Sleep Epidemiology,[10] and the purpose of our Editorial is further to highlight recent developments to give the reader an idea why the coming years are likely to see an increasing interest in sleep studies. Figure 1 Exposures AND Epidemiology 2000–2010 Figure 2 Sleep/insomnia AND Epidemiology by year Why the upsurge in interest? There are several reasons for an increase in interest in sleep from an epidemiological perspective. First, sleep problems are associated with accidents and human errors. It has been estimated that 10–15% of fatal motor-vehicle crashes are due to sleepiness or driver fatigue. Furthermore, by 2020 the number of people killed in motor-vehicle crashes is expected to double to 2.3 million deaths worldwide, of which approximately 230,000–345,000 will be due to sleepiness or fatigue.[11] It has been estimated that nearly 100,000 deaths occur each year in US hospitals due to medical errors and sleep deprivation have been shown to make a significant contribution.[12] Similarly, in a national sample in Sweden of over 50,000 people interviewed over 20 years disturbed sleep almost doubled the risk of a fatal accident at work.[13] Second, sleep problems are common. Population studies show that sleep deprivation and disorders affect many more people worldwide than had been previously thought. A recent study found 20% of 25–45 year-olds slept “90 minutes less than they needed to be in good shape”.[14] Insomnia is the most common specific sleep disorder, with ‘some insomnia problems over the past year’ reported by approximately 30% of adults and chronic insomnia by approximately 10%.[15] Prevalence of obstructive sleep apnoea, characterized by respiratory difficulties during sleep, is also very high with estimates of 9–21% in women and 24–31% in men.[16;17] Third, sleep problems are likely to increase. The rapid advent of the 24/7 society involving round-the-clock activities and increasing night time use of TV, internet and mobile phones mean that adequate sleep durations may become increasingly compromised. Some data suggest a decline in sleep duration of up to 18 minutes per night over the past 30 years.[18;19] Complaints of sleeping problems have increased substantially over the same period, with short sleep (<6 hours/night) in full-time workers becoming more prevalent.[19;20] As more shift work is required to service 24/7 societies the proportion of workers exposed to circadian rhythm disorders, such as shift work sleep disorder, and their effects on health and performance is likely to rise. Sleep architecture is known to change with age; slow-wave (or deep) sleep decreases and lighter sleep increases. Other changes include increases in nocturnal sleep disruption and daytime sleepiness. As the proportion of elderly people in populations across the world increases, these changing sleep patterns will raise the prevalence of sleep disorders. Similarly, the increasing worldwide obesity epidemic and the prevalence of obstructive sleep apnoea, which is over double among the obese, ensure sleep disorders will be of increasing public health importance in lower as well as high income countries.[16;21] Fourth, sleep problems are associated with short and long-term effects on health and well-being. Immediate effects at the individual level relate to well-being, performance, daytime sleepiness and fatigue. Longer term, evidence has accumulated of associations between sleep deprivation and sleep disorders and numerous health outcomes including premature mortality, cardiovascular disease, hypertension, inflammation, obesity, diabetes and impaired glucose tolerance, and psychiatric disorders, such as anxiety and depression. As this evidence represents the core of Sleep Epidemiology, we provide below a snapshot on key findings.

The Link Between Homeless Women's Mental Health and Service System Use

Introduction Sleep disorders and psychiatric disease are closely related, and psychiatric diseases are associated with elevated suicide risks. Yet, it is not clear if sleep disorders are associated with suicide as previous studies were limited by self-reported measures. The aim of this study was to examine whether people with a hospital-diagnosis of sleep disorders had higher suicide rates than people with no diagnosis. Methods Using a retrospective cohort design, national data on all persons aged 15 years and over who lived in Denmark during 1980–2016 (males: 3,674,563, females: 3,688,164) were obtained. People with sleep disorders were identified in somatic hospital registers. The main outcome was death by suicide as recorded in the Danish Cause of Death register. Incidence Rate Ratios were obtained using Poisson regressions while adjusting for relevant covariates. Results Out of 23,927 male and 11,556 female suicide deaths, 299 and 117 had been diagnosed with a sleep disorder, respectively. Males with sleep disorders had a suicide rate of 47.4 (95% CI, 42.0–52.7) per 100,000 person-years compared to 29.9 (95% CI, 29.5–30.3) among those with no sleep disorders. For females the respective rates were 42.3 (95% CI, 34.7–50.0) versus 13.9 (95% CI, 13.6–14.1). An adjusted IRR of 1.6 (95% CI, 1.4–1.7) and 2.2 (95% CI, 1.8–2.6) was noted among males and females with sleep disorders, respectively, when compared to those with no disorders. Excess rates were noted with respect to insomnia, narcolepsy and, in males, sleep apnea. A difference with respect to age and sex was observed (p&amp;lt;0.001). Furthermore,IRRs of 4.1(95% CI, 3.1–5.5) and 7.0 (95% CI, 4.8–10.1) were noted for males and females, respectively, during the first 6 months of diagnosis when compared to those not diagnosed. The association between sleep disorders and suicide remained significant when adjusting for psychiatric disorders, although those with psychiatric disorders also had elevated rates, particularly amongst females. Conclusion In this study, individuals with sleep disorders had an increased suicide rate when compared to those with no sleep disorders. Higher suicide rates were found for individuals suffering from narcolepsy, insomnia and sleep apnea. More attention towards risks of suicide among people with sleep disorders might be needed. Support (if any):

What’s Next for Somatic Symptom Disorder?

IntroductionChronic medical conditions like hypertension may increase the risk of mental disorders such as anxiety and depression.ObjectivesThis study aimed to investigate if hypertension is associated with a higher incidence of major mental disorders, including anxiety disorders, depressive disorders, bipolar disorders, psychotic disorders, sleep disorders, vascular dementia, and Alzheimer’s dementia, compared to controls.MethodsI analyzed standardized data from patients with hypertension (n = 48,466) and those without hypertension (n = 442,660) at a university hospital. Clinical data was standardized into a common data model. Using propensity score matching (PSM) at a 1:5 ratio, I compared the incidence of mental disorders between the hypertension and control groups over a 5-year period. A multivariate Cox proportional hazards model was used to estimate the risk of mental disorders, with hazard ratios (HR) and 95% confidence intervals (CI).ResultsAfter PSM, the hypertension group had a higher prevalence of being elderly (over 60 years old) and having conditions like diabetes, hyperlipidemia, atrial fibrillation, cerebrovascular disease, and heart disease compared to controls. The hypertension group also had significantly increased use of antithrombotic agents, beta-blockers, calcium channel blockers, diuretics, acid-related disorder drugs, diabetes medications, lipid-modifying agents, and opioids. The incidence rates per 1,000 patient-years for mental disorders were as follows: anxiety disorders (7.22 vs. 4.49), depressive disorders (8.51 vs. 5.47), bipolar disorders (1.13 vs. 0.91), psychotic disorders (0.18 vs. 0.22), sleep disorders (16.32 vs. 8.60), vascular dementia (0.77 vs. 0.14), and Alzheimer’s dementia (9.29 vs. 2.53). Compared to controls, the hypertension group had a higher risk of developing vascular dementia (HR, 6.03; 95% CI, 4.34–8.44; p<0.01), Alzheimer’s dementia (HR, 3.89; 95% CI, 3.56–4.24; p<0.01), sleep disorders (HR, 1.96; 95% CI, 1.85–2.07; p<0.01), anxiety disorders (HR, 1.69; 95% CI, 1.56–1.83; p<0.01), and depressive disorders (HR, 1.64; 95% CI, 1.52–1.76; p<0.01). There were no significant differences for bipolar disorders (HR, 1.17; 95% CI, 0.95–1.43; p=0.12) or psychotic disorders (HR, 0.85; 95% CI, 0.51–1.34; p=0.50).ConclusionsHypertensive patients have an increased risk of major mental disorders, particularly vascular dementia, Alzheimer’s dementia, sleep disorders, anxiety disorders, and depressive disorders. Older age, age-related diseases, and various medication uses contribute to this increased risk.Disclosure of InterestNone Declared

Menopause in the female life cycle is a special period due to important hormonal, physical and psychological changes. Sleep disruption represents a common complaint for midlife and menopausal women, related to primary sleep disorders, including insomnia, sleep disordered breathing, restless legs syndrome (RLS), mood and anxiety disorder, other medical illness, hormonal-related vasomotor symptoms, and aging per se. Aims of our study were to evaluate the prevalence of sleep disorders in a sample of pre and post menopausal women, and to investigate the relationship between sleep and other medical disorders, and life habits. Among workers in the six participant centers, we enrolled 334 women, aged between 40 and 60 years, that completed a questionnaire that included screening on menarche, menstrual cycle, fertility, parity, menopause, life habits, personal medical and sleep history and related treatment, and self-administered scales for sleep quality (PSQI), excessive daytime sleepiness [Epworth Sleepiness Scale (ESS)], mood disorder [Beck Depression Inventory (BDI)], Berlin Questionnaire for sleep disordered breathing (SDB), IRLS diagnostic interview and Rating Scale. Menopausal and perimenopausal women showed an increased prevalence of poor sleep, high risk of SDB, and mood disorder; menopausal women also reported increased RLS severity. Mood disorder had a significant impact on night sleep measures and excessive daytime sleepiness, as well as on RLS severity, and had a greater prevalence in hypertensive women. Sleep disturbances are frequent in menopausal women. Their aetiology is unclear, but probably multifactorial, and many factors contribute to the sleep disruption. Our data suggest the importance of correctly investigate and address sleep problems associated with menopause, through sleep history, and a sleep study could be obtained if clinically warranted. Pharmacological and behavioural treatment strategies should then be aimed at improving sleep and life quality in perimenopausal and menopausal women.

Cerebrovascular diseases often complicated with sleep disorders, they are mainly associated with the lesion sites, and psychiatric and psychological factors. Attentions should be paid to the patients with cerebrovascular diseases complicated with sleep disorders. Actively finding out the cause of the disease, undergoing early treatment, and reducing complications will help to improve the quality of life in patients, This article reviews the causes, clinical features, diagnosis, prevention and treatment of sleep disorders in patients with cerebrovascular diseases. Key words: cerebrovascular disorders; sleep disorder

563 Objective: This study identified factors associated with use of the emergency department for medical reasons among individuals with serious mental illness. Methods: A total of 200 randomly selected outpatients who were receiving community-based psychiatric care were recruited for the study and interviewed with items from the National Health Interview Survey and other national health surveys. Results: Emergency department use (37 percent of the sample) was negatively associated with older age and positively associated with the number of co-occurring medical conditions, smoking, recent injury, and recent change in health care provider. Conclusions: The relatively high rate of emergency department use may be suggestive of inappropriate use or may reflect perceived barriers to care. Future work should identify specific reasons for seeking care in the emergency department and develop interventions to optimize appropriate emergency department use. (Psychiatric Services 57: 563–566, 2006)