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CME / ABIM MOC / CE

Sleep Complaints In Major Depressive Disorder: Red Flags For Other Psychiatric Disorders?

  • Authors: News Author: Batya Swift Yasgur, MA, LSW; CME Author: Laurie Barclay, MD
  • CME / ABIM MOC / CE Released: 2/24/2023
  • Valid for credit through: 2/24/2024, 11:59 PM EST
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  • Credits Available

    Physicians - maximum of 0.25 AMA PRA Category 1 Credit(s)™

    ABIM Diplomates - maximum of 0.25 ABIM MOC points

    Nurses - 0.25 ANCC Contact Hour(s) (0 contact hours are in the area of pharmacology)

    Pharmacists - 0.25 Knowledge-based ACPE (0.025 CEUs)

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    IPCE - 0.25 Interprofessional Continuing Education (IPCE) credit

    You Are Eligible For

    • Letter of Completion
    • ABIM MOC points

Target Audience and Goal Statement

This activity is intended for psychiatrists, family medicine/primary care clinicians, internists, neurologists, nurses, pharmacists, physician assistants, sleep medicine clinicians, and other members of the health care team for patients with major depressive disorder or major depressive episode and sleep complaints.

The goal of this activity is for learners to be better able to describe the incidence of psychiatric disorders after sleep complaints in adults with major depressive episode.

Upon completion of this activity, participants will:

  • Assess the incidence of psychiatric disorders after sleep complaints in adults with major depressive episode, based on an analysis of data from a large, nationally representative US survey
  • Evaluate the clinical implications of the incidence of psychiatric disorders after sleep complaints in adults with major depressive episode, based on an analysis of data from a large, nationally representative US survey
  • Outline implications for the healthcare team


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News Author

  • Batya Swift Yasgur, MA, LSW

    Freelance writer, Medscape

    Disclosures

    Batya Swift Yasgur, MA, LSW, has no relevant financial relationships.

CME Author

  • Laurie Barclay, MD

    Freelance writer and reviewer
    Medscape, LLC

    Disclosures

    Laurie Barclay, MD, has no relevant financial relationships.

Editor/Compliance Reviewer  ​

  • Amanda Jett, PharmD, BCACP  ​​

    Associate Director, Accreditation and Compliance, Medscape, LLC​ ​

    Disclosures

    Amanda Jett, PharmD, BCACP, has no relevant financial relationships.

Nurse Planner

  • Stephanie Corder, ND, RN, CHCP

    Associate Director, Accreditation and Compliance, Medscape, LLC

    Disclosures

    Stephanie Corder, ND, RN, CHCP, has no relevant financial relationships.

Peer Reviewer

This activity has been peer reviewed and the reviewer has no relevant financial relationships.


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CME / ABIM MOC / CE

Sleep Complaints In Major Depressive Disorder: Red Flags For Other Psychiatric Disorders?

Authors: News Author: Batya Swift Yasgur, MA, LSW; CME Author: Laurie Barclay, MDFaculty and Disclosures

CME / ABIM MOC / CE Released: 2/24/2023

Valid for credit through: 2/24/2024, 11:59 PM EST

processing....

Clinical Context

Major depressive episode (MDE) is a disabling condition affecting approximately 7% of adults, with sleep disturbance in 92%, and increased risk for medical and psychiatric comorbidities. Risk for poorer medical outcomes is greater than in the general population.

Shorter sleep duration is associated with many psychiatric disorders. The bidirectional association between MDE and sleep disturbance suggests the latter as a predictive prodromal symptom.

Study Synopsis and Perspective

Sleep complaints by patients with a MDE may be a red flag signaling a higher risk for developing other psychiatric disorders, new research suggests.

Investigators studied 3-year incidence rates of psychiatric disorders in almost 3000 patients experiencing an MDE. Results showed that having a history of difficulty falling asleep, early morning awakening, and hypersomnia increased risk for incident psychiatric disorders.

“The findings of this study suggest the potential value of including insomnia and hypersomnia in clinical assessments of all psychiatric disorders,” write the investigators, led by Bénédicte Barbotin, MD, from the Département de Psychiatrie et d’Addictologie, Assistance Publique-Hôpitaux de Paris, Hôpital Bichat-Claude Bernard, France.

“Insomnia and hypersomnia symptoms may be prodromal transdiagnostic biomarkers and easily modifiable therapeutic targets for the prevention of psychiatric disorders,” they add.

The findings were published online December 21, 2022, in the Journal of Clinical Psychiatry.

Bidirectional Association

The researchers note that sleep disturbance is “one of the most common symptoms” associated with major depressive disorder and may be “both a consequence and a cause” of the condition.

Moreover, improving sleep disturbances for patients with MDE “tends to improve depressive symptoms and outcomes,” they add.

Although the possibility of a bidirectional association between MDE and sleep disturbances “offers a new perspective that sleep complaints might be a predictive prodromal symptom,” the association of sleep complaints with the subsequent development of other psychiatric disorders in MDE “remains poorly documented,” the investigators write.

The observation that sleep complaints are associated with psychiatric complications and adverse outcomes, such as suicidality and substance overdose, suggests that longitudinal studies “may help to better understand these relationships.”

To investigate these issues, the researchers examined 3 sleep complaints among patients with MDE: trouble falling asleep, early morning awakening, and hypersomnia. They adjusted for an array of variables, including antisocial personality disorders, use of sedatives or tranquilizers, sociodemographic characteristics, MDE severity, poverty, obesity, educational level, and stressful life events.

They also used a “bifactor latent variable approach” to “disentangle” a number of effects, including those shared by all psychiatric disorders; those specific to dimensions of psychopathology, such as internalizing dimension; and those specific to individual psychiatric disorders, such as dysthymia.

They drew on data from waves 1 and 2 of the National Epidemiological Survey on Alcohol and Related Conditions, a large, nationally representative survey conducted in 2001 to 2002 (wave 1) and 2004 to 2005 (wave 2) by the National Institute on Alcoholism and Alcohol Abuse.

The analysis included 2864 participants who experienced MDE in the year before wave 1 and who completed interviews at both waves.

The researchers assessed past-year Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV), axis I disorders and baseline sleep complaints at wave 1, as well as incident DSM-IV axis I disorders between the 2 waves, including substance use, mood, and anxiety disorders.

Screening Needed?

Results showed a wide range of incidence rates for psychiatric disorders between wave 1 and wave 2, ranging from 2.7% for cannabis use to 8.2% for generalized anxiety disorder.

The lifetime prevalence of sleep complaints was higher among participants who developed a psychiatric disorder between the 2 waves than among those who did not have sleep complaints. The range (from lowest to highest percentage) is shown in the following table.

Sleep complaint

Psychiatric disorder

Percentage

Difficulty falling asleep

Cannabis use disorder

67.6

Panic disorder

76.4

Morning awakenings

Cannabis use disorder

43.3

Dysthymia

55.6

Hypersomnia

Nicotine use disorder

51.3

Social anxiety disorder

72.1

A higher number of sleep complaints was also associated with higher percentages of psychiatric disorders.

Hypersomnia, in particular, significantly increased the odds of having another psychiatric disorder. For patients with major depressive disorder who reported hypersomnia, the mean number of sleep disorders was significantly higher than for patients without hypersomnia (2.08 vs 1.32; P<.001).

After adjusting for sociodemographic and clinical characteristics and antisocial personality disorder, the effects shared across all sleep complaints were “significantly associated with the incident general psychopathology factor, representing mechanisms that may lead to incidence of all psychiatric disorders in the model,” they add.

The researchers note that insomnia and hypersomnia can impair cognitive function, decision-making, problem-solving, and emotion processing networks, thereby increasing the onset of psychiatric disorders in vulnerable individuals.

Shared biological determinants, such as monoamine neurotransmitters that play a major role in depression, anxiety, substance use disorders, and the regulation of sleep stages, may also underlie both sleep disturbances and psychiatric disorders, they speculate.

“These results suggest the importance of systematically assessing insomnia and hypersomnia when evaluating psychiatric disorders and considering these symptoms as non-specific prodromal or at-risk symptoms, also shared with suicidal behaviors,” the investigators write. “In addition, since most individuals who developed a psychiatric disorder had at least 1 sleep complaint, all psychiatric disorders should be carefully screened among individuals with sleep complaints,” they add.

Transdiagnostic Phenomenon

Commenting for Medscape Medical News, Roger McIntyre, MD, professor of psychiatry and pharmacology at the University of Toronto, Ontario, Canada, and head of the Mood Disorders Psychopharmacology Unit, noted that the study replicates previous observations that a bidirectional relationship exists between sleep disturbances and mental disorders and that there “seems to be a relationship between sleep disturbance and suicidality that is bidirectional.”

He added that he appreciated the fact that the investigators “took this knowledge one step further; and what they are saying is that within the syndrome of depression, it is the sleep disturbance that is predicting future problems.”

The data suggest that, “conceptually, sleep disturbance is a transdiagnostic phenomenon that may also be the nexus when multiple comorbid mental disorders occur,” he said.

“If this is the case, clinically, there is an opportunity here to prevent incident mental disorders in persons with depression and sleep disturbance, prioritizing sleep management in any patient with a mood disorder,” Dr McIntyre added.

The study received no specific funding from any funding agency, commercial, or not-for-profit sectors. The investigators’ relevant financial relationships are listed in the original article. Dr McIntyre has received research grant support from CIHR/GACD/National Natural Science Foundation of China and the Milken Institute; has received speaker/consultation fees from Lundbeck, Janssen, Alkermes, Neumora Therapeutics, Boehringer Ingelheim, Sage, Biogen, Mitsubishi Tanabe, Purdue, Pfizer, Otsuka, Takeda, Neurocrine, Sunovion, Bausch Health, Axsome, Novo Nordisk, Kris, Sanofi, Eisai, Intra-Cellular, NewBridge Pharmaceuticals, Viatris, AbbVie, and Atai Life Sciences; and is a CEO of Braxia Scientific Corp.

J Clin Psychiatry. Published online December 21, 2022.[1]

Study Highlights

  • Structural equation modeling assessed shared and specific effects of trouble falling asleep, early morning awakening, and hypersomnia on incidence of common comorbid DSM-IV disorders among patients with MDE.
  • Analyses were adjusted for sociodemographic and clinical factors, including sedative or tranquilizer use.
  • Among participants with MDE at wave 1, 3-year incidence rates were dysthymia, 2.9%; general anxiety disorder, 8.2%; panic disorder, 3.4%; social anxiety disorder, 4.0%; specific phobia, 3.0%; alcohol use disorder, 8.1%; nicotine dependence, 6.2%; cannabis use disorder, 2.7%; and other drug use disorder, 4.9%.
  • Participants developing psychiatric disorders within 3 years commonly had trouble falling asleep, ranging from 67.6% (cannabis use disorder) to 76.4% (panic disorder), early morning awakening (from 43.3% for cannabis use disorder to 55.6% for dysthymia), and hypersomnia (from 51.3% for nicotine use disorder to 72.1% for social anxiety disorder).
  • Higher number of sleep complaints was also associated with higher percentages of psychiatric disorders.
  • Among all sleep complaints, only hypersomnia significantly increased odds of psychiatric disorders (social anxiety, specific phobia, cannabis use disorder, and other drug use disorder).
  • For patients with major depressive disorder with vs without hypersomnia, the mean number of sleep disorders was significantly higher (2.08 vs 1.52; P<.001).
  • Effects of the incident general psychopathology factor, representing mechanisms related to incidence of all psychiatric disorders, occurred almost exclusively via a factor representing shared effect across all sleep complaints, after adjustment for sociodemographic and clinical characteristics and antisocial personality disorder.
  • The investigators concluded that sleep complaints were associated with increased risk for incident psychiatric disorders, independent of sociodemographic and clinical characteristics including sedative or tranquilizer use.
  • These associations were mediated by a single latent factor, representing mechanisms shared by all 3 sleep complaints.
  • Study limitations include potential unmeasured confounding precluding causal inferences.

Clinical Implications

  • Sleep complaints in patients with MDE were associated with increased risk for incident psychiatric disorders.
  • Sleep complaints might represent prodromal transdiagnostic biomarkers and easily modifiable therapeutic targets for prevention of psychiatric disorders.
  • Implications for the Health Care Team: Members of the healthcare team should evaluate sleep complaints in all psychiatric disorders and prioritize sleep management.

 

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