Depression and short REM latency in subjects with chronic fatigue syndrome.

OBJECTIVE: The hypothesized polysomnographic marker for depression, Rapid Eye Movement Latency (REML), was used to investigate two groups of subjects; Chronic Fatigue Syndrome (CFS)-not depressed and CFS-depressed. METHOD: CFS subjects were classified into depressed and not depressed groups, using the Diagnostic Interview Schedule (DIS), and subsequently were studied in a sleep laboratory to ascertain REML. RESULTS: Short REML showed a statistically significant correlation with the depressed state in CFS subjects. CONCLUSION: Short REM latency is associated with depression in the CFS population.

Randomized, double-blind, placebo-controlled crossover trial of modafinil in the treatment of excessive daytime sleepiness in narcolepsy.

Seventy-five patients meeting international diagnostic criteria for narcolepsy enrolled in a 6-week, three-period, randomized, crossover, placebo-controlled trial. Patients received placebo, modafinil 200 mg, or modafinil 400 mg in divided doses (morning and noon). Evaluations occurred at baseline and at the end of each 2-week period. Compared with placebo, modafinil 200 and 400 mg significantly increased the mean sleep latency on the Maintenance of Wakefulness Test by 40% and 54%, with no significant difference between the two doses. Modafinil, 200 and 400 mg, also reduced the combined number of daytime sleep episodes and periods of severe sleepiness noted in sleep logs. The likelihood of falling asleep as measured by the Epworth Sleepiness Scale was equally reduced by both modafinil dose levels. There were no effects on nocturnal sleep initiation, maintenance, or architecture, nor were there any effects on sleep apnea or periodic leg movements. Neither dose interfered with the patients' ability to nap voluntarily during the day nor with their quantity or quality of nocturnal sleep. Modafinil produced no changes in blood pressure or heart rate in either normotensive or hypertensive patients. The only significant adverse effects were seen at the 400-mg dose, which was associated with more nausea and more nervousness than either placebo or the 200-mg dose. As little as a 200-mg daily dose of modafinil is therefore an effective and well-tolerated treatment of excessive daytime somnolence in narcoleptic persons.

Adult headbanging: sleep studies and treatment.

Headbanging is a rhythmic movement disorder (RMD) along with headrolling, bodyrocking and bodyrolling. The International Classification of Sleep Disorders defines RMD as a group of stereotyped, repetitive movements involving large muscles, usually of the head and neck, that typically occur immediately prior to sleep onset and are sustained into light sleep. The average onset is 9 months, and by 10 years of age the majority of subjects no longer complain of headbanging. If it continues, it is usually associated with mental retardation of autism. Headbanging is said to occur during presleep drowsiness or early non-rapid eye movement sleep. Often there is no need for treatment other than reassurance. Behavior modification has had little success. Benzodiazepines (such as oxazepam and diazepam) and tricyclic antidepressants have been used with variable success. We present two cases of headbanging with polysomnographic findings and treatment. The patients are two healthy adult males. They both experienced significant daytime somnolence and repeatedly wakened their partners. Only one of our patients had recorded head movements during his overnight sleep study. There was evidence of headbanging during stage 1 and stage 2 sleep but also during slow wave sleep. Headbanging was recorded during 14% of the epochs. Both patients responded to treatment with clonazepam (at a dose of 1.0 mg nightly) with decreased frequency and severity of headbanging. Although headbanging is most common in childhood, there may be significant number of cases that persist into adulthood. To our knowledge, this is the first report of the treatment of headbanging with clonazepam. Both patients benefited from this treatment.

Multicenter, placebo-controlled study of fluoxetine in seasonal affective disorder.

OBJECTIVE: The authors investigated the efficacy and safety of fluoxetine in the treatment of winter seasonal affective disorder. METHOD: Sixty-eight outpatients who met the DSM-III-R criteria for recurrent major depressive episodes, seasonal (winter) pattern, were randomly assigned to 5 weeks of treatment with fluoxetine, 20 mg/day (N = 36), or placebo (N = 32). The outcome measures included the 29-item modified Hamilton Depression Rating Scale, administered by experienced clinicians, and the self-rated Beck Depression Inventory; adverse events and safety data were also recorded. Clinical response was defined as a greater than 50% reduction in depression score between baseline and study termination. RESULTS: Both groups showed significant improvement. The fluoxetine group had lower depression scores at termination than the placebo group, but these differences did not achieve statistical significance. However, the rate of clinical response in the fluoxetine group (59%) was superior to that in the placebo group (34%). Post hoc analyses showed that the greatest fluoxetine responses were in the most markedly depressed patients and that overall response was greater for patients studied later in the season. Fluoxetine was well tolerated, and few subjects dropped out because of adverse events. CONCLUSIONS: On the basis of clinical response rate, fluoxetine appears to be an effective, well-tolerated treatment for seasonal affective disorder. Because the differences between fluoxetine and placebo in the continuous outcome measures did not reach statistical significance, further studies with larger study groups and longer treatment periods are required to conclusively demonstrate efficacy of fluoxetine for seasonal affective disorder.

Shiftwork: the special challenges for women.

1. Humans are designed to sleep at night and work during the day; thus, shiftwork is inherently non-physiological. The species has not yet evolved to the point of being able to adjust to a 24 hour day, despite society's demands. 2. Certain individuals may be better able to cope with the requirements of shiftwork than others. Women may be less able than men to do so because of the demands of home and family life and physiological differences. 3. Shifts can be designed to be more or less difficult for certain individuals. "Night owl" individuals might do best with evening shifts, "morning larks" with shifts starting in the early morning.

Determination of observer-rated alpha activity during sleep.

Patients suffering from chronic fatigue syndrome (CFS) have been described as having alpha intrusion into sleep. In a separate study of the relationship between depression and CFS, we investigated the sleep of CFS patients. We could not detect any observable alpha anomaly in our group of CFS patients. It is possible that there is a subgroup of CFS patients in whom no alpha anomaly is present. However, the sleep electroencephalogram (EEG) montage used in our study was different to that employed by previous researchers. This paper investigates the influence of electrode derivations on the outcome of observable alpha ratings. We compared simultaneous recordings of sleep EEG using three commonly employed montages. Our results indicate that use of the mastoid reference (montage 1) results in the highest observer-related alpha. This may suggest that data regarding alpha intrusion should always be collected using montage 1. However, there is a possibility that the mastoid electrode is not electrically silent and is contaminating the data of the referenced channels. The implications of these findings are discussed in relation to the validity of alpha intrusion measurement of CFS and fibromyalgia.

Neuroendocrine assessment of serotonin (5-HT) function in chronic fatigue syndrome.

Prolactin and cortisol responses to dl-fenfluramine challenge were examined in 11 patients with chronic fatigue syndrome and in 11 healthy controls who were age and gender matched. After obtaining two baseline samples, each subject was given 60 mg of dl-fenfluramine orally and further blood samples were drawn hourly during the following five hours in order to measure prolactin and cortisol levels. There was no difference in either baseline or fenfluramine-induced hormonal responses between patients with chronic fatigue syndrome and controls. There was also no correlation between depression scores on HAM-D and hormonal responses in patients with chronic fatigue syndrome. The findings of this study do not support a role for 5-HT in chronic fatigue syndrome.

A psychiatric fellowship in the United States.

The development of subspecialty fields in psychiatry will likely motivate many new graduates of Canadian psychiatric residency programs to seek additional fellowship training. There is little information to guide psychiatric residents interested in arranging a fellowship year. This article discusses the experience of three Canadian psychiatrists who recently completed a fellowship year in a well known academic centre in the United States. The reasons for considering an additional year of training are discussed. The practical aspects of finding and funding a fellowship year are also addressed. The individual experiences of the authors as fellows in consultation-liaison psychiatry, psychopharmacology and psychobiology, and sleep disorders medicine are described. Finally, personal stresses which appeared to be commonly experienced by psychiatric fellows are explored.