Inhibited autonomy for promoting physical health: qualitative analysis of narratives from persons living with severe mental illness.

BACKGROUND: Autonomy is a key factor in the reduction of inequitable physical healthcare among people with severe mental illness compared with the general population.AimsTo clarify the critical mechanism underlying autonomy in physical health promotion based on the perspectives of people with severe mental illness. METHOD: We employed a conventional content analysis of narrative data from the Healthy Active Lives in Japan (HeAL Japan) workshop meetings. RESULTS: 'Inhibited autonomy' was extracted as a central component and shaped by the users' experiences, both in a healthcare setting and in real life. This component emerged based on the lack of an empowerment mechanism in psychiatric services. CONCLUSIONS: A barrier to the encouragement of autonomy in physical health promotion was found in current psychiatric services. An effective strategy should be explored to foster an empowerment mechanism in psychiatric and mental health services.Declaration of interestNone.

Screening of clock gene polymorphisms demonstrates association of a PER3 polymorphism with morningness-eveningness preference and circadian rhythm sleep disorder.

A system of self-sustained biological clocks controls the 24-h rhythms of behavioral and physiological processes such as the sleep-wake cycle. The circadian clock system is regulated by transcriptional and translational negative feedback loops of multiple clock genes. Polymorphisms in circadian clock genes have been associated with morningness-eveningness (diurnal) preference, familial advanced sleep phase type (ASPT), and delayed sleep phase type (DSPT). We genotyped single-nucleotide polymorphisms in circadian clock genes in 182 DSPT individuals, 67 free-running type (FRT) individuals, and 925 controls. The clock gene polymorphisms were tested for associations with diurnal preference and circadian rhythm sleep disorder (CRSD) phenotypes. The PER3 polymorphism (rs228697) was significantly associated with diurnal preference and the FRT phenotype. The minor allele of rs228697 was more prevalent in evening types than in morning types (sex-adjusted odds ratio (OR), 2.483, Bonferroni-corrected P = 0.012) and in FRT individuals compared with the controls (age- and sex-adjusted OR, 2.021, permutated P = 0.017). Our findings support the notion that PER3 polymorphisms could be a potential genetic marker for an individual's circadian and sleep phenotypes.

Impact of frequency of nightmares comorbid with insomnia on depression in Japanese rural community residents: a cross-sectional study.

OBJECTIVE: Nightmares and insomnia are known to be associated with the development and aggravation of depression. Our community-based study was conducted to clarify the relation between the impacts of nightmares and insomnia on depression. METHODS: A cross-sectional questionnaire-based survey was administered to residents of a rural community in Japan. In all, 2822 participants responded to questions assessing personal characteristics, the Pittsburgh Sleep Quality Index (PSQI) for assessing insomnia, and a 12-item version of the Center for Epidemiological Studies Depression scale (CES-D) for evaluating depression. Nightmare frequency was assessed using an item for nightmares on the PSQI. RESULTS: Nightmares more frequently occurred in participants with insomnia than those without (P < .01). Multiple regression analysis revealed that the scores of both nightmares and insomnia were significantly associated with the increase in depression score (nightmares (ß = 0.09, P < .01); insomnia (ß = 0.39, P < .01)). Participants with coexisting nightmares and insomnia showed higher depression scores than participants with insomnia alone or those with nightmares who did not have insomnia (P < .01). CONCLUSIONS: Insomnia and nightmares independently and additively impact the aggravation of depression.

Carryover effect on next-day sleepiness and psychomotor performance of nighttime administered antihistaminic drugs: a randomized controlled trial.

BACKGROUND: Antihistamines with strong sedative-hypnotic properties are frequently prescribed for insomnia secondary to allergy, but the potential risks of such administration have not been fully elucidated. SUBJECTS AND METHODS: This randomized, double-blind, placebo-controlled crossover study was conducted to evaluate next-day sleepiness and psychomotor performance following the administration of antihistamines. Twenty-two healthy male participants participated in four drug administration sessions with more than a 1-week interval between the sessions. Either zolpidem 10 mg, or diphenhydramine 50 mg, or ketotifen 1 mg, or a placebo was administered before sleep, and polysomnography was conducted to evaluate sleep. In the morning and afternoon of the day after administration, the participants were evaluated for subjective sleepiness, objective sleepiness, and psychomotor performance. RESULTS: The antihistamines with high blood-brain barrier-crossing efficiency were significantly associated with sleepiness and psychomotor performance decline the next day. Ketotifen showed the strongest carryover effect, followed by diphenhydramine. Compared with the placebo, no significant carryover effect was observed with zolpidem. CONCLUSION: The results suggest that the risk-benefit balance should be considered in the ready use of antihistamines that easily cross the blood-brain barrier for alleviating secondary insomnia associated with allergies.

Quality of life in patients with narcolepsy with cataplexy, narcolepsy without cataplexy, and idiopathic hypersomnia without long sleep time: comparison between patients on psychostimulants, drug-naïve patients and the general Japanese population.

OBJECTIVE: To assess the quality of life of patients with narcolepsy with cataplexy (NA-CA), narcolepsy without cataplexy (NA w/o CA), and idiopathic hypersomnia without long sleep time (IHS w/o LST) who were taking psychostimulant medication, and to ascertain which factors (including psychosocial and environmental variables) influence quality of life in this population. METHODS: In total, 185 patients who had received regular treatment were enrolled in the study (NA-CA, n=83; NA w/o CA, n=48; IHS w/o LST, n=54). Patients were asked to complete questionnaires including the Short Form-36 Health Survey (SF-36), the Epworth Sleepiness Scale (ESS), and items concerning psychosocial and environmental variables. RESULTS: All three diagnostic groups had significantly lower scores for most SF-36 domains compared with the Japanese normative data, and the ESS score was significantly reduced with treatment. Multiple logistic regression analyses revealed that several SF-36 domains were associated with the ESS score; autonomy in controlling own job schedule, experience of divorce or break up with a partner due to symptoms, experience of being forced to relocate or being dismissed due to symptoms, and perception of support from others. CONCLUSIONS: The severity of subjective sleepiness and psychological and environmental variables influenced quality of life in patients with these hypersomnias of central origin.

Criterion and construct validity of the CogState Schizophrenia Battery in Japanese patients with schizophrenia.

BACKGROUND: The CogState Schizophrenia Battery (CSB), a computerized cognitive battery, covers all the same cognitive domains as the Measurement and Treatment Research to Improve Cognition in Schizophrenia (MATRICS) Consensus Cognitive Battery but is briefer to conduct. The aim of the present study was to evaluate the criterion and construct validity of the Japanese language version of the CSB (CSB-J) in Japanese patients with schizophrenia. METHODOLOGY/PRINCIPAL FINDINGS: Forty Japanese patients with schizophrenia and 40 Japanese healthy controls with matching age, gender, and premorbid intelligence quotient were enrolled. The CSB-J and the Brief Assessment of Cognition in Schizophrenia, Japanese-language version (BACS-J) were performed once. The structure of the CSB-J was also evaluated by a factor analysis. Similar to the BACS-J, the CSB-J was sensitive to cognitive impairment in Japanese patients with schizophrenia. Furthermore, there was a significant positive correlation between the CSB-J composite score and the BACS-J composite score. A factor analysis showed a three-factor model consisting of memory, speed, and social cognition factors. CONCLUSIONS/SIGNIFICANCE: This study suggests that the CSB-J is a useful and rapid automatically administered computerized battery for assessing broad cognitive domains in Japanese patients with schizophrenia.

Relation between morningness-eveningness score and depressive symptoms among patients with delayed sleep phase syndrome.

OBJECTIVES: Depressive symptoms are observed in a relatively large series of patients with delayed sleep phase syndrome (DSPS). This study was undertaken to investigate the prevalence, characteristics, and factors associated with depressive symptoms among DSPS patients. METHODS: This study targeted 90 consecutive patients (54 men, 27.1±9.2 years old) diagnosed as having DSPS. Demographic and clinical characteristics were assessed at their initial visit, including application of the Zung self-rating depression scale (SDS) and morningness-eveningness questionnaire. A series of logistic regression analyses were conducted to determine the factors associated with depressive symptoms (determined as SDS⩾48). RESULTS: Sixty-four percent of the DSPS patients were in a moderate or severe depressive state. Diurnal variation, sleep disturbance, fatigue, and psychomotor retardation were the main depressive symptom items on SDS in the DSPS patients. Logistic regression analyses showed that SDS⩾48 was significantly associated with moderate and definite evening chronotype. In contrast, self-reported nocturnal sleep onset and offset times were not associated with depressive symptoms. CONCLUSIONS: There is a high prevalence of depressive symptoms among the DSPS patients. The symptomatic structure of depressive symptoms in this population appears to differ from those of typical depression. Moreover, results of our study suggest that depressive symptoms are more associated with the preference of the evening chronotype rather than sleep-wake phase among DSPS patients.

Cortical regional differences of delta waves during all-night sleep in schizophrenia.

BACKGROUND: Delta sleep is mediated by thalamocortical circuits and is postulated to be abnormal in schizophrenia. Delta wave deficits during sleep have been observed in patients with schizophrenia. Negative symptoms have been reported to reflect frontal lobe dysfunction and to be associated with decreased delta wave sleep. This investigation was undertaken to identify cortical functional abnormalities in patients with schizophrenia shown on the electroencephalogram. METHODS: We compared seventeen male, medically treated or neuroleptic-naive outpatients with schizophrenia and 18 healthy male volunteers by all-night polysomnography and investigated cortical regional differences of delta waves. All-night sleep data was evaluated by period amplitude analyses. Delta waves during sleep were investigated in bilateral frontal, central, parietal, and occipital regions by computer analysis. The associations between delta waves in all regions and measures of clinical variables were also estimated. RESULTS: Patients with schizophrenia showed lower total delta wave counts during all-night sleep than did control subjects in all regions. Control subjects showed significantly higher delta wave counts in the right frontal and central region than in the left, which was not observed in patients with schizophrenia. Significant inverse correlations were observed between negative symptom scores and delta wave counts in all regions. Control subjects showed significant inverse correlations between delta wave counts and age, which were not identified in patients with schizophrenia. CONCLUSIONS: Delta wave deficits in all regions may reflect thalamocortical dysfunction in schizophrenia. Reduced right frontal and central delta wave dominance is suggested to be involved in the pathophysiology of schizophrenia.

10-year course of social adjustment in major depression.

BACKGROUND: It is now widely acknowledged that depression is accompanied by major deficits in social functioning. However, the course of this dysfunction and its relationship with depressive symptoms in the long term is less understood. METHODS: The Group for Longitudinal Affective Disorders Study (GLADS) in Japan has conducted a 10-year prospective, serial follow-up of a cohort of mood disorder patients starting treatment for their index episode. The vicissitudes of the social adjustment of patients with major depression were analyzed using the standardized instrument (Social Adjustment Scale - Self-Report) and in conjunction with the measurement of depressive severity (Centre for Epidemiologic Studies Depression). RESULTS: The results showed: (i) psychiatric patients with major depression commencing treatment showed moderate to extremely large social dysfunction at baseline; (ii) this dysfunction declined rapidly in the first six months of treatment but then levelled off and showed fluctuating patterns up to 10 years of follow-up; (iii) the degree of dysfunction varied from domain to domain, most notable in Work and least notable in Economy subscales; and (iv) the influence of persistent depression also varied from domain to domain, stronger in Housework and Leisure and weakest in Work spheres. CONCLUSION: Future studies of social functioning in depression need to differentiate its various aspects.

Sleep-related problems and use of hypnotics in inpatients of acute hospital wards.

OBJECTIVE: Although sleep disorders are highly prevalent among patients with physical disorders, only limited information is available about the actual status of sleep-related problems in inpatients of acute hospital wards. We conducted a multicenter cross-sectional observational survey investigating the prevalence of sleep disorders and use of hypnotic-sedative drugs among inpatients of acute wards in 44 general hospitals in Japan. METHOD: Questionnaire-, actigraph- and observation-based sleep evaluations were simultaneously performed in 557 adult inpatients [mean age 72.8 + or - 12.8 (S.D.) years] of acute wards during a one-month period in July 2007. RESULTS: Of the 421 patients with data available, 22.3% had at least one of the following sleep disorders: sleep apnea syndrome, restless legs syndrome, periodic limb movement disorder and nocturnal behavior disorder. Similarly, 62.7% had insomnia, 6.9% had severe daytime sleepiness and 12.8% had other sleep-related symptoms. Only 13.8% were free of any sleep-related problem. Although 33.7% of insomnia patients were taking hypnotic-sedative drugs, 65.2% of them complained of residual insomnia symptoms. CONCLUSION: The findings obtained in this study have revealed the remarkably high prevalence of sleep-related problems experienced by inpatients of acute hospital wards in Japan. Proper diagnosis of sleep disorders should be made among patients with physical disorders.

Time estimation during sleep relates to the amount of slow wave sleep in humans.

Humans have the ability to estimate the amount of time that has elapsed during sleep (time estimation ability; TEA) that enables a subset of individuals to wake up at a predetermined time without referring to a watch or alarm clock. Although previous studies have indicated sleep structure as a key factor that might influence TEA during sleep, which sleep parameters could affect the TEA has not been clarified. We carried out an experimental study in which 20 healthy volunteers participated in six time estimation trials during the 9-h nighttime sleep (NS) experiment or daytime sleep (DS) experiment. The time estimation ratio (TER, ratio of the subjective estimated time interval to actual time interval) decreased significantly from the first to the sixth trial in both the NS and DS experiments. TER correlated positively with slow wave sleep (SWS) in both experiments, suggesting that SWS was a determining factor in accurate time estimation, irrespective of circadian phase they slept. No other sleep parameters showed steady influence on TEA. The present findings demonstrate that longer period of SWS is associated with the longer sleep time they subjectively experienced during sleep.

Health-related quality of life among drug-naïve patients with narcolepsy with cataplexy, narcolepsy without cataplexy, and idiopathic hypersomnia without long sleep time.

OBJECTIVE: To evaluate the health-related quality life (HRQOL) of drug-naïve patients with narcolepsy with cataplexy (NAwith CA), narcolepsy without cataplexy (NA without CA) and idiopathic hypersomnia without long sleep time (IHS without LST), and to explore the factors influencing the HRQOL. Factors associated with the occurrence of automobile accidents are also discussed. METHODS: A total of 137 consecutive drug naïve patients who met the criteria of the 2nd edition of the International Classification of Sleep Disorders (NA with CA, n = 28; NA without CA, n = 27; IHS without LST, n = 82) were enrolled. The patients were asked to fill out questionnaires, including the SF-36, Epworth Sleepiness Scale (ESS), sociodemographic variables, and items regarding driving habits and the experiences related to automobile accidents. RESULTS: All 3 diagnostic groups had significantly lower scores in most SF-36 domains compared with Japanese normative data. Significant differences among the 3 diagnostic groups were not observed. Specific factors in SF-36 domains were not found with multiple linear regression analyses, while disease duration was positively correlated with mental health among all subjects. Among the patients reporting driving habits, ESS score (> or =16) was positively associated with the experience of automobile accidents. CONCLUSIONS: Our results indicated that HRQOL decreases in drug-naïve patients with hypersomnia, but neither disease category nor severity of the disorder appears as an associated factor. Increased severity of hypersomnia, however, was thought to play an important role in the occurrence of automobile accidents.

Adequacy of continuation and maintenance treatments for major depression in Japan.

Guidelines for treating depression often recommend continuing antidepressants at least for 6 months after remission. Whether this recommendation is implemented in daily practices represents a serious concern. We aimed to examine adequacy of continuation and maintenance treatment in Japan. A naturalistic prospective follow-up study with mood disorders was undertaken in 23 psychiatric departments from all over Japan. A total of 95 patients diagnosed with major depression were followed up every month until treatment termination and every 6 months thereafter. In this study, the cohort received 45.1 (SD = 64.7) mg of imipramine or equivalent per day during continuation phase, and about 74% were prescribed inadequate doses, i.e. less than 75 mg/day. At maintenance phase immediately before relapse, average dosage was 42.0 (SD = 74.7) mg/day and 83% were prescribed inadequate doses. There is gross under-treatment of depression during continuation and maintenance phases in Japan.

Clinical significance and correlates of behaviorally induced insufficient sleep syndrome.

BACKGROUND AND PURPOSE: The aim of this study was to investigate the demographic variables and clinical characteristics of behaviorally induced insufficient sleep syndrome (BIISS) and to compare it with the other major hypersomnia disorders. PATIENTS AND METHODS: One-thousand two-hundred forty-three consecutive patients referred to the outpatient clinic for complaint of excessive daytime sleepiness (EDS) were retrospectively investigated. RESULTS: The rate of BIISS in patients with EDS was 7.1%, predominant in males. The mean age of initial visit was younger than that for obstructive sleep apnea syndrome (OSAS), while the mean age of onset of symptoms was older than that for idiopathic hypersomnia, narcolepsy, and circadian rhythm sleep disorders. The mean Epworth sleepiness scale (ESS) score before treatment was lower than that for narcolepsy but higher than that for both OSAS and circadian rhythm sleep disorders. Twenty-two percent of BIISS cases reported having accidents or near-miss accidents during the five-year period preceding the investigation, and this group showed higher ESS scores than the group without accidents. CONCLUSIONS: Our findings showed that an unignorably large number of people suffer from BIISS, and that people with severe cases of the disorder are at high risk for getting into an accident. Characteristics and demographic information could be helpful for making a differential diagnosis of BIISS.

Reduced frontal asymmetry of delta waves during all-night sleep in schizophrenia.

Delta wave deficits during sleep have been observed in patients with schizophrenia. Decreased slow-wave sleep is reported to be associated with negative symptoms. Frontal lobe dysfunction is also believed to underlie negative symptoms of schizophrenia. This study was designed to identify functional abnormalities in schizophrenia manifested on patients' electroencephalograms. Polysomnograph examinations were performed in 12 healthy male volunteers and 11 male outpatients with schizophrenia. We investigated the laterality of frontal cortical delta waves in patients with schizophrenia and in healthy control subjects. Laterality of frontal cortex delta wave counts during all-night sleep was investigated by computer analysis. Total delta wave counts were lower in patients with schizophrenia than in control subjects. Control subjects showed significantly higher delta wave counts in the right frontal cortex than in the left. This asymmetry was not observed in patients with schizophrenia. These findings suggest that reduced right frontal delta wave dominance is involved in the pathophysiology of schizophrenia.

Effect of benzodiazepine hypnotic triazolam on relationship of blood pressure and Paco2 to cerebral blood flow during human non-rapid eye movement sleep.

We sought to clarify the effect of short-acting benzodiazepine hypnotic on the relationship of arterial blood pressure and arterial partial pressure of carbon dioxide (Paco2) to regional cerebral blood flow (rCBF) during human non-rapid-eye-movement (non-REM) sleep. Nine young normal volunteers were treated in a randomized, crossover design with triazolam or placebo and underwent positron emission tomography at night. During wakefulness and stage 2 and slow wave (stages 3 and 4) sleep, we measured mean arterial blood pressure (MAP), Paco2, and absolute CBF. With triazolam compared to placebo, MAP reduced gradually. During stage 2 sleep, Paco2 increased and whole-brain mean CBF decreased. With triazolam, relative rCBF of the left orbital basal forebrain decreased more during stage 2 than slow wave sleep, whereas absolute CBF of the occipital cortex and cerebral white matter remained constant. During triazolam-induced stage 2 sleep, absolute CBF of the cerebral white matter correlated more strongly to both MAP and Paco2 than during placebo sleep and also correlated more strongly to both MAP and Paco2 than absolute CBF of the occipital cortex. In the frontal white matter, during triazolam-induced stage 2 sleep compared to wakefulness, absolute CBF was significantly better correlated to MAP, but not to Paco2. During triazolam-induced stage 2, the cerebral white matter may receive a modulated CBF regulation having the strengthened relationship of Paco2 to CBF and, more locally, the frontal white matter may depend precariously on CBF regulation.

Clinical analyses of sighted patients with non-24-hour sleep-wake syndrome: a study of 57 consecutively diagnosed cases.

STUDY OBJECTIVES: The objective of this study was to clarify the clinical features of sighted patients with non-24-hour sleep-wake syndrome. DESIGN: Clinical analyses of consecutive patients suffering from non-24-hour sleep-wake syndrome. SETTING: The sleep disorders clinic at Kohnodai Hospital, National Center of Neurology and Psychiatry, Japan. PATIENTS: Fifty-seven patients who were diagnosed consecutively as having non-24-hour sleep-wake syndrome between 1991 and 2001 were included in the study. MEASUREMENTS AND RESULTS: The clinical features and sleep characteristics of the patients were analyzed. A semistructured psychiatric interview that included the criteria for Axis I or II disorders of Diagnostic and Statistical Manual of Mental Disorders, Third Edition-Revised was conducted, and relationships between psychiatric problems and non-24-hour sleep-wake syndrome were analyzed. The patient cohort included 41 (72%) men and 16 (28%) women. The onset of non-24-hour sleep-wake syndrome had occurred during the teenage years in 63% of the cohort, and the mean ( +/-SD) period of the sleep-wake cycle was 24.9 +/- 0.4 hours (range 24.4-26.5 hours). The mean sleep length of the patients was 9.3 +/- 1.3 hours, and 44% of them had a sleep length of between 9 and 10 hours. Psychiatric disorders had preceded the onset of non-24-hour sleep-wake syndrome in 16 patients (28%); of the remaining 41 patients, 14 (34%) developed major depression after the onset of non-24-hour sleep-wake syndrome. CONCLUSIONS: These results represent the first detailed clinical review of a relatively large number of sighted patients with non-24-hour sleep-wake syndrome.