2023 Guidelines on the Diagnosis and Treatment of Insomnia in Adults - Brazilian Sleep Association.

Chronic insomnia disorder (simplified in this document as insomnia) is an increasingly common clinical condition in society and a frequent complaint at the offices of different areas of health practice (particularly Medicine and Psychology). This scenario has been accompanied by a significant evolution in treatment, as well as challenges in approaching patients in an appropriately way. This clinical guideline, coordinated by the Brazilian Sleep Association and the Brazilian Association of Sleep Medicine and counting on the active participation of various specialists in the area, encompasses an update on the diagnosis and treatment of insomnia in adults. To this end, it followed a structured methodology. Topics of interest related to diagnosis were written based on theoretical framework, evidence in the literature, and professional experience. As for the topics related to the treatment of insomnia, a series of questions were developed based on the PICO acronym (P - Patient, problem, or population; I - Intervention; C - Comparison, control, or comparator; O - Outcome). The work groups defined the eligible options within each of these parameters. Regarding pharmacological interventions, only the ones currently available in Brazil or possibly becoming available in the upcoming years were considered eligible. Systematic reviews were conducted to help prepare the texts and define the level of evidence for each intervention. The final result is an objective and practical document providing recommendations with the best scientific support available to professionals involved in the management of insomnia.

Abnormalities in sleep patterns in individuals at risk for psychosis and bipolar disorder.

AIM: To compare patterns of sleep and the presence of sleep disturbances in individuals in at-risk mental states (ARMS) for psychosis and bipolar disorder (BD) with a healthy control (HC) group. METHODS: This was a comparative study involving 20 individuals in ARMS for psychosis or BD, according to the Comprehensive Assessment of At-Risk Mental States, and 20 age- and sex-matched healthy controls. Quality of sleep in the previous month was assessed using the Pittsburgh Sleep Quality Index, diurnal somnolence was evaluated using The Epworth Sleepiness Scale, and chronotype was determined using the Questionnaire of Morningness/Eveningness (QME). All of the participants underwent polysomnography (PSG) during the entire night for two consecutive nights. The first night aimed to adapt the subject to the environment, and only the data from the second night were used for the analysis. RESULTS: Compared with the HC group, individuals in the ARMS group reported significantly worse sleep quality, as measured by the Pittsburgh Sleep Quality Index. Both groups had scores consistent with daytime sleepiness on the Epworth Sleepiness Scale, and there were no differences with regard to chronotype between the groups, with a predominance of the indifferent type in both groups. In the PSG assessment, we observed increased Sleep Latency (SL) and increased Rapid Eye Movement Sleep Onset Latency (REMOL) in the ARMS group, compared to the HC group. CONCLUSION: The results of this study indicated that sleep abnormalities could be found early in the course of mental diseases, even in at-risk stages, and support the further investigation of their predictive value in the transition to psychosis and BD.

Circadian rest-activity rhythm in individuals at risk for psychosis and bipolar disorder.

BACKGROUND: At-risk mental states (ARMS) are clinical syndromes that are associated with higher risk, compared with the general population, for developing psychosis and bipolar disorder. Circadian rhythm misalignments have been proposed to be part of this early phase of the clinical course. OBJECTIVE: To compare circadian rhythm of activity and rest changes between ARMS individuals and a healthy control group. METHODS: Forty volunteers of both genders, aged between 13 and 27years old, participated in this study (n=20 ARMS group, and n=20 healthy controls). The ARMS individuals were classified as ultra-high risk for psychosis according to the CAARMS (Comprehensive Assessment of At-risk Mental State) or at high risk for bipolar disorder according to criteria proposed by Bechdolf and colleagues. Participants used an actigraph for fifteen days, kept a sleep diary, and completed the Epworth Sleepiness Scale, the Pittsburgh Sleep Quality Index, and a Morningness-Eveningness Questionnaire. RESULTS: Compared with healthy volunteers, the ARMS group presented worse sleep quality (P=0.010); longer nap durations (P=0.038), shorter wake times (P=0.001), higher total sleep times (P=0.011), and shorter activity duration (P=0.021), sleep rhythms were more fragmented, the circadian rest-activity rhythms were less synchronized with the dark-light cycle and had lower amplitudes of motor activity. CONCLUSION: The results suggest alterations in the circadian rest-activity rhythms (and likely in sleep-wake cycle patterns) in ARMS individuals compared with healthy controls. It is possible that circadian rhythms of activity and rest changes are one of the prodromal clinical and behavioral expressions of the brain changes that underlie ARMS individuals.

Do sleep abnormalities and misaligned sleep/circadian rhythm patterns represent early clinical characteristics for developing psychosis in high risk populations?

Sleep architecture changes, such as slow-wave sleep (SWS) percentage variations and reductions in latency and density of rapid eye movement (REM), are found in most patients with schizophrenia and are considered to be an important part of the pathophysiology of the disorder. In addition to these sleep parameters changes, disruptions in sleep homeostasis and the sleep/circadian rhythm also occur in these patients. Sleep/circadian rhythm abnormalities negatively affect neocortical plasticity and cognition and often precede the diagnosis of the illness. Thus, it has been suggested that the sleep/circadian rhythm might be involved in the pathophysiology of psychosis. Recent advances in the identification of individuals at a high risk for developing schizophrenia allow us to investigate several neurobiological processes involved in the development of psychosis. In this article, we review the current evidence of the effects of sleep parameter abnormalities, disruptions in sleep homeostasis and misalignments of sleep circadian rhythm on the early stages of schizophrenia. In addition, we discuss the preliminary evidence of sleep and circadian rhythm abnormalities during the prodromal stages of psychosis and propose that these abnormalities can be explored as potential predictors, as an adjunct to clinical diagnosis, of developing a psychotic disorder in at risk populations.

Peripheral chemokine levels in women with recurrent major depression with suicidal ideation.

OBJECTIVE: To compare serum levels of MCP-1/CCL2, RANTES/CCL5, and Eotaxin/CCL11 between female patients with recurrent major depressive disorder (MDD) and healthy controls, verifying if there is a difference in the levels of these mediators between those with or without current suicidal ideation. METHODS: Thirty female outpatients with recurrent MDD were divided in two groups accordingly the presence or absence of suicidal ideation. These groups were compared with 16 healthy controls. Serum levels of MCP-1/CCL2, RANTES/CCL5, and Eotaxin/CCL11 were determined. Depression severity was evaluated by Beck Depression Inventory (BDI). Suicidal ideation was assessed by SCID-I and BDI. RESULTS: Patients with recurrent MDD and healthy controls did not differ in age, socioeconomic status, and education. All patients reported high scores of BDI (mean, SD, n; 29.75, 10.55, 28). Multivariable analysis of covariance adjusted for age and BMI showed that MDD patients with suicidal ideation presented lower levels of MCP-1/ CCL2 and RANTES/CCL5 (p < 0.001) and higher levels of Eotaxin/CCL11 (p = 0.04) compared to healthy controls. These differences remained significant after adjusting for depression severity. CONCLUSION: The findings of this study indicated that the presence of recurrent MDD with suicidal ideation is associated with differences in inflammatory chemokines when compared to those without suicidal ideation.

Peripheral chemokine levels in women with recurrent major depression with suicidal ideation / Níveis periféricos de quimiocina em mulheres com depressão maior com ideação suicida

OBJECTIVE: To compare serum levels of MCP-1/CCL2, RANTES/CCL5, and Eotaxin/CCL11 between female patients with recurrent major depressive disorder (MDD) and healthy controls, verifying if there is a difference in the levels of these mediators between those with or without current suicidal ideation. METHODS: Thirty female outpatients with recurrent MDD were divided in two groups accordingly the presence or absence of suicidal ideation. These groups were compared with 16 healthy controls. Serum levels of MCP-1/CCL2, RANTES/CCL5, and Eotaxin/CCL11 were determined. Depression severity was evaluated by Beck Depression Inventory (BDI). Suicidal ideation was assessed by SCID-I and BDI. RESULTS: Patients with recurrent MDD and healthy controls did not differ in age, socioeconomic status, and education. All patients reported high scores of BDI (mean, SD, n; 29.75, 10.55, 28). Multivariable analysis of covariance adjusted for age and BMI showed that MDD patients with suicidal ideation presented lower levels of MCP-1/ CCL2 and RANTES/CCL5 (p < 0.001) and higher levels of Eotaxin/CCL11 (p = 0.04) compared to healthy controls. These differences remained significant after adjusting for depression severity. CONCLUSION: The findings of this study indicated that the presence of recurrent MDD with suicidal ideation is associated with differences in inflammatory chemokines when compared to those without suicidal ideation.

OBJETIVO: Comparar os níveis séricos de MCP-1/CCL2, RANTES/CCL5 e Eotaxin/CCL11 entre pacientes do sexo feminino com transtorno depressivo maior (TDM) recorrente e controles saudáveis, verificando se há diferença nos níveis desses mediadores entre os indivíduos com ou sem ideação suicida. MÉTODOS: Trinta pacientes do sexo feminino com TDM recorrente foram divididas em dois grupos de acordo com a presença ou ausência de ideação suicida. Esses grupos foram comparados com 16 controles saudáveis. Os níveis séricos de MCP-1/CCL2, RANTES/CCL5 e Eotaxin/CCL11 foram determinados. A gravidade da depressão foi avaliada usando o Beck Depression Inventory (BDI) e a ideação suicida foi avaliada usando o SCID-I e o BDI. RESULTADOS: As pacientes com TDM recorrente e os controles saudáveis não diferiram em idade, status socioeconômico e educação. Todas as pacientes relataram altas pontuações no BDI (média, SD, n; 29,75, 10,55, 28). A análise de covariância multivariada ajustada para idade e de IMC mostrou que as pacientes com TDM e ideação suicida apresentaram níveis mais baixos de MCP-1/CCL2 e RANTES/CCL5 (p < 0,001) e níveis mais elevados de Eotaxin/CCL11 (p = 0,04) em comparação com os controles saudáveis. Essas diferenças permaneceram significantes após o ajuste para gravidade da depressão. CONCLUSÃO: Os resultados deste estudo indicaram que a presença de TDM recorrente com ideação suicida está associada a diferenças nas quimiocinas inflamatórias na comparação com os indivíduos sem ideação suicida.