SPHYNCS: Feasibility of long-term monitoring with Fitbit smartwatches in central disorders of hypersomnolence and extraction of digital biomarkers in narcolepsy.

The Swiss Primary Hypersomnolence and Narcolepsy Cohort Study (SPHYNCS) is a multicenter research initiative to identify new biomarkers in central disorders of hypersomnolence (CDH). Whereas narcolepsy type 1 (NT1) is well characterized, other CDH disorders lack precise biomarkers. In SPHYNCS, we utilized Fitbit smartwatches to monitor physical activity, heart rate, and sleep parameters over one year. We examined the feasibility of long-term ambulatory monitoring using the wearable device. We then explored digital biomarkers differentiating patients with NT1 from healthy controls (HC). A total of 115 participants received a Fitbit smartwatch. Using a compliance metric to evaluate the usability of the wearable device, we found an overall compliance rate of 80% over one year. We calculated daily physical activity, heart rate, and sleep parameters from two weeks of greatest compliance to compare NT1 (n=20) and HC (n=9) subjects. Compared to controls, NT1 patients demonstrated findings consistent with increased sleep fragmentation, including significantly greater wake-after-sleep onset (p=0.007) and awakening index (p=0.025), as well as standard deviation of time in bed (p=0.044). Moreover, NT1 patients exhibited a significantly shorter REM latency (p=0.019), and sleep latency (p=0.001), as well as a lower peak heart rate (p=0.008), heart rate standard deviation (p=0.039) and high-intensity activity (p=0.009) compared to HC. This ongoing study demonstrates the feasibility of long-term monitoring with wearable technology in patients with CDH and potentially identifies a digital biomarker profile for NT1. While further validation is needed in larger datasets, these data suggest that long-term wearable technology may play a future role in diagnosing and managing narcolepsy.

Wrist actigraphic approach in primary, secondary and tertiary care based on the principles of predictive, preventive and personalised (3P) medicine.

ABSTRACT: Sleep quality and duration as well as activity-rest-cycles at individual level are crucial for maintaining physical and mental health. Although several methods do exist to monitor these parameters, optimal approaches are still under consideration and technological development. Wrist actigraphy is a non-invasive electro-physical method validated in the field of chronobiology to record movements and to allow for monitoring human activity-rest-cycles. Based on the continuous recording of motor activity and light exposure, actigraphy provides valuable information about the quality and quantity of the sleep-wake rhythm and about the amount of motor activity at day and night that is highly relevant for predicting a potential disease and its targeted prevention as well as personalisation of medical services provided to individuals in suboptimal health conditions and patients. Being generally used in the field of sleep medicine, actigraphy demonstrates a great potential to be successfully implemented in primary, secondary and tertiary care, psychiatry, oncology, and intensive care, military and sports medicines as well as epidemiological monitoring of behavioural habits as well as well-being medical support, amongst others. PREDICTION OF DISEASE DEVELOPMENT AND INDIVIDUAL OUTCOMES: Activity-rest-cycles have been demonstrated to be an important predictor for many diseases including but not restricted to the development of metabolic, psychiatric and malignant pathologies. Moreover, activity-rest-cycles directly impact individual outcomes in corresponding patient cohorts. TARGETED PREVENTION: Data acquired by actigraphy are instrumental for the evidence-based targeted prevention by analysing individualised patient profiles including light exposure, sleep duration and quality, activity-rest-cycles, intensity and structure of motion pattern. PERSONALISED THERAPY: Wrist actigraphic approach is increasingly used in clinical care. Personalised measurements of sedation/agitation rhythms are useful for ICU patients, for evaluation of motor fatigue in oncologic patients, for an individual enhancement of performance in military and sport medicine. In the framework of personalised therapy intervention, patients can be encouraged to optimise their behavioural habits improving recovery and activity patterns. This opens excellent perspectives for the sleep-inducing medication and stimulants replacement as well as for increasing the role of participatory medicine by visualising and encouraging optimal behavioural patterns of the individual.

Insomnia Associated with Tinnitus and Gender Differences.

Chronic tinnitus causes a decrease in well-being and can negatively affect sleep quality. It has further been indicated that there are clinically relevant gender differences, which may also have an impact on sleep quality. By conducting a retrospective and explorative data analysis for differences in patients with tinnitus and patients diagnosed with tinnitus and insomnia, hypothesized differences were explored in the summed test scores and on item-level of the validated psychometric instruments. A cross-sectional study was conducted collecting data from a sample of tinnitus patients (n = 76). Insomnia was diagnosed in 49 patients. Gender differences were found on aggregated test scores of the MADRS and BDI with men scoring higher than women, indicating higher depressive symptoms in men. Women stated to suffer more from headaches (p < 0.003), neck pain (p < 0.006) and nervousness as well as restlessness (p < 0.02). Women also reported an increase in tinnitus loudness in response to stress compared to men (p < 0.03). Male individuals with tinnitus and insomnia have higher depression scores and more clinically relevant depressive symptoms than women, who suffer more from psychosomatic symptoms. The results indicate a need for a targeted therapy of depressive symptoms in male patients and targeted treatment of psychosomatic symptoms, stress-related worsening of insomnia and tinnitus in women.

The Swiss Primary Hypersomnolence and Narcolepsy Cohort study (SPHYNCS): Study protocol for a prospective, multicentre cohort observational study.

Narcolepsy type 1 (NT1) is a disorder with well-established markers and a suspected autoimmune aetiology. Conversely, the narcoleptic borderland (NBL) disorders, including narcolepsy type 2, idiopathic hypersomnia, insufficient sleep syndrome and hypersomnia associated with a psychiatric disorder, lack well-defined markers and remain controversial in terms of aetiology, diagnosis and management. The Swiss Primary Hypersomnolence and Narcolepsy Cohort Study (SPHYNCS) is a comprehensive multicentre cohort study, which will investigate the clinical picture, pathophysiology and long-term course of NT1 and the NBL. The primary aim is to validate new and reappraise well-known markers for the characterization of the NBL, facilitating the diagnostic process. Seven Swiss sleep centres, belonging to the Swiss Narcolepsy Network (SNaNe), joined the study and will prospectively enrol over 500 patients with recent onset of excessive daytime sleepiness (EDS), hypersomnia or a suspected central disorder of hypersomnolence (CDH) during a 3-year recruitment phase. Healthy controls and patients with EDS due to severe sleep-disordered breathing, improving after therapy, will represent two control groups of over 50 patients each. Clinical and electrophysiological (polysomnography, multiple sleep latency test, maintenance of wakefulness test) information, and information on psychomotor vigilance and a sustained attention to response task, actigraphy and wearable devices (long-term monitoring), and responses to questionnaires will be collected at baseline and after 6, 12, 24 and 36 months. Potential disease markers will be searched for in blood, cerebrospinal fluid and stool. Analyses will include quantitative hypocretin measurements, proteomics/peptidomics, and immunological, genetic and microbiota studies. SPHYNCS will increase our understanding of CDH and the relationship between NT1 and the NBL. The identification of new disease markers is expected to lead to better and earlier diagnosis, better prognosis and personalized management of CDH.

[Recommendations on performing polygraphy or polysomnography in the fields of psychiatry and psychotherapy : Position paper of the working group on sleep medicine of the German Association for Psychiatry, Psychotherapy and Psychosomatics]. / Empfehlungen zur Durchführung einer Polygraphie oder Polysomnographie im Bereich Psychiatrie und Psychotherapie : Positionspapier des DGPPN-Referats Schlafmedizin.

Difficulties in falling asleep and maintaining sleep, nonrestorative sleep and decreased daytime wakefulness represent very common but relatively unspecific health complaints. Around 100 specific sleep-related disorders will be classified in their own major chap. 7 (sleep wake disorders) for the first time in the upcoming 11th version of the International Classification of Diseases (ICD 11). With respect to the disciplines of psychiatry and psychotherapy there is a bidirectional relationship between mental health and sleep wake disorders. Sleep wake disorders can be an independent risk factor for the onset of a mental disorder and have a negative influence on the course of the disease. In addition, sleep wake disorders can also precede a mental disease as an early symptom and therefore be an important indication for early recognition. Many sleep wake disorders can be diagnosed based on the anamnesis and routine clinical investigations. In special cases, examination in a specialized sleep laboratory and treatment in a sleep medicine center following a staged care approach can be mandatory. Polysomnography represents the gold standard for the differential diagnostics; however, there is no legal foundation in the field of neuropsychiatric disorders for remuneration in the German healthcare system. This review summarizes the current guidelines with respect to the criteria for an investigation in a sleep laboratory from the perspective of the disciplines of psychiatry and psychotherapy. From this the requirements for guideline-conform diagnostics and treatment are derived.

[Sleep Disturbances in General Practitioners' Offices: From Screening to Initial Therapy - Update 2019]. / Schlafprobleme in der Allgemeinpraxis: Vom Screening zur initialen Therapie ­ Update 2019.

Sleep Disturbances in General Practitioners' Offices: From Screening to Initial Therapy - Update 2019 Abstract. The field of sleep medicine has established internationally as an interdisciplinary specialization. Due to prevailing evidence, sleep disturbances are listed in a separate chapter in the new ICD 11 classification system. With the International Classification of Sleep Disorders (ICSD-3rd version) a standalone classification system exists. In Switzerland, one third of the population suffers from sleep disturbances. Even differential diagnosis is hard to establish. The current article aims at practitioners, who are frequently confronted with sleep complaints and must categorize, triage and initially treat their patients with simple screening methods.

Management of Chronic Tinnitus and Insomnia with Repetitive Transcranial Magnetic Stimulation and Cognitive Behavioral Therapy - a Combined Approach.

It has been estimated that up to 80% of people will experience symptoms of tinnitus over the courses of their lives, with rates of comorbid sleeping problems ranging from 50 to 77%. Because of a potential connection between tinnitus and sleep disorders as well as high rates of comorbid psychiatric disorders, interdisciplinary approaches to treatment seem to be the most efficient option. In this study, we present the case of a 53-year-old male patient, who started to experience symptoms of tinnitus at the age of 49, most likely caused by work-related stress. Over the course of his illness, the patient developed comorbid insomnia. He consulted us for treatment of both conditions and we developed a treatment plan with ten sessions of repetitive transcranial magnetic stimulation (rTMS) followed by 10 sessions of cognitive behavioral therapy (CBT). We used the Tinnitus Fragebogen (TF) to assess the severity of the tinnitus, the Beck Depression Inventory (BDI-II) for depressive symptoms, and the WHO Well-being Index (WHO-5) for subjective well-being. Improvements could be achieved with regard to both diagnoses and the patient went from severe (48) to clinically negligible (12) TF scores, from minimal (BDI-II score 10) to no (0) depressive symptoms, and from just above critical (WHO-5 percentile 52) to above average (84) well-being. The combination of technological and psychological approaches to treat tinnitus and insomnia thus proved successful in this case. One may therefore conclude that rTMS may be considered an effective first therapeutic step for tinnitus treatment prior to CBT. To our knowledge this is the first published case in which rTMS and CBT were combined for tinnitus therapy. The approach proved successful since it led to a considerable increase in well-being and everyday functioning. To gauge the effect on a more general level, large-scale studies are still needed to cancel out potential placebo effects. Likewise, the importance of the order of the two treatments, and the possibility of using other therapies in combination with CBT to address certain tinnitus subtypes and different etiologies must be studied in greater detail.

Obstructive sleep apnea (OSA) and clinical depression-prevalence in a sleep center.

BACKGROUND: This study aimed to determine the prevalence of clinical depression as defined by ICD-10 criteria in all patients with obstructive sleep apnea (OSA) referred to a sleep center. METHODS: Prospective general and sleep evaluations were conducted in 447 consecutive patients referred to our sleep center during the first quarter of 2008. Inclusion criteria were Apnea Hypopnea Index (AHI) > 9, completion of the Beck Depression Inventory (BDI-II) with a score ≥14 and World Health Organization WHO-5 Well-Being Index (WHO-5) ≤ 13. The subsequent psychiatric examination according to ICD-10 criteria was performed by in-house clinical sleep specialists. RESULTS: A total of 447 patients were surveyed, of whom 322 had an AHI > 9. Out of these, 85 met the combined screening criterion BDI II ≥ 14 and WHO-5 ≤ 13. Eighty-one patients underwent a psychiatric examination by psychiatric sleep specialists. In 21.5 % of the sample, clinical depression was diagnosed. Other complaints existed in 12 % (n = 10); 7 % (n = 6) of patients had a different psychiatric diagnosis. CONCLUSIONS: The prevalence of clinical depression according to ICD-10 criteria in a selected clinical sample (referred to the sleep center) was 21.5 %. Mood scales tend to overestimate complaints as compared to psychiatric consultation. Interdisciplinary cooperation is recommended for both OSA patients with symptoms of depression and depressed patients with treatment resistance.

Prevention of fatigue and insomnia in shift workers-a review of non-pharmacological measures.

BACKGROUND: Excessive fatigue and insomnia are common among shift workers and can lead to negative effects such as reduced work performance, processing errors, accidents at work, absenteeism, reduced quality of life, and symptoms of depression. Moreover, work in rotating shifts can be a risk factor for different somatic and psychiatric diseases and may contribute to poor health, especially in elder adults and women. This review aims to show non-pharmacological preventive measures against fatigue and insomnia in shift workers. METHOD: Computerized literature searches in MedLine and in the Cochrane Library were performed with the following key words: shift work disorder, fatigue, insomnia, shift work, measures, treatment, therapy, strategies and coping. The search was limited to non-pharmacological studies that were conducted on human subjects and published as English-language articles in peer-reviewed journals since 1970. Additional studies were identified through the reference sections of relevant articles. Eighteen articles on fatigue in shift workers, including six original research articles with a total sample size of 3504 probands consisting of industrial workers, office employees, aircraft maintenance engineers, and non-shift workers working in simulated shifts, were analyzed, as well as seven articles on insomnia, including an original research article with a sample size of 26 media workers. Also, 4 reviews on shift work disorder were analyzed. MAIN: The occurrence of fatigue and insomnia in shift workers associated with a working period is described as shift work disorder. Estimations on the prevalence of shift work disorder in shift workers vary between 5 % and about 20 %; about one in three shift workers is affected by insomnia and up to 90 % of shift workers report regular fatigue and sleepiness at the workplace. We concluded that there is a necessity for treatments to improve the sleep quality of the shift working population. The most common non-pharmacological recommendations to improve sleep quality and to reduce insomnia and fatigue were scheduling, bright light exposure, napping, psychoeducation for sleep hygiene, and cognitive-behavioral measures. CONCLUSION: Some important preventive coping strategies for fatigue associated with shift work such as napping and exposure to bright light have already been investigated and are generally approved. A few studies also provide good evidence for the efficacy of cognitive-behavioral techniques in the treatment of chronic primary and comorbid insomnia. These coping strategies summarized in this paper should be considered in the workplace health promotion programs of each work environment to improve working conditions for shift workers and to save money.

Recommendations for the prevention of breast cancer in shift workers.

The functioning of the human body is regulated by the rhythmical change between rest and activity. The SCN (suprachiasmatic nucleus) is responsible for the central control of the biorhythm and the genetic prediction of the individual chronotype, whereas peripheral time cues such as light, social contacts and times of meals modulate the rhythmical activity of the body. Shift workers suffer from a disruption of the sleep-wake rhythm, insomnia and a lack of melatonin. These factors might trigger the development of breast cancer in female shift workers. The growing amount of data which indicate the high risk of breast cancer in female shift workers demonstrates the need for the implementation of prevention strategies against insomnia in shift workers. These strategies include regular sleep education courses on the prevention of sleep disorders in companies. The individual chronotype could be an important predictor for the adaptability to shift work.

Health promotion and work: prevention of shift work disorders in companies.

Workplace health promotion is a strategy to improve the health and well-being of people at work. The measures aim at the personal, organisational and work environment. Shift work is one of many reasons provoking increased job stress. According to worldwide epidemiological data, up to 30% of the working population are employed in shifts. Taking into consideration that shift work causes a large number of somatic and psychiatric diseases which bear considerable negative consequences for the health status and the quality of life, it seems to be important to initiate health promotion strategies for shift workers in the companies. The results of recent studies indicate that well-scheduled und targeted health programmes can change the lifestyle of shift working employees and have an impact on the risk factors involved. One problem, though, is a considerable time lag till effects become apparent; therefore, the long-term economic effects of workplace health promotion have not been evaluated sufficiently to date. These definitely positive effects highlight the demand for trainings and workshops for people in shift work. We urgently suggest a speedy implementation of the recommended strategies by companies with shift work systems. In our view, this poses a challenge to the "infant" interdisciplinary field of sleep medicine that should be solved.

Effects of olanzapine and clozapine upon pulse rate variability.

Based upon their in vitro receptor binding profiles, the atypical antipsychotics clozapine and olanzapine exhibit cholinergic receptor binding of similar potency. Data comparing the in vivo anticholinergic effects, however, of these neuroleptics upon neurocardiac control are sparse. The goal of this study was to compare the in vivo effects of clozapine and olanzapine upon neurocardiac control by assessment of the pulse rate variability (PRV) in schizophrenic patients and healthy controls. Twenty patients with schizophrenia (according to DSM-III-R criteria) treated with either clozapine (100-600 mg/day) or olanzapine (10-20 mg/day), and ten healthy controls, were recruited into the study. PRV was assessed by continuously recording the skin blood volume in the fingertip of the second digit under resting conditions and PRV parameters were calculated. When significant differences in PRV parameters between the patients and controls were detected by Kruskal-Wallis tests, Mann-Whitney tests were used to test for group differences between the olanzapine- and clozapine-treated patients. In comparison to the healthy controls, the PRV parameters of the clozapine- and olanzapine-treated schizophrenic patients were significantly reduced. Indeed the reduction of PRV was significantly greater in the clozapine-treated group compared to the olanzapine-treated group (P<0.05). Compared to the controls, only the clozapine-treated patients showed a significantly diminished low-frequency (LF)/high frequency (HF)-ratio, a PRV parameter reflecting sympatho-vagal balance. The significantly greater reductions in PRV parameters of the clozapine-treated compared to olanzapine-treated patients may be caused by clozapine's higher affinity for alpha(1)-adrenergic receptors in vivo compared with olanzapine. The similar LF/HF ratios of the healthy controls and olanzapine-treated patients suggests that the sympathetic-parasympathetic modulation of PRV remains relatively unchanged even during olanzapine treatment.