Augmentation of antidepressants with bright light therapy in patients with comorbid depression and borderline personality disorder.

BACKGROUND: Borderline personality disorder (BPD) is typically characterized by instability and impaired behaviour, affectivity, interpersonal relations and lifestyle. The most common condition comorbid with BPD is a depressive episode. Depression is associated with severe disturbance of the circadian rhythms. This is apparent in depressive patients with BPD. Both sleep and diurnal rhythms are disturbed and the symptoms fluctuate. Bright light may be an effective in treatment of seasonal affective disorder, circadian sleep disorder and jet lag. It also improves sleep-wake patterns and behavioural disorders in hospitalized patients with Alzheimer's disease. Several studies have suggested antidepressant effects of phototherapy in non-seasonal depressive episodes. The treatment of comorbid depressive disorder and borderline personality disorder (BPD) is usually reported to be less successful than the treatment of patients without personality disorder. Studies describing the use of bright light in depressed patients with comorbid BPD have not been published so far. METHOD: The aim of this open study was to assess the effectiveness of a 6-week combined therapy with the application of bright light (10,000 lux, 6:30 to 7:30 a.m. for 6 weeks) added to SSRIs in drug-resistant depressed patients with comorbid BPD who did not respond with improvement to 6-week administration of antidepressants. The study comprised 13 female patients who met the ICD-10 diagnostic criteria for research and the DSM-IV-TR diagnostic criteria for major depression. The participants were regularly evaluated using the CGI, HAMD and MADRS scales and the BDI and BDI self-report inventories. RESULTS: According to all the assessment instruments, the application of bright white light leads to a significant improvement. However, the results must be interpreted with caution due to the open nature of the study.

Trazodone improves the results of cognitive behaviour therapy of primary insomnia in non-depressed patients.

OBJECTIVES: Cognitive behaviour therapy (CBT) of primary insomnia is frequently combined with various pharmacological treatments, including sedative antidepressants. The present study was undertaken to evaluate the clinical efficacy of CBT, singly and combined with trazodone pharmacotherapy, for primary insomnia. DESIGN AND SETTING: Randomised, comparative clinical trial, at a single academic medical centre. METHODS: Twenty outpatients (15 women, 5 men) with chronic primary insomnia were randomly assigned to CBT or CBT +100mg trazodone and treated for 8 weeks. The treatment outcome was estimated by mean changes from baseline in self-reported clinical scales, sleep continuity data and sleep architecture parameters. RESULTS: All patients perceived significant subjective sleep improvements. Sleep latency significantly shortened (p=0.03), sleep efficiency increased (p=0.004) and the total sleep time was significantly prolonged (p=0.006) after the CBT treatment in both groups. Sleep architecture showed that the combined approach (CBT + trazodone) resulted in a significant increase in slow wave sleep duration compared to treatment by CBT only (p=0.04). CONCLUSIONS: CBT, singly and combined with the sedative antidepressant trazodone, is effective for the short-term management of chronic primary insomnia. Trazodone combined with CBT significantly increases slow wave sleep duration and this influence seems to be unrelated to its antidepressant effect.

Discontinuation of hypnotics during cognitive behavioural therapy for insomnia.

BACKGROUND: In practical sleep medicine, therapists face the question of whether or not to discontinue the ongoing use of hypnotics in patients, as well as the possible effects of discontinuation. The aim of this study was to evaluate the effects of discontinuing third-generation hypnotics on the results of cognitive-behavioural therapy (CBT) for primary insomnia in patients after long-term abuse. METHODS: Twenty-eight outpatients were treated by CBT for 8 weeks. The treatment outcome was estimated by means of differences among subjective clinical scales and polysomnography variables assessed before and after the treatment period. The therapeutic effect in a subgroup of 15 patients who had previously received hypnotics and were successively withdrawn during weeks 2-6 was compared to the effect achieved in patients who had not used hypnotics before CBT. RESULTS: There were no significant differences in baseline subjective and objective sleep characteristics between the hypnotic abusers and non-abusers. According to clinical scales and most polysomnographic measures, CBT was highly effective in both groups of subjects; it produced the greatest changes in total sleep time, REM sleep and sleep efficiency. Unexpectedly, discontinuation of hypnotics, as a factor in the analysis, was followed by an additional improvement of sleep efficiency and wake after sleep onset parameters. CONCLUSION: Our study confirmed the efficacy of CBT in both hypnotic-abusing and non-abusing patients with chronic insomnia. The results of this study suggest that tapered withdrawal of third-generation hypnotics during CBT therapy for chronic insomnia could be associated with improvement rather than worsening of sleep continuity.

The effect of tryptophan depletion on the action of haloperidol in MK-801-treated rats.

We investigated the effect of tryptophan depletion (tryptophan-free mixture) on locomotor activity in an animal model of schizophrenia, induced by acute administration of 5R,10S-(+)-5-methyl-10,11-dihydro-5H-dibenzo[a,d]-cyclohepten-5,10-imine hydrogen maleate (MK-801), and the influence of the tryptophan-free mixture on the action of the typical antipsychotic haloperidol. Male rats were pre-treated with haloperidol 60 min after receiving the tryptophan-free mixture (or water). We measured total distance travelled in an open field during a 90-min period. Administration of the tryptophan-free mixture resulted in decreased levels of tryptophan, serotonin and its metabolite 5-hydroxyindolacetic acid in the frontal cortex. Serotonin depletion increased the total distance travelled by MK-801-treated rats, modified the inhibitory effect of haloperidol and normalized the locomotor activity pattern in the model of schizophrenia-like behaviour. The effect of the tryptophan-free mixture combined with the classical antipsychotic haloperidol in MK-801-treated rats indicates the possibly important role of the serotonergic system in the action of antipsychotics.

Subjective and objective evaluation of alertness and sleep quality in depressed patients.

BACKGROUND: The reliability of the subjective statements reports on disturbed night sleep and alertness in the daytime was assessed by their correlation to the objective indicators in patients with mild depression. METHOD: Among patients with depression, altogether 28 patients with insomnia were examined. Their answers to typical questions, as they are used during a psychiatric interview, were scored. In parallel, night sleep quality and alertness level in the daytime were objectively estimated by means of polygraphic recording. RESULTS: The subjective statements on the type of insomnia, the estimated time of falling asleep, frequent awakenings and occurrence of disturbing dreams seem to be unreliable. Similarly, the results were disappointing when the patients were asked about alertness disturbances in the daytime. An unexpected finding was the lack of any significant correlation to the scores obtained by means of Epworth's scale. Among the factors possibly influencing the patients' reports, age, sex, coffee intake and also chronic administration of sedatives or hypnotics showed a low correlation with the sleep and alertness indicators. CONCLUSION: The statistical evaluation indicated rather poor agreement between the subjective and objective items. The statistical evaluation suggested that anxiety and depression significantly influence reports on sleep quality and alertness disturbances in the daytime.