Observed relationships among symptoms of stress, depression, subjective sleep complaints, and electroencephalographic power may be relevant to the discrepancy between subjective and objective measures of sleep in patients with insomnia and may be more broadly applicable to sleep complaints in association with stressful life events and major depression.
Laboratory sleep findings in posttraumatic stress disorder (PTSD) have been characterized as incongruent with subjective complaints. Most findings relate to rapid eye movement (REM) sleep. Chronicity confounds relationships between objective sleep and PTSD. The authors report relationships between PTSD symptoms and objective sleep measures from the early aftermath of trauma. Thirty-five patients received polsomnography and PTSD assessment within a month of traumatic injury. Posttraumatic stress disorder status was established at 2 months. The REM segment duration correlated negatively with initial PTSD and insomnia severity, which also correlated with total sleep time. Relative beta frequency during REM sleep from a subset of cases correlated negatively with PTSD and nightmare severity. These findings suggest a link between subjective symptoms and REM sleep phenomena acutely following trauma.
Effective management of insomnia begins with recognition and adequate assessment. Family doctors and other health care providers such as practice nurses and psychologists should routinely enquire about sleep habits as a component of overall health assessment. Identification and treatment of primary psychiatric disorders, medical conditions, circadian disorders, or specific physiological sleep disorders--eg, sleep apnoea and periodic limb movement disorder--are essential steps in management of insomnia. Conditioned aspects of insomnia can be primary (psychophysiological insomnia) or may complicate sleep disturbance owing to other causes. Approved hypnotic drugs have clearly been shown to improve subjective and objective sleep measures in various short-term situations. Despite widespread use of standard hypnotics and sedating antidepressants for chronic insomnia, their role for this indication still remains to be further defined by research evidence. Non-pharmacological treatments, particularly stimulus control and sleep restriction, are effective for conditioned aspects of insomnia and are associated with durable long-term improvement in sleep.
Benzodiazepines and zolpidem produced reliable improvements in commonly measured parameters of sleep in patients with chronic insomnia. Relative to the chronic and recurring course of insomnia, both the limited duration of treatments studied and the lack of follow-up data from controlled trials represent challenges for developing evidence-based guidelines for the use of hypnotics in the management of chronic insomnia.
We report a longitudinal study of diary- and laboratory-based sleep measures in 50 healthy elderly subjects followed prospectively over a 3-year interval. Our hypothesis was that "old old" subjects (aged 75 to 87; n = 27) would show decline over time in measures of sleep quality, continuity, and depth, whereas "young old" subjects (aged 61 to 74; n = 23) were expected to show stability of outcome measures. Using analysis of variance-based planned contrast procedures, we found that this hypothesis was strongly supported for subjective sleep quality and laboratory measures of sleep latency, sleep efficiency, wakefulness after sleep onset, and slow-wave sleep percent. These changes were accompanied by increased napping in the old old. However, there was no change of habitual time in bed (total time or temporal placement of nighttime sleep), daily social rhythms, or sleep apnea. Change in medical burden scores did not correlate significantly with change in sleep efficiency or other outcome variables in the old old. Intervention designed to slow age-dependent decreases in sleep quality, continuity, and depth is discussed. The current results are representative of healthy elderly; sleep would probably deteriorate earlier and more quickly in elderly with more serious health problems and heavier medication use.
We tested two interventions for improving sleep consolidation and depth in normal elderly participants: a modification of sleep-restriction therapy and sleep-hygiene education. Twenty-one elderly participants without sleep disorders were randomized to sleep hygiene plus bed restriction (i.e., restricting time in bed by 30 minutes nightly for one year) or to sleep hygiene alone. Participants in the bed-restriction group showed a median increase in sleep efficiency of 6.1% versus 1.8% in participants receiving sleep hygiene instruction, and an increase in allnight delta EEG power. Self-reported mood on awakening in the morning showed greater improvement over the first eight weeks in the sleep-hygiene condition. The use of sleep hygiene was associated with initial improvement in daytime well-being, whereas bed restriction led to sustained improvements in sleep continuity and sleep depth.
Mood disorders and chronic insomnia share complex theoretical and clinical relationships. This article reviews the subjective symptoms and polysomnographic findings of subjects with mood and insomnia syndromes. The polysomnographic findings reviewed include macro-architectural and micro-architectural data. Various treatments of patients with insomnia and mood disorders will be presented, including both behavioral and pharmacological interventions.
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