DEPRESSION AND INSOMNIA: BIRDS OF A FEATHER?

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1 DEPRESSION AND INSOMNIA: BIRDS OF A FEATHER? DEPRESSION AND INSOMNIA DO BIRDS OF A FEATHER FLOCK TOGETHER? THE ISSUE IS INSOMNIA A SYMPTOM OF DEPRESSION? OR IS INSOMNIA A COMORBID DISORDER

2 THE COMMON WISDOM IS/WAS INSOMNIA, WHENEVER PRESENT WITH ANOTHER DISORDER, IS A SYMPTOM OTTO WETTERSTRAND, 1897

3 SLEEPLESSNESS IS NO DISEASE IN ITSELF, BUT A SYMPTOM OF DISEASE. IT MAY BE PRESENT IN ALL DISEASES AND COMMENCE AND END WITH THEM. -- OTTO WETTERSTRAND, 1897 "INSOMNIA IS NOT A DISEASE OR A DIAGNOSTIC CATEGORY IN ITSELF; IT IS A SYMPTOM, LIKE FEVER OR CHEST PAIN " PATRICIA LACKS 1987 BEHAVIORAL TREATMENT FOR PERSISTENT INSOMNIA, P.3. C/O JACK EDINGER LET S CONSIDER THE ALTERNATIVE PROPOSITION

4 WHAT EVIDENCE IS THERE THAT INSOMNIA, IN THE CONTEXT OF MAJOR DEPRESSION, EXISTS AS A COMORBID DISORDER? INSOMNIA AND MAJOR DEPRESSION DO NOT NECESSARILY CO-OCCUR INSOMNIA IS A RISK FACTOR FOR NEW ONSET AND RECURRENCE OF MDD INSOMNIA SEVERITY INCREASES PRIOR TO RECURRENCE INSOMNIA IS A RISK FACTOR FOR NON-RESPONSE, NON-REMISSION, AND RELAPSE PRIMARY INSOMNIA AND MAJOR DEPRESSION HAVE DIFFERENT NEURBIOLOGIC PROFILES SUCCESSFUL TREATMENT FOR DEPRESSION DOES NOT NECCESARILY ELIMINATE THE SYMPTOM OF INSOMNIA TARGETED TREATMENT FOR INSOMNIA INFLUENCES THE CLINICAL COURSE OF MDD INSOMNIA AND MAJOR DEPRESSION DO NOT NECESSARILY CO-OCCUR 17-40% OF PATIENTS WITH MDD DO NOT HAVE INSOMNIA Tsuno, J. of Clinical Psychiatry, 2005; Perlis et al. Biol. Psychiatry, 1997; Reynolds & Kupfer, 1987; Thase, 1998; Ford & Kamerow, 1989; Hamilton, % OF PATIENTS WITH INSOMNIA DO NOT HAVE MDD (OR PSYCHIATRIC ILLNESS) Ohayon, Sleep Med Review, 2002

5 INSOMNIA IS A RISK FOR NEW ONSET AND RECURRENCE OF MDD 14+ STUDIES SHOW THAT INSOMNIA IS A RISK FACTOR (A PREDISPOSING FACTOR) FOR MDD INSOMNIA IS A RISK FOR NEW ONSET OF MDD Breslau et al. Bio. Psychiatry 1996 INSOMNIA SEVERITY INCREASES PRIOR TO RECURRENCE INSOMNIA SEVERITY INCREASES AS REMITTED SUBJECTS APPROACH RECURRENCE. ACCORDINGLY, INSOMNIA MAY BE A PRODROME OF, OR A PRECIPTATING FACTOR FOR, MDD Perlis et al. Journal of Affective Disorders, 1997

6 INSOMNIA IS A RISK FACTOR FOR NON-RESPONSE, NON-REMISSION AND RELAPSE THE GREATER THE SLEEP IMPAIRMENT THE SLOWER THE RECOVERY Dew et al. Arch Gen Psychiatry, 1997 PERSISTENT INSOMNIA INCREASES THE LIKELIHOOD OF NON-REMISSION FOLLOWING TREATMENT Pigeon et al (Data from the IMPACT Cohort Study) RESIDUAL LATE INSOMNIA IN TX RESPONDERS CONFERS 3X THE RISK FOR RELAPSE Taylor, et al. Sleep. 2004;27 (Abstract Suppl.):A346.

7 SUCCESSFUL TREATMENT FOR DEPRESSION DOES NOT NECCESARILY ELIMINATE THE SYMPTOM OF INSOMNIA Reynolds et al Nierenberg AA et al. J Clin. Psychiatry 1999 PRIMARY INSOMNIA AND MAJOR DEPRESSION HAVE DIFFERENT NEURBIOLOGIC PROFILES

8 POLYSOMNOGRAPHIC SLEEP PATTERNS PROLONGED REDUCED SHORT SLEEP SLOW REM WAVE LATENCY SLEEP PROLONGED REDUCED SHORT SLEEP SLOW REM WAVE LATENCY SLEEP BRAIN ACTIVITY DURING SLEEP PERLIS ET AL. J. SLEEP RES NEUROHORMONAL ACTIVITY DURING SLEEP IRWIN ET AL. BRAIN BEHAVIORAL AND IMMUNITY 2001

9 TARGETED TREATMENT FOR INSOMNIA INFLUENCES THE CLINICAL COURSE OF MDD CBT-I IN PATIENTS WITH MILD DEPRESSION PRODUCED A 57% CHANGE IN MDD SEVERITY Taylor, Behav Ther, 2007 TARGETED TREATMENT FOR INSOMNIA INFLUENCES THE CLINICAL COURSE OF MDD 11-20% MORE SUBJECTS RESPOND OR REMIT WITHIN 8 WEEKS WHEN CO-TREATED FOR INSOMNIA Fava, Bio. Psychiatry, 2006

10 5-15% MORE SUBJECTS RESPOND OR REMIT AT ANY GIVEN TIME POINT ALSO LATENCY TO RESPONSE Fava, Bio. Psychiatry, 2006 CBT-I IN PATIENTS WITH MILD DEPRESSION SIGNIFICANTLY INCREASED RATE OF REMISSION AND DECREASED AVERAGE ILLNESS SEVERITY MANBER ET AL SLEEP THIS EXPERIMENT WAS DONE A 2 ND TIME (COLLEEN CARNEY & RACHEL MANBER) THIS TIME IT GOT NOTICED!!!!

11 OTHER

12 OTHER

13 SO WHAT IS THIS? IT S A BAD THING TO BE AWAKE WHEN REASON SLEEPS

14 WHY? NO SOCIAL CONSTRAINTS NO SOCIAL SUPPORTS ACCESS TO ALCOHOL AND SUBSTANCES CIRCADIAN PRESS FOR FRONTAL LOBE DISINHIBITION? INSOMNIA RELATED HYPFRONTALITY? HAS SUCH DATA CHANGED HOW INSOMNIA IS VIEWED FROM A NOSOLOGIC POINT OF VIEW? YES!

15 DSM-V

16 THUS THE CONCEPT OF SECONDARY INSOMNIA HAS BEEN ELIMINATED INSOMNIA WHEN CHRONIC IS NOT CLASSIFIED AS A SYMPTOM OF OTHER CO-OCCURING ILLNESSES BUT INSTEAD IT IS CLASSIFIED AS A DISORDER. THIS PARADAMATIC SHIFT WAS BROUGHT TO YOU BY McCrae & Lichstein, 2001 Stepanski & Rybarczyk, 2005 Lichstein, 2006

17 WHAT IS THE MAJOR CLINICAL IMPLICATION OF THE CHANGE IN DEFINITION? INSOMNIA, AS A DISORDER THAT IS COMORBID WITH DEPRESSION, MEANS THAT BOTH ARE LEGITIMATE TARGETS FOR INTERVENTION IN SUMMARY

18 INSOMNIA AND MAJOR DEPRESSION DO NOT NECESSARILY CO-OCCUR INSOMNIA IS A RISK FACTOR FOR NEW ONSET AND RECURRENCE OF MDD INSOMNIA SEVERITY INCREASES PRIOR TO RECURRENCE INSOMNIA IS A RISK FACTOR FOR NON-RESPONSE, NON-REMISSION, AND RELAPSE SUCCESSFUL TREATMENT FOR DEPRESSION DOES NOT NECCESARILY ELIMINATE THE SYMPTOM OF INSOMNIA TARGETED TREATMENT FOR INSOMNIA INFLUENCES THE CLINICAL COURSE OF MDD PRIMARY INSOMNIA AND MAJOR DEPRESSION HAVE DIFFERENT NEURBIOLOGIC PROFILES Michael Perlis PhD Director, Upenn Behavioral Sleep Medicine Program

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