Sertraline and periodic limb movement during sleep: an 8 ...
Sertraline and rapid eye movement sleep without atonia: an 8-week, open-label study in depressed patientsWord Count: 4480 words (main body) with 2 figures and 4 tablesVersion: 1Abstract Previous studies have reported that selective serotonin reuptake inhibitors (SSRIs) may induce or exacerbate rapid eye movement (REM) sleep without atonia (RSWA) and increase the risk of developing REM sleep behavior disorder (RBD). However, most of these studies of them were retrospective and cross-sectional studies in nature with small sample size on a mixture of SSRIswith small sample sizes, and they included data on a mixture of SSRIs. As Because different SSRIs have different pharmacological profiles, the specific effects of a singleof individual SSRIs on RSWA should be studied. In an 8-week, open-label trial of sertraline in depressed patients (n=31), depressed patients were administered 50 mg of sertraline at 8 am on the 1st day, ; this dose and was subsequently titrated up to a maximum of 200 mg/day. All patients had underwent repeated video-polysomnography (vPSG) (at baseline and on days, 1st day, 14th day, 28th day, and 56th day). Both tonic (submental) and phasic (submental and anterior tibialis) RSWA were visually countedassessed. The tTonic RSWA increased from 3.2±1.8% at baseline to 5.1±2.3% on the 1st day on sertraline and to 10.4±2.7% on the 14th day;, with this value then remained stable measures until the 56th day. A similar profile was observed for phasic RSWA as well as and for the proportion of patients with abnormal phasic anterior tibialis RSWA. No RBD was observed. The increase of in tonic muscle tone during REM sleep over time was correlated with reduced REM sleep Latency latency (r=0.56, p=0.004), PLMI (r =0.39, p=0.047), and improvement in depression (HRSD score, r =-0.43, p=0.03). The increases of in phasic submental RSWA (r =-0.51, p=0.02) and anterior tibialis (r=0.41, p=0.04) RSWA was were correlated with decreased REM sleep Llatency, and it were was not correlated with patient s’ demographics and or clinical characteristics. Sertraline could induced or exacerbated RSWA, but did not induce RBD. Compared with idiopathic RBD, the sertraline-related RSWA had some specific characteristics of being correlated with REM latency and no predominance of male sex gender and or elder older age, so suggesting they that RSWA and idiopathic RBD might have involve different mechanisms with than idiopathic RBD. Key-wordsKey words: rapid eye movement (REM) sleep without atonia (RSWA); REM sleep behavior disorder (RBD); sSertraline; depressed patientClinical Trial Registry: An 8-week, open-label study to evaluate the effect of sertraline on the polysomnographic resultsam of depressive patients with insomnia, (HYPERLINK "http:/---ct2-show-NCT01032434" HYPERLINK " " ). Registry identifier: NCT01032434.Abbreviations: 5-HT: serotonin; AASM-2007: American Academy of Sleep Medicine 2007 version; AHI: apnea-hypopnea index; AI: arousal index; ANOVA: one-way analysis of variance; BMI: body mass index; CT: Computed computed tTomography; DA: dopaminergic; DSM-IV: diagnostic and statistical manual of mental disorders, fourth edition; ECG: Electrocardiographelectrocardiograph; EMG: electromyogram; EOG: electrooculography; ESS: Epworth sleepiness scale; HRSD: Hamilton rating scale for depression; MSLT: multiple sleep latency test; OSA: obstructive sleep apnea; OCD: obsessive-compulsive disorder; PD: parkinson’sParkinson’s disorderdisease; PLMI: periodic limb movement index; PLMS: periodic limb movement during sleep; PSG: pPolysomnographym; PSQI: Pittsburgh sleep quality index; REM: rapid eye movement; RSWA: REM sleep without atonia; RLS: restless legs syndrome; SCID-2: the second version of the Structured Clinical Interview for DSM-IV Axis I Disorders; SE: Sleep sleep Efficiencyefficiency; SL: Sleep sleep Latencylatency; SSRI: selective serotonin reuptake inhibitors; TESS-S: treatment emergent symptom scale-severity; TESS-T: treatment emergent symptom scale-treatment; TRT: total recording time; TST: total sleep time; vPSG: video-ploysomnographypolysomnography; WASO: wake after sleep onset. 1. INTRODUCTIONRapid eye movement (REM) sleep behavior disorder (RBD) is a parasomnia characterized by the loss of normal atonia during REM sleep and dream- enacting behavior PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5TY2hlbmNrPC9BdXRob3I+PFllYXI+MjAwMjwvWWVhcj48
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ADDIN EN.CITE.DATA (Schenck and Mahowald, 2002, AASM, 2005). Idiopathic RBD is a male-predominant disorder that usually emerges after 50 years the of age of 50 years PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5TY2hlbmNrPC9BdXRob3I+PFllYXI+MjAwMjwvWWVhcj48
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ADDIN EN.CITE.DATA (Gagnon et al., 2006, Arnulf, 2012, AASM, 2005). According to the international International classification Classification of sleep Sleep disorders Disorders, Ssecond edition Edition (ICSD-2), the criteria of for RBD include the appearance of elevated submental electromyogram (EMG) tone and/or excessive phasic submental or anterior tibialis EMG activity during REM, combined with sleep sleep-related injurious, potentially injurious, or abnormal REM sleep behaviors documented during polysomnographic (PSG) monitoring.; while On the other hand, the criteria of for subclinical RBD only include the REM sleep PSG abnormalities and but withoutdo not a include a clinical history of RBD ADDIN EN.CITE <EndNote><Cite><Author>AASM</Author><Year>2005</Year><RecNum>105</RecNum><DisplayText>(AASM, 2005)</DisplayText><record><rec-number>105</rec-number><foreign-keys><key app="EN" db-id="x05vd9szpszzdmefz2kv2vp2555v925dff00">105</key></foreign-keys><ref-type name="Book">6</ref-type><contributors><authors><author>AASM</author></authors></contributors><titles><title>International Classification of Sleep Disorders: Diagnostic and Coding Manual</title></titles><edition>2nd</edition><section>182-186</section><dates><year>2005</year></dates><pub-location>Westchester, Illinois</pub-location><publisher>American Academy of Sleep Medicine</publisher><urls></urls></record></Cite></EndNote>(AASM, 2005). The An “abnormal amount” of RSWA (as a percentage of REM sleep) has been determined by different methods, based on measures in normal subjects and in patients with idiopathic RBD. When using theUsing the American Academy of Sleep Medicine 2007 version (AASM-2007) criteria for measuring tonic and phasic muscle activity ADDIN EN.CITE <EndNote><Cite><Author>Iber C</Author><Year>2007</Year><RecNum>42</RecNum><DisplayText>(Iber C, 2007)</DisplayText><record><rec-number>42</rec-number><foreign-keys><key app="EN" db-id="x05vd9szpszzdmefz2kv2vp2555v925dff00">42</key></foreign-keys><ref-type name="Book">6</ref-type><contributors><authors><author>Iber C, Ancoli-Israel S, Cheeson A, and Quan SF for the academy of Sleep Medicine</author></authors></contributors><titles><title>The AASM Manual for the Scoring of Sleep and Associated Events: Rules, Terminology and Technical Specifications</title></titles><edition>1st</edition><dates><year>2007</year></dates><pub-location>Westchester, Illinois</pub-location><publisher>American Academy of Sleep Medicine</publisher><urls></urls></record></Cite></EndNote>(Iber C, 2007), 18% of REM sleep time with in which any 3-second lasting tonic or phasic muscle activity lasted 3 seconds on in an epoch was specific characterized of as RBD in a series of 15 patients with idiopathic RBD, 15 patients with RBD associated with Pparkinson’s disease and 30 matched controls PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5GcmF1c2NoZXI8L0F1dGhvcj48WWVhcj4yMDEyPC9ZZWFy
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ADDIN EN.CITE.DATA (Frauscher et al., 2012). Gagnon argued that a similar cutoff (greater than 20% )%) of the tonic submental muscle activity during REM sleep was a reasonable threshold for defining muscle activity as excessive or potentially pathological ADDIN EN.CITE <EndNote><Cite><Author>Gagnon</Author><Year>2006</Year><RecNum>114</RecNum><DisplayText>(Gagnon et al., 2006)</DisplayText><record><rec-number>114</rec-number><foreign-keys><key app="EN" db-id="x05vd9szpszzdmefz2kv2vp2555v925dff00">114</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Gagnon, J. F.</author><author>Postuma, R. B.</author><author>Montplaisir, J.</author></authors></contributors><auth-address>Centre d'Etude du Sommeil et des Rythmes Biologiques, Hopital du Sacre-Coeur de Montreal, Institut Universitaire de Geriatrie de Montreal, Montreal, Quebec, Canada.</auth-address><titles><title>Update on the pharmacology of REM sleep behavior disorder</title><secondary-title>Neurology</secondary-title><alt-title>Neurology</alt-title></titles><periodical><full-title>Neurology</full-title><abbr-1>Neurology</abbr-1></periodical><alt-periodical><full-title>Neurology</full-title><abbr-1>Neurology</abbr-1></alt-periodical><pages>742-7</pages><volume>67</volume><number>5</number><edition>2006/09/13</edition><keywords><keyword>Anticonvulsants/adverse effects/*therapeutic use</keyword><keyword>Clonazepam/*therapeutic use</keyword><keyword>Humans</keyword><keyword>Monoamine Oxidase Inhibitors/administration & dosage/adverse effects</keyword><keyword>REM Sleep Behavior Disorder/diagnosis/*drug therapy/epidemiology/physiopathology</keyword></keywords><dates><year>2006</year><pub-dates><date>Sep 12</date></pub-dates></dates><isbn>1526-632X (Electronic)
0028-3878 (Linking)</isbn><accession-num>16966533</accession-num><work-type>Research Support, Non-U.S. Gov't</work-type><urls><related-urls><url>;(Gagnon et al., 2006). In another study being consisted ofthat included 80 patients with idiopathic RBD, tonic submental muscle activity greater accounting for more than 30% of the total REM sleep time, and a phasic submental muscle activity greater accounting for more than 15% of the total REM sleep time were considered optimal cut-offs to for the diagnose diagnosis of idiopathic RBD from in normal controls PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5Nb250cGxhaXNpcjwvQXV0aG9yPjxZZWFyPjIwMTA8L1ll
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ADDIN EN.CITE.DATA (Montplaisir et al., 2010). In view of the clinical lore and a small number of published studies, antidepressants may induce or exacerbate RSWA and increase the risk of developing RBD or subclinical RBD PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5TY2hlbmNrPC9BdXRob3I+PFllYXI+MTk5MjwvWWVhcj48
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ADDIN EN.CITE.DATA (Guilleminault et al., 1976, Bental et al., 1979, Schenck et al., 1992, Onofrj et al., 2003, Winkelman and James, 2004, Zhang et al., 2010, Hoque and Chesson, 2010). A recent clinical epidemiological study on parasomnia in psychiatric out-patients find outrevealed that the lifetime and 1-year prevalences of RBD and/or subclinical RBD among psychiatric out-patients are were 5.8% and 3.8% respectively%, respectively. It These prevalences are is ten times more commonhigher than the prevalencethe prevalence of RBD in the general population. Further, compared with RBD patients in the general population, these psychiatric outpatients with RBD are were of younger in age, were predominantly female predominance, being were associated withmore likely to be using antidepressants usage, and no had lessfewer concurrent neurodegenerative diseases compared to the RBD patients in the general population PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5MYW08L0F1dGhvcj48WWVhcj4yMDA4PC9ZZWFyPjxSZWNO
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ADDIN EN.CITE.DATA (Lam et al., 2008). In recent decades, The sselective serotonin (5-HT) reuptake inhibitors (SSRIs) are have become the first-line antidepressants, and they are suspected to; in recent decades, and their potentialexert effects on RSWA can beare suspected from based on basic knowledge on of muscle atonia during REM sleep. The normal loss of muscle tone during REM sleep results from occurs due to two mechanisms:, one is passive, and onewhile the other is active. During non-REM sleep, the firing of sSerotonergic neurons descending to the nuclei of the cranial nerves and to the lower motor neurons is reduced their firing, leading to the disfacilitation ofing the neurons; during REM sleep, the during non non-REM sleep, and cease firing of serotonergic neurons ceases during REM sleep ADDIN EN.CITE <EndNote><Cite><Author>Siegel</Author><Year>2006</Year><RecNum>158</RecNum><DisplayText>(Siegel, 2006)</DisplayText><record><rec-number>158</rec-number><foreign-keys><key app="EN" db-id="x05vd9szpszzdmefz2kv2vp2555v925dff00">158</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Siegel, J. M.</author></authors></contributors><titles><title>The stuff dreams are made of: anatomical substrates of REM sleep</title><secondary-title>Nat Neurosci</secondary-title><alt-title>Nature neuroscience</alt-title></titles><periodical><full-title>Nat Neurosci</full-title><abbr-1>Nature neuroscience</abbr-1></periodical><alt-periodical><full-title>Nat Neurosci</full-title><abbr-1>Nature neuroscience</abbr-1></alt-periodical><pages>721-2</pages><volume>9</volume><number>6</number><edition>2006/05/30</edition><keywords><keyword>Animals</keyword><keyword>Brain Stem/anatomy & histology/*physiology</keyword><keyword>Humans</keyword><keyword>Hypothalamus/anatomy & histology/physiology</keyword><keyword>Models, Neurological</keyword><keyword>Neural Pathways/anatomy & histology/*physiology</keyword><keyword>Neurotransmitter Agents/physiology</keyword><keyword>Reticular Formation/anatomy & histology/*physiology</keyword><keyword>Sleep Disorders/physiopathology</keyword><keyword>Sleep, REM/*physiology</keyword><keyword>Synaptic Transmission/physiology</keyword></keywords><dates><year>2006</year><pub-dates><date>Jun</date></pub-dates></dates><isbn>1097-6256 (Print)
1097-6256 (Linking)</isbn><accession-num>16732200</accession-num><work-type>News</work-type><urls><related-urls><url>;(Siegel, 2006). As a consequence, muscle tone is reduced from light to deep non-REM sleep, as well as and then during REM sleep, leading to hypotonia (postural muscle tone is reduced but still present). In addition to this passive mechanism, an active paralysis of postural muscle tone (termed atonia) (named atonia) occurs specifically during REM sleep,, and the postsynaptic lower motor neurons are eventually blocked via the uses a the cholinergic-glutaminergic-glycinergic pathway to eventually block the postsysnapticpostsynaptic lower motor neurons. In humans, drugs that stimulate the serotonin system (e.g., fluoxetine, paroxetine, and venlafaxine) and those that block acetylcholine transmission (tricyclics such as clomipramine) can induce RSWA and/or RBD, possibly because due to their they prevention of the normal sleep-related hypotonia (serotoninergic drugs) or the normal REM sleep-related atonia (anticholinergics) ADDIN EN.CITE <EndNote><Cite><Author>Arnulf</Author><Year>2012</Year><RecNum>159</RecNum><DisplayText>(Arnulf, 2012)</DisplayText><record><rec-number>159</rec-number><foreign-keys><key app="EN" db-id="x05vd9szpszzdmefz2kv2vp2555v925dff00">159</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Arnulf, I.</author></authors></contributors><auth-address>Sleep disorders unit, Pitie-Salpetriere Hospital, Pierre and Marie Curie University, Inserm U975, CRICM, Paris, France. isabelle.arnulf@psl.aphp.fr</auth-address><titles><title>REM sleep behavior disorder: motor manifestations and pathophysiology</title><secondary-title>Mov Disord</secondary-title><alt-title>Movement disorders : official journal of the Movement Disorder Society</alt-title></titles><periodical><full-title>Mov Disord</full-title><abbr-1>Movement disorders : official journal of the Movement Disorder Society</abbr-1></periodical><alt-periodical><full-title>Mov Disord</full-title><abbr-1>Movement disorders : official journal of the Movement Disorder Society</abbr-1></alt-periodical><pages>677-89</pages><volume>27</volume><number>6</number><edition>2012/03/27</edition><keywords><keyword>Cognition Disorders/complications/*physiopathology</keyword><keyword>Dementia/complications/*physiopathology</keyword><keyword>Humans</keyword><keyword>Parkinson Disease/complications/*physiopathology</keyword><keyword>REM Sleep Behavior Disorder/complications/*physiopathology</keyword><keyword>Sleep, REM/*physiology</keyword></keywords><dates><year>2012</year><pub-dates><date>May</date></pub-dates></dates><isbn>1531-8257 (Electronic)
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ADDIN EN.CITE.DATA (Schenck et al., 1992, Winkelman and James, 2004, Gagnon et al., 2006, Zhang et al., 2010, Hoque and Chesson, 2010). However, most of these researches studies are were retrospective, and cross-sectional studies with small sample size on a mixture of SSRIswith small sample sizes, thatand the subjects received a mixture of SSRIs. It is well known that not all SSRIs do not have the same pharmacological profiles, ; so thus, different SSRIs might have different ial tendencyies to induce RSWA. With this in mind, tThe specific effects of a singleindividual SSRIs on RSWA should be studied. The main purpose of this study is was to characterize the effect of sertraline on RSWA in depressed patients in an 8-week clinical trial with using repeated video-ploysomnographypolysomnography (vPSG) assessment. 2. METHODS2.1. Patients and Study DesignThe protocol of this study protocol was approved by the Independent Ethics Committee (IEC) of Guangdong Provincial Mental Health CentreCenter. Written informed consents were was signed obtained from each patient prior to participation. All patients were enrolled from the inpatient population of Guangdong Provincial Mental Health Center. If a patient was diagnosed with a single or recurrent type of major depressive disorder according to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) upon admission, the specific diagnosis of the patient’s diagnosis of the patient would was be ascertainedwas determined by one of the authors (BZ) using the second version of the Structured Clinical Interview for DSM-IV Axis I Disorders (SCID-2) ADDIN EN.CITE <EndNote><Cite><Author>First MB</Author><Year>1996</Year><RecNum>41</RecNum><DisplayText>(First MB, 1996)</DisplayText><record><rec-number>41</rec-number><foreign-keys><key app="EN" db-id="x05vd9szpszzdmefz2kv2vp2555v925dff00">41</key></foreign-keys><ref-type name="Book">6</ref-type><contributors><authors><author>First MB, Spitzer RL, Williams JBW, Gibbon M, Williams JWB</author></authors></contributors><titles><title>User's Guide for the Structured Clinical Interview for DSM-IV Axis I Disorders: SCID-II Clinician Version</title></titles><dates><year>1996</year></dates><publisher>American Psychiatric Association</publisher><urls></urls></record></Cite></EndNote>(First MB, 1996). None of the patients included in the study fulfilled any other current or lifetime diagnostic criteria of for DSM-IV Axis I disorders. The pPatients were males and females, aged 18 to 65 years, with a Hamilton Rating Scale for Depression (HRSD) scores ≥ 18 and HRSD-a sleep disturbance factor scores in HRSD ≥ 3 ADDIN EN.CITE <EndNote><Cite><Author>Hamilton</Author><Year>1960</Year><RecNum>17</RecNum><DisplayText>(Hamilton, 1960)</DisplayText><record><rec-number>17</rec-number><foreign-keys><key app="EN" db-id="x05vd9szpszzdmefz2kv2vp2555v925dff00">17</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Hamilton, M.</author></authors></contributors><titles><title>A rating scale for depression</title><secondary-title>J Neurol Neurosurg Psychiatry</secondary-title></titles><periodical><full-title>J Neurol Neurosurg Psychiatry</full-title></periodical><pages>56-62</pages><volume>23</volume><keywords><keyword>*Depression</keyword><keyword>*Psychometrics</keyword></keywords><dates><year>1960</year><pub-dates><date>Feb</date></pub-dates></dates><accession-num>14399272</accession-num><urls><related-urls><url> </url></related-urls></urls></record></Cite></EndNote>(Hamilton, 1960), reflecting a moderate-to-high level of illness severity (depression and insomnia). Possible concurrent medical disorders were ruled out by a thorough medical examination and laboratory tests (eElectroencephalograph [EEG], eElectrocardiograph [ECG], cComputed tTomography [CT], and blood analysis, and urinary urine analysisanalyses). Patients were excluded if they had experienced serious adverse events while taking sertraline; , if they currently had significant suicidal or homicidal tendencies (either frombased on their medical history histories or HSRSD scores ≥ 4 on item 3, “suicide”), in HSRD ≥ 4); if they were currently pregnant or breastfeeding; , if they were currently shift workers; , if they currently had a significant sleep disorder (e.g., RBD, obstructive sleep apnea [OSA], periodic limb movement during sleep [PLMS], restless legs syndrome [RLS], and so on),; or if they had a serious medical condition in the previous 3 months. After a 7-day washout phase for patients receiving who had received medicine treatmentmedication in the previous 3 months and a subsequent 2-night baseline vPSG assessmentthe following 2-night baseline vPSG assessment, the patients received sertraline for 8 weeks. At baseline and during the 4 visits (days 1st day, 14th day, 28th day, and 56th day), the patients were assessed by the HRSD (which measures clinical improvement), Treatment Emergent Symptom Scale (TESS-Severity [TESS-S] and TESS-Treatment [TESS-T], which measure: side effects) ADDIN EN.CITE <EndNote><Cite><Author>Guy</Author><Year>1976</Year><RecNum>48</RecNum><DisplayText>(Guy, 1976)</DisplayText><record><rec-number>48</rec-number><foreign-keys><key app="EN" db-id="x05vd9szpszzdmefz2kv2vp2555v925dff00">48</key></foreign-keys><ref-type name="Book">6</ref-type><contributors><authors><author>Guy, W.</author></authors></contributors><titles><title>ECDEU assessment manual for psychopharmacology, revised</title></titles><pages>341-350</pages><dates><year>1976</year></dates><publisher>USA: Rockville, DEW</publisher><urls></urls></record></Cite></EndNote>(Guy, 1976), Epworth Sleepiness Scale (ESS, which measures: sleepiness) ADDIN EN.CITE <EndNote><Cite><Author>Johns</Author><Year>1992</Year><RecNum>19</RecNum><DisplayText>(Johns, 1992)</DisplayText><record><rec-number>19</rec-number><foreign-keys><key app="EN" db-id="x05vd9szpszzdmefz2kv2vp2555v925dff00">19</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Johns, M. W.</author></authors></contributors><auth-address>Sleep Disorders Unit, Epworth Hospital, Melbourne, Victoria, Australia.</auth-address><titles><title>Reliability and factor analysis of the Epworth Sleepiness Scale</title><secondary-title>Sleep</secondary-title></titles><periodical><full-title>Sleep</full-title></periodical><pages>376-81</pages><volume>15</volume><number>4</number><keywords><keyword>Adolescent</keyword><keyword>Adult</keyword><keyword>Chi-Square Distribution</keyword><keyword>Female</keyword><keyword>Humans</keyword><keyword>Male</keyword><keyword>Questionnaires</keyword><keyword>Reproducibility of Results</keyword><keyword>Sleep/*physiology</keyword></keywords><dates><year>1992</year><pub-dates><date>Aug</date></pub-dates></dates><accession-num>1519015</accession-num><urls><related-urls><url> </url></related-urls></urls></record></Cite></EndNote>(Johns, 1992), and Pittsburgh Sleep Quality Index (PSQI, which measures: sleep quality) ADDIN EN.CITE <EndNote><Cite><Author>Buysse</Author><Year>1989</Year><RecNum>18</RecNum><DisplayText>(Buysse et al., 1989)</DisplayText><record><rec-number>18</rec-number><foreign-keys><key app="EN" db-id="x05vd9szpszzdmefz2kv2vp2555v925dff00">18</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Buysse, D. J.</author><author>Reynolds, C. F., 3rd</author><author>Monk, T. H.</author><author>Berman, S. R.</author><author>Kupfer, D. J.</author></authors></contributors><auth-address>Department of Psychiatry, University of Pittsburgh School of Medicine, PA.</auth-address><titles><title>The Pittsburgh Sleep Quality Index: a new instrument for psychiatric practice and research</title><secondary-title>Psychiatry Res</secondary-title></titles><periodical><full-title>Psychiatry Res</full-title></periodical><pages>193-213</pages><volume>28</volume><number>2</number><keywords><keyword>Adult</keyword><keyword>Aged</keyword><keyword>Aged, 80 and over</keyword><keyword>Depression/*psychology</keyword><keyword>Female</keyword><keyword>Humans</keyword><keyword>Male</keyword><keyword>Middle Aged</keyword><keyword>*Psychological Tests</keyword><keyword>Psychometrics</keyword><keyword>Sleep Initiation and Maintenance Disorders/*diagnosis/psychology</keyword><keyword>*Sleep Stages</keyword></keywords><dates><year>1989</year><pub-dates><date>May</date></pub-dates></dates><accession-num>2748771</accession-num><urls><related-urls><url> </url></related-urls></urls></record></Cite></EndNote>(Buysse et al., 1989). On the 1st day, 50 mg of sertraline was administered at 8 am on the 1st day. It was thenThen, the dose was titrated according to the clinical efficacy and side effects;, with the a maximum dosage of was 200 mg/day. Similar to the 1st day, sertraline usually was usually administered at 8 am during thisthroughout the clinical trial, except for cases ofin which the patient was significantly sedatedion and or was receiving a dosages of 200 mg/day. Sertraline would bewas administered at 8 pm for patients with who were significantly sedatedion, and sertraline would be administeredand twice daily (8 am and 4 pm) for patients with receiving the dosage of 200 mg/day,. Concomitant use of central nervous system medications during the trial, especially benzodiazepines and sedatives, was prohibited. 2.2. Video-Polysomnographic StudyAt baseline, the sleep laboratory test consisted of two consecutive nocturnal vPSG assessments followed by a daytime Multiple Sleep Latency Test (MSLT). Because of the first night effect, the first night was regarded as an adaptation night ADDIN EN.CITE <EndNote><Cite><Author>Agnew</Author><Year>1966</Year><RecNum>61</RecNum><DisplayText>(Agnew et al., 1966)</DisplayText><record><rec-number>61</rec-number><foreign-keys><key app="EN" db-id="x05vd9szpszzdmefz2kv2vp2555v925dff00">61</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Agnew, H. W., Jr.</author><author>Webb, W. B.</author><author>Williams, R. L.</author></authors></contributors><titles><title>The first night effect: an EEG study of sleep</title><secondary-title>Psychophysiology</secondary-title><alt-title>Psychophysiology</alt-title></titles><periodical><full-title>Psychophysiology</full-title><abbr-1>Psychophysiology</abbr-1></periodical><alt-periodical><full-title>Psychophysiology</full-title><abbr-1>Psychophysiology</abbr-1></alt-periodical><pages>263-6</pages><volume>2</volume><number>3</number><edition>1966/01/01</edition><keywords><keyword>Adolescent</keyword><keyword>Adult</keyword><keyword>*Electroencephalography</keyword><keyword>Female</keyword><keyword>Humans</keyword><keyword>Male</keyword><keyword>*Sleep</keyword></keywords><dates><year>1966</year><pub-dates><date>Jan</date></pub-dates></dates><isbn>0048-5772 (Print)
0048-5772 (Linking)</isbn><accession-num>5903579</accession-num><urls><related-urls><url>;(Agnew et al., 1966). Measurements of tThe vPSG variables on the second night and the MSLT result on ofobtained on the third daytime were defined as baseline data. Because of daytimethe MSLT was conducted during the day, the third night was not suitable for vPSG assessment. Thus, the vPSG assessment for the 1st day of drug treatment was initiated on the fourth 4th night, and 50 mg of sertraline was administered at 8 am on the fourth 4th day. The acute effects of Sertraline sertraline on RSWA and sleep architecture was were evaluated in during the 1st day vPSG assessment, which was not conducted in most of previous researchesstudies. Further, these patients were assessed by vPSG in three following subsequent visits (days 14th day, 28th day, and 56th day). On each of the subsequent 3 visits during the 8-week trial, the patients were assessed by with one night of PSG followed by the MSLT. According to theThe nocturnal vPSG, included the following basic recordings included : a standard EEG (F4-A1, C4-A1, O2-A1, C3-A2), an electrooculographelectrooculography (EOG: LE-A2, RE-A1), a submental electromyographelectromyography (EMG), a bilateral leg’s EMG (anterior tibialis muscles), an ECG, nasal airflow pressure, thoracic and abdominal respiratory efforts, oxyhemoglobin saturation, breathing sound, and body position. All of the sleep variables were derived from the visual scoring of the recordings using standard criteria and were divided into two groups: sleep continuity indices and sleep architecture indices. Sleep continuity indices included the total recording time (TRT, “lights out” to “lights on” in minutes), total sleep time (TST), sleep efficiency (SE, the TST divided by the TRT), sleep latency ( SL, “lights out” to the first epoch of any sleep in minutes), REM latency (sleep onset to the first epoch in the REM stage in minutes), wake after sleep onset (WASO, stage W during the TRT, minus the SL, in minutes) and arousal index (AI: the number of arousals divided by the TST). The sleep architecture indices included the percentages of time spent in each stage (the time in stage 1, stage 2, stage 3, and the stage REM stage divided by the TST) ADDIN EN.CITE <EndNote><Cite><Author>Iber C</Author><Year>2007</Year><RecNum>42</RecNum><DisplayText>(Iber C, 2007)</DisplayText><record><rec-number>42</rec-number><foreign-keys><key app="EN" db-id="x05vd9szpszzdmefz2kv2vp2555v925dff00">42</key></foreign-keys><ref-type name="Book">6</ref-type><contributors><authors><author>Iber C, Ancoli-Israel S, Cheeson A, and Quan SF for the academy of Sleep Medicine</author></authors></contributors><titles><title>The AASM Manual for the Scoring of Sleep and Associated Events: Rules, Terminology and Technical Specifications</title></titles><edition>1st</edition><dates><year>2007</year></dates><pub-location>Westchester, Illinois</pub-location><publisher>American Academy of Sleep Medicine</publisher><urls></urls></record></Cite></EndNote>(Iber C, 2007). The 5-nap MSLT was performed according to the standard recommendations to determine the mean SL ADDIN EN.CITE <EndNote><Cite><Author>Carskadon</Author><Year>1986</Year><RecNum>62</RecNum><DisplayText>(Carskadon et al., 1986)</DisplayText><record><rec-number>62</rec-number><foreign-keys><key app="EN" db-id="x05vd9szpszzdmefz2kv2vp2555v925dff00">62</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Carskadon, M. A.</author><author>Dement, W. C.</author><author>Mitler, M. M.</author><author>Roth, T.</author><author>Westbrook, P. R.</author><author>Keenan, S.</author></authors></contributors><titles><title>Guidelines for the multiple sleep latency test (MSLT): a standard measure of sleepiness</title><secondary-title>Sleep</secondary-title><alt-title>Sleep</alt-title></titles><periodical><full-title>Sleep</full-title></periodical><alt-periodical><full-title>Sleep</full-title></alt-periodical><pages>519-24</pages><volume>9</volume><number>4</number><edition>1986/12/01</edition><keywords><keyword>Humans</keyword><keyword>Methods</keyword><keyword>Reaction Time</keyword><keyword>Sleep Disorders/*diagnosis</keyword></keywords><dates><year>1986</year><pub-dates><date>Dec</date></pub-dates></dates><isbn>0161-8105 (Print)
0161-8105 (Linking)</isbn><accession-num>3809866</accession-num><urls><related-urls><url>;(Carskadon et al., 1986). All computerized sleep data were further edited by an experienced blinded PSG technologist, and this technologist were who was blinded to this the researchstudy. Sleep stages, respiratory events, and periodic limb movements were scored according to the AASM-2007 criteria at 30-second intervals ADDIN EN.CITE <EndNote><Cite><Author>Iber C</Author><Year>2007</Year><RecNum>42</RecNum><DisplayText>(Iber C, 2007)</DisplayText><record><rec-number>42</rec-number><foreign-keys><key app="EN" db-id="x05vd9szpszzdmefz2kv2vp2555v925dff00">42</key></foreign-keys><ref-type name="Book">6</ref-type><contributors><authors><author>Iber C, Ancoli-Israel S, Cheeson A, and Quan SF for the academy of Sleep Medicine</author></authors></contributors><titles><title>The AASM Manual for the Scoring of Sleep and Associated Events: Rules, Terminology and Technical Specifications</title></titles><edition>1st</edition><dates><year>2007</year></dates><pub-location>Westchester, Illinois</pub-location><publisher>American Academy of Sleep Medicine</publisher><urls></urls></record></Cite></EndNote>(Iber C, 2007);, but however, the REM sleep was scored according to a modified method ADDIN EN.CITE <EndNote><Cite><Author>Lapierre</Author><Year>1992</Year><RecNum>146</RecNum><DisplayText>(Lapierre and Montplaisir, 1992)</DisplayText><record><rec-number>146</rec-number><foreign-keys><key app="EN" db-id="x05vd9szpszzdmefz2kv2vp2555v925dff00">146</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Lapierre, O.</author><author>Montplaisir, J.</author></authors></contributors><auth-address>Centre d'etude du sommeil, Hopital du Sacre-Coeur, Montreal, PQ, Canada.</auth-address><titles><title>Polysomnographic features of REM sleep behavior disorder: development of a scoring method</title><secondary-title>Neurology</secondary-title><alt-title>Neurology</alt-title></titles><periodical><full-title>Neurology</full-title><abbr-1>Neurology</abbr-1></periodical><alt-periodical><full-title>Neurology</full-title><abbr-1>Neurology</abbr-1></alt-periodical><pages>1371-4</pages><volume>42</volume><number>7</number><edition>1992/07/01</edition><keywords><keyword>Adult</keyword><keyword>Aged</keyword><keyword>Electroencephalography</keyword><keyword>Electromyography</keyword><keyword>Female</keyword><keyword>Humans</keyword><keyword>Male</keyword><keyword>Middle Aged</keyword><keyword>Reaction Time/physiology</keyword><keyword>Sleep Disorders/*physiopathology</keyword><keyword>Sleep, REM/*physiology</keyword></keywords><dates><year>1992</year><pub-dates><date>Jul</date></pub-dates></dates><isbn>0028-3878 (Print)
0028-3878 (Linking)</isbn><accession-num>1620348</accession-num><work-type>Research Support, Non-U.S. Gov't</work-type><urls><related-urls><url>;(Lapierre and Montplaisir, 1992). In this method, the first epoch with the occurrence of in which rapid eye movement and a low-amplitude, mixed-frequency EEG were observed was used to determine the onset of an REM sleep period. The termination of an REM sleep period was identified either by the occurrence of specific EEG features (K complexes, sleep spindles, or EEG signs of arousal), ) or by the absence of rapid eye movement and low-amplitude, mixed-frequency EEG during for 180 seconds ADDIN EN.CITE <EndNote><Cite><Author>Lapierre</Author><Year>1992</Year><RecNum>146</RecNum><DisplayText>(Lapierre and Montplaisir, 1992)</DisplayText><record><rec-number>146</rec-number><foreign-keys><key app="EN" db-id="x05vd9szpszzdmefz2kv2vp2555v925dff00">146</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Lapierre, O.</author><author>Montplaisir, J.</author></authors></contributors><auth-address>Centre d'etude du sommeil, Hopital du Sacre-Coeur, Montreal, PQ, Canada.</auth-address><titles><title>Polysomnographic features of REM sleep behavior disorder: development of a scoring method</title><secondary-title>Neurology</secondary-title><alt-title>Neurology</alt-title></titles><periodical><full-title>Neurology</full-title><abbr-1>Neurology</abbr-1></periodical><alt-periodical><full-title>Neurology</full-title><abbr-1>Neurology</abbr-1></alt-periodical><pages>1371-4</pages><volume>42</volume><number>7</number><edition>1992/07/01</edition><keywords><keyword>Adult</keyword><keyword>Aged</keyword><keyword>Electroencephalography</keyword><keyword>Electromyography</keyword><keyword>Female</keyword><keyword>Humans</keyword><keyword>Male</keyword><keyword>Middle Aged</keyword><keyword>Reaction Time/physiology</keyword><keyword>Sleep Disorders/*physiopathology</keyword><keyword>Sleep, REM/*physiology</keyword></keywords><dates><year>1992</year><pub-dates><date>Jul</date></pub-dates></dates><isbn>0028-3878 (Print)
0028-3878 (Linking)</isbn><accession-num>1620348</accession-num><work-type>Research Support, Non-U.S. Gov't</work-type><urls><related-urls><url>;(Lapierre and Montplaisir, 1992). At the first night of baseline vPSG assessment, sSubjects with significant PLMS (PLM index [PLMI] ≥ 15), or significant OSA (apnea-hypopnea index [AHI] ≥ 15) on the first night of the baseline vPSG assessment would bewere excluded from the study. The video recordings were also examined by the sleep technician for to identify any abnormal movement, behavior and/or vocalization during REM sleep. 2.3. Tonic and Phasic EMG Activities during REM SleepAccording to the AASM-2007 criteria, tonic muscle activity during REM sleep was defined as an epoch of REM sleep with in which the submental EMG amplitude was greater than the minimum amplitude demonstrated in NREM sleep for at least 50% of the duration of the epoch having had a submental EMG amplitude greater than the minimum amplitude demonstrated in NREM sleep. Phasic muscle activity during REM sleep was defined by following criteria. : iIn a 30-second epoch of REM sleep divided into 10 sequential, 3-second mini-epochs, at least 5 (50%) of the mini-epochs contained bursts of transient muscle activity. These excessive bursts of transient muscle activity bursts were 0.1-5.0 seconds in duration, and their amplitudes were at least 4 times as highhigher in amplitude as than that of the background EMG activity. Tonic muscle activity was only scored in the submental EMGs, while phasic muscle activity was scored in both submental and anterior tibialis EMGs ADDIN EN.CITE <EndNote><Cite><Author>Iber C</Author><Year>2007</Year><RecNum>42</RecNum><DisplayText>(Iber C, 2007)</DisplayText><record><rec-number>42</rec-number><foreign-keys><key app="EN" db-id="x05vd9szpszzdmefz2kv2vp2555v925dff00">42</key></foreign-keys><ref-type name="Book">6</ref-type><contributors><authors><author>Iber C, Ancoli-Israel S, Cheeson A, and Quan SF for the academy of Sleep Medicine</author></authors></contributors><titles><title>The AASM Manual for the Scoring of Sleep and Associated Events: Rules, Terminology and Technical Specifications</title></titles><edition>1st</edition><dates><year>2007</year></dates><pub-location>Westchester, Illinois</pub-location><publisher>American Academy of Sleep Medicine</publisher><urls></urls></record></Cite></EndNote>(Iber C, 2007). To exclude the the disruption of REM sleep of by physiologic events for REM sleep, REM epochs in which an EEG arousal, a snore artifact in the submental EMG, PLMS, or hypopnea was present were eliminated from further analyses ADDIN EN.CITE <EndNote><Cite><Author>Winkelman</Author><Year>2004</Year><RecNum>115</RecNum><DisplayText>(Winkelman and James, 2004)</DisplayText><record><rec-number>115</rec-number><foreign-keys><key app="EN" db-id="x05vd9szpszzdmefz2kv2vp2555v925dff00">115</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Winkelman, J. W.</author><author>James, L.</author></authors></contributors><auth-address>Division of Psychiatry, Brigham and Women's Hospital, Sleep Health Center, Harvard Medical School, Boston, Mass 02459, USA. jwinkelman@</auth-address><titles><title>Serotonergic antidepressants are associated with REM sleep without atonia</title><secondary-title>Sleep</secondary-title><alt-title>Sleep</alt-title></titles><periodical><full-title>Sleep</full-title></periodical><alt-periodical><full-title>Sleep</full-title></alt-periodical><pages>317-21</pages><volume>27</volume><number>2</number><edition>2004/05/06</edition><keywords><keyword>Adult</keyword><keyword>Depression/drug therapy</keyword><keyword>Electromyography</keyword><keyword>Female</keyword><keyword>Humans</keyword><keyword>Male</keyword><keyword>Middle Aged</keyword><keyword>Muscle Tonus/*drug effects</keyword><keyword>Polysomnography</keyword><keyword>Serotonin Uptake Inhibitors/*adverse effects/classification</keyword><keyword>Severity of Illness Index</keyword><keyword>Sleep Apnea, Obstructive/diagnosis</keyword><keyword>Sleep, REM/*drug effects/physiology</keyword></keywords><dates><year>2004</year><pub-dates><date>Mar 15</date></pub-dates></dates><isbn>0161-8105 (Print)
0161-8105 (Linking)</isbn><accession-num>15124729</accession-num><urls><related-urls><url>;(Winkelman and James, 2004). Finally, the numbers of 30-second epochs without atonia, 30-second epochs with phasic submental muscle activity, and 30-second epochs with phasic anterior tibialis muscle activity were computed separately for each REM period. The number of their epochs was then divided separately by the total number of epochs of REM sleep to obtain the exact percentages of phasic and tonic RSWA. In this study, Both of the aabnormal tonic and abnormal phasic RSWA were defined as being more greater than 18% in this study PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5GcmF1c2NoZXI8L0F1dGhvcj48WWVhcj4yMDEyPC9ZZWFy
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ADDIN EN.CITE.DATA (Frauscher et al., 2012).2.4. Data AanalysisThe data were are presented as the mean ± standard deviation for continuous variables and as numbers or percentages for categorical variables. Parametric and non-parametric data were compared using the independent t-test and Mann-Whitney U test respectivelyt, respectively (2 groups). A oneOne-way analysis of variance (ANOVA) and Kruskal Wallis Test tests were performed for to comparing compare parametric and non-parametric data (≥ 3 groups). Significant effects in from ANOVAs were further examined with post-hoc tests using the least significant difference method with a BoferrroniBonferroni correction for multiple comparisons. Mann-–Whitney U tests with adjusted p P-values (significant at P=0.005) were used for multiple pairwise comparisons. The cChi-square test was used to analyze the differences in categorical variables. The cCorrelations between the reducing reduced score rates ofchanges in the clinical and polysomnographic measures and the reducing reduced score rates ofchanges in tonic and phasic EMG activities during REM sleep were performed determined using the Pearson test. A two-sided 5% level of significance was considered statistically significantapplied. All statistical procedures were performed by using the Statistical Package for the Social Sciences 17.0 for Windows (SPSS, IncInc., Chicago, IL).3. RESULTS3.1. Recruitment Pprocess Fifty-five patients with major depressive disorder were initially enrolled in this study. Seventeen patients were excluded for the following reasons: 11 patients had other comorbid DSM-IV comorbid Axis I disorders, and 6 patients did not have moderate or severe insomnia (HRSD-sleep disturbance score < 3). Among these the 38 remaining patients, 11 patients without who were not taking any medicine treatmentmedication directly entered underwent the baseline vPSG assessment. During the first night of baseline vPSG assessment, 7 patients were excluded for the following reasons: 3 patients were diagnosed as with significant OSA, and 4 patients were diagnosed as with significant PLMS. Therefore, a total of 31 depressed patients with insomnia were enrolled in this study. Nine patients discontinued treatment during the trial period. Of these 9, 5 . Five patients discontinued treatment before the 14th day (2 due to worsening symptoms and combinations with other drugs; , 1 due to a gastrointestinal side effect; , 1 due to emerging psychotic symptoms requiring the addition of antipsychotic drugs; , and 1 due to refusal of to participate in further sleep tests). One patient discontinued during between the 14th - and 28th day due to a revised diagnosis of bipolar disorder. , and Three 3 patients discontinued during between the 28th - and 56th day (1 due to a revised diagnosis of OCD and 2 due to refusal of to participate in further sleep tests). Finally, 22 patients completed this trial. Theis recruitment process was is shown illustrated in Figure 1.-------------------------------------Insert Figure 1--------------------------------------3.2. Demographic and Cclinical CcharacteristicsThe thirty-one patients were predominantly young (32.7±9.2 years old) and female (female: 61.3%) subjects. Their demographic and clinical characteristics are presented in Table 1. -------------------------------------Insert Table 1--------------------------------------3.3. Clinical AssessmentTable 2 shows selected clinical and polysomnographic measures. The mean daily sertraline doses for sertraline were 126.9±25.4 (100-150) mg on the 14th day, 144.0±30.0 (100-200) mg on the 28th day, and 134.1±28.4 (100-200) mg on the 56th day. Only a few patients took received a sertraline dose of 2000m mg/day of sertraline (2 patients in on the 28th day and 1 patient in on the 56th day), ); so sertraline were was administratedadministered twice daily for to them these patients (1000m mg at 8 am and 1000m mg at 4 pm). Further, no patient was administered sertraline was not administered to any of the patients at night for significant sedation. In addition, there were onlyOnly limited side effects (TESS) were observed during the 8-week trial. The HRSD scores started began to improve starting fromon the 14th day of treatment. The HRSD-sleep disturbance scores were became significantly lowered decreased after the 28th day. The scores of PSQI and ESS scores decreased gradually during this trial, ; and both questionnaires on the 14th, 28th, and 56th days, the scores of both questionnaires were significantly lower than those at baseline. No patient reported any violent, enacted dreams at home during the study that, which could evoke indicate clinical RBD. 3.4. Polysomnographic AssessmentThere were no significant differences in the TRTs during the trial. From the 14th day onward, the TSTs and SEs became longer and higher, respectively, than compared with those at the baseline or on the 1st day respectivelyy, respectively. From the 14th day onward, the SL and WASO scores decreased significantly, and the SL scores reached a normal range (< 30 minutes) after the 14th day. The AI reached the highest level on the 1st day and showed awas decreased at the subsequent visits. There was were no statistical differencesignificant differences between baseline and the latter last 3 visits. The percentage of stage 1 sleep decreased during the trial; and it was significantly lower on the 28th and 56th days than on the 1st day and at baseline. The percentage of stage 2 sleep remained stable during throughout the trial. The percentage of stage 3 sleep increased gradually and was greater and was more than 10% at during the last 3 3 latter visits compared with baseline and the 1st day. Compared with baseline, the the REM latency latencies was were significantly prolonged significantly on the 1st day and decreased gradually during the treatment. However, the REM latency latencies was were longer at during each of the visits than at baseline. No statistical differencesignificant differences was were shown observed in the percentages of REM sleep during throughout the trial. Compared with their levels at baseline, the PLMI scores increased as soon as theimmediately after sertraline administration of sertraline on the 1st day. From the 14th day onward, the PLMI scores continued to increase, and it were became significantly higher in during all three latterthe last 3 visits than atcompared with baseline andor the 1st day. The AHI kept scores remained stable during throughout the this clinical trial. During the daytime assessment (MSLT), the mean SL remained stable during the trial (Ttable 2).-------------------------------------Insert Table 2--------------------------------------3.5. Tonic and Phasic RSWA during REM Sleep Tonic and phasic RSWA increased mildly and non-significantly from the baseline to the first night after sertraline intaketreatment. Then, from the 14th day onward, all ofboth tonic (submental) and phasic (submental and anterior tibialis) RSWA increased and became significantly higher in all threethe last 3 latter visits than compared with baseline and the 1st day. There were no further differences between the last three last measurementss,, which were taken on the at 14th, 28th and 56th days.. At the endpoint of this clinical trial (the 56th day), tonic RSWA reached 12.0%±4.3%, phasic submental RSWA reached 11.4%±4.2%, and phasic anterior tibialis RSWA reached 15.1%±6.6%. According to cutoffs the cutoff of for abnormal tonic and phasic RSWA of > 18%, the proportion of patients with abnormal phasic anterior tibialis RSWA became was significantly higher in all three latterthe last 3 visits than at baseline and on the 1st day, while the proportions of patients with abnormal tonic and phasic submental RSWA kept remained stable during the current trailthroughout the trial (table Table 3 & figure Figure 2 a-c). Notably, no abnormal movement, behavior and or vocalization were was observed during REM sleep on the video recordings in REM sleep. -------------------------------------Insert Table 3---------------------------------------------------------------------------Insert Figure 2 a-c--------------------------------------Because the recurrent major depression (defined as up to 7 episodes in the this study) should share some biological and clinical aspects features with bipolar sepctrumspectrum disorders, we compared tonic and phasic RSWA between single type depression and recurrent type depression, . and noNo significant difference was shown between the two groups during the currentthe trial (table Table 4). -------------------------------------Insert Table 4--------------------------------------We calculated the reducing score rates of thechanges in clinical and polysomnographic measures and tonic and phasic RSWA from endpoint to baseline ([the value at the endpoint - the value at baseline] / the value at baseline × 100%). The reducing change in score rate of tonic RSWA scores (216.4% ± 53.9%) was positively correlated positively with the reducing changes score rates ofin REM Latency latency (37.0% ± 22.7%) (r =0.56, p=0.004) and PLMI (129.4% ± 49.8%) (r =0.39, p=0.047) scores, and was negatively correlated negatively with the reducing change in score rates of HRSD scores (-68.6% ± -21.3%) (r =-0.43, p=0.03). The reducing score rates ofchanges in phasic submental (202.9% ± 87.1%) (r =-0.51, p=0.02) and anterior tibialis (151.3% ± 61.5%) (r =0.41, p=0.04) RSWA scores were positively correlated with the reducing changes in score rates ofthe REM lLatency scores. The amount of RSWA did not correlate with the dosage of sertraline. On the other hand, no significant correlations were shown observed between the reducing score rates ofinchanges in RSWA scores and continuous demographic and clinical characteristics, (such as: age) age at the baseline, ,and and the reducing changes in score rates of RSWA scores were not significantly different among categorical demographic and clinical characteristics, (such as: gender,) at the baseline. 4. DISCUSSION In the current study, Sertraline sertraline exacerbated RSWA during the current study, but did not induced RBD. From the 14th day onward, the tonic and phasic RSWA and the proportion of patients with abnormal (>18%) phasic anterior tibialis RSWA (>18%) becamewere significantly higher increased than that ofcompared with their levels at baseline and on the 1st day;, and thensubsequently, these levels then keptremained stable. The results ofTo some extent, the phasic RSWA results were not inconsistent with those described byin Winkelman and James’s study to some extent. In Winkelman’s that study, compared with normal control, only tonic RSWA was significantly increasedaltered in subjects taking serotonergic antidepressants compared with normal controls only had significantly tonic RSWA,; and the both submental and anterior tibialis phasic (submental and anterior tibialis) RSWA in levels both submental and anterior tibialis did not reach thechange significantly level ADDIN EN.CITE <EndNote><Cite><Author>Winkelman</Author><Year>2004</Year><RecNum>115</RecNum><DisplayText>(Winkelman and James, 2004)</DisplayText><record><rec-number>115</rec-number><foreign-keys><key app="EN" db-id="x05vd9szpszzdmefz2kv2vp2555v925dff00">115</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Winkelman, J. W.</author><author>James, L.</author></authors></contributors><auth-address>Division of Psychiatry, Brigham and Women's Hospital, Sleep Health Center, Harvard Medical School, Boston, Mass 02459, USA. jwinkelman@</auth-address><titles><title>Serotonergic antidepressants are associated with REM sleep without atonia</title><secondary-title>Sleep</secondary-title><alt-title>Sleep</alt-title></titles><periodical><full-title>Sleep</full-title></periodical><alt-periodical><full-title>Sleep</full-title></alt-periodical><pages>317-21</pages><volume>27</volume><number>2</number><edition>2004/05/06</edition><keywords><keyword>Adult</keyword><keyword>Depression/drug therapy</keyword><keyword>Electromyography</keyword><keyword>Female</keyword><keyword>Humans</keyword><keyword>Male</keyword><keyword>Middle Aged</keyword><keyword>Muscle Tonus/*drug effects</keyword><keyword>Polysomnography</keyword><keyword>Serotonin Uptake Inhibitors/*adverse effects/classification</keyword><keyword>Severity of Illness Index</keyword><keyword>Sleep Apnea, Obstructive/diagnosis</keyword><keyword>Sleep, REM/*drug effects/physiology</keyword></keywords><dates><year>2004</year><pub-dates><date>Mar 15</date></pub-dates></dates><isbn>0161-8105 (Print)
0161-8105 (Linking)</isbn><accession-num>15124729</accession-num><urls><related-urls><url>;(Winkelman and James, 2004). It This differencet might be due to the small sample size (n=15) and a mixture of antidepressants used in the study performed by Winkelman and James’s study. Indeed, tTwo subjects were even taking bupropion (2000m mg/day), which might have diminished RSWA ADDIN EN.CITE <EndNote><Cite><Author>Winkelman</Author><Year>2004</Year><RecNum>115</RecNum><DisplayText>(Winkelman and James, 2004)</DisplayText><record><rec-number>115</rec-number><foreign-keys><key app="EN" db-id="x05vd9szpszzdmefz2kv2vp2555v925dff00">115</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Winkelman, J. W.</author><author>James, L.</author></authors></contributors><auth-address>Division of Psychiatry, Brigham and Women's Hospital, Sleep Health Center, Harvard Medical School, Boston, Mass 02459, USA. jwinkelman@</auth-address><titles><title>Serotonergic antidepressants are associated with REM sleep without atonia</title><secondary-title>Sleep</secondary-title><alt-title>Sleep</alt-title></titles><periodical><full-title>Sleep</full-title></periodical><alt-periodical><full-title>Sleep</full-title></alt-periodical><pages>317-21</pages><volume>27</volume><number>2</number><edition>2004/05/06</edition><keywords><keyword>Adult</keyword><keyword>Depression/drug therapy</keyword><keyword>Electromyography</keyword><keyword>Female</keyword><keyword>Humans</keyword><keyword>Male</keyword><keyword>Middle Aged</keyword><keyword>Muscle Tonus/*drug effects</keyword><keyword>Polysomnography</keyword><keyword>Serotonin Uptake Inhibitors/*adverse effects/classification</keyword><keyword>Severity of Illness Index</keyword><keyword>Sleep Apnea, Obstructive/diagnosis</keyword><keyword>Sleep, REM/*drug effects/physiology</keyword></keywords><dates><year>2004</year><pub-dates><date>Mar 15</date></pub-dates></dates><isbn>0161-8105 (Print)
0161-8105 (Linking)</isbn><accession-num>15124729</accession-num><urls><related-urls><url>;(Winkelman and James, 2004). Further, using if the a cutoff of abnormal tonic RSWA greater than 20% was used ADDIN EN.CITE <EndNote><Cite><Author>Gagnon</Author><Year>2006</Year><RecNum>114</RecNum><DisplayText>(Gagnon et al., 2006)</DisplayText><record><rec-number>114</rec-number><foreign-keys><key app="EN" db-id="x05vd9szpszzdmefz2kv2vp2555v925dff00">114</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Gagnon, J. F.</author><author>Postuma, R. B.</author><author>Montplaisir, J.</author></authors></contributors><auth-address>Centre d'Etude du Sommeil et des Rythmes Biologiques, Hopital du Sacre-Coeur de Montreal, Institut Universitaire de Geriatrie de Montreal, Montreal, Quebec, Canada.</auth-address><titles><title>Update on the pharmacology of REM sleep behavior disorder</title><secondary-title>Neurology</secondary-title><alt-title>Neurology</alt-title></titles><periodical><full-title>Neurology</full-title><abbr-1>Neurology</abbr-1></periodical><alt-periodical><full-title>Neurology</full-title><abbr-1>Neurology</abbr-1></alt-periodical><pages>742-7</pages><volume>67</volume><number>5</number><edition>2006/09/13</edition><keywords><keyword>Anticonvulsants/adverse effects/*therapeutic use</keyword><keyword>Clonazepam/*therapeutic use</keyword><keyword>Humans</keyword><keyword>Monoamine Oxidase Inhibitors/administration & dosage/adverse effects</keyword><keyword>REM Sleep Behavior Disorder/diagnosis/*drug therapy/epidemiology/physiopathology</keyword></keywords><dates><year>2006</year><pub-dates><date>Sep 12</date></pub-dates></dates><isbn>1526-632X (Electronic)
0028-3878 (Linking)</isbn><accession-num>16966533</accession-num><work-type>Research Support, Non-U.S. Gov't</work-type><urls><related-urls><url>;(Gagnon et al., 2006), the proportions of patients with abnormal tonic RSWA in the current study were was similar among the current study andto that ofin two previous studies (the current study: 4.5% [1/21], Winkelman and James: 13.3% [2/15], Zhang et al.: 14.3% [3/21]; χ2=1.44, p=0.09) PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5XaW5rZWxtYW48L0F1dGhvcj48WWVhcj4yMDA0PC9ZZWFy
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ADDIN EN.CITE.DATA (Winkelman and James, 2004, Zhang et al., 2010). In summary, these results support the notioned that SSRIs could can induce or exacerbate RSWA, especially for phasic anterior tibialis RSWA. It was reported that mostMost abnormal sleep behaviors seen observed in RBD have been reported to correspond to movements of the limbs ADDIN EN.CITE <EndNote><Cite><Author>Schenck</Author><Year>2005</Year><RecNum>168</RecNum><DisplayText>(Schenck, 2005)</DisplayText><record><rec-number>168</rec-number><foreign-keys><key app="EN" db-id="x05vd9szpszzdmefz2kv2vp2555v925dff00">168</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Schenck, C. H.</author></authors></contributors><titles><title>Clinical and research implications of a validated polysomnographic scoring method for REM sleep behavior disorder</title><secondary-title>Sleep</secondary-title><alt-title>Sleep</alt-title></titles><periodical><full-title>Sleep</full-title></periodical><alt-periodical><full-title>Sleep</full-title></alt-periodical><pages>917-9</pages><volume>28</volume><number>8</number><edition>2005/10/13</edition><keywords><keyword>Electromyography</keyword><keyword>Humans</keyword><keyword>Muscle Tonus/drug effects</keyword><keyword>Muscle, Skeletal/physiopathology</keyword><keyword>Polysomnography/*methods</keyword><keyword>REM Sleep Behavior Disorder/chemically induced/*diagnosis/physiopathology</keyword><keyword>Serotonin Uptake Inhibitors/adverse effects</keyword><keyword>Sleep, REM/drug effects</keyword></keywords><dates><year>2005</year><pub-dates><date>Aug 1</date></pub-dates></dates><isbn>0161-8105 (Print)
0161-8105 (Linking)</isbn><accession-num>16218073</accession-num><work-type>Comment
Senior Editorial</work-type><urls><related-urls><url>;(Schenck, 2005). However, no patients reported some abnormal behaviors being related with to RBD in the current study. It This result might be have occurred due to these the following reasons. F: firstly, some subtle behaviors might be have been ignored by patients and their bed -partners, and even couldmay not be have been detected by in the concomitant videos. ; Secondlysecond, because the clinical meaning significance for of RSWA was is still elusiveunclear, and RSWA which might only simply be an unusual PSG finding and may could not develop into overt clinical RBD. ; Thirdlythird, it is possible that RSWA could can develop into RBD, but, by chances, it this did was not happened occur in the current study with due to the small sample size. Further, RSWA could might also be a necessary (permissive) but not a sufficient (active) condition to promote RBD. One may might also imagine that higher amounts levels of RSWA are necessary for the RBD-associated dreaming behavior to be enactoccured. In this directionMoreover, an average of a mean of 39% the amount of tonic RSWA was observed in of patients with idiopathic and PD-associated RBD experienced tonic RSWA in a previous study PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5JcmFuem88L0F1dGhvcj48WWVhcj4yMDA1PC9ZZWFyPjxS
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ADDIN EN.CITE.DATA ( HYPERLINK \l "_ENREF_15" \o "Iranzo, 2005 #160" Iranzo et al., 2005) is a mean 39%, which is large greater than the 12% found in our study. PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5JcmFuem88L0F1dGhvcj48WWVhcj4yMDA1PC9ZZWFyPjxS
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ADDIN EN.CITE.DATA ( HYPERLINK \l "_ENREF_15" \o "Iranzo, 2005 #160" Iranzo et al., 2005). Also,Additionally, RSWA amounts are were higherwas more common in patients with multiple systemic atrophy than in those with PD or idiopathic RBD;, but however, the severity of the corresponding behaviors is was milder PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5JcmFuem88L0F1dGhvcj48WWVhcj4yMDA1PC9ZZWFyPjxS
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ADDIN EN.CITE.DATA (Iranzo et al., 2005). This suggests that both conditions, RBD and RSWA, are strongly, but not linearly, linked. The REM sleep suppression (e.g., increased REM latency and, decreased REM sleep duration, and so on) is characteristic for of antidepressants, and is strongly linked to increased serotoninergic tone PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5SdXNoPC9BdXRob3I+PFllYXI+MTk4OTwvWWVhcj48UmVj
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ADDIN EN.CITE.DATA (Rush et al., 1989, McNamara et al., 2010). In this study, the reducing reduction in score rate of REM latency scores was positively correlated with the reducing reduction inscore rates of all ofboth tonic and phasic RSWA. It This result was is consistent with the study of Winkelman and James’s suggestionstudy, in which the extent of prolonging prolonged REM latency was suggested to serve as a marker of the degree of RSWA ADDIN EN.CITE <EndNote><Cite><Author>Winkelman</Author><Year>2004</Year><RecNum>115</RecNum><DisplayText>(Winkelman and James, 2004)</DisplayText><record><rec-number>115</rec-number><foreign-keys><key app="EN" db-id="x05vd9szpszzdmefz2kv2vp2555v925dff00">115</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Winkelman, J. W.</author><author>James, L.</author></authors></contributors><auth-address>Division of Psychiatry, Brigham and Women's Hospital, Sleep Health Center, Harvard Medical School, Boston, Mass 02459, USA. jwinkelman@</auth-address><titles><title>Serotonergic antidepressants are associated with REM sleep without atonia</title><secondary-title>Sleep</secondary-title><alt-title>Sleep</alt-title></titles><periodical><full-title>Sleep</full-title></periodical><alt-periodical><full-title>Sleep</full-title></alt-periodical><pages>317-21</pages><volume>27</volume><number>2</number><edition>2004/05/06</edition><keywords><keyword>Adult</keyword><keyword>Depression/drug therapy</keyword><keyword>Electromyography</keyword><keyword>Female</keyword><keyword>Humans</keyword><keyword>Male</keyword><keyword>Middle Aged</keyword><keyword>Muscle Tonus/*drug effects</keyword><keyword>Polysomnography</keyword><keyword>Serotonin Uptake Inhibitors/*adverse effects/classification</keyword><keyword>Severity of Illness Index</keyword><keyword>Sleep Apnea, Obstructive/diagnosis</keyword><keyword>Sleep, REM/*drug effects/physiology</keyword></keywords><dates><year>2004</year><pub-dates><date>Mar 15</date></pub-dates></dates><isbn>0161-8105 (Print)
0161-8105 (Linking)</isbn><accession-num>15124729</accession-num><urls><related-urls><url>;(Winkelman and James, 2004). Since Because the correlation between REM latency and RSWA was has never been reported in previous studies for patients with idiopathic RBD or neurodegenerative disease-related RBD in previous studies, so the mechanisms of producingunderlying RSWA should beare likely different between idiopathic RBD and antidepressant-related RBD. It This notion might be supported by some certain risk factors (male sex gender and elder older age) for idiopathic RBD not that were being not shown found in this study and or some previous studies PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5OYXNoPC9BdXRob3I+PFllYXI+MjAwMzwvWWVhcj48UmVj
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ADDIN EN.CITE.DATA (Nash et al., 2003, Hoque and Chesson, 2010, Zhang et al., 2010, Winkelman and James, 2004, Gagnon et al., 2006). Unlike the effects observed with to most antidepressants, the percentage of REM sleep kept was stable during throughout the this trial. This phenomenon was also reported by another research study about testingthat tested the effects of sertraline on sleep architecture (Jindal et al., 2003), so it might suggestsuggesting that sertraline had has less of a suppressive effecton on the duration of REM sleep duration than most antidepressants. In addition, the percentages of REM sleep after sertraline administration were somewhat lower than those at baseline, ; however, although all of them did not reach thenone of these differences were statistical differencesignificant difference., It mightpossibly be due to the small sample size in this research studyto some extent. In some previous case reports, the antidepressant-related RBD could disappeared as soon as theimmediately following the discontinuation of antidepressant uses discontinuation ADDIN EN.CITE <EndNote><Cite><Author>Onofrj</Author><Year>2003</Year><RecNum>129</RecNum><DisplayText>(Onofrj et al., 2003)</DisplayText><record><rec-number>129</rec-number><foreign-keys><key app="EN" db-id="x05vd9szpszzdmefz2kv2vp2555v925dff00">129</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Onofrj, M.</author><author>Luciano, A. L.</author><author>Thomas, A.</author><author>Iacono, D.</author><author>D'Andreamatteo, G.</author></authors></contributors><auth-address>Department of Oncology and Neuroscience, University G. D'Annunzio, Pescara, Italy. onofrj@unich.it</auth-address><titles><title>Mirtazapine induces REM sleep behavior disorder (RBD) in parkinsonism</title><secondary-title>Neurology</secondary-title><alt-title>Neurology</alt-title></titles><periodical><full-title>Neurology</full-title><abbr-1>Neurology</abbr-1></periodical><alt-periodical><full-title>Neurology</full-title><abbr-1>Neurology</abbr-1></alt-periodical><pages>113-5</pages><volume>60</volume><number>1</number><edition>2003/01/15</edition><keywords><keyword>Aged</keyword><keyword>Antidepressive Agents, Tricyclic/*adverse effects</keyword><keyword>Depression/complications/drug therapy</keyword><keyword>Electroencephalography</keyword><keyword>Humans</keyword><keyword>Levodopa/therapeutic use</keyword><keyword>Male</keyword><keyword>Mianserin/*adverse effects/*analogs & derivatives</keyword><keyword>Neuropsychological Tests</keyword><keyword>Parkinsonian Disorders/complications/*drug therapy</keyword><keyword>Polysomnography</keyword><keyword>REM Sleep Behavior Disorder/*chemically induced/complications</keyword></keywords><dates><year>2003</year><pub-dates><date>Jan 14</date></pub-dates></dates><isbn>1526-632X (Electronic)
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ADDIN EN.CITE.DATA (Mendelson, 1996, Kugaya et al., 2003). Thus, RSWA, PLMS, REM latency, and HRSD scores might be involved in the mechanisms about 5approximatelyof 5-HT and/or DA neurotransmission to some extent; this likely explains, why all of these scores wereso it was understandable that all of them correlated with each other. For clinicians, the central question is remains whether the sertraline-induced RSWA being induced by sertraline can beis associated with clinical repercussions. According to subjective sleep and mood aspects parameters and the objective sleep quality and continuity observed viain PSG, sertraline-induced RSWA being induced by sertraline doesdid not have cause significant clinical disturbance in the current clinical trial. Or inIn other words, the potential adverse effects of sertraline-induced of induction of RSWA by sertraline might be outweighed by the significant improvements of in mood and sleep parameters caused by sertraline. It was noted that depressionNotably, depression is a common mental disorder with the a prevalence of 10-20% ADDIN EN.CITE <EndNote><Cite><Author>Murray</Author><Year>1996</Year><RecNum>155</RecNum><DisplayText>(Murray, 1996)</DisplayText><record><rec-number>155</rec-number><foreign-keys><key app="EN" db-id="x05vd9szpszzdmefz2kv2vp2555v925dff00">155</key></foreign-keys><ref-type name="Book">6</ref-type><contributors><authors><author>Murray, D.J., Lopez, A.D.</author></authors></contributors><titles><title>The global burden of disease: a comprehensive assessment of morality and disability from diseases, injuries, and risk factors in 1990 and projected to 2020. </title></titles><dates><year>1996</year></dates><pub-location>Cambridge, MA</pub-location><publisher>Harvard School of Public Health in behalf of the World Health Organization and the Word Bank</publisher><urls></urls></record></Cite></EndNote>(Murray, 1996), and most of depressive patients were are currently treated by with antidepressants, especially SSRIs in the current timeSSRIs. Thus, SSRIs-related RSWA should be considered a serious public health problem in depressed patients, since because it might be represent a potential risk factor for RBD. However, the SSRIs-related RBD is usually ignored by most physicians. For If patients with the usage of use antidepressants, and if they reported abnormal movements, behaviors and vocalizations behaviours during sleep, vPSG should be a routinely be used to assess ment for aandn accuratelye estimateing their RSWA. Some caution should be exercised in interpreting the effects results reported here. First, no a placebo -control group was not involved used in this researchstudy. Second, the sample size in this study was small.5. CONCLUSIONSIn the current study, Sertraline sertraline exacerbated RSWA during the current study, but did not induced RBD. Unlike idiopathic RBD, the sertraline-related RSWA had was correlated with REM latency and no was not predominance predominantly associated with the of male sex gender and or elder older age, suggesting the involvement ofthat different mechanisms are involved in idiopathic RBD and sertraline-related RSWA. Further, although the sertraline-induced RSWA seems did not causenot to have significant clinical disturbance, and no overt RBD was not found observed in the current study, . regarding Despite these observationsfindings, RBD being the greaterincreased prevalence of RBD t in patients with the usageusing of antidepressants compared with than than that in the general population, indicates that the antidepressant-related RSWA should is be a potential public health problem issue forin the depressed patients.AcknowledgmentsThe work was supported by the an Investigator-Initiated Research (IIR) Program grant from Pfizer Pharma, (Study Code: WS458774) to Dr. Bin Zhang and a grant from the National Natural Science Foundation of China (Grant No: 30800303), both awarded to Dr. Bin Zhang. REFERENCES ADDIN EN.REFLIST AASM 2005. International Classification of Sleep Disorders: Diagnostic and Coding Manual, Westchester, Illinois, American Academy of Sleep Medicine.AGNEW, H. W., JR., WEBB, W. 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W., KIM, S. W., O'CONNOR, K. A. & HURWITZ, T. D. 1992. Prominent eye movements during NREM sleep and REM sleep behavior disorder associated with fluoxetine treatment of depression and obsessive-compulsive disorder. Sleep, 15, 226-35.SIEGEL, J. M. 2006. The stuff dreams are made of: anatomical substrates of REM sleep. Nat Neurosci, 9, 721-2.WINKELMAN, J. W. & JAMES, L. 2004. Serotonergic antidepressants are associated with REM sleep without atonia. Sleep, 27, 317-21.ZHANG, B., LI, X. L. & ZHOU, P. 2010. The effect of selective serotonin reuptake inhibitor on Electromyography of rapid eye movement sleep in depressive patient. Chinese Journal of Psychiatry, 43, 201-205.Table 1. Demographic and clinical characteristics of the depressed patients (n=31)Mean ± standard derivation deviation (range) or nNumberDemographic characteristicsAge (in years)32.7±9.2 (18-57)Gender (males/females)12/19Marriage (married/single/divorced or widowed)17/9/5Occupation (full-time/part-time/no job or retired)16/7/8Education (university or above/middle school/primary school or below)11/16/4Residencet (city/town/country)13/10/8clinicalClinical characteristicsAge at onset (in years)23.9±8.0 (15-33)BMI (kg/m2)23.2±6.2 (19.4-25.3)Total duration of illness (years)9.7±10.4 (0-27)Single type/recurrent type8/23Number of illness episodes of illness2.7±1.9 (1-7)Length of the current illness (in weeks)6.6±5.0 (2-12)BMI: body mass indexTable 2. Changes in cClinical and polysomnographic measures across theduring sertraline treatment in of depressed patients Baseline(n=31)1st day(n=31)14th day(n=26)28th day(n=25)56th day(n=22)StatisticsDosage (mg/day)50.0 a126.9±25.4 b144.0±30.0 b134.1±28.4bF=103.90, P<0.001HRSD22.4±5.3 a23.1±5.3 a14.5±4.1 b9.7±2.6 b, c6.9±1.9 cF=13.02, P<0.001HRSD-sleep disturbance factor4.1±3.3 a4.0±3.6 a3.5±3.1 a, b2.7±1.4 b2.5±1.5 bKW=11.85, P=0.01TESS-S0.8±1.50.7±0.70.5±0.60.5±0.6KW =0.94, P=0.24TESS-T0.6±1.60.6±1.00.4±0.50.4±0.4KW =0.57, P=0.60PSQI13.5±6.2 a7.9±4.7 b6.3±3.4 b6.0±3.5 bF=11.14, P<0.001ESS7.2±4.5 a5.3±3.9 b3.8±4.1 b4.0±3.5 bKW=15.57, P=0.003TRT (min)504.7±71.9492.2±86.0507.4±77.2511.1±59.4499.5±63.4F=0.79, P=0.87TST (min)364.9±103.5 a347.5±114.3 a423.2±98.6 b440.1±103.7 b427.1±88.5 bF=14.09, P=0.01SE (%)72.2±22.8 a70.6±29.1 a83.4±27.5 a, b86.1±31.3 b85.5±27.8 bF=5.71, P=0.03SL (min)51.9±29.5 a46.6±23.5 a25.3±14.1 b21.7±11.8 b22.4±12.3 bF=13.25, P<0.001REM lLatency (min)77.3±38.1 a134.3±82.9 b121.3±67.0 b109.4±73.1 b105.2±60.3 bF=27.05, P<0.001WASO (min)87.9±31.9 a98.1±35.6 a58.9±19.8 b49.3±21.3 b50.0±17.7 bF=35.93, P<0.001AI8.9±6.6 a13.8±7.2 b7.3±6.8 a6.4±4.8 a6.0±5.2 aF =6.66, P=0.04% Stage 112.8±5.9 a15.2±6.6 a9.0±4.4 a, b7.0±1.7 b8.0±2.9 bF=5.03, P=0.03% Stage 259.2±21.357.4±18.757.9±20.556.8±19.353.2±22.4F=1.73, P=0.34% stageStage 33.2±1.5 a2.8±2.2 a12.9±5.8 b14.1±8.4 b16.0±7.9 bF=12.06, P<0.001% REM sleep24.8±7.124.6±6.920.2±8.522.1±10.422.8±9.6F=0.86, P=0.72PLMI3.6±1.5 a5.1±3.9 b8.7±3.1 c8.3±3.7 c8.5±3.6 cF=9.81, P=0.003AHI6.2±1.76.3±1.75.9±2.06.0±1.95.9±1.9F=0.24, P=0.27Mean SL of MSLT (min)16.4±11.314.7±8.915.2±9.517.1±10.414.6±9.0F=0.30, P=0.34HRSD: Hamilton rating scale for depression, TESS-S: treatment emergent symptom scale-severity, TESS-T: treatment emergent symptom scale-treatment, PSQI: Pittsburgh sleep quality index, ESS: Epworth sleepiness scale, TRT: total recording time, TST: total sleep time, SE: Sleep sleep Efficiencyefficiency, SL: Sleep sleep lLatency, WASO: wake after sleep onset, AI: arousal index, REM: rapid eye movement, PLMI: periodic limb movement index, AHI: apnea-hypopnea index, MSLT: multiple sleep latency test.a, b, c Groups with different superscript letters are significantly different.F: ANOVA, KW: Kruskal- Wallis tTest.Table 3. Percentages of epochs with tonic and phasic RSWA across theduring sertraline treatment in of depressed patients Thirty30-second EpochBaseline(n=31)1st day(n=31)14th day(n=26)28th day(n=25)56th day(n=22)Statistics% Tonic RSWA3.2 ± 1.8 a5.1±2.3 a10.4±2.7 b10.2±2.5 b12.0±4.3 bF=52.62, P<0.001Patients with abnormal tonic RSWA (> 18%), n (%)00002 (9.1%)χ2=7.42, P=0.12% Phasic submental RSWA3.4 ± 1.9 a4.8±2.2 a9.4± 3.8 b10.3±3.9 b11.4±4.2 bF=32.38, P<0.001Patients with abnormal phasic submental RSWA (> 18%), n (%)0001 (4.0%)0χ2=3.44, P=0.49% Phasic anterior tibialis RSWA6.2± 2.1 a8.2± 2.8 a14.6± 6.8 b15.5± 6.6 b15.1± 6.6 bF=20.73, P<0.001Patients with abnormal phasic anterior tibialis RSWA (> 18%), n (%)0 a0 a8 (30.8%) b9 (36%) b7 (31.8%) bχ2=33.44, P<0.001RSWA: REM sleep with atonia.% tonicTonic and phasic RSWA: the numbers of 30-second epochs with tonic and phasic RSWA being were divided separately by the total number of epochs of REM sleep.F: ANOVA, χ2: cChi-square test.Table 4. Percentages of epochs with tonic and phasic RSWA betweenin patients with single type and recurrent type depression across theundergoing sertraline treatment in of depressed patientsSingle typeRecurrent typeStatisticsBaseline n=8n=23% Tonic RSWA2.9 ± 1.93.3 ± 2.1MWU=1.82, P=0.39% Phasic submental RSWA3.6 ± 2.13.3 ± 1.9MWU=1.14, P=0.51% Phasic anterior tibialis RSWA6.0± 2.56.3±2.2T=1.37, P=0.471st dayn=8n=23% Tonic RSWA5.2±2.65.1±2.4T=0.54, P=0.72% Phasic submental RSWA5.0±2.74.7±2.3T=0.77, P=0.63% Phasic anterior tibialis RSWA8.5± 3.38.0± 2.9T=1.32, P=0.4614th dayn=8n=18% Tonic RSWA9.8±3.210.7±3.0T=1.37, P=0.38% Phasic submental RSWA9.6± 4.09.3± 3.7T=0.90, P=0.53% Phasic anterior tibialis RSWA12.9± 5.714.8± 7.0T=1.76, P=0.2728th dayn=7n=18% Tonic RSWA12.1±3.910.0±2.7T=1.08, P=0.56% Phasic submental RSWA10.2±4.410.1±3.8T=0.27, P=0.68% Phasic anterior tibialis RSWA18.1± 8.215.1± 6.7F=1.50, P=0.4756th dayn=6n=16% Tonic RSWA13.9±5.711.6±4.7T=0.93, P=0.49% Phasic submental RSWA12.7±5.811.1±4.6T=0.46, P=0.67% Phasic anterior tibialis RSWA14.5± 7.815.3± 5.9T=0.62, P=0.55RSWA: REM sleep with atonia.% tonic Tonic and phasic RSWA: the numbers of 30-second epochs with tonic and phasic RSWA being were divided separately by the total number of epochs of REM sleep.T: independent t-test, MWU: Mann-Whitney U test.Legend of the figuresFigure legendsFigure 1. Flow diagram documenting illustrating the recruitment and treatment of depressed patients with insomnia. PSG: Polysomnographyam; DSM-IV: Ddiagnostic and Sstatistical Mmanual of Mmental Ddisorders, Ffourth Eedition; HRSD: Hamilton Rrating Sscale for Ddepression; OSA: obstructive sleep apnea; PLMS: periodic limb movement during sleep; OCD: obsessive-compulsive disorder.Figure 2 a-c. Tonic and phasic EMG activities in REM sleep across theduring sertraline treatment in of depressed patients. Figure 2 a. Tonic EMG activities in REM sleep (x axis, : baseline and days 1, 14, 28, and 56, the 1st day, the 14th day, the 28th day, and the 56th day; y axis, : % of 30-second epochs with tonic RSWA). Figure 2 b. Phasic submental EMG activities in REM sleep (x axis, : baseline and days 1, 14, 28, and 56, the 1st day, the 14th day, the 28th day, and the 56th day; y axis, : % of 30-second epochs with phasic submental RSWA). Figure 2 c. Phasic anterior tibialis EMG activities in REM sleep (x axis:, baseline and days 1, 14, 28, and 56, the 1st day, the 14th day, the 28th day, and the 56th day; y axis, : % of 30-second epochs with phasic anterior tibialis RSWA). EMG: electromyogram; REM: rapid eye movement; RSWA: REM sleep without atonia. ................
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