Abstract
Residual symptoms are common in depression, and their presence is associated with poorer clinical outcomes of depression. We conducted a case series study of first-onset major depression to elucidate the clinical course of residual insomnia and examine the relationship between residual insomnia and recurrence of depression. Subjects were 128 patients (57 males; mean age 52.8 years) with first-onset major depression. For all patients, we continuously assessed the number and breakdown of residual symptoms listed on the 17-item Hamilton Rating Scale for Depression and quantities of prescribed psychotropic medications during the depressive and remission phases. Even during the first remission phase, 85.9% of the patients with first-onset major depression experienced an average of 2.95 residual symptoms. The most common residual symptom was insomnia (65.4%), followed by reduced work and interests (43.3%) and fatigue (39.4%). Each additional recurrence resulted in a significantly shorter remission phase as well as significant increases in antidepressant and hypnotics dosages. Hypnotics dosage during the first remission phase for patients with three or more recurrent episodes was significantly higher than that for those with only a single episode. Our findings suggest a possible link between treatment-resistant residual insomnia during the first remission phase and recurrence risk of depression. In particular, it is possible that presence of treatment-resistant insomnia during the first remission phase is related to later recurrence of depressive episodes. It is important to see patients with treatment-resistant insomnia of early stage carefully, with special attention to treatment adherence.
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Narrow WE, Rae DS, Robins LN et al. Revised prevalence estimates of mental disorders in the United States: using a clinical significance criterion to reconcile 2 surveys’ estimates. Arch. Gen. Psychiatry 2002; 59: 115–23.
Kawakami N, Takeshima T, Ono Y et al. Twelve-month prevalence, severity, and treatment of common mental disorders in communities in Japan: preliminary finding from the World Mental Health Japan Survey 2002–2003. Psychiatry Clin. Neurosci. 2005; 59: 441–52.
Kessler RC, Angermeyer M, Anthony JC et al. Lifetime prevalence and age-of-onset distributions of mental disorders in the World Health Organization’s World Mental Health Survey Initiative. World Psychiatry 2007; 6: 168–76.
McIntyre RS, O’Donovan C. The human cost of not achieving full remission in depression. Can. J. Psychiatry 2004; 49 (3 Suppl 1): 10S–6S.
Von Korff M, Ormel J, Katon W et al. Disability and depression among high utilizers of health care. A longitudinal analysis. Arch. Gen. Psychiatry 1992; 49: 91–100.
Wells KB, Rogers W, Burnam A et al. How the medical comorbidity of depressed patients differs across health care settings: results from the Medical Outcomes Study. Am. J. Psychiatry 1991; 148: 1688–96.
Armitage R. The effects of antidepressants on sleep in patients with depression. Can. J. Psychiatry 2000; 45: 803–9.
Diagnostic and Statistical Manual of Mental Disorders, 4th edn, Text Revision. American Psychiatric Association: Washington, DC, 2000.
Thase ME. Antidepressant treatment of the depressed patient with insomnia. J. Clin. Psychiatry 1999; 60(Suppl 17): 28–31; discussion 46–8.
Taylor DJ, Lichstein KL et al. Epidemiology of insomnia, depression, and anxiety. Sleep 2005; 28: 1457–64.
Ford DE, Kamerow DB. Epidemiologic study of sleep disturbances and psychiatric disorders. An opportunity for prevention? JAMA 1989; 262: 1479–84.
Perlis ML, Giles DE, Buysse DJ et al. Self-reported sleep disturbance as a prodromal symptom in recurrent depression. J. Affect. Disord. 1997; 42 (2–3): 209–12.
Breslau N, Roth T, Rosenthal L et al. Sleep disturbance and psychiatric disorders: a longitudinal epidemiological study of young adults. Biol. Psychiatry 1996; 39: 411–18.
Dryman A, Eaton WW. Affective symptoms associated with the onset of major depression in the community: findings from the US National Institute of Mental Health Epidemiologic Catchment Area Program. Acta Psychiatr. Scand. 1991; 84 (1): 1–5.
Weissman MM, Greenwald S, Nino-Murcia G et al. The morbidity of insomnia uncomplicated by psychiatric disorders. Gen. Hosp. Psychiatry 1997; 19: 245–50.
Hohagen F, Rink K, Kappler C et al. Prevalence and treatment of insomnia in general practice. A longitudinal study. Eur. Arch. Psychiatry Clin. Neurosci. 1993; 242: 329–36.
Roberts RE, Shema SJ, Kaplan GA et al. Sleep complaints and depression in an aging cohort: a prospective perspective. Am. J. Psychiatry 2000; 157 (1): 81–8.
Vollrath M, Wicki W, Angst J. The Zurich study. VIII. Insomnia: association with depression, anxiety, somatic syndromes, and course of insomnia. Eur. Arch. Psychiatry Neurol. Sci. 1989; 239: 113–24.
Livingston G, Blizard B, Mann A. Does sleep disturbance predict depression in elderly people? A study in inner London [see comments]. Br. J. Gen. Pract. 1993; 43 (376): 44–58.
Breslau N, Roth T, Rosenthal L et al. Daytime sleepiness: an epidemiological study of young adults. Am. J. Public Health 1997; 87: 1649–53.
Chang PP, Ford DE, Mead LA et al. Insomnia in young men and subsequent depression. The Johns Hopkins Precursors Study. Am. J. Epidemiol. 1997; 146: 105–14.
Mallon L, Broman JE, Hetta J. Relationship between insomnia, depression, and mortality: a 12-year follow-up of older adults in the community. Int. Psychogeriatr. 2000; 12: 295–306.
Fava M, Hoog SL, Judge RA et al. Acute efficacy of flu-oxetine versus sertraline and paroxetine in major depressive disorder including effects of baseline insomnia. J. Clin. Psychopharmacol. 2002; 22: 137–47.
Menza M, Marin H, Opper RS. Residual symptoms in depression: can treatment be symptom-specific? J. Clin. Psychiatry 2003; 64: 516–23.
Nierenberg AA, Keefe BR, Leslie VC et al. Residual symptoms in depressed patients who respond acutely to fluoxetine. J. Clin. Psychiatry 1999; 60: 221–5.
Carney CE, Segal ZV, Edinger JD et al. A comparison of rates of residual insomnia symptoms following pharma-cotherapy or cognitive-behavioral therapy for major depressive disorder. J. Clin. Psychiatry 2007; 68: 254–60.
Paykel ES, Ramana R, Cooper Z et al. Residual symptoms after partial remission: an important outcome in depression. Psychol. Med. 1995; 25: 1171–80.
Cho HJ, Lavretsky H, Olmstead R et al. Sleep disturbance and depression recurrence in community-dwelling older adults: a prospective study. Am. J. Psychiatry 2008; 165: 1543–50.
Mendlewicz J. Sleep disturbances: core symptoms of major depressive disorder rather than associated or comorbid disorders. World J. Biol. Psychiatry 2009; 10: 269–75.
Inagaki A, Inada T. Dose equivalence of psychotropic drugs. Part XVIII. Dose equivalence of psychotropic drugs: 2006-version. (in Japanese). Rinsho Seishin Yakuri (Jpn. J. Clin. Psychopharmacol.) 2006; 9: 1443–7.
Inagaki A, Inada T. Dose equivalence of psychotropic drugs. Part XXI. Dose equivalence of novel antipsychot-ics: blonanserin (in Japanese). Rinsho Seishin Yakuri (Jpn. J. Clin. Psychopharmacol.) 2008; 11: 887–90.
Thase ME. Depression, sleep, and antidepressants. J. Clin. Psychiatry 1998; 59 (Suppl 4): 55–65.
Perlis ML, Giles DE, Buysse DJ et al. Which depressive symptoms are related to which sleep electroencephalo-graphic variables? Biol. Psychiatry 1997; 42: 904–13.
Tranter R, O’Donovan C, Chandarana P et al. Prevalence and outcome of partial remission in depression. J. Psychiatry Neurosci. 2002; 27: 241–7.
Fava M, Davidson KG. Definition and epidemiology of treatment-resistant depression. Psychiatr. Clin. North Am. 1996; 19: 179–200.
Kupfer DJ, Frank E, McEachran AB et al. Delta sleep ratio. A biological correlate of early recurrence in unipolar affective disorder. Arch. Gen. Psychiatry 1990; 47: 1100–5.
Buysse DJ, Reynolds CF III, Hoch CC et al. Longitudinal effects of nortriptyline on EEG sleep and the likelihood of recurrence in elderly depressed patients. Neuropsy-chopharmacology 1996; 14: 243–52.
Dombrovski AY, Cyranowski JM, Mulsant BH et al. Which symptoms predict recurrence of depression in women treated with maintenance interpersonal psychotherapy? Depress. Anxiety 2008; 25: 1060–6.
Casper RC, Katz MM, Bowden CL et al. The pattern of physical symptom changes in major depressive disorder following treatment with amitriptyline or imipramine. J. Affect. Disord. 1994; 31: 151–64.
Reynolds CF III, Frank E, Houck PR et al. Which elderly patients with remitted depression remain well with continued interpersonal psychotherapy after discontinuation of antidepressant medication? Am. J. Psychiatry 1997; 154: 958–62.
Roth T, Roehrs T, Pies R. Insomnia: pathophysiology and implications for treatment. Sleep Med. Rev. 2007; 11 (1): 71–9.
Fava M, McCall WV, Krystal A et al. Eszopiclone co-administered with fluoxetine in patients with insomnia coexisting with major depressive disorder. Biol. Psychiatry 2006; 59: 1052–60.
Bonnet MH, Arand DL. 24-Hour metabolic rate in insomniacs and matched normal sleepers. Sleep 1995; 18: 581–8.
Basta M, Chrousos GP, Vela-Bueno A et al. Chronic insomnia and stress system. Sleep Med. Clin. 2007; 2: 279–91.
Buysse DJ. Chronic insomnia. Am. J. Psychiatry 2008; 165: 678–86.
Hamilton M. A rating scale for depression. J. Neurol. Neurosurg. Psychiatry 1960; 23: 56–62.
The International Classification of Sleep Disorders, 2nd Edition. Diagnostic and Coding Manual. American Academy of Sleep Medicine: Westchester, IL, 2005.
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Iwaki, S., Satoh, K., Matsumoto, Y. et al. Treatment-resistant residual insomnia in patients with recurrent major depressive episodes. Sleep Biol. Rhythms 10, 202–211 (2012). https://doi.org/10.1111/j.1479-8425.2012.00564.x
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DOI: https://doi.org/10.1111/j.1479-8425.2012.00564.x