Faculty Bibliography

OBJECTIVE: To investigate the presence of temperament dysregulation in healthy relatives of bipolar probands (RBP), a population at high risk for developing mood disorders, by comparing them with clinically recovered bipolar patients (BP) and normal controls (NC). METHOD: 52 RBP and 23 BP were originally recruited for a multicenter genetic study in bipolar disorders. NC (n=102) were also recruited by newspaper advertisement, radio and television announcements, flyers, newsletters, or word of mouth. All volunteers were asked to complete the TEMPS-A Scale, a self-report questionnaire designed to measure temperamental variations in psychiatric patients and healthy volunteers. In scoring temperaments, we relied upon the short validated version of the TEMPS-A [J. Affect. Disord. (2004)], from which traits with loadings <0.035 had been deleted. RESULTS: To examine differences in temperament dimensions among the three groups, a MANCOVA model was constructed using diagnostic group as the fixed factor (BP vs. RBP vs. NC); effects of age and gender were adjusted as covariates. MANCOVA showed overall group effect on the dependent variables (Hotelling's F5,175=6.64, p<0.001). Four dependent variables (dysthymic, cyclothymic, irritable, and anxious temperaments) showed significant between-group differences. RBP showed lower cyclothymic temperament scores than BP, but higher scores than NC. BP and RBP showed higher anxious temperament scores than NC. Hyperthymic scores were significantly highest in the NC. LIMITATION: In view of the small cell sizes, bipolar I vs. bipolar II subanalyses could not be conducted. CONCLUSIONS: Methodologic strengths of the present analyses is that the BP group had clinically recovered, and we used the validated short version of the TEMPS-A for the present analyses. Our findings suggest that some clinically healthy relatives of bipolar probands exhibit a subclinical cyclothymic instability in mood, interest, self-confidence, sleep, and/or energy as well as anxiety proneness that is not observed among normal controls. These traits may represent vulnerability markers and could presumably be used to identify individuals at high risk for developing bipolar spectrum disorders, or specific clinical subtypes (e.g., bipolar I, bipolar II) within this spectrum. This is a conceptual perspective with many unanswered questions. Resolution of these questions will require innovative definitions of phenotypes to be included in the analyses of the temperament subscales in different populations. The temperament subscales themselves need to be calibrated properly, to find out which traits or specific combinations of trains are most promising. More extensive and complex quantitative trait analyses of these temperaments in a much expanded sample are reported elsewhere in this issue [J. Affect. Disord. (2004)].

OBJECTIVE: To validate a short English-language version of the Temperament Evaluation of Memphis, Pisa, Paris and San Diego-autoquestionnaire version (TEMPS-A), a self-report questionnaire designed to measure temperamental variations in psychiatric patients and healthy volunteers. Its constituent subscales and items were formulated on the basis of the diagnostic criteria for affective temperaments (cyclothymic, dysthymic, irritable, hyperthymic, and anxious), originally developed by the first author and his former collaborators. Further item wording and selection were achieved at a later stage through an iterative process that incorporated feedback from clinicians, researchers, and research volunteers. METHOD: A total of 510 volunteers (284 patients with mood disorders, 131 relatives of bipolar probands, and 95 normal controls) were recruited by advertisement in the newspapers, announcements on radio and television, flyers and newsletters, and word of mouth. All participants were interviewed using the Structured Clinical Interview for DSM-III-R, and completed the 110-item TEMPS-A and the Temperament and Character Inventory (TCI-125). The factorial structure, the alpha coefficients, and the item-total correlations coefficients of the TEMPS-A and the correlation coefficients between the dimensions of the TCI and the TEMPS-A subscales were then determined. RESULTS: A principal components analysis with a Varimax rotation found that 39 out of the 110 original items of the TEMPS-A loaded on five factors that were interpreted as representing the cyclothymic, depressive, irritable, hyperthymic, and anxious factors. Coefficients alpha for internal consistency were 0.91 (cyclothymic), 0.81 (depressive), 0.77 (irritable), 0.76 (hyperthymic), and 0.67 (anxious) subscales. We found statistically significant positive correlations between all-but the hyperthymic-subscales and harm avoidance. Positive correlations with the hyperthymic and cyclothymic, and novelty seeking and negative correlations with the remaining subscales were also recorded. Other major findings included positive correlations between the hyperthymic and reward dependence, persistence and self-directedness; positive correlation between the self-transcendence and the cyclothymic, hyperthymic and the anxious; and negative correlations between the depressive, cyclothymic, irritable, anxious and cooperativeness. LIMITATION: As the full-scale anxious temperament was added after the four scales of the TEMPS-A were developed, it has only been evaluated in 345 subjects. CONCLUSIONS: These data indicate that the TEMPS-A in its shortened version is a psychometrically valid scale with good internal consistency. The proposed five subscale structure is upheld. Concurrent validity against the TCI is shown. Most importantly, for each of the temperaments, we were able to show positive attributes which are meaningful in an evolutionary context, along with traits which make a person vulnerable to mood shifts. This hypothesized dual nature of temperament, which is upheld by our data, is a desirable characteristic for a putative behavioral endophenotype in an oligogenic model of inheritance for bipolar disorder.

OBJECTIVE: To examine differences in temperament profiles between patients with recurrent unipolar and bipolar depression. METHOD: Depressed individuals with recurrent major depressive disorder (MDD) (n = 94) and those with bipolar (n = 59) disorders (about equally divided between types I and II) were recruited by newspaper advertisement, radio and television announcements, flyers and newsletters, and word of mouth. All patients were interviewed using the Structured Clinical Interview for DSM III-R (SCID) and had the severity of their depressive episode assessed by means of the 17-item Hamilton Rating Scale for Depression. All patients filled out the TEMPS-A, a validated instrument. RESULTS: Temperament differences between bipolar and MDD patients were examined using MANCOVA. Overall significant effect of the fixed factor (bipolar vs. unipolar) was noted for the temperament scores [Hotelling's F((5,142)) = 2.47, p < 0.05]. Overall effects were found for age [F((5,142)) = 2.40, p < 0.05], but not for gender and severity of depression [F((5,142)) = 1.65, p = 0.15 and F((5,142)) = 0.66, p = 0.66, respectively]. Dependent variables included the five subscales of the TEMPS-A, but only the cyclothymic temperament scores showed significant between-group differences. LIMITATION: Small bipolar subsample cell sizes did not permit to test the specificity of the findings for bipolar II vs. bipolar I patients. CONCLUSION: The finding that the clyclothymic subscale is significantly elevated in the bipolar vs. the unipolar depressive group supports the theoretical assumptions upon which the scale is based, and suggests that it might become a useful tool for clinical and research purposes.

This study investigated differences in sleep-disordered breathing (SDB) between hypertensives without a family history of hypertension and hypertensives with a family history. Furthermore, it examined whether these two groups differed in the severity of SDB. Patients were African Americans (n=162, mean age=51.19+/-13.77 years; mean body mass index (BMI)=37.85+/-9.51 kg/m2, male=57%), who were referred to the clinic because of a sleep complaint. Sleep was recorded in the laboratory using standard physiological parameters; all parameters were analysed by a trained scorer. Altogether, 91% of the patients received an SDB diagnosis. Of these patients, 25% were hypertensives without a family history, 20% were hypertensives with a family history, and 55% were normotensives. We found a significant difference between these patient groups regarding the severity of SDB (F14,158=1.823, P<0.05), but no significant group difference was observed in the rate of SDB. Increasing weight was accompanied by increasing severity of SDB. The finding that hypertensive patients with or without a positive family history showed worse oxygenation and respiratory characteristics than did normotensives is consistent with previous research. Of note, hypertensives reporting a family history were characterized by a greater number of oxygen desaturations and apnoea hypopnoea index than those typified only by a current diagnosis of hypertension. Hypertensives with a family history are likely to show a profile of greater blood pressure, higher BMI, and more severe SDB, which by all accounts are more common among African Americans.

Evidence suggests that ocular pathology could reduce light-stimulated neuronal signaling to the suprachiasmatic nuclei. This study investigated associations of ambient illumination with moods, while considering the contribution of ophthalmic dysfunctions. Seventy Black (59%) and White (41%) Americans participated in the study. Their average age was 68.27+/-5.97 years; 73% were women. Baseline data included: physical health, mood, and sociodemographics. Ophthalmic factors including visual acuity, visual field defects, intraocular pressure, vertical and horizontal cup-to-disk ratios, and nerve-fiber-layer thickness were assessed at SUNY Downstate's eye clinic. The following week, participants wore the Actiwatch-L at home to monitor ambient illumination and sleep. Cosine analyses were performed on the logarithm of measured illumination, yielding the mesor and acrophase of daily illumination exposure. Sleep was estimated with an automatic scoring algorithm. Of the sample, 25% reported visual impairment and 85% reported good to excellent health; 27% were visually impaired according to American criteria. Partial correlation analyses showed an inverse correlation of daily illumination levels to depressed mood [r(p)=-0.33, P<0.05], when age, sex, ethnicity, income, BMI, diabetes, hypertension, respiratory disease, and habitual sleep duration were controlled. With further control for ophthalmic factors, the magnitude and significance of the correlation diminished [r(p)=-0.26, NS]. Individuals receiving daily illumination later in the day reported more depressed moods [r(p)=0.36, P<0.01]; of note, this correlation was not significant after control for the covariates [r(p)=0.18, NS]. Regression analysis indicated that the ophthalmic factors explained 13% of the variance in depression. Our results show that both the level and timing of ambient illumination are associated with mood. Furthermore, they suggest that visual impairment has a mediating effect on the associations of ambient illumination with depression, supporting the notion that ocular pathology lessens the efficacy of daily illumination in promoting positive moods.

BACKGROUND: This study examined how ethnic differences in sleep and depression were related to environmental illumination and circadian rhythms. METHODS: In an ancillary study to the Women's Health Initiative, 459 postmenopausal women were recorded for one week in their homes, using wrist monitors. Sleep and illumination experience were estimated. Depression was self-rated with a brief adjective check list. Affective diagnoses were made using the SCID interview. Sleep disordered breathing was monitored with home pulse oximetry. RESULTS: Hispanic and African-American women slept less than European-American women, according to both objective recordings and their own sleep logs. Non-European-American women had more blood oxygen desaturations during sleep, which accounted for 26% of sleep duration variance associated with ethnicity. Hispanic women were much more depressed. Hispanic, African-American and Native-American women experienced less daily illumination. Less daily illumination experience was associated with poorer global functioning, longer but more disturbed sleep, and more depression. CONCLUSIONS: Curtailed sleep and poor mood were related to ethnicity. Sleep disordered breathing was a factor in the curtailed sleep of minority women. Less illumination was experienced by non-European-American women, but illumination accounted for little of the contrasts between ethnic groups in sleep and mood. Social factors may be involved.

BACKGROUND: This report describes the associations between sleep complaints and reported visual impairment in an urban community-residing older adult sample. METHODS: A total of 1118 volunteers from a biracial cohort participated in the study (mean age = 74 +/- 6; mean body mass index = 28 +/- 10). Volunteers were recruited using a stratified, cluster sampling technique. In a standard order, several questionnaires were administered, soliciting information on socioeconomic status, physical health, social support, and emotional experience. The physical health questionnaire included questions on whether or not the volunteer experienced sleep disorder, visual impairment, heart disease, respiratory disease, arthritis, and hypertension. In this report, we present data on the prevalence of reported sleep problems and visual impairment among older adults. RESULTS: Of the total sample, 9% used sleep medicine, 25% reported difficulty falling asleep, 52% indicated experiencing difficulty maintaining sleep, 28% reported waking up early in the morning, and 12% reported daytime sleep longer than 2 hours. Chi-square results showed greater sleep complaints for volunteers with visual impairment. Consistent with these results, analysis of variance revealed that visually impaired volunteers had a higher index rate of sleep disturbance (F((1, 1110)) = 35.32, p <.0001). CONCLUSIONS: These data provide evidence that older adults reporting visual impairment are also likely to report sleep complaints. This verifies laboratory findings of an association of ophthalmic diseases with sleep-wake problems and with circadian rhythm abnormalities.

OBJECTIVES: To examine whether dim illumination in the evening is a factor in sleep disturbances of aging, depression, and circadian phase advance. DESIGN: One-week continuous recordings were made to record illumination exposure and to infer 24-hour sleep patterns from wrist activity. SETTING: Recordings took place during normal home and community activities. PARTICIPANTS: Complete data of 154 postmenopausal women, mean age 66.7, were selected from a larger study of participants in the Women's Health Initiative. MEASUREMENTS: Illumination in lux was averaged for 4 hours before bedtime and over 24 hours. Mood was measured using a brief eight-item screen. RESULTS: Illumination in the 4 hours before bedtime was quite dim: median 24 lux. Nevertheless, evening light exposure was not significantly related to sleep amount (in bed or out of bed) sleep efficiency, sleep latency, wake within sleep, or mood. In contrast, the overall amount of light throughout the 24 hours was negatively correlated with sleep latency, wake within sleep, and depressed mood. CONCLUSIONS: Low evening lighting does not appear to be a crucial factor in sleep and mood disturbances of aging, but overall lighting may contribute to these disturbances.

Progress in transducer design and empirical characterization of wrist movement has led to diverse wrist activity monitors, each with its unique features and modality of operation. This study compared sleep--wake estimates from nocturnal wrist activity quantified by different motion-quantifying algorithms. Healthy young adults wore an Actillume and a Mini Motionlogger on the same wrist while nocturnal polysomnography data were recorded simultaneously in the laboratory. Activity data were analyzed with ACTION3 using scoring algorithms independently calibrated for each measurement modality. Overall, each modality yielded accurate and reliable sleep estimates relative to polysomnographic estimates (agreement rates: 91.4--96.5%, correlations for sleep duration: 0.79--0.94). Estimates derived from Actillume modalities were comparable to those of Mini Motionloggers, suggesting that the transducers of these two devices performed comparably for monitoring sleep and wakefulness. Wrist movement quantified by the Mini Motionlogger proportional-integrating mode yielded the best accuracy for detection of sleep--wake states.