Undiagnosed Obstructive Sleep Apnea and Acute COVID-19 Infection—A Case Series

A recently published study on coronavirus disease 2019 (COVID-19) and obstructive sleep apnea (OSA) suggested that there might be an association between certain risk factors and comorbidities associated with OSA, which are also associated with poor COVID-19 outcomes. However, it is unclear whether undiagnosed OSA correlates with COVID-19 severity in a South Korean population. We identified 7 patients who presented with nocturnal hypoxemia during hospitalization due to COVID-19. All patients underwent polysomnography 5–9 weeks after the infection. We retrospectively collected the patients’ baseline characteristics, hospital admission data, and polysomnography findings. Of the 7 patients, all were diagnosed with OSA after COVID-19 infection. Their mean (±SD) age was 45.4±16.3 years, 57.1% were men, and their mean (±SD) body mass index was 33.4±6.0 kg/m2. Six patients presented with COVID-19-related pneumonia on chest X-rays, 3 of whom were admitted to the intensive care unit during the acute phase. The overnight polysomnography showed a mean AHI of 59.0±38.5/h and an oxygen desaturation index of 57.6±39.7/h. Undiagnosed OSA is a prevalent condition associated with moderate to severe COVID-19 infection. The study patients with sleep apnea and COVID-19 had obesity and severe oxygen desaturation but did not complain of daytime sleepiness.

Association Between Frontal Alpha Asymmetry With Cognitive Symptoms, Depression Severity, and Insomnia

Objective: Previous studies have compared depressive episodes between bipolar disorder (BD) and major depressive disorder (MDD) using quantitative electroencephalogram (QEEG); however, there are no distinct discriminating feature between them. Here, we used QEEG to directly compare the alpha asymmetry and absolute power of each band between patients with BD and MDD.Methods: Fifty in-patients with major depressive episodes between 2019 and 2021 were retrospectively enrolled. Self-reported questionnaires including the Beck Depression Inventory (BDI), Korean version of the Childhood Trauma Questionnaire, and Adult Attention-Deficit/Hyperactivity Disorder Self Report Scale (ASRS) were used to evaluate the symptoms. The absolute power of QEEG delta, theta, alpha, beta, high beta waves, and the Z-scores of frontal alpha asymmetry were collected. A t-test and Pearson’s correlation test were conducted using these data and based on these results, an analysis of covariance was conducted.Results: There were no significant differences between MDD and BD in QEEG power or alpha asymmetry. Patients with severe depression (BDI ≥29) had higher alpha power at FP1 (p=0.037), FP2 (p=0.028), F3 (p=0.047), F4 (p=0.016), and higher right frontal alpha asymmetry at F3–F4 (p=0.039). Adult patients with features consistent with ADHD (ASRS ≥4) had higher right frontal alpha asymmetry at F3–F4 (p=0.046). Patients with insomnia had higher left frontal alpha asymmetry at F3–F4 (p=0.003).Conclusion: QEEG limited the differential diagnosis of MDD and BD. However, frontal alpha asymmetry did exist in depression and affected cognitive impairment, insomnia, and depression severity in particular. Future studies with improved methodologies are needed for a better comparison.

Rest-Activity Pattern and Circadian Phase Alterations Across the Alzheimer’s Disease Clinical Spectrum

Actigraphy-derived locomotor activity recordings are novel and critical tools for evaluating rest-activity pattern and circadian phase in humans. We conducted a narrative review assessing rest-activity pattern and circadian phase alterations within various stages of Alzheimer’s disease, in consideration of the reciprocal associations between neurodegeneration and circadian rhythm disruption in patients with Alzheimer’s disease. The goal of this review was to characterize possible associations between circadian rhythm disruption and neurodegeneration in Alzheimer’s disease. To the best of our knowledge, only two studies have assessed rest-activity pattern and circadian phase alterations in the preclinical Alzheimer’s disease stage and the results of the studies were inconsistent. Several studies have evaluated rest-activity pattern and circadian phase alterations in patients with Alzheimer’s dementia. The most replicated findings were delayed phase and increased activity fragmentation, represented as increased intra-daily variability. Unfortunately, many studies performed in dementia patients have not examined neuroimaging biomarkers or structured neuropsychological tests, thus limiting the specification of dementia clinical diagnoses. Future studies should consider a more comprehensive evaluation of various clinical and biomarker characteristics in patients with dementia or Alzheimer’s disease.

Can Digital Therapeutics Open a New Era of Sleep Medicine?

Digital therapeutics (DTx) are products that provide evidence-based interventions driven by high-quality software programs to prevent, manage, or treat a medical disease. DTx are receiving increasing attention as a new therapeutic approach. Several DTx for insomnia are on the market, some of which have received approval by national regulatory agencies. DTx for insomnia are usually based on cognitive behavioral therapy for insomnia. No DTx for other sleep disorders, such as narcolepsy or sleep-related breathing disorders, have received regulatory authority approval as a medical device. DTx have the substantial benefits of being accessible and relatively low-cost. However, several issues related to DTx have not yet been fully resolved, and discussions regarding DTx are still in the early stages. To use DTx for sleep disorders as an effective treatment option in the future, considering the current status of DTx is necessary. This review discusses definitions and background of DTx; specific DTx for insomnia that have been developed; use of DTx for sleep and related psychiatric comorbid symptoms; global regulatory processes for DTx, including prescribing and medical billing issues; and remaining challenges regarding the use of DTx.

Prescription Dose Analysis of Quetiapine in the Elderly and Insomnia

Objective: The purpose of this study is to investigate the appropriate dose of quetiapine in clinical psychiatric diseases by examining the drug prescription dose in the elderly and insomnia group through an analysis of the tendency of quetiapine dose prescribed by psychiatric diagnosis.Methods: Among the patients who had been taking outpatient treatment to the mental health department for about 7 years and 8 months from May 1, 2010 to December 31, 2017, 2,794 patients who were continuously taking quetiapine immediate-release form drugs were retrospectively tested. In addition, all subjects were classified into a total of four groups according to their maintenance dose, four mental diseases that most commonly prescribe quetiapine were selected and grouped, and further analyzed whether there was a difference in prescription capacity by age and comorbidities for the insomnia group.Results: Prescription dose of quetiapine was found to be less than 50 mg in depressive disorders and insomnia, which is a relatively low dose prescribed compared to schizophrenia and bipolar disorder. In the case of insomnia, quetiapine prescribed in the elderly patient group was 30.03±9.14 mg, which was relatively high compared to the non-elderly group. And in the case of insomnia accompanied by depressive disorder, 50.28±11.41 mg was prescribed, more than 60% higher doses than that of primary insomnia.Conclusion: In the case of primary insomnia, quetiapine dose prescribed in the elderly patient group is higher than that in the non-elderly patient group.

Identifying Obstructive Sleep Apnea Subtypes and Its Correlation With Mood States

Objective: It has been difficult to establish specific subtypes of obstructive sleep apnea (OSA) due to the heterogeneous nature of the disor- der. Previous studies have attempted to exact clinical subgroups or phenotypes of the disorder. However, the psychiatric impact of OSA has been often overlooked, and thus, this study used cluster analysis to examine subgroups of OSA incorporating mood states.Methods: This study is comprised of 346 adult OSA patients (apnea-hypopnea index, AHI≥5) who underwent polysomnography at Nowon Eulji Medical Center from January 2003 to November 2012. Their data also included validated self-report questionnaires that evaluate daytime sleepi- ness, sleep quality, morningness-eveningness, and mood states: Epworth Sleepiness Scale, Korean version of the Pittsburgh Sleep Quality In- dex (PSQI-K), Horne and Östberg Questionnaire, and Korean edition of Profile of Mood States (K-POMS), respectively. A K-means cluster analy- sis was performed to determine the optimal number of clusters and characteristics.Results: We identified three clusters: cluster 1, moderately symptomatic OSA with the least disturbed mood (n=166); cluster 2, severely symptomatic OSA not so disturbed mood (n=90); cluster 3, moderately symptomatic with highest disturbed mood (n=90). Cluster 1 had the lowest AHI and the lowest K-POMS total scores. Cluster 2, despite having the most severe OSA parameters, did not show mood disturbances. Cluster 3 had the highest K-POMS total scores and PSQI-K scores.Conclusion: Certain individuals with OSA are more likely to suffer from disturbed mood states without serious OSA indices. Psychiat- ric manifestations should also be considered when determining the severity of the disorder.

Review of Sleep Problems Related to Social Distancing and Home Confinement During the COVID-19 Pandemic

Since the first outbreak of coronavirus disease (COVID-19) in December 2019, we have experienced many changes that we have never ex- perienced before. Governments around the world have instituted various forms of social isolation measures to prevent the spread of COV- ID-19. These measures include social distancing, home confinement, quarantine, and lockdown. Unfortunately, these measures have in- creased the ambiguity of the economic situation and the uncertainty regarding the future. For many individuals, these actions resulted in changes in routines at home, school, and work; changes in roles at home, mental health, and physical activity; and changes in circadian cues. All of these alterations resulted in disruptions in sleep patterns and sleep difficulties. In this paper, the alterations in sleep patterns and the sleep difficulties related to social isolation policies would be reviewed. These include social distancing and home confinement. Finally, meth- ods to improve sleep problems also reviewed.