Nordic Journal of Psychiatry
ISSN: 0803-9488 (Print) 1502-4725 (Online) Journal homepage: http://www.tandfonline.com/loi/ipsc20
Prevalence of restless legs symptoms according to depressive symptoms and depression type: a cross-sectional study Piritta Auvinen, Pekka Mäntyselkä, Hannu Koponen, Hannu Kautiainen, Katariina Korniloff, Tiina Ahonen & Mauno Vanhala To cite this article: Piritta Auvinen, Pekka Mäntyselkä, Hannu Koponen, Hannu Kautiainen, Katariina Korniloff, Tiina Ahonen & Mauno Vanhala (2017): Prevalence of restless legs symptoms according to depressive symptoms and depression type: a cross-sectional study, Nordic Journal of Psychiatry, DOI: 10.1080/08039488.2017.1385849 To link to this article: http://dx.doi.org/10.1080/08039488.2017.1385849
Published online: 09 Oct 2017.
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Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=ipsc20 Download by: [RMIT University Library]
Date: 16 October 2017, At: 07:40
NORDIC JOURNAL OF PSYCHIATRY, 2017 https://doi.org/10.1080/08039488.2017.1385849
ORIGINAL ARTICLE
Prevalence of restless legs symptoms according to depressive symptoms and depression type: a cross-sectional study Piritta Auvinena , Pekka M€antyselk€aa,b, Hannu Koponenc, Hannu Kautiainend,e,f, Katariina Korniloffg, Tiina Ahonenh and Mauno Vanhalai
Downloaded by [RMIT University Library] at 07:40 16 October 2017
a Institute of Public Health and Clinical Nutrition, General Practice Unit, University of Eastern Finland, Kuopio, Finland; bPrimary Health Care Unit, Kuopio University Hospital, Kuopio, Finland; cDepartment of Psychiatry, University of Helsinki and Helsinki University Hospital, Helsinki, Finland; dPrimary Health Care Unit, Kuopio University Hospital, Kuopio, Finland; eUnit of Primary Health Care, Helsinki University Central Hospital, Helsinki, Finland; fDepartment of General Practice, University of Helsinki, Helsinki, Finland; gSchool of Health and Social Studies, JAMK University of Applied Sciences, Jyv€askyl€a, Finland; hPrimary Health Care Unit, Central Finland Central Hospital, Jyv€askyl€a, Finland; i Central Finland Central Hospital, Jyv€askyl€a, Finland
ABSTRACT
ARTICLE HISTORY
Background: Restless legs syndrome is a sensorimotor disorder and it is associated with several other diseases especially mental illnesses. Aims: To analyze the relationship between the symptoms of restless legs syndrome and the severity of depressive symptoms and the prevalence of restless legs symptoms in depression subtypes. Methods: A cross-sectional study of primary care patients in the Central Finland Hospital District. The prevalence of restless legs symptoms was studied in 706 patients with increased depressive symptoms and 426 controls without a psychiatric diagnosis by using a structured questionnaire. The depressive symptoms were evaluated with the Beck Depression Inventory (BDI) and the psychiatric diagnosis was confirmed by means of a diagnostic interview (Mini-International Neuropsychiatric Interview). The subjects with increased depressive symptoms were divided into three groups (subjects with depressive symptoms without a depression diagnosis, melancholic depression and non-melancholic depression). Results: In the whole study population, the prevalence of restless legs symptoms increased with the severity of depressive symptoms. The prevalence of restless legs symptoms was highest in the melancholic and non-melancholic depressive patients (52 and 46%, respectively) and then in subjects with depressive symptoms without a depression diagnosis (43.4%), but the prevalence was also substantial (24.6%) in subjects without a psychiatric diagnosis. Conclusions: Restless legs symptoms are very common in primary care among subjects with depression, regardless of the depression type. The prevalence of restless legs symptoms increased with increasing severity of depressive symptoms, regardless of the diagnosis. These findings should be considered in clinical evaluation and treatment of patients visiting their physician due to restless legs or depressive symptoms.
Received 1 November 2016 Revised 30 August 2017 Accepted 25 September 2017
Introduction Restless legs syndrome is a common sensorimotor disorder [1]. The main symptoms of restless legs syndrome are characterized by an unpleasant sensation in the limbs that appears at rest in the evening or during the night [2], but daytime symptoms are also common [3,4]. Patients describe the symptoms as, for example, ‘a need to move’, ‘crawl’, ‘tingle’ and ‘ache’ [5]. In addition, patients suffer from an urge to move their limbs, particularly the legs. Moving or stretching the legs relieves the symptoms [2]. These symptoms are related to sleep disturbances and insomnia, because patients have difficulty getting to sleep and they wake up several times a night [6,7]. In previous studies, the prevalence of restless legs syndrome has been between 5% and as much as 24% in the primary care patient population [8–13]. Knowledge about CONTACT Piritta Auvinen [email protected] 1627, FI-70211 Kuopio, Finland ß 2017 The Nordic Psychiatric Association
KEYWORDS
Restless legs syndrome; depressive disorder; melancholia; depression; primary health care
restless legs syndrome pathophysiology and clinical experience have increased during the last decade [2,14]. The exact pathophysiology of restless legs syndrome is not known, but several different theories such as deficient dopaminergic neurotransmission, iron deficiency, opioid system abnormalities [15,16], genetics [17] and peripheral hypoxia [18] have been suggested. There are effective medical treatments for restless legs symptoms, including dopaminergic agents and calcium-channel ligands such as pregabalin [19,20]. Even though knowledge about restless legs syndrome has increased, it is still an underdiagnosed and undertreated syndrome [21,22]. Restless legs symptoms impair the quality of life due to disturbance of sleep and normal daily activities, feelings of pain and anxiety, among other things [8,23,24]. There are numerous studies about the relationship between depressed
University of Eastern Finland, Institute of Public Health and Clinical Nutrition, General Practice Unit, P.O.B.
2
P. AUVINEN ET AL.
Downloaded by [RMIT University Library] at 07:40 16 October 2017
mood or depression and restless legs symptoms [12,25–28]. However, previous studies have not analyzed this relationship between different subtypes of depression, for example, nonmelancholic or melancholic depression. Melancholic depression manifests itself as psychomotor slowing, a distinct quality of mood, social withdrawal, body immobility, slowed speech, a non-reactive mood or a loss of emotion. Nonmelancholic depression symptoms include minimal or absent psychomotor dysfunction, tearfulness and mood reactivity [29,30], and it has been found to be associated with metabolic syndrome [31], as well. While restless legs symptoms have been found to be associated with metabolic disturbances [32,33], it could be hypothesized that restless legs symptoms are more common among subjects with nonmelancholic depression than with melancholic depression.
Aims Due to non-existent data on the prevalence of restless legs symptoms in various subtypes of depression in primary care, we decided to study restless legs symptoms in a geographically defined sample of primary care patients with depressive symptoms without a depression diagnosis, non-melancholic depression or melancholic depression and population-based control subjects without a psychiatric diagnosis. In addition, the relationship between restless legs symptoms and the severity of depressive symptoms was also scrutinized.
Material and methods New patients over 35 years of age who went themselves or were referred by a general practitioner to a depression nurse case manager in 2008–2009 due to depressive symptoms and a score higher than 10 in the Beck Depression Inventory (BDI) were enlisted in this study. Altogether, 706 patients were involved. The study was conducted in municipalities belonging to the Central Finland Hospital District [the Finnish Depression and Metabolic Syndrome in Adults (FDMSA) study] with a catchment area of 274,000 residents. Notification was based on written and oral patient information and written consent was obtained before any study procedures. The study protocol was approved by the Ethics Committee of the Central Finland Hospital District. All the participants filled in a standard questionnaire form containing questions about previously diagnosed somatic disorders and use of medications, including antidepressants and hormone replacement therapy in females. Data on current smoking, years of education, use of alcohol (number of drinks per week) and leisure-time physical activity (number of 30-min exercise sessions) were also collected. Leisure-time physical activity was classified low (0–2 sessions per month), moderate (1–2 sessions per week) and high (three or more sessions per week). Quality of sleep was evaluated with two structured questions about sufficient sleep and feeling rested in the morning. Sufficient sleep was evaluated by a question ‘Do you think that your sleep is sufficient (1 ¼ yes, almost always; 2 ¼ yes, often; 3 ¼ rarely or hardly ever; 4 ¼ I cannot say)’. Subjects responding ‘almost’ or ‘often’ were regarded
as having sufficient sleep. Feeling rested in the morning was evaluated by a question ‘How tired do you feel during the first 30 minutes after you have woken up in the morning (1 ¼ very tired; 2 ¼ quite tired; 3 ¼ quite rested; 4 ¼ I feel fresh)?’ Subjects responding ‘quite rested’ or feeling fresh were regarded as rested in the morning. Glucose and lipid level determinations were based on fasting blood samples that were drawn between 8 and 11 o’clock after 12 h of fasting. Serum total cholesterol, highdensity lipoprotein (HDL) cholesterol, low-density lipoprotein (LDL) cholesterol, triglycerides and plasma glucose were analyzed using Modular Analytics SWA (Hitachi HighTechnologies Corporation, Tokyo, Japan). The severity of depressive symptoms was measured with the 21-item BDI [34], which was completed by the participants. The psychiatric diagnosis was confirmed with a diagnostic interview (Mini-International Neuropsychiatric Interview (M.I.N.I.) [35]) conducted by a trained study nurse [36]. Among the whole study population, 439 subjects had a BDI score of 10 or higher and the diagnosis of depression was determined with a diagnostic interview (M.I.N.I.). The melancholic subtype was identified by M.I.N.I. criteria for major depressive episode with melancholic features [35,37,38]. The participants’ restless legs symptoms were detected by using a structured and tested question that takes into account the core marks of restless legs discomfort: an urge to move the legs, primarily during rest or inactivity, and partial or total relief with movement, with presence or worsening exclusively in the evening or at night. According to the previous validation study, the questionnaire had 100% sensitivity and 96.8% specificity. Moreover, likelihood ratio for a positive result (LRþ ¼31,25) adverted to the positive test had conclusive increase in the probability of restless legs syndrome [11]. Random sampling was used to select a group of 426 middle-aged (> 35 years) persons as controls from residents in the participating municipalities. Concurrently with the patient recruitment in 2008–2009, an age, sex and community-stratified random sample representing the population in the study region was taken by the Statistics Finland (http://www.stat.fi). All the subjects in the control group had a BDI score below 10 and no psychiatric diagnosis or current depressive symptoms and they used no psychoactive medications. There were a total of 27 subjects in all four study groups who did not answer the question about the symptoms of restless legs syndrome, resulting in a total number of 1105 study subjects.
Statistical analysis Statistical significance between groups was tested with analysis of variance, the Kruskal–Wallis test and the chi-square test. We investigated the relationship between prevalence of restless legs symptoms and depression groups using a crude and adjusted logistic regression models. Model adjusted using age, smoking, education years, body mass index, physical activity and education years. A possible non-linear relationship between prevalence of restless legs symptoms
NORDIC JOURNAL OF PSYCHIATRY
3
Table 1. Demographic and clinical traits of the subjects. 21-Item Beck Depression Inventory 10
Downloaded by [RMIT University Library] at 07:40 16 October 2017
Controls (A) N ¼ 410 Male, n (%) Age, mean (SD) Education years, mean (SD) Body mass index (kg/m2), mean (SD) Current smoking, n (%) Alcohol use, doses, n (%) 0 1–9 10 Leisure-time physical activity, n (%) Low Moderate High Heart rate (beats/min), mean (SD) BP (mmHg), mean (SD) Systolic Diastolic Plasma glucose (mmol/l), mean (SD) Serum cholesterol (mmol/l), mean (SD) Serum LDL cholesterol (mmol/l), mean (SD) Serum HDL cholesterol (mmol/l), mean (SD) Serum triglycerides (mmol/l), mean (SD) Perceived to have sufficient sleep, N (%) Felt rested in the morning
165 53 12.0 26.8 67
(40) (10) (3.4) (4.6) (16)
Without depression (B) N ¼ 256 67 53 11.0 27.9 59
Non-melancholic depression (C) N ¼ 149
(26) (11) (3.3) (5.9) (23)
48 51 11.1 28.0 40
(32) (10) (3.0) (5.1) (27)
Melancholic depression (D) N ¼ 290 83 51 11.0 28.1 102
(29) (10) (3.1) (6.2) (35)
p-value
ISSN: 0803-9488 (Print) 1502-4725 (Online) Journal homepage: http://www.tandfonline.com/loi/ipsc20
Prevalence of restless legs symptoms according to depressive symptoms and depression type: a cross-sectional study Piritta Auvinen, Pekka Mäntyselkä, Hannu Koponen, Hannu Kautiainen, Katariina Korniloff, Tiina Ahonen & Mauno Vanhala To cite this article: Piritta Auvinen, Pekka Mäntyselkä, Hannu Koponen, Hannu Kautiainen, Katariina Korniloff, Tiina Ahonen & Mauno Vanhala (2017): Prevalence of restless legs symptoms according to depressive symptoms and depression type: a cross-sectional study, Nordic Journal of Psychiatry, DOI: 10.1080/08039488.2017.1385849 To link to this article: http://dx.doi.org/10.1080/08039488.2017.1385849
Published online: 09 Oct 2017.
Submit your article to this journal
Article views: 9
View related articles
View Crossmark data
Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=ipsc20 Download by: [RMIT University Library]
Date: 16 October 2017, At: 07:40
NORDIC JOURNAL OF PSYCHIATRY, 2017 https://doi.org/10.1080/08039488.2017.1385849
ORIGINAL ARTICLE
Prevalence of restless legs symptoms according to depressive symptoms and depression type: a cross-sectional study Piritta Auvinena , Pekka M€antyselk€aa,b, Hannu Koponenc, Hannu Kautiainend,e,f, Katariina Korniloffg, Tiina Ahonenh and Mauno Vanhalai
Downloaded by [RMIT University Library] at 07:40 16 October 2017
a Institute of Public Health and Clinical Nutrition, General Practice Unit, University of Eastern Finland, Kuopio, Finland; bPrimary Health Care Unit, Kuopio University Hospital, Kuopio, Finland; cDepartment of Psychiatry, University of Helsinki and Helsinki University Hospital, Helsinki, Finland; dPrimary Health Care Unit, Kuopio University Hospital, Kuopio, Finland; eUnit of Primary Health Care, Helsinki University Central Hospital, Helsinki, Finland; fDepartment of General Practice, University of Helsinki, Helsinki, Finland; gSchool of Health and Social Studies, JAMK University of Applied Sciences, Jyv€askyl€a, Finland; hPrimary Health Care Unit, Central Finland Central Hospital, Jyv€askyl€a, Finland; i Central Finland Central Hospital, Jyv€askyl€a, Finland
ABSTRACT
ARTICLE HISTORY
Background: Restless legs syndrome is a sensorimotor disorder and it is associated with several other diseases especially mental illnesses. Aims: To analyze the relationship between the symptoms of restless legs syndrome and the severity of depressive symptoms and the prevalence of restless legs symptoms in depression subtypes. Methods: A cross-sectional study of primary care patients in the Central Finland Hospital District. The prevalence of restless legs symptoms was studied in 706 patients with increased depressive symptoms and 426 controls without a psychiatric diagnosis by using a structured questionnaire. The depressive symptoms were evaluated with the Beck Depression Inventory (BDI) and the psychiatric diagnosis was confirmed by means of a diagnostic interview (Mini-International Neuropsychiatric Interview). The subjects with increased depressive symptoms were divided into three groups (subjects with depressive symptoms without a depression diagnosis, melancholic depression and non-melancholic depression). Results: In the whole study population, the prevalence of restless legs symptoms increased with the severity of depressive symptoms. The prevalence of restless legs symptoms was highest in the melancholic and non-melancholic depressive patients (52 and 46%, respectively) and then in subjects with depressive symptoms without a depression diagnosis (43.4%), but the prevalence was also substantial (24.6%) in subjects without a psychiatric diagnosis. Conclusions: Restless legs symptoms are very common in primary care among subjects with depression, regardless of the depression type. The prevalence of restless legs symptoms increased with increasing severity of depressive symptoms, regardless of the diagnosis. These findings should be considered in clinical evaluation and treatment of patients visiting their physician due to restless legs or depressive symptoms.
Received 1 November 2016 Revised 30 August 2017 Accepted 25 September 2017
Introduction Restless legs syndrome is a common sensorimotor disorder [1]. The main symptoms of restless legs syndrome are characterized by an unpleasant sensation in the limbs that appears at rest in the evening or during the night [2], but daytime symptoms are also common [3,4]. Patients describe the symptoms as, for example, ‘a need to move’, ‘crawl’, ‘tingle’ and ‘ache’ [5]. In addition, patients suffer from an urge to move their limbs, particularly the legs. Moving or stretching the legs relieves the symptoms [2]. These symptoms are related to sleep disturbances and insomnia, because patients have difficulty getting to sleep and they wake up several times a night [6,7]. In previous studies, the prevalence of restless legs syndrome has been between 5% and as much as 24% in the primary care patient population [8–13]. Knowledge about CONTACT Piritta Auvinen [email protected] 1627, FI-70211 Kuopio, Finland ß 2017 The Nordic Psychiatric Association
KEYWORDS
Restless legs syndrome; depressive disorder; melancholia; depression; primary health care
restless legs syndrome pathophysiology and clinical experience have increased during the last decade [2,14]. The exact pathophysiology of restless legs syndrome is not known, but several different theories such as deficient dopaminergic neurotransmission, iron deficiency, opioid system abnormalities [15,16], genetics [17] and peripheral hypoxia [18] have been suggested. There are effective medical treatments for restless legs symptoms, including dopaminergic agents and calcium-channel ligands such as pregabalin [19,20]. Even though knowledge about restless legs syndrome has increased, it is still an underdiagnosed and undertreated syndrome [21,22]. Restless legs symptoms impair the quality of life due to disturbance of sleep and normal daily activities, feelings of pain and anxiety, among other things [8,23,24]. There are numerous studies about the relationship between depressed
University of Eastern Finland, Institute of Public Health and Clinical Nutrition, General Practice Unit, P.O.B.
2
P. AUVINEN ET AL.
Downloaded by [RMIT University Library] at 07:40 16 October 2017
mood or depression and restless legs symptoms [12,25–28]. However, previous studies have not analyzed this relationship between different subtypes of depression, for example, nonmelancholic or melancholic depression. Melancholic depression manifests itself as psychomotor slowing, a distinct quality of mood, social withdrawal, body immobility, slowed speech, a non-reactive mood or a loss of emotion. Nonmelancholic depression symptoms include minimal or absent psychomotor dysfunction, tearfulness and mood reactivity [29,30], and it has been found to be associated with metabolic syndrome [31], as well. While restless legs symptoms have been found to be associated with metabolic disturbances [32,33], it could be hypothesized that restless legs symptoms are more common among subjects with nonmelancholic depression than with melancholic depression.
Aims Due to non-existent data on the prevalence of restless legs symptoms in various subtypes of depression in primary care, we decided to study restless legs symptoms in a geographically defined sample of primary care patients with depressive symptoms without a depression diagnosis, non-melancholic depression or melancholic depression and population-based control subjects without a psychiatric diagnosis. In addition, the relationship between restless legs symptoms and the severity of depressive symptoms was also scrutinized.
Material and methods New patients over 35 years of age who went themselves or were referred by a general practitioner to a depression nurse case manager in 2008–2009 due to depressive symptoms and a score higher than 10 in the Beck Depression Inventory (BDI) were enlisted in this study. Altogether, 706 patients were involved. The study was conducted in municipalities belonging to the Central Finland Hospital District [the Finnish Depression and Metabolic Syndrome in Adults (FDMSA) study] with a catchment area of 274,000 residents. Notification was based on written and oral patient information and written consent was obtained before any study procedures. The study protocol was approved by the Ethics Committee of the Central Finland Hospital District. All the participants filled in a standard questionnaire form containing questions about previously diagnosed somatic disorders and use of medications, including antidepressants and hormone replacement therapy in females. Data on current smoking, years of education, use of alcohol (number of drinks per week) and leisure-time physical activity (number of 30-min exercise sessions) were also collected. Leisure-time physical activity was classified low (0–2 sessions per month), moderate (1–2 sessions per week) and high (three or more sessions per week). Quality of sleep was evaluated with two structured questions about sufficient sleep and feeling rested in the morning. Sufficient sleep was evaluated by a question ‘Do you think that your sleep is sufficient (1 ¼ yes, almost always; 2 ¼ yes, often; 3 ¼ rarely or hardly ever; 4 ¼ I cannot say)’. Subjects responding ‘almost’ or ‘often’ were regarded
as having sufficient sleep. Feeling rested in the morning was evaluated by a question ‘How tired do you feel during the first 30 minutes after you have woken up in the morning (1 ¼ very tired; 2 ¼ quite tired; 3 ¼ quite rested; 4 ¼ I feel fresh)?’ Subjects responding ‘quite rested’ or feeling fresh were regarded as rested in the morning. Glucose and lipid level determinations were based on fasting blood samples that were drawn between 8 and 11 o’clock after 12 h of fasting. Serum total cholesterol, highdensity lipoprotein (HDL) cholesterol, low-density lipoprotein (LDL) cholesterol, triglycerides and plasma glucose were analyzed using Modular Analytics SWA (Hitachi HighTechnologies Corporation, Tokyo, Japan). The severity of depressive symptoms was measured with the 21-item BDI [34], which was completed by the participants. The psychiatric diagnosis was confirmed with a diagnostic interview (Mini-International Neuropsychiatric Interview (M.I.N.I.) [35]) conducted by a trained study nurse [36]. Among the whole study population, 439 subjects had a BDI score of 10 or higher and the diagnosis of depression was determined with a diagnostic interview (M.I.N.I.). The melancholic subtype was identified by M.I.N.I. criteria for major depressive episode with melancholic features [35,37,38]. The participants’ restless legs symptoms were detected by using a structured and tested question that takes into account the core marks of restless legs discomfort: an urge to move the legs, primarily during rest or inactivity, and partial or total relief with movement, with presence or worsening exclusively in the evening or at night. According to the previous validation study, the questionnaire had 100% sensitivity and 96.8% specificity. Moreover, likelihood ratio for a positive result (LRþ ¼31,25) adverted to the positive test had conclusive increase in the probability of restless legs syndrome [11]. Random sampling was used to select a group of 426 middle-aged (> 35 years) persons as controls from residents in the participating municipalities. Concurrently with the patient recruitment in 2008–2009, an age, sex and community-stratified random sample representing the population in the study region was taken by the Statistics Finland (http://www.stat.fi). All the subjects in the control group had a BDI score below 10 and no psychiatric diagnosis or current depressive symptoms and they used no psychoactive medications. There were a total of 27 subjects in all four study groups who did not answer the question about the symptoms of restless legs syndrome, resulting in a total number of 1105 study subjects.
Statistical analysis Statistical significance between groups was tested with analysis of variance, the Kruskal–Wallis test and the chi-square test. We investigated the relationship between prevalence of restless legs symptoms and depression groups using a crude and adjusted logistic regression models. Model adjusted using age, smoking, education years, body mass index, physical activity and education years. A possible non-linear relationship between prevalence of restless legs symptoms
NORDIC JOURNAL OF PSYCHIATRY
3
Table 1. Demographic and clinical traits of the subjects. 21-Item Beck Depression Inventory 10
Downloaded by [RMIT University Library] at 07:40 16 October 2017
Controls (A) N ¼ 410 Male, n (%) Age, mean (SD) Education years, mean (SD) Body mass index (kg/m2), mean (SD) Current smoking, n (%) Alcohol use, doses, n (%) 0 1–9 10 Leisure-time physical activity, n (%) Low Moderate High Heart rate (beats/min), mean (SD) BP (mmHg), mean (SD) Systolic Diastolic Plasma glucose (mmol/l), mean (SD) Serum cholesterol (mmol/l), mean (SD) Serum LDL cholesterol (mmol/l), mean (SD) Serum HDL cholesterol (mmol/l), mean (SD) Serum triglycerides (mmol/l), mean (SD) Perceived to have sufficient sleep, N (%) Felt rested in the morning
165 53 12.0 26.8 67
(40) (10) (3.4) (4.6) (16)
Without depression (B) N ¼ 256 67 53 11.0 27.9 59
Non-melancholic depression (C) N ¼ 149
(26) (11) (3.3) (5.9) (23)
48 51 11.1 28.0 40
(32) (10) (3.0) (5.1) (27)
Melancholic depression (D) N ¼ 290 83 51 11.0 28.1 102
(29) (10) (3.1) (6.2) (35)
p-value
