‘Tas Joona op Nenvous ano Mewes Disa Conyrieit @ 114 by The Wiles & Wilkins Ca FIRST NIGHT EFFECT REVISITED: A CLINICAL NOTE DAVID J, KUPFER, MD,} BRIAN L. WEISS, M.D, THOMAS P, DETRE, MD, ‘sso F. GORDON FOSTER, M.D. Tthas been a neatly universal practice among sleep researchers not to use the first night or two of recordings because of “adaptational artifact.” Since this custom is costly and might result in the inadvertent loss of valuable data, this study examines the records of the first two nights and compares them with records obtained in subsequent recordings (third and fourth nights). Thirty-five psychiatric inpatients wore studied for four consecutive nights. Several diagnostic groups were represented: psyehotie (V = 7) and nonpsychotie (= 12) unipolar depressives and nonpsychotie bipolar (V = 5) depressives, schizophrenia (NV = 7) and others (N = 4). Re- sults indicate a striking constaney in nearly all sleep parameters when nights 1 and 2 were compared to nights 3 and 4 for the entire sample, Of the 26 sleep parameters investigated, only sleep Iateney differed significantly ‘on the latter two nights. Similarly, no significant differences were found in comparing nights 1 and 2 to nights 3 and 4 in any of the diagnostic sub- groups. The implications of these findings to inpatient and outpatient ot 17, No. Prise in USA sleep research are discussed. Since its introduction by Berger over 40 yeurs ago, the electroencephalogram (EEG) nas become a valuable tool in the diagnosis of various neurological disorders, especially seizure states. With the discovery of REM sleep in 1953 (2), clinicians became inter- ested in conducting all-night sleep EEG studies in an effort to identify characteristic patterns that eould be used in the diagnosis of mental illness, an approach that has al- ready yielded significant findings in the study of affective disorders (10). Gradu- ally, methods of recording and interpreting sleep EEG studies have been standardized and it is now possible to compare studies originating from different laboratories. Be- cause of the long held tradition that the first night or two represents the adaptation to a new envitonment (1, 9), to date the "Department of Paychistry, University of Pittsburgh School of Medicine, and Weetern Dey chiatric Tastitute and Clinic, 3811 O'Hara Street, Pittsburgh, Penneylvanie 15261 “The authors wish to thank Richard MePartland for his technical sosatanoe and the aursing sail of the search ward for thei invaluable help. This work was supported in pact by a Research Scientist Development Award KOI-M-70012 to D. J. Kupfer records of the initial period have usually not been utilized except in few cases (7). ‘Thus, the results from sleep studies have usually been based on several consecutive (postadaptational) nights of recording for each patient. Since this practice represents an important inerement in cost and time, we decided to examine the records of the first two nights and compare them with rec- ords obtained in subsequent recordings (third and fourth nights) to determine whether valuable information was unneces- sarily being discarded. ‘Thirty-five psychiatric inpatients (14 males and 21 females with « mean age of 40.6 + 2.5) were studied for four consecu- tive nights on the clinical research unit. A structured diagnostic interview, self-rating symptom form, and clinical behavior symp- tom form were used to establish the diggno- sis in each case (4). On the basis of the clinical ratings,? patients were divided into several groups: psyehotie (NV = 7) and * Copies of the clinical retings used in this study are available upon request from Dr. David J. Kupfer. 205,206 KUPFER nonpsychotic 12) unipolar depres- sives and nonpsychotio bipolar (N = 5) depressives; schizophrenia, chronic or re- current (N= 7) and other diagnoses ( 4). ‘The thirty-five patients were studied by continuous nightly recordings of their BEG, horizontal eleetrooculogram (BOG) and submental electromyogram (EMG) while they slept in their own rooms on the re- search ward. Patients reeeived no medica tion for at least 14 days prior to initiating sleep studies and no medications were dis- pensed during the studies. The majority (80 per cent) of our patients had been drug-free prior to admission and hence sleep studies ‘were begun within the first few days of their admission. Methods used in obtaining and scoring our sleep studies have been de- scribed previously (5). The 140 sleep ree- ords were evaluated according to the Recht- TABLE 1 Mean Non-REM Steep Parameters (se S.E.M.) Jor the Entire Sample eh 3nd ‘Total recording perivd (TRP 218 |urs 238 sleep latency (SL), = 8s [3.2 289 ening (EMEA) £07 | 276 2 85 Intermittent wwak- ening (A) +04 TESS ‘Time spen: asleep (TSA), sb W8p7T1 £188 ‘Time spent asieep/ time recording period (PSA/TRP), 71.7 + 2.7 | 73.6 + 2.6 Delta #28 188555 Non-REM cleep (NREM) to.son2.2 14 Stage 1 = 3.9 (80.0 445 Stage 2 910 bos.s + 0's Stage 3 = 23/168 3.0 Stage 4 09] 2112 Non-REM sleep % (NREM %) $11 | 817 £22 Stage 1%. = 10/169 3.6 Stage 2% a4 | 08.0 = 25 Intermittent _awak- ening % (AM) tit] 6a a1 “©All measurements in minutes unless s0 indi- cated, p< 08 using the two-tailed Lest for paired observations BP AL. schaffen and Kales eriteria (8) by a scorer unaware of the patients’ clinical status. In addition, each minute of recon! was scored on a 9-point (0 to 8) scale for REM patterns, the sum for the entire night pro- viding the measure of “REM activity.” Paired (-tests were performed to obtain sta~ tistical confidence levels on the sleep data {or particular nights or groups of nights. esuLns We first compared the mean values for the various sleep parameters for the first ‘vo nights with the mean values for nights 3 and 4. As Tables 1 and 2 indicate, there was in fact a remarkable constancy in nearly all sleep parameters when nights 1 and 2 were compared to nights 3 and 4. Not only were the absolute values similar, but the intervals between consecutive REM pe- riods (T 1-2, T 2-8, T 3-4) as well as other measures of sleep’ architecture were also virtually unchanged. Of the 26 sleep pa- rameters investigated, only sleep latency (SL) differed significantly on nights 3 and 4, being reduced by an average of 14 min- utes, ‘When the four nights of sleep were com pared to each other (Table 3) for the entire sample, 00 significant. differences were found between nights 1 and 2 nor were there significant differences when nights 1 ‘TABLE 2 Mean REM Sloop Parameters (de S.E.M.) for ‘he Batre Sample , REM activity (A) REM index (1, REM activity tire spent asleep (RA/TSA) Tie T23 rsa. ‘No, of REM periods Stage REM % Amount of period: O atio of REM activity to stage REM time, “Interval between consecutive REM periodsINST NIGHT EFFECT 207 TABLE 3 Mean Valves of Sleep Parameters (de S.H.M.) on Individual Nights for the Entire Sample Night | iene 2 ‘Night ree. 42.5 £89) 445.6 = 10.1 SL. 85.0 223 37.0 = 10.9, EMA aL #51 6 £76 A 38.5 aia 40.2 29.3 TSA 19.8 = Skt 200.8 = 17.0 Tsa/TRP. 0.3 & #31 71.3 £44 RL oo raat ors eB, RT. 553 #51 06.0 = 5.2 Ra mas bt 130.6 + 5, No. of REM periods | 2.3 £02, 3840.2 NEM, 22.0 & +185 DLs edt Stage 1 31.3 #40 1k a Stage 2 2067 =D7 100.2 + 128 Delta wet £30 16.1 3.3 ‘or 2 were compared to nights 3 or 4. Simi- larly, no significant differences were found in comparing nights 1 and 2 with nights 3 and 4 in any of the diagnostic subgroups (Table 4). In order to determine whether these findings were characteristic of subgroups of depressives, the sample was divided into psychotic unipolar depressives, nonpsyehotie unipolar depressives, and bi- polar depressives. As in our previous studies (6), their records were characterized by sleep fragmentation, reduced REM latency and reduced delta sleep, but no significant changes among nights 1, 2, 8, and 4 were noted (Table 5). iscusstoN In contrast to observations reported from studies of normal subjects, where the first and possibly the second night of laboratory sleep contain more awake periods and re- duced REM sleep in association with an inereased REM latency than do succeeding nights of laboratory sleep, very few differ- ences in sleep parameters were noted in our psychiatric inpatients over the four consec- utive nights. In particular, the comparison of the first two nights with the third and fourth nights (the nights most often used for baseline data in clinical studies) yielded results which were markedly similar. Not only were the absolute values of the variou sleep parameters virtually unchanged, but the architecture of the sleep stages #ls0 re- TABLE 4 Mean Sleep Parameters (2 S.E.M.) for the Schizophrente Subgeosy fe waa | Bae Babi “Ras Be | aS RT, 40.9 £ 3.4 | 49.8 BE RRS Bo ga mained fairly constant throughout the four nights. This finding is in agreement. with tho Mendels and Hawkins study of de- pressed patients, where it was shown that with the exception of stage 2 sleep, sleep parameters between the first and second nights were quite similar (7). Tt is true that the sleep latency was reduced during the third and fourth nights, results which mav208 KUPPER 5 Az. TABLE 5 Mean Sleep Parameters (4 S.E.M.) for Depressive Subgroups ‘Uniple Nonsyehatic Pipes Nonerebace ‘Uniptar Poyhotc | iets tand2 | Sipbeesands | igh and 2 2 TRE. $00.0 © 8.9 | 404.3 & 12.6] 180.5 4 21.1) 401.8 a 25.0] 444.8 20.91447.9 = 18.6 SL. 70.0 # 13.4) 56.5 + 13.7] 42.0 43.0 | 18248 / 47 & 19.0 S40 4 0.6 EMA, $52 295.5 7 40.5 | 6 £02) 88275) 04 1081 46.5 + 188 A 37 285) 902 49:8 | 45.9 = 25.0 16.6251 65.0 4 11.5] 81.5 + 20.7 ‘TSA 818.0 a 29.2| 890-4 -k 21.7] 480.2 2417] 907-6 -k 80.1] 806.9 24.01200.1 12. TSATHE || O92 + 5.6] T0248] Tea 4a] 856 £24] 08.8 4 4.0] 088 x 40 RL. Bo £00| M3473 | SLT e127] 43% 18.9 178 = 5.0/2.7 + OP RT, O62 277 | 12491) Se7 S22] Be 80) B79 = 9.8 60.0 & 91 Ra, 190.7 3 22.6) 177.5 24.5) 124.6 oe 25.7] 122-4 3 27.7, 142.5 & 38.2)08.9 35.0 NREM. || 258.0 4 10:5, 201-0 17,9) 302.1 ot 24.1] $20.7 = 92.5 D19.4 & 19.0)007.8 & 17.0 Stage 1 35.2 25.6| 78 LOG) TS +63) HS eA8| S21 2 7.8[ 5.7 48.8 Stage 2..| 218.3 19.5] 218.0 4 11.0] 25815 + 25.9) 250.8 a 85.8] 189.4 = 16.0199.6 = 17.7 Delta. Woeai| 91236 wo FO7| 8248.0) 96.0) 76226 No. of REM periods | 3.4203] 35408| 44405) 41403 405/ 39405 be important in the evaluation of short term studies on hypnoties. ‘As described in earlier reports, the lowest REM latency (178 minutes) was found in the psychotic depressives (8), Of the find ings reported here and in previous studies, the reduced REM latoney in depressive syndromes appears to be particularly strik- ing in that studies with normal subjects showed that the REM latency on the first night or two tends to be prolonged; while in this investigation REM lateney is higher on subsequent nights, at least in certain de- pressives. If confirmed in « larger saxople, this “paradoxical” inerease in REM latency might have broader implications in the di- agnostic evaluation of depressed patients ‘The difference between our findings and those studies on normals could imply that the so-called first night effect in the “nor~ mal subject” or psyehiatrie outpatient rep- resents a normal stress response to @ novel situation, a response which extinguishes over succeeding nights as the subject, be- ‘comes more comfortable in his new environ- ‘ment. The lack of adaptation shown by the payehiatrie inpatient. who shows virtually no ehange in sleep pattern over at least the fins four nights may, in fact, be evidence of lessened adaptability to siress-provoking situations or, in other words, simply # man- ifestation of impairment. Tn fact, that ad aptation may not occur throughout hospi- ‘alization is supported by findings from our longitudinal studies. Since the majority of our psychiatric inpatients were sleep stud- ied within the first few days of admission, often on the first night of hospitalization, prior adaptation to the research ward can be ruled out as the basis for this lack of adaptation, REFERENCES 1. Agnew, H. W., Webb, W. B, and Williams, R. ‘L.'The fret'night effect: An BBG study of tleep. Payehophysiology, #: 269-288, 1066 2. Amrinsky, Band Kleiman, N. Regulaely ‘occurring periods of eye motility and con- ‘omitent phenomena during sleep. Seience, 11g! 273-244, 1953. 8, Kupfer, D. J, and Foster, F, G. Interval be- Ihwcen anset of sleep and rapid eye movement sleep as an indieator of deprestion. Lenoct, 22054086, 1972 4. Kupfer, D. J, and Foster, F. G. Sleep and ac- tivity in a! payehotic doprossion. J. Nerv Ment. Dis, 180: 941-848, 1973 5. Kupfer, D. J, and Heninger, G. R. REM ac tivity) ask correlate of ‘mood changes throwghout the night. Arch. Gen. Pevehistry, 27 388.873, 1972. 6. Kupfer, D. J, Foster, F. 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