Grima et al. BMC Medicine (2018) 16:8 DOI 10.1186/s12916-017-0995-1 RESEARCHARTICLE Open Access Efficacy of melatonin for sleep disturbance following traumatic brain injury: a randomised controlled trial Natalie A. Grima1, Shantha M. W. Rajaratnam2, Darren Mansfield3, Tracey L. Sletten2, Gershon Spitz2 and Jennie L. Ponsford2,4* Abstract Background: The study aimed to determine the efficacy of melatonin supplementation for sleep disturbances in patients with traumatic brain injury (TBI). Methods: This is a randomised double-blind placebo-controlled two-period two-treatment (melatonin and placebo) crossover study. Outpatients were recruited from Epworth and Austin Hospitals Melbourne, Australia. They had mild to severe TBI (n = 33) reporting sleep disturbances post-injury (mean age 37 years, standard deviation 11 years; 67% men). They were given prolonged-release melatonin formulation (2 mg; Circadin®) and placebo capsules for 4 weeks each in a counterbalanced fashion separated by a 48-hour washout period. Treatment was taken nightly 2 hours before bedtime. Serious adverse events and side-effects were monitored. Results: Melatonin supplementation significantly reduced global Pittsburgh Sleep Quality Index scores relative to placebo, indicating improved sleep quality [melatonin 7.68 vs. placebo 9.47, original score units; difference -1.79; 95% confidence interval (CI), -2.70 to -0.88; p ≤ 0.0001]. Melatonin had no effect on sleep onset latency (melatonin 1.37 vs. placebo 1.42, log units; difference -0.05; 95% CI, -0.14 to 0.03; p = 0.23). With respect to the secondary outcomes, melatonin supplementation increased sleep efficiency on actigraphy, and vitality and mental health on the SF-36 v1 questionnaire (p ≤ 0.05 for each). Melatonin decreased anxiety on the Hospital Anxiety Depression Scale and fatigue on the Fatigue Severity Scale (p ≤ 0.05 for both), but had no significant effect on daytime sleepiness on the Epworth Sleepiness Scale (p = 0.15). No serious adverse events were reported. Conclusions: Melatonin supplementation over a 4-week period is effective and safe in improving subjective sleep quality as well as some aspects of objective sleep quality in patients with TBI. Trial registration: Identifier: 12611000734965; Prospectively registered on 13 July 2011. Keywords: Sleep, Insomnia, Traumatic brain injury, Acquired brain injury Background high prevalence, sleep disturbances are often overlooked Sleep disturbances are commonly reported following trau- in the TBI population and evidence-based treatments are matic brain injury (TBI), occurring across the spectrum of lacking [3]. Consequently, untreated sleep disturbances severity and persisting years following injury [1, 2]. following TBI contribute to ongoing cognitive dysfunction Insomnia and hypersomnia are among the most preva- [4], poorer rehabilitation outcomes [5], lower productivity lent sleep disorders in TBI patients [2, 3]. Despite a [6] and poorer functional status [7]. Although numerous mechanisms may contribute to sleep disturbance in TBI [1], our research demonstrates * Correspondence: [email protected] that TBI is associated with attenuated and delayed mela- 2School of Psychological Sciences, Monash University, 18 Innovation Walk, Clayton Campus, Wellington Road, Melbourne, Victoria 3800, Australia tonin profiles [8, 9]. Specifically, we observed reduced 4Monash-Epworth Rehabilitation Research Centre, Epworth Healthcare, 89 evening [9] and overnight melatonin [8] production in Bridge Road, Richmond 3121, Victoria, Australia TBI patients compared to age and sex matched controls, Full list of author information is available at the end of the article © The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Grima et al. BMC Medicine (2018) 16:8 Page 2 of 10 with evening melatonin production positively correlated (PTA). All participants had an identifiable sleep com- with REM sleep [9]. As endogenous melatonin has plaint corroborated by a Pittsburgh Sleep Quality Index sleep-promoting effects and is involved in the circadian (PSQI) global score ≥8, followed by a confirmed diagno- control of the sleep–wake cycle, attenuated melatonin sis of chronic insomnia according to the International profiles may contribute to sleep-related disturbances fol- Classification of Sleep Disorders, 3rd Edition [13]. A glo- lowing TBI. Thus, restoring melatonin with supplemen- bal PSQI of 8 has been shown to have high specificity tation may help to alleviate sleep disturbances in and sensitivity to a diagnosis of insomnia in patients individuals with TBI. The aim of the current study was with TBI [14]. Participants were excluded if they self-re- to evaluate the effect of melatonin supplementation ported sleep problems, fatigue or neurological conditions (2 mg/d) on sleep quality in patients with TBI reporting prior to TBI; were pregnant (screened with a blood test); sleep disturbances. had undertaken trans-meridian travel across more than onetimezoneorworkednightshiftsinthepreceding Methods three months; were deemed at a high risk of obstructive Trial design sleep apnoea by responses on the Berlin Questionnaire; A randomised placebo-controlled double-blind two- reported consuming non-prescription sleep medication, period two-treatment crossover phase III clinical trial benzodiazepines or hypnotics in the preceding 6 weeks; or was conducted. In light of the known heterogeneity be- used illicit or psychoactive substances in the previous tween TBI patients and sleep disturbances in this popu- 12 months. Participants’ urine was screened to rule out lation, the use of a crossover design minimised the illicit substance use. Participants were permitted to con- influence of confounding covariates, such as injury- tinue with ongoing rehabilitative treatment and allowable related characteristics and factors contributing to sleep medications (refer to Table 1), provided that the dosage did disturbances, such as mood, anxiety and pain. The study not change during the study. Participants were not permit- was conducted in accordance with the Declaration of ted to commence new interventions or medications during Helsinki and it was approved by Monash University the entirety of the trial. To ensure compliance, participants (CF11/1900-2011001061), Epworth HealthCare (52111) were sent daily text messages asking them to consume and Austin Health (H2013/04950) human research their medication and to fill in their sleep diary. They were ethics committees. Participants gave informed consent also contacted weekly to monitor for adverse symptoms. If before taking part. The clinical trial was prospectively new medications were needed during the trial, the partici- registered with the Australian New Zealand Clinical pant’s prescribing physician was contacted and treatment Trials Registry (12611000734965) in July 2011. deferred to study completion. The study was conducted from August 2011 until Interested participants were screened for eligibility after November 2016, with the first patient enrolled on 9 providing verbal consent. Their medical history was cor- April 2012. The 10-week study comprised a 2-week roborated from hospital records. Participants satisfying baseline run-in period followed by two treatment pe- the inclusion criteria were referred to a sleep physician riods, during which participants received either mela- (DM) for clinical examination to rule out respiratory sleep tonin or placebo for 4 weeks, followed by a crossover disorders according to the American Academy of Sleep with the alternative treatment for a further 4 weeks, Medicine’s international classification of sleep disorders separated by a 48-hour washout period. The washout [15]. All participants were deemed in good health, estab- period was chosen to minimise the carry-over of treatment lished by physical examination, blood biochemistry, urine [10–12], and to provide time for medication turnaround toxicology and body mass index (BMI) less than 35 kg/m2. and recharging of the Actiwatch. Patient involvement Participants The rationale for the study was based on self-reports from People with acquired brain injury from trauma (TBI) or people with TBI who told us that sleep was a significant stroke were eligible to participate in the study. However, problem. This study involved a community-based sample, as only three stroke patients completed treatment, this and no patients, caregivers or laypeople were involved in manuscript reports only on patients with TBI. Partici- developing the research question or study design. Neither pants were community-dwelling adults, aged 18 to patients nor laypersons assisted with the conceptualisation 65 years, who had sustained mild to severe TBI. We re- of the study or outcome measures, the interpretation of cruited participants from Epworth and Austin Hospitals the results or drafting the manuscript. Outcome measures via referrals from physicians and allied health profes- were selected based on previous studies on sleep and TBI sionals. TBI participants