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Dreyer RP, Berkowitz A, Yaggi HK, Schneeberg L, Shah ND, Emanuel L, Kolla B, Jeffery MM, Deeg M, Ervin K, Thorndike F, Ross JS. Pre Scription Digita L Th Erap Eutic for Patients with Insomnia ( SLEEP-I): a protocol for a pragmatic randomised controlled trial. BMJ Open 2022; 12:e062041. [PMID: 35940841 PMCID: PMC9364397 DOI: 10.1136/bmjopen-2022-062041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Accepted: 07/17/2022] [Indexed: 11/25/2022] Open
Abstract
INTRODUCTION Cognitive behavioural therapy for insomnia (CBT-I) is effective at treating chronic insomnia, yet in-person CBT-I can often be challenging to access. Prior studies have used technology to bridge barriers but have been unable to extensively assess the impact of the digital therapeutic on real-world patient experience and multidimensional outcomes. Among patients with insomnia, our aim is to determine the impact of a prescription digital therapeutic (PDT) (PEAR-003b, FDA-authorised as Somryst; herein called PDT) that provides mobile-delivered CBT-I on patient-reported outcomes (PROs) and healthcare utilisation. METHODS AND ANALYSIS We are conducting a pragmatically designed, prospective, multicentre randomised controlled trial that leverages Hugo, a unique patient-centred health data-aggregating platform for data collection and patient follow-up from Hugo Health. A total of 100 participants with insomnia from two health centres will be enrolled onto the Hugo Health platform, provided with a linked Fitbit (Inspire 2) to track activity and then randomised 1:1 to receive (or not) the PDT for mobile-delivered CBT-I (Somryst). The primary outcome is a change in the insomnia severity index score from baseline to 9-week postrandomisation. Secondary outcomes include healthcare utilisation, health utility scores and clinical outcomes; change in sleep outcomes as measured with sleep diaries and a change in individual PROs including depressive symptoms, daytime sleepiness, health status, stress and anxiety. For those allocated to the PDT, we will also assess engagement with the PDT. ETHICS AND DISSEMINATION The Institutional Review Boards at Yale University and the Mayo Clinic have approved the trial protocol. This trial will provide important data to patients, clinicians and policymakers about the impact of the PDT device delivering CBT-I on PROs, clinical outcomes and healthcare utilisation. Findings will be disseminated to participants, presented at professional meetings and published in peer-reviewed journals. TRIAL REGISTRATION NUMBER NCT04909229.
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Affiliation(s)
- Rachel P Dreyer
- Department of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut, USA
- Department of Biostatistics, Yale University School of Public Health, New Haven, Connecticut, USA
| | - Alyssa Berkowitz
- Center for Outcomes Research and Evaluation, Yale-New Haven Health, New Haven, Connecticut, USA
| | - Henry Klar Yaggi
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Lynelle Schneeberg
- Department of Psychiatry, Yale School of Medicine, New Haven, Connecticut, USA
| | - Nilay D Shah
- Department of Health Sciences Research, Mayo Clinic, Rochester, New York, USA
| | - Lindsay Emanuel
- Department of Health Sciences Research, Mayo Clinic, Rochester, New York, USA
| | - Bhanuprakash Kolla
- Department of Psychiatry and Psychology, Mayo Clinic, Rochester, New York, USA
| | - Molly Moore Jeffery
- Department of Quantitative Health Sciences, Mayo Clinic, Rochester, New York, USA
| | - Mark Deeg
- Cullgen Inc, Boston, Massachusetts, USA
| | - Keondae Ervin
- National Evaluation System for Health Technology Coordinating Center (NESTcc), Arlington, Virginia, USA
| | | | - Joseph S Ross
- Center for Outcomes Research and Evaluation, Yale-New Haven Health, New Haven, Connecticut, USA
- Internal Medicine, Yale School of Medicine, New Haven, Connecticut, USA
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Optimizing computation of overnight decline in delta power: Evidence for slower rate of decline in delta power in insomnia patients. Clin Neurophysiol 2021; 132:545-553. [PMID: 33450577 DOI: 10.1016/j.clinph.2020.12.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2019] [Revised: 08/12/2020] [Accepted: 12/07/2020] [Indexed: 10/22/2022]
Abstract
OBJECTIVE To determine the best of commonly used methods for computing the rate of decline in non-rapid eye movement (NREM) sleep EEG delta power overnight (Delta Decline) in terms of vulnerability to missing data and to evaluate whether this rate is slower in insomnia patients than healthy controls (HC). METHODS Fifty-one insomnia patients and 53 HC underwent 6 nights of polysomnography. Four methods for estimating Delta Decline were compared (exponential and linear best-fit functions using NREM (1) episode mean, (2) peak, and (3) total delta power and (4) delta power for all available NREM epochs). The best method was applied to compare groups on linear and exponential rates of Delta Decline. RESULTS Best-fit models using all available NREM epochs were significantly less vulnerable to deviation due to missing data than other methods. Insomnia patients displayed significantly slower linear and exponential Delta Decline than HC. CONCLUSIONS Computing Delta Decline using all available NREM epochs was the best of the methods studied for minimizing the effects of missing data. Insomnia patients display slower Delta Decline, which is not explained by differences in total sleep time or wake after sleep onset. SIGNIFICANCE This study supports using all available NREM epochs in Delta Decline computation and suggests a slower rate in insomnia.
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Chan NY, Chan JWY, Li SX, Wing YK. Non-pharmacological Approaches for Management of Insomnia. Neurotherapeutics 2021; 18:32-43. [PMID: 33821446 PMCID: PMC8116473 DOI: 10.1007/s13311-021-01029-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/15/2021] [Indexed: 02/06/2023] Open
Abstract
Insomnia is a prevalent sleep problem associated with a constellation of negative health-related outcomes and significant socioeconomic burden. It commonly co-occurs with psychiatric and medical conditions, which may further exacerbate these comorbid conditions and hinder treatment response. There is much empirical evidence to support the clinical efficacy of non-pharmacological treatment for insomnia, especially cognitive behavioral therapy for insomnia (CBT-I), in managing insomnia in a wide range of populations. This article reviews the research on the efficacy of CBT-I for primary insomnia and insomnia comorbid with other psychiatric and medical conditions, the empirical evidence regarding different CBT-I treatment modalities, the implementation of CBT-I across different age groups, and some initial evidence on the sequential combination of insomnia treatments. A brief overview of other non-pharmacological treatment with regard to complementary alternative medicine is also provided.
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Affiliation(s)
- Ngan Yin Chan
- Li Chiu Kong Family Sleep Assessment Unit, Departments of Psychiatry, Faculty of Medicine, The Chinese University of Hong Kong, Shatin, Hong Kong SAR, China
| | - Joey Wing Yan Chan
- Li Chiu Kong Family Sleep Assessment Unit, Departments of Psychiatry, Faculty of Medicine, The Chinese University of Hong Kong, Shatin, Hong Kong SAR, China
| | - Shirley Xin Li
- Department of Psychology, The University of Hong Kong, Pokfulam, Hong Kong SAR, China.
- The State Key Laboratory of Brain and Cognitive Sciences, The University of Hong Kong, Pokfulam, Hong Kong SAR, China.
| | - Yun Kwok Wing
- Li Chiu Kong Family Sleep Assessment Unit, Departments of Psychiatry, Faculty of Medicine, The Chinese University of Hong Kong, Shatin, Hong Kong SAR, China.
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Dietch JR, Furst AJ. Perspective: Cognitive Behavioral Therapy for Insomnia Is a Promising Intervention for Mild Traumatic Brain Injury. Front Neurol 2020; 11:530273. [PMID: 33117253 PMCID: PMC7575746 DOI: 10.3389/fneur.2020.530273] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2020] [Accepted: 09/04/2020] [Indexed: 11/13/2022] Open
Abstract
Mild traumatic brain injury (mTBI) is a significant public health problem. Insomnia is one of the most common symptoms of TBI, occurring in 30–50% of patients with TBI, and is more frequently reported in patients with mild as opposed to moderate or severe TBI. Although insomnia may be precipitated by mTBI, it is unlikely to subside on its own without specific treatment even after symptoms of mTBI reduce or remit. Insomnia is a novel, highly modifiable treatment target in mTBI, treatment of which has the potential to make broad positive impacts on the symptoms and recovery following brain injury. Cognitive-behavioral therapy for insomnia (CBT-I) is the front-line intervention for insomnia and has demonstrated effectiveness across clinical trials; between 70 and 80% of patients with insomnia experience enduring benefit from CBT-I and about 50% experience clinical remission. Examining an existing model of the development of insomnia in the context of mTBI suggests CBT-I may be effective for insomnia initiated or exacerbated by sustaining a mTBI, but this hypothesis has yet to be tested via clinical trial. Thus, more research supporting the use of CBT-I in special populations such as mTBI is warranted. The current paper provides a background on existing evidence for using CBT-I in the context of TBI, raises key challenges, and suggests considerations for future directions including need for increased screening and assessment of sleep disorders in the context of TBI, examining efficacy of CBT-I in TBI, and exploring factors that impact dissemination and delivery of CBT-I in TBI.
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Affiliation(s)
- Jessica R Dietch
- War Related Illness and Injury Study Center (WRIISC CA), VA Palo Alto Health Care System, Palo Alto, CA, United States.,Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Palo Alto, CA, United States
| | - Ansgar J Furst
- War Related Illness and Injury Study Center (WRIISC CA), VA Palo Alto Health Care System, Palo Alto, CA, United States.,Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Palo Alto, CA, United States.,Department of Neurology and Neurological Sciences, Stanford University School of Medicine, Palo Alto, CA, United States.,Polytrauma System of Care (PSC), VA Palo Alto Health Care System, Palo Alto, CA, United States
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Nowakowski S, Meers JM. Cognitive Behavioral Therapy for Insomnia and Women's Health: Sex as a Biological Variable. Sleep Med Clin 2019; 14:185-197. [PMID: 31029186 DOI: 10.1016/j.jsmc.2019.01.002] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Differences in sleep for men and women begin at a very early age, with women reporting poorer sleep and having a higher risk for insomnia compared with men. Women are particularly vulnerable to developing insomnia during times of reproductive hormonal change. Sleep across the woman's lifespan and special treatment considerations for using cognitive behavioral therapy for insomnia (CBT-I) in women will be addressed in this review.
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Affiliation(s)
- Sara Nowakowski
- Department of Obstetrics and Gynecology, University of Texas Medical Branch, 301 University Boulevard, Galveston, TX 77555-0587, USA.
| | - Jessica M Meers
- Department of Psychology, University of Houston, 4800 Calhoun Road, Houston, TX 77204, USA
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Birling Y, Wang J, Li G, Wu E, Yu Z, Feng Y, Wu Y. Culturally Adapted CBTI for Chinese Insomnia Patients: a One-Arm Pilot Trial. Int J Behav Med 2019. [PMID: 29536428 DOI: 10.1007/s12529-017-9710-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE Insomnia is a common mental disorder with severe consequences. Cognitive-behavioral therapy for insomnia (CBTI) has been proved effective against insomnia, but most of the research is limited to Western countries. This trial objective is to develop a Chinese culture-adapted CBTI program and assess its efficacy. METHOD An 8-week culturally adapted CBTI program was developed that included mixed group and individual session and culturally adapted relaxation and cognitive restructuring treatment components. A one-arm clinical trial was conducted at a public hospital between March 2016 and January 2017. Seventy-two Chinese adults (15 males, 57 females; mean age, 50 years) with insomnia disorder underwent the culturally adapted CBTI program. Sleep diaries and self-report scales, as well as polysomnography (PSG, for a subgroup only), were used to assess qualitative and quantitative measures of sleep, mental health status, and quality of life at baseline, post-treatment, and 4-month follow-up. RESULTS Pre-post analyses showed significant changes in sleep diary sleep onset latency (SOL), wake after sleep onset (WASO), and total sleep time of respectively - 37.03 min (CI, - 48.90 to - 25.16), - 28.16 min (CI, - 40.22 to - 16.10), and + 27.49 min (CI, 10.51 to 44.47). Self-reported sleep quality, mental health, and quality of life improved compared to baseline. The self-reported outcomes were mainly stable at follow-up. PSG outcomes globally failed to show improvement. CONCLUSION The design of a CBTI program adapted to Chinese population was achieved. Culturally adapted CBTI showed promising results. More rigorously designed studies are needed to ensure efficacy.
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Affiliation(s)
| | - Jian Wang
- Guang'an Men Hospital, Beijing, 100053, China.
| | - Guixia Li
- Guang'an Men Hospital, Beijing, 100053, China
| | - Enlai Wu
- Institute of Psychology, Chinese Academy of Sciences, Beijing, 100049, China
| | - Zhidan Yu
- Institute of Psychology, Chinese Academy of Sciences, Beijing, 100049, China
| | - Yunshu Feng
- Guang'an Men Hospital, Beijing, 100053, China
| | - Yuting Wu
- Institute of Psychology, Chinese Academy of Sciences, Beijing, 100049, China
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Furer T, Nayak K, Shatkin JP. Exploring Interventions for Sleep Disorders in Adolescent Cannabis Users. Med Sci (Basel) 2018; 6:E11. [PMID: 29419734 PMCID: PMC5872168 DOI: 10.3390/medsci6010011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2018] [Revised: 02/02/2018] [Accepted: 02/05/2018] [Indexed: 11/17/2022] Open
Abstract
This review summarizes the available literature on the intersection of adolescent cannabis use and sleep disturbances, along with interventions for adolescent cannabis users who suffer sleep impairments. Adolescents are susceptible to various sleep disorders, which are often exacerbated by the use of substances such as cannabis. The relationship between cannabis and sleep is bidirectional. Interventions to improve sleep impairments among adolescent cannabis users to date have demonstrated limited efficacy, although few studies indicating the benefits of behavioral interventions-such as Cognitive Behavior Therapy for Insomnia or Mindfulness Based Stress Reduction-appear promising in the treatment of sleep disorders, which are present for users of cannabis. Further research is necessary to elucidate the precise mechanisms by which cannabis use coexists with sleep impairments, along with effective interventions for those users who suffer sleep difficulties.
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Affiliation(s)
- Tzvi Furer
- Department of Child and Adolescent Psychiatry, Child Study Center at Hassenfeld Children's Hospital of New York at NYU Langone, One Park Avenue, 7th Floor, New York, NY 10016, USA.
| | - Komal Nayak
- Department of Child and Adolescent Psychiatry, Child Study Center at Hassenfeld Children's Hospital of New York at NYU Langone, One Park Avenue, 7th Floor, New York, NY 10016, USA.
| | - Jess P Shatkin
- Department of Child and Adolescent Psychiatry, Child Study Center at Hassenfeld Children's Hospital of New York at NYU Langone, One Park Avenue, 7th Floor, New York, NY 10016, USA.
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Mao H, Ji Y, Xu Y, Tang G, Yu Z, Xu L, Shen C, Wang W. Group cognitive-behavioral therapy in insomnia: a cross-sectional case-controlled study. Neuropsychiatr Dis Treat 2017; 13:2841-2848. [PMID: 29200858 PMCID: PMC5701563 DOI: 10.2147/ndt.s149610] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
BACKGROUND Group cognitive-behavioral therapy (GCBT) might meet the considerable treatment demand of insomnia, but its effectiveness needs to be addressed. PARTICIPANTS This study recruited 27 insomnia patients treated with 16-weeks of zolpidem (zolpidem group), 26 patients treated with 4-weeks of zolpidem and also treated with 12-weeks of GCBT (GCBT group), and 31 healthy control volunteers. METHODS Before treatment and 16 weeks after intervention, participants were evaluated using the Patient Health Questionnaires (Patient Health Questionnaire-9 [PHQ-9] and Patient Health Questionnaire-15 [PHQ-15]), the Dysfunctional Beliefs and Attitudes about Sleep-16 (DBAS-16), and the Pittsburgh Sleep Quality Index (PSQI). RESULTS Compared to the zolpidem and healthy control groups, the scale scores of PHQ-9, PHQ-15, DBAS-16 and PSQI were significantly reduced after intervention in the GCBT group. Regarding the score changes, there were correlations between PSQI, DBAS-16, PHQ-9, and PHQ-15 scales in the zolpidem group, but there were limited correlations between PSQI and some DBAS-16 scales in the GCBT group. CONCLUSION Our results indicate that GCBT is effective to treat insomnia by improving sleep quality and reducing emotional and somatic disturbances; thus, the study supports the advocacy of applying group psychotherapy to the disorder.
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Affiliation(s)
- Hongjing Mao
- Department of Psychosomatic Disorders, The Seventh People’s Hospital, Mental Health Center
| | - Yutian Ji
- Department of Clinical Psychology and Psychiatry, School of Public Health, Zhejiang University College of Medicine, Hangzhou, Zhejiang, People’s Republic of China
| | - You Xu
- Department of Psychosomatic Disorders, The Seventh People’s Hospital, Mental Health Center
| | - Guangzheng Tang
- Department of Psychosomatic Disorders, The Seventh People’s Hospital, Mental Health Center
| | - Zhenghe Yu
- Department of Psychosomatic Disorders, The Seventh People’s Hospital, Mental Health Center
| | - Lianlian Xu
- Department of Psychosomatic Disorders, The Seventh People’s Hospital, Mental Health Center
| | - Chanchan Shen
- Department of Clinical Psychology and Psychiatry, School of Public Health, Zhejiang University College of Medicine, Hangzhou, Zhejiang, People’s Republic of China
| | - Wei Wang
- Department of Psychosomatic Disorders, The Seventh People’s Hospital, Mental Health Center
- Department of Clinical Psychology and Psychiatry, School of Public Health, Zhejiang University College of Medicine, Hangzhou, Zhejiang, People’s Republic of China
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Assari S, Sonnega A, Pepin R, Leggett A. Residual Effects of Restless Sleep over Depressive Symptoms on Chronic Medical Conditions: Race by Gender Differences. J Racial Ethn Health Disparities 2017; 4:59-69. [PMID: 26823066 PMCID: PMC4965357 DOI: 10.1007/s40615-015-0202-z] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2015] [Revised: 12/07/2015] [Accepted: 12/29/2015] [Indexed: 12/23/2022]
Abstract
BACKGROUND Sleep and depression are comorbid problems that contribute to the development of chronic medical conditions (CMC) over time. Although racial and gender differences in the bidirectional associations between sleep, depression, and CMC are known, very limited information exists on heterogeneity of the residual effects of sleep problems over depressive symptoms on CMC across race by gender groups. AIM Using a life-course perspective, the present study compared race by gender groups for residual effects of restless sleep over depressive symptoms on CMC. METHODS We used data from waves 1 (year 1986), 4 (year 2001), and 5 (year 2011) of the Americans' Changing Lives Study (ACL). The study followed 294 White men, 108 Black men, 490 White women, and 237 Black women for 25 years. Restless sleep, depressive symptoms (Center for Epidemiological Studies-Depression scale [CES-D]), and number of chronic medical conditions (hypertension, diabetes, chronic lung disease, heart disease, stroke, cancer, and arthritis) were measured in 1986, 2001, and 2011. We employed multi-group cross-lagged modeling, with chronic medical conditions as the outcome and race by gender as the groups. RESULTS Major group differences were found in the residual effect of restless sleep on CMC over depressive symptoms across race by gender groups. Restless sleep in 2001 predicted CMC 10 years later in 2011 among Black women (standardized adjusted B = .135, P < .05) and White men (standardized adjusted = .145, P < .01) and White women (standardized adjusted B = .171, P < .001) but not Black men (standardized adjusted B = .001, P > .05). CONCLUSION Race by gender heterogeneity in the residual effect of restless sleep over depressive symptoms on CMC over 25 years suggests that comorbid poor sleep and depressive symptoms differently contribute to development of multi-morbidity among subpopulations based on the intersection of race and gender. Thus, interventions that try to prevent comorbid sleep problems and depression as a strategy to prevent medical conditions may benefit from tailoring based on the intersection of race and gender.
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Affiliation(s)
- Shervin Assari
- Department of Psychiatry, University of Michigan, 4250 Plymouth Road, SPC 5763, Ann Arbor, MI, 48109-2700, USA.
- Center for Research on Ethnicity, Culture and Health, School of Public Health, University of Michigan, Ann Arbor, MI, USA.
| | - Amanda Sonnega
- Institute for Social Research, University of Michigan, Ann Arbor, MI, USA
| | - Renee Pepin
- Dartmouth Centers for Health and Aging, Geisel School of Medicine, Dartmouth College, Lebanon, NH, USA
| | - Amanda Leggett
- Department of Psychiatry, University of Michigan, 4250 Plymouth Road, SPC 5763, Ann Arbor, MI, 48109-2700, USA
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Boullin P, Ellwood C, Ellis JG. Group vs. Individual Treatment for Acute Insomnia: A Pilot Study Evaluating a "One-Shot" Treatment Strategy. Brain Sci 2016; 7:brainsci7010001. [PMID: 28025539 PMCID: PMC5297290 DOI: 10.3390/brainsci7010001] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2016] [Revised: 12/12/2016] [Accepted: 12/20/2016] [Indexed: 12/18/2022] Open
Abstract
Background: Despite undeniable evidence for the efficacy and effectiveness of Cognitive Behaviour Therapy for Insomnia (CBT-I), the potential for its widespread dissemination and implementation has yet to be realised. A suggested reason for this is that traditional CBT-I is considered too burdensome for deployment, in its current form, within the context of where it would be most beneficial—Primary Care. One strategy, aimed to address this, has been to develop briefer versions of CBT-I, whilst another has been to deliver CBT-I in a group format. An alternative has been to attempt to address insomnia during its acute phase with a view to circumventing its progression to chronic insomnia. The aim of the present study was to compare a brief version of CBT-I (one-shot) when delivered individually or in groups to those with acute insomnia. Method: Twenty-eight individuals with acute insomnia (i.e., meeting full DSM-5 criteria for insomnia disorder for less than three months) self-assigned to either a group or individual treatment arm. Treatment consisted of a single one-hour session accompanied by a self-help pamphlet. Subjects completed measures of insomnia severity, anxiety and depression pre-treatment and at one-month post-treatment. Additionally, daily sleep diaries were compared between pre-treatment and at the one-month follow up. Results: There were no significant between group differences in treatment outcome on any sleep or mood measures although those in the group treatment arm were less adherent than those who received individual treatment. Furthermore, the combined (group and individual treatment arms) pre-post test effect size on insomnia symptoms, using the Insomnia Severity Index, was large (d = 2.27). Discussion: It appears that group treatment is as efficacious as individual treatment within the context of a “one shot” intervention for individuals with acute insomnia. The results are discussed with a view to integrating one-shot CBT-I in Primary Care.
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Affiliation(s)
- Pam Boullin
- Northumbria Sleep Research Laboratory, Northumbria University, Newcastle-upon-Tyne NE18ST, UK.
| | - Christina Ellwood
- Northumbria Sleep Research Laboratory, Northumbria University, Newcastle-upon-Tyne NE18ST, UK.
| | - Jason G Ellis
- Northumbria Sleep Research Laboratory, Northumbria University, Newcastle-upon-Tyne NE18ST, UK.
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Parthasarathy S, Carskadon MA, Jean-Louis G, Owens J, Bramoweth A, Combs D, Hale L, Harrison E, Hart CN, Hasler BP, Honaker SM, Hertenstein E, Kuna S, Kushida C, Levenson JC, Murray C, Pack AI, Pillai V, Pruiksma K, Seixas A, Strollo P, Thosar SS, Williams N, Buysse D. Implementation of Sleep and Circadian Science: Recommendations from the Sleep Research Society and National Institutes of Health Workshop. Sleep 2016; 39:2061-2075. [PMID: 27748248 PMCID: PMC5103795 DOI: 10.5665/sleep.6300] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2016] [Accepted: 09/26/2016] [Indexed: 01/03/2023] Open
Affiliation(s)
| | - Mary A. Carskadon
- Department of Psychiatry and Human Behavior at the Warren Alpert Medical School of Brown University, Providence, RI
- Centre for Sleep Research, School of Psychology, Social Work and Social Policy, University of South Australia, Adelaide, Australia
| | | | | | - Adam Bramoweth
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA
| | - Daniel Combs
- UAHS Center for Sleep and Circadian Sciences, University of Arizona, Tucson, AZ
| | - Lauren Hale
- Department of Family, Population and Preventive Medicine, Stony Brook State University of New York, Stony Brook, Stony Brook, NY
| | | | - Chantelle N. Hart
- Social and Behavioral Sciences and the Center for Obesity Research and Education, College of Public Health, Temple University, Phildelphia, PA
| | - Brant P. Hasler
- Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Sarah M. Honaker
- Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN
| | | | - Samuel Kuna
- Center for Sleep and Circadian Neurobiology, University of Pennsylvania, Phildelphia, PA
| | | | - Jessica C. Levenson
- Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Caitlin Murray
- Psychology Department, Loyola University Chicago, Chicago, IL
| | - Allan I. Pack
- Center for Sleep and Circadian Neurobiology, University of Pennsylvania, Phildelphia, PA
| | - Vivek Pillai
- Sleep Disorders & Research Center, Henry Ford Health System, Detroit, MI
| | - Kristi Pruiksma
- Department of Psychiatry, University of Texas Health Science Center, San Antonio, TX
| | - Azizi Seixas
- Department of Population Health, NYU School of Medicine, New York, NY
| | - Patrick Strollo
- Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvannia
| | - Saurabh S. Thosar
- Oregon Institute of Occupational Health Sciences, Oregon Health & Science University, Portland, OR
| | - Natasha Williams
- Department of Population Health, NYU School of Medicine, New York, NY
| | - Daniel Buysse
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA
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Garland SN, Roscoe JA, Heckler CE, Barilla H, Gehrman P, Findley JC, Peoples AR, Morrow GR, Kamen C, Perlis ML. Effects of armodafinil and cognitive behavior therapy for insomnia on sleep continuity and daytime sleepiness in cancer survivors. Sleep Med 2015; 20:18-24. [PMID: 27318221 DOI: 10.1016/j.sleep.2015.12.010] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2015] [Revised: 11/29/2015] [Accepted: 12/22/2015] [Indexed: 12/21/2022]
Abstract
STUDY OBJECTIVES This study involves the analysis of a secondary outcome of a trial examining whether cognitive behavior therapy for insomnia (CBT-I), a wake-promoting medication (armodafinil), or both results in greater improvement in prospectively assessed sleep continuity and daytime sleepiness than a placebo-alone group among a heterogeneous group of cancer survivors. Whether or not armodafinil alone, and/or when combined with CBT-I, affected adherence with CBT-I was evaluated. DESIGN This study is a randomized, placebo-controlled, clinical trial. SETTING This study was conducted at two northeastern academic medical centers. PARTICIPANTS Eighty-eight cancer survivors with chronic insomnia were recruited between October 2008 and November 2012. Participants were assigned to one of four conditions: 1) CBT-I and placebo (CBT-I+P); 2) CBT-I and armodafinil (CBT-I + A); 2) armodafinil alone (ARM); or 4) placebo alone (PLA). INTERVENTIONS CBT-I was delivered in seven weekly individual therapy sessions (three in person, four via telephone). The armodafinil dosage was 50 mg BID. MEASUREMENTS AND RESULTS Sleep continuity was measured with daily sleep diaries assessing sleep latency (SL), wake after sleep onset (WASO), and total sleep time (TST). The Epworth Sleepiness Scale (ESS) measured daytime sleepiness. Compared to the PLA group, the CBT-I+P and CBT-I+A groups reported a significant reduction in SL with effect sizes of 0.67 and 0.58, respectively. A significant reduction was observed in WASO in the CBT-I+A group with an effect size of 0.64. An increasing trend of TST was observed in the CBT-I+P, CBT-I+A, and PLA groups, but not in the ARM group. No statistically significant reductions in daytime sleepiness (ESS) were observed for any of the groups. CONCLUSION CBT-I alone and in combination with armodafinil caused significant improvement in sleep continuity. The addition of armodafinil did not appear to improve daytime sleepiness or enhance adherence to CBT-I.
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Affiliation(s)
- Sheila N Garland
- Department of Family Medicine and Community Health, University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA 19104, USA; Abramson Cancer Center, University of Pennsylvania, 3400 Civic Center Blvd, Philadelphia, PA 19104, USA; Behavioral Sleep Medicine Program, Department of Psychiatry, University of Pennsylvania, 3535 Market Street, Suite 670, Philadelphia, PA 19104, USA; Department of Psychology, Memorial University of Newfoundland, 232 Elizabeth Avenue, St. John's, NL A1B 3X9, Canada.
| | - Joseph A Roscoe
- James P. Wilmot Cancer Center, University of Rochester, 265 Crittenden Blvd. CU 420658, Rochester, NY 14642, USA
| | - Charles E Heckler
- James P. Wilmot Cancer Center, University of Rochester, 265 Crittenden Blvd. CU 420658, Rochester, NY 14642, USA
| | - Holly Barilla
- Behavioral Sleep Medicine Program, Department of Psychiatry, University of Pennsylvania, 3535 Market Street, Suite 670, Philadelphia, PA 19104, USA
| | - Philip Gehrman
- Behavioral Sleep Medicine Program, Department of Psychiatry, University of Pennsylvania, 3535 Market Street, Suite 670, Philadelphia, PA 19104, USA
| | - James C Findley
- Behavioral Sleep Medicine Program, Department of Psychiatry, University of Pennsylvania, 3535 Market Street, Suite 670, Philadelphia, PA 19104, USA
| | - Anita R Peoples
- James P. Wilmot Cancer Center, University of Rochester, 265 Crittenden Blvd. CU 420658, Rochester, NY 14642, USA
| | - Gary R Morrow
- James P. Wilmot Cancer Center, University of Rochester, 265 Crittenden Blvd. CU 420658, Rochester, NY 14642, USA
| | - Charles Kamen
- James P. Wilmot Cancer Center, University of Rochester, 265 Crittenden Blvd. CU 420658, Rochester, NY 14642, USA
| | - Michael L Perlis
- Behavioral Sleep Medicine Program, Department of Psychiatry, University of Pennsylvania, 3535 Market Street, Suite 670, Philadelphia, PA 19104, USA.
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Affiliation(s)
- Maria Die Trill
- Hospital Universitario Gregorio Marañón, Psycho-Oncology Unit, Madrid, Spain
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14
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Hall MH, Kline CE, Nowakowski S. Insomnia and sleep apnea in midlife women: prevalence and consequences to health and functioning. F1000PRIME REPORTS 2015; 7:63. [PMID: 26097736 PMCID: PMC4447062 DOI: 10.12703/p7-63] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Sleep disturbance is common during the menopausal transition, with numerous downstream consequences to health and functioning, including reduced quality of life, impaired mental health, and increased physical health morbidity. Insomnia affects approximately 50% of midlife women and is characterized by nocturnal symptoms of difficulties initiating or maintaining sleep (or both) and daytime symptoms that impair occupational, social, or other components of functioning. In addition, approximately 20% of midlife women develop sleep-disordered breathing during the menopausal transition. This commentary summarizes the prevalence, risk factors, and treatment options for each of these sleep disorders in midlife women, with specific focus on first-line treatments for insomnia (cognitive behavioral therapy for insomnia) and sleep-disordered breathing (continuous positive airway pressure) and unique considerations for treating sleep disorders in midlife women. Future directions are also discussed.
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Affiliation(s)
- Martica H. Hall
- Department of Psychiatry, University of Pittsburgh School of Medicine3811 O'Hara Street, Pittsburgh, PA 15213USA
| | - Christopher E. Kline
- Department of Psychiatry, University of Pittsburgh School of Medicine3811 O'Hara Street, Pittsburgh, PA 15213USA
| | - Sara Nowakowski
- Department of Obstetrics and Gynecology, University of Texas Medical Branch301 University Boulevard, Galveston, TX 77555-0587USA
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Van Ravesteyn LM, Tulen JHM, Kamperman AM, Raats ME, Schneider AJT, Birnie E, Steegers EAP, Hoogendijk WJG, Tiemeier HW, Lambregtse-van den Berg MP. Perceived sleep quality is worse than objective parameters of sleep in pregnant women with a mental disorder. J Clin Sleep Med 2014; 10:1137-41. [PMID: 25317095 DOI: 10.5664/jcsm.4118] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE Disturbed sleep during pregnancy is associated with adverse obstetric outcomes and less mental well-being. In pregnant women with a mental disorder, who frequently suffer from sleep problems, it is unknown whether predominantly objective or subjective sleep quality is more affected. To clarify this, we compared objective and subjective parameters of sleep quality between patients and healthy controls during pregnancy. METHODS This observational study was embedded in an ongoing study among pregnant women with a mental disorder at the department of Psychiatry of Erasmus University Medical Center Rotterdam, the Netherlands. We compared 21 pregnant women with a confirmed mental disorder with 33 healthy controls (gestational age, 23-29 weeks). To measure objective parameters of sleep quality, all participants continuously wore a wrist actigraph for 7 days and nights. Subjective sleep quality was retrospectively assessed using the Pittsburgh Sleep Quality Index (PSQI) and on a daily basis with the Subjective Sleep Quality-scale (SSQ). Differences in parameters of sleep between patients and controls were tested using a multivariate linear regression analysis adjusted for parity, gestational age, educational level, and employment status. RESULTS Objective parameters of sleep quality and subjective sleep quality as assessed by the PSQI did not differ significantly between patients and controls. Daily sleep reports showed that, relative to controls, patients had a significantly worse average SSQ-score (5.2 vs. 7.6, adjusted β = 0.12, 95%CI = 0.03-0.53, p < 0.01). CONCLUSIONS Our exploratory study suggests that perceived sleep quality reported on a daily basis by pregnant women with a mental disorder is worse than the sleep quality as measured by wrist actigraphy.
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Affiliation(s)
| | - Joke H M Tulen
- Department of Psychiatry, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Astrid M Kamperman
- Department of Psychiatry, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Monique E Raats
- Department of Psychiatry, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - A J Tom Schneider
- Department of Obstetrics and Gynaecology, subdivision of Obstetrics and Prenatal Medicine, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Erwin Birnie
- Institute of Health Management and Policy, Erasmus University, Rotterdam, the Netherlands
| | - Eric A P Steegers
- Department of Obstetrics and Gynaecology, subdivision of Obstetrics and Prenatal Medicine, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Witte J G Hoogendijk
- Department of Psychiatry, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Henning W Tiemeier
- Department of Psychiatry, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Mijke P Lambregtse-van den Berg
- Department of Psychiatry, Erasmus University Medical Center, Rotterdam, the Netherlands ; Department of Child and Adolescent Psychiatry, Erasmus University Medical Center, Rotterdam, the Netherlands
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16
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Pigeon WR, Bishop TM, Marcus JA. Advances in the management of insomnia. F1000PRIME REPORTS 2014; 6:48. [PMID: 24991425 PMCID: PMC4047947 DOI: 10.12703/p6-48] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Insomnia is highly prevalent and associated with considerable morbidity. Several very efficacious treatments, both pharmacologic and non-pharmacologic, exist for the management of insomnia. New modes of delivery and new formulations of existing sedative-hypnotic medications have been introduced. Novel agents are still being developed and tested to arrive at a hypnotic that has limited side effects while still being efficacious. Innovations with respect to behavioral interventions, which are drastically under-utilized, have focused mainly on making these interventions more widely available through dissemination efforts, briefer formats and more accessible platforms.
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Affiliation(s)
- Wilfred R. Pigeon
- Center of Excellence for Suicide Prevention, Canandaigua VA Medical Center400 Fort Hill Avenue, Canandaigua, NY 14424USA
- Center for Integrated Healthcare800 Irving Avenue, Syracuse, NY 13210USA
- Department of Psychiatry, University of Rochester Medical CenterRochester, NY 14642USA
| | - Todd M. Bishop
- Center for Integrated Healthcare800 Irving Avenue, Syracuse, NY 13210USA
- Department of Psychology430 Huntington Hall, Syracuse UniversitySyracuse
| | - Jonathan A. Marcus
- Department of Neurology, University of Rochester Medical CenterRochester, NY 14642USA
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Stoffers D, Altena E, van der Werf YD, Sanz-Arigita EJ, Voorn TA, Astill RG, Strijers RLM, Waterman D, Van Someren EJW. The caudate: a key node in the neuronal network imbalance of insomnia? Brain 2014; 137:610-20. [PMID: 24285642 PMCID: PMC3914473 DOI: 10.1093/brain/awt329] [Citation(s) in RCA: 103] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2013] [Revised: 09/16/2013] [Accepted: 10/05/2013] [Indexed: 11/20/2022] Open
Abstract
Insomnia is prevalent, severe and partially heritable. Unfortunately, its neuronal correlates remain enigmatic, hampering the development of mechanistic models and rational treatments. Consistently reported impairments concern fragmented sleep, hyper-arousal and executive dysfunction. Because fronto-striatal networks could well play a role in sleep, arousal regulation and executive functioning, the present series of studies used an executive task to evaluate fronto-striatal functioning in disturbed sleep. Patients with insomnia showed reduced recruitment of the head of the left caudate nucleus during executive functioning, which was not secondary to altered performance or baseline perfusion. Individual differences in caudate recruitment were associated with hyper-arousal severity. Seed-based functional connectivity analysis suggested that attenuated input from a projecting orbitofrontal area with reduced grey matter density contributes to altered caudate recruitment in patients with insomnia. Attenuated caudate recruitment persisted after successful treatment of insomnia, warranting evaluation as a potential vulnerability trait. A similar selective reduction in caudate recruitment could be elicited in participants without sleep complaints by slow-wave sleep fragmentation, providing a model to facilitate investigation of the causes and consequences of insomnia.
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Affiliation(s)
- Diederick Stoffers
- 1 Department of Sleep and Cognition, Netherlands Institute for Neuroscience, an Institute of the Royal Netherlands Academy of Arts and Sciences, Amsterdam, The Netherlands
| | - Ellemarije Altena
- 1 Department of Sleep and Cognition, Netherlands Institute for Neuroscience, an Institute of the Royal Netherlands Academy of Arts and Sciences, Amsterdam, The Netherlands
- 2 Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| | - Ysbrand D. van der Werf
- 1 Department of Sleep and Cognition, Netherlands Institute for Neuroscience, an Institute of the Royal Netherlands Academy of Arts and Sciences, Amsterdam, The Netherlands
- 3 Department of Anatomy and Neurosciences, VU University Medical Centre, Amsterdam, The Netherlands
| | - Ernesto J. Sanz-Arigita
- 1 Department of Sleep and Cognition, Netherlands Institute for Neuroscience, an Institute of the Royal Netherlands Academy of Arts and Sciences, Amsterdam, The Netherlands
- 4 CITA-Alzheimer Foundation, San Sebastian, Spain
| | - Thom A. Voorn
- 1 Department of Sleep and Cognition, Netherlands Institute for Neuroscience, an Institute of the Royal Netherlands Academy of Arts and Sciences, Amsterdam, The Netherlands
| | - Rebecca G. Astill
- 1 Department of Sleep and Cognition, Netherlands Institute for Neuroscience, an Institute of the Royal Netherlands Academy of Arts and Sciences, Amsterdam, The Netherlands
| | - Rob L. M. Strijers
- 5 Department of Clinical Neurophysiology, VU University Medical Centre, Amsterdam, The Netherlands
| | - Dé Waterman
- 6 Samenwerkingsverband Psychologen, Almere, The Netherlands
| | - Eus J. W. Van Someren
- 1 Department of Sleep and Cognition, Netherlands Institute for Neuroscience, an Institute of the Royal Netherlands Academy of Arts and Sciences, Amsterdam, The Netherlands
- 7 Department of Medical Psychology, VU University Medical Centre, Amsterdam, The Netherlands
- 8 Department of Integrative Neurophysiology, Centre for Neurogenomics and Cognitive Research, VU University, Amsterdam, The Netherlands
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18
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Vallières A, Ceklic T, Bastien CH, Espie CA. A preliminary evaluation of the physiological mechanisms of action for sleep restriction therapy. SLEEP DISORDERS 2013; 2013:726372. [PMID: 24349793 PMCID: PMC3856159 DOI: 10.1155/2013/726372] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/27/2013] [Revised: 09/08/2013] [Accepted: 09/16/2013] [Indexed: 11/26/2022]
Abstract
Our objective was to investigate the physiological mechanisms involved in the sleep restriction treatment of insomnia. A multiple baseline across subjects design was used. Sleep of five participants suffering from insomnia was assessed throughout the experimentation by sleep diaries and actigraphy. Ten nights of polysomnography were conducted over five occasions. The first two-night assessment served to screen for sleep disorders and to establish a baseline for dependent measures. Three assessments were undertaken across the treatment interval, with the fifth and last one coming at follow-up. Daily cortisol assays were obtained. Sleep restriction therapy was applied in-lab for the first two nights of treatment and was subsequently supervised weekly. Interrupted time series analyses were computed on sleep diary data and showed a significantly decreased wake time, increased sleep efficiency, and decreased total sleep time. Sleepiness at night seems positively related to sleep variables, polysomnography data suggest objective changes mainly for stage 2, and power spectral analysis shows a decrease in beta-1 and -2 powers for the second night of treatment. Cortisol levels seem to be lower during treatment. These preliminary results confirm part of the proposed physiological mechanisms and suggest that sleep restriction contributes to a rapid decrease in hyperarousal insomnia.
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Affiliation(s)
- Annie Vallières
- École de psychologie, Université Laval, Québec, QC, Canada G1V A06
- Centre d'étude des troubles du sommeil, Centre de recherche de l'institut universitaire en santé mentale de Québec, Québec, QC, Canada G1J 2G3
- Centre de recherche du centre hospitalier universitaire en santé mentale du Québec, Québec, QC, Canada G1V 4G2
| | - Tijana Ceklic
- École de psychologie, Université Laval, Québec, QC, Canada G1V A06
- Centre d'étude des troubles du sommeil, Centre de recherche de l'institut universitaire en santé mentale de Québec, Québec, QC, Canada G1J 2G3
| | - Célyne H. Bastien
- École de psychologie, Université Laval, Québec, QC, Canada G1V A06
- Centre d'étude des troubles du sommeil, Centre de recherche de l'institut universitaire en santé mentale de Québec, Québec, QC, Canada G1J 2G3
| | - Colin A. Espie
- Nuffield Department of Clinical Neurosciences, Sleep & Circadian Neuroscience Institute, University of Oxford, Oxford OX3 9DU, UK
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Fields BG, Schutte-Rodin S, Perlis ML, Myers M. Master's-level practitioners as cognitive behavioral therapy for insomnia providers: an underutilized resource. J Clin Sleep Med 2013; 9:1093-6. [PMID: 24127157 PMCID: PMC3778184 DOI: 10.5664/jcsm.3096] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Despite the efficacy of cognitive behavioral therapy for insomnia (CBT-I) in treating chronic insomnia, it remains underutilized. Lack of appropriately-trained CBT-I providers is a major reason. Master's-level practitioners (MLPs) may, in addition to doctoral-level psychologists, be uniquely positioned to fill this role, based not only on "goodness of professional fit" but also given a handful of studies showing these individuals' care outcomes meet or exceed standard outcomes. However, the ability of MLPs to provide CBT-I will be significantly restricted until a clear pathway is established that extends from training opportunities to credentialing. Further questions remain about how to attract and incorporate MLPs into established practices.
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Affiliation(s)
- Barry G. Fields
- Center for Sleep and Circadian Neurobiology, University of Pennsylvania Medical Center, Philadelphia, PA
- Division of Sleep Medicine, University of Pennsylvania Medical Center, Philadelphia, PA
| | - Sharon Schutte-Rodin
- Center for Sleep and Circadian Neurobiology, University of Pennsylvania Medical Center, Philadelphia, PA
- Division of Sleep Medicine, University of Pennsylvania Medical Center, Philadelphia, PA
| | - Michael L. Perlis
- Center for Sleep and Circadian Neurobiology, University of Pennsylvania Medical Center, Philadelphia, PA
- Division of Sleep Medicine, University of Pennsylvania Medical Center, Philadelphia, PA
- Department of Psychiatry, University of Pennsylvania Medical Center, Philadelphia, PA
| | - Megin Myers
- Center for Sleep and Circadian Neurobiology, University of Pennsylvania Medical Center, Philadelphia, PA
- Division of Sleep Medicine, University of Pennsylvania Medical Center, Philadelphia, PA
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20
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Pech M, O'Kearney R. A randomized controlled trial of problem-solving therapy compared to cognitive therapy for the treatment of insomnia in adults. Sleep 2013; 36:739-49. [PMID: 23633757 DOI: 10.5665/sleep.2640] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
STUDY OBJECTIVES To compare the efficacy of problem-solving therapy (PST) combined with behavioral sleep strategies to standard cognitive therapy (CT) combined with behavioral sleep strategies in the treatment of insomnia. DESIGN A six-week randomized controlled trial with one month follow-up. SETTING The Australian National University Psychology Clinic, Canberra, Australia. PARTICIPANTS Forty-seven adults aged 18-60 years recruited from the community meeting the Research Diagnostic Criteria for insomnia. INTERVENTIONS Participants received 6 weeks of treatment including one group session (sleep education and hygiene, stimulus control instructions and progressive muscle relaxation) followed by 5 weeks of individual treatment of PST or CT. MEASUREMENTS AND RESULTS Primary outcomes included sleep efficiency (SE) from sleep diaries, the Insomnia Severity Index (ISI), and the Pittsburgh Sleep Quality Index (PSQI). Secondary measures assessed dysfunctional sleep beliefs, problem-solving skills and orientations, and worry. Both treatments produced significant post therapy improvements in sleep which were maintained at 1 month follow-up (on SE Cohen d = 1.42, 95% CI 1.02-1.87 for PST; d = 1.26, 95% CI 0.81-1.65 for CT; on ISI d = 1.46, 95% CI 1.03-1.88 for PST; d = 1.95, 95% CI 0.52-2.38 for CT; for PSQI d = 0.97, 95% CI 0.55-1.40 for PST and d = 1.34, 95% CI 0.90-1.79 for the CT). There were no differences in PST and CT in the size or rate of improvement in sleep although CT produced a significant faster rate of decline in negative beliefs about sleep than PST and there was a trend (P = 0.08) for PST to produce a faster rate of improvement in negative problem orientation than CT. CONCLUSIONS The results provide preliminary support for problem solving treatment as an equally efficacious alternative component to cognitive therapy in psychological interventions for insomnia.
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Affiliation(s)
- Melissa Pech
- Research School of Psychology, The Australian National University, Canberra, Australian Capital Territory, Australia
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21
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Arnedt JT, Cuddihy L, Swanson LM, Pickett S, Aikens J, Chervin RD. Randomized controlled trial of telephone-delivered cognitive behavioral therapy for chronic insomnia. Sleep 2013; 36:353-62. [PMID: 23450712 DOI: 10.5665/sleep.2448] [Citation(s) in RCA: 61] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
STUDY OBJECTIVES To compare the efficacy of telephone-delivered cognitive-behavioral therapy for insomnia to an information pamphlet control on sleep and daytime functioning at pretreatment, posttreatment, and 12-wk follow-up. DESIGN Randomized controlled parallel trial. SETTING N/A. PARTICIPANTS Thirty individuals with chronic insomnia (27 women, age 39.1 ± 14.4 years, insomnia duration 8.7 ± 10.7 years). INTERVENTIONS Cognitive behavioral therapy for insomnia (CBTI) delivered in up to eight weekly telephone sessions (CBTI-Phone, n = 15) versus an information pamphlet control (IPC, n = 15). MEASUREMENTS AND RESULTS Sleep/wake diary, sleep-related questionnaires (Insomnia Severity Index, Pittsburgh Sleep Quality Index, 16-item Dysfunctional Beliefs and Attitudes about Sleep), and daytime symptom assessments (fatigue, depression, anxiety, and quality of life) were completed at pretreatment, posttreatment, and 12-wk follow-up. Linear mixed models indicated that sleep/wake diary sleep efficiency and total sleep time improved significantly at posttreatment in both groups and remained stable at 12-wk follow-up. More CBTI-Phone than IPC patients showed posttreatment improvements in unhelpful sleep-related cognitions (P < 0.001) and were classified as "in remission" from insomnia at follow-up (P < 0.05). Posttreatment effect sizes on most daytime symptoms were large (Cohen d = 0.8-2.5) for CBTI-Phone patients and small to moderate (Cohen d = -0.1-0.6) for IPC patients. All CBTI-Phone patients completed posttreatment and 12-wk follow-up assessments, but three IPC patients discontinued the study. CONCLUSIONS The findings provide preliminary support for telephone-delivered CBTI in the treatment of chronic insomnia. Future larger-scale studies with more diverse samples are warranted. Some individuals with insomnia may also benefit from pamphlet-delivered CBTI with brief telephone support. CITATION Arnedt JT; Cuddihy L; Swanson LM; Pickett S; Aikens J; Chervin RD. Randomized controlled trial of telephone-delivered cognitive behavioral therapy for chronic insomnia. SLEEP 2013;36(3):353-362.
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Affiliation(s)
- J Todd Arnedt
- Sleep and Chronophysiology Laboratory, Department of Psychiatry, University of Michigan, Ann Arbor, MI 48109-2700, USA.
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Khawaja IS, Dieperink ME, Thuras P, Kunisaki KM, Schumacher MM, Germain A, Amborn B, Hurwitz TD. Effect of sleep skills education on sleep quality in patients attending a psychiatry partial hospitalization program. Prim Care Companion CNS Disord 2013; 15:PCC.12m01440. [PMID: 23724356 PMCID: PMC3661334 DOI: 10.4088/pcc.12m01440] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2012] [Accepted: 09/19/2012] [Indexed: 10/27/2022] Open
Abstract
OBJECTIVE To evaluate the effectiveness of cognitive-behavioral therapy for insomnia (CBT-I)-informed sleep skills education on sleep quality and initial sleep latency in patients attending a psychiatry partial hospitalization program. METHOD This retrospective chart review was conducted in a psychiatry partial hospitalization program of a teaching Veterans Affairs medical center located in Minneapolis, Minnesota. Patients typically attend the program for 1 month. Data were collected from a continuous improvement project from November 2007 to March 2009. The Pittsburgh Sleep Quality Index (PSQI) was administered to the patients at the time of entry into the program and at their discharge. Patients who completed both PSQI assessments were included in the study. RESULTS A total of 183 patients completed both PSQI assessments. Of those, 106 patients attended CBT-I-informed sleep skills education and 77 did not (all patients completed the psychiatry partial hospitalization program). For all patients, the mean ± SD baseline PSQI score was 12.5 ± 4.8. PSQI scores improved by a mean of 3.14 points (95% CI, 2.5-3.8; P < .001) in all patients who completed the psychiatry partial hospitalization program. For all patients, there were significant reductions in sleep latency (17.6 minutes) (t 183 = 6.58, P < .001) and significant increases in overall sleep time, from 6.1 to 6.7 hours (t 183 = 4.72, P < .001). There was no statistically significant difference in PSQI scores of patients who attended CBT-I-informed sleep skills education and those who did not during their stay in the partial hospitalization program. CONCLUSIONS The quality of sleep and initial sleep latency improved in patients who completed the psychiatry partial hospitalization program regardless of whether they attended CBT-I-informed sleep skills education or not. In this study, a structured psychiatry partial hospitalization program improved perceived sleep quality and initial sleep latency. Additional randomized controlled trials with a higher intensity of CBT-I-informed sleep skills education are needed.
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Affiliation(s)
- Imran S Khawaja
- Departments of Psychiatry, Minneapolis VA Health Care System, University of Minnesota, Minnesota, USA
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Artner J, Cakir B, Spiekermann JA, Kurz S, Leucht F, Reichel H, Lattig F. Prevalence of sleep deprivation in patients with chronic neck and back pain: a retrospective evaluation of 1016 patients. J Pain Res 2012; 6:1-6. [PMID: 23300350 PMCID: PMC3536352 DOI: 10.2147/jpr.s36386] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Chronic low back pain (CLBP) and chronic neck pain (CNP) have become a serious medical and socioeconomic problem in recent decades. Patients suffering from chronic pain seem to have a higher prevalence of sleep disorders. PURPOSE To calculate the prevalence of sleep deprivation in patients with CLBP and CNP and to evaluate the factors that may contribute to sleep impairment. METHODS This study was a retrospective evaluation of 1016 patients with CNP and CLBP who consulted an orthopedic department at a university hospital. Factors assessed were gender, age, diagnosis, grade of sleep deprivation, pain intensity, chronification grade, and migrational background. Pearson's chi-squared test was performed to calculate the relationship between these factors and the grade of sleep deprivation. Regression analysis was performed to explore the correlation between the grade of sleep deprivation and age, pain intensity, and chronification grade. RESULTS A high prevalence of sleep deprivation (42.22%) was calculated in patients with CNP and CLBP, even when analgesics had been taken. About 19.88% of the patients reported serious sleep impairments (ie, <4 hours of sleep per night). The grade of sleep deprivation did not correlate with the gender or age distribution. A significant relationship was found between the grade of sleep deprivation and pain intensity, failed back surgery syndrome, and patients with a migrational background. There was a moderate relationship with intervertebral disc disease and no relationship with spinal stenosis. CONCLUSION Sleep disturbance should be assessed when treating patients with CNP or CLBP, especially in patients with higher pain intensity, failed back surgery syndrome, and a migrational background. Further research is needed to explore the complex relationship of sleep disturbance and chronic pain.
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Affiliation(s)
- Juraj Artner
- Department of Orthopedic Surgery, University of Ulm, Ulm, Germany
| | - Balkan Cakir
- Department of Orthopedic Surgery, University of Ulm, Ulm, Germany
| | - Jane-Anna Spiekermann
- Department of Psychosomatic Medicine and Psychotherapy, University of Ulm, Ulm, Germany
| | - Stephan Kurz
- Department of Orthopedic Surgery, University of Ulm, Ulm, Germany
| | - Frank Leucht
- Department of Orthopedic Surgery, University of Ulm, Ulm, Germany
| | - Heiko Reichel
- Department of Orthopedic Surgery, University of Ulm, Ulm, Germany
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Epstein DR, Sidani S, Bootzin RR, Belyea MJ. Dismantling multicomponent behavioral treatment for insomnia in older adults: a randomized controlled trial. Sleep 2012; 35:797-805. [PMID: 22654199 PMCID: PMC3353033 DOI: 10.5665/sleep.1878] [Citation(s) in RCA: 82] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
STUDY OBJECTIVE Recently, the use of multicomponent insomnia treatment has increased. This study compares the effect of single component and multicomponent behavioral treatments for insomnia in older adults after intervention and at 3 months and 1 yr posttreatment. DESIGN A randomized, controlled study. SETTING Veterans Affairs medical center. PARTICIPANTS 179 older adults (mean age, 68.9 yr ± 8.0; 115 women [64.2%]) with chronic primary insomnia. INTERVENTIONS Participants were randomly assigned to 6 wk of stimulus control therapy (SCT), sleep restriction therapy (SRT), the 2 therapies combined into a multicomponent intervention (MCI), or a wait-list control group. MEASUREMENTS AND RESULTS Primary outcomes were subjective (daily sleep diary) and objective (actigraphy) measures of sleep-onset latency (SOL), wake after sleep onset (WASO), total sleep time (TST), time in bed (TIB), and sleep efficiency (SE). Secondary outcomes were clinical measures including response and remission rates. There were no differences between the single and multicomponent interventions on primary sleep outcomes measured by diary and actigraphy. All treatments produced significant improvement in diary-reported sleep in comparison with the control group. Effect sizes for sleep diary outcomes were medium to large. Treatment gains were maintained at follow-up for diary and actigraph measured SOL, WASO, and SE. The MCI group had the largest proportion of treatment remitters. CONCLUSIONS For older adults with chronic primary insomnia, the findings provide initial evidence that SCT, SRT, and MCI are equally efficacious and produce sustainable treatment gains on diary, actigraphy, and clinical outcomes. From a clinical perspective, MCI may be a preferred treatment due to its higher remission rate. CLINICAL TRIAL INFORMATION Behavioral Intervention for Insomnia in Older Adults. NCT01154023. URL: http://clinicaltrials.gov/ct2/show/NCT01154023?term=Behavioral+Intervention+for+Insomnia+in+Older+Adults&rank=1.
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Affiliation(s)
- Dana R Epstein
- Phoenix Veterans Affairs Health Care System, Phoenix, AZ, USA.
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Maroti D, Folkeson P, Jansson-Fröjmark M, Linton SJ. Does Treating Insomnia With Cognitive–Behavioural Therapy Influence Comorbid Anxiety and Depression? An Exploratory Multiple Baseline Design With Four Patients. BEHAVIOUR CHANGE 2012. [DOI: 10.1375/bech.28.4.195] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
AbstractObjectives:Although cognitive–behaviour therapy for insomnia (CBT-I) has been shown to be effective for primary insomnia, the impact of CBT-I on insomnia comorbid with psychiatric conditions is largely unknown.Design:A multiple baseline design with 2–3 weeks of baseline, 6 weeks of CBT-I, and a 3-week follow-up was employed.Methods:Four patients with insomnia comorbid with both anxiety and depressive disorders participated. Sleep onset latency (SOL), wake time after sleep onset (WASO), total sleep time (TST), the Insomnia Severity Index (ISI), the Beck Anxiety Inventory (BAI), and the Beck Depression Inventory (BDI-II) were used as outcome measures.Results:Improvements in SOL, WASO, and TST were observed for all the four patients. Based on ISI, there were reductions for all the patients (32–92%), three patients responded to treatment, and two patients remitted. Based on BAI, reductions on anxiety were observed for all the patients (40–76%), three patients were treatment responders, and two patients remitted. Based on BDI-II, all the patients experienced reductions in depression (36–53%), three patients responded to treatment, and one patient remitted.Conclusions:CBT-I was able to reduce insomnia and co-morbid anxiety and depression, thus providing preliminary evidence for using CBT-I on insomnia co-morbid with psychiatric conditions.
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Harris J, Lack L, Kemp K, Wright H, Bootzin R. A randomized controlled trial of intensive sleep retraining (ISR): a brief conditioning treatment for chronic insomnia. Sleep 2012; 35:49-60. [PMID: 22215918 PMCID: PMC3242687 DOI: 10.5665/sleep.1584] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
STUDY OBJECTIVE To investigate the effectiveness of intensive sleep retraining in comparison and combination with traditional behavioral intervention for chronic primary insomnia. PARTICIPANTS Seventy-nine volunteers with chronic sleep-onset insomnia (with or without sleep maintenance difficulties) were randomly assigned either to intensive sleep retraining (ISR), stimulus control therapy (SCT), ISR plus SCT, or the control (sleep hygiene) treatment condition. INTERVENTION ISR treatment consisted of 50 sleep onset trials over a 25-h sleep deprivation period. MEASUREMENTS AND RESULTS Treatment response was assessed with sleep diary, activity monitoring, and questionnaire measures. The active treatment groups (ISR, SCT, ISR+SCT) all resulted in significant improvements in sleep onset latency and sleep efficiency, with moderate to large effect sizes from pre- to post-treatment. Wake time after sleep onset decreased significantly in the SCT and ISR+SCT groups. Total sleep time increased significantly in the ISR and ISR+SCT treatment groups. Participants receiving ISR (ISR, ISR+SCT) experienced rapidly improved SOL and TST during treatment, suggesting an advantage of rapid improvements in sleep in response to ISR. Although there were few statistically significant differences between groups on individual variables, ISR+SCT resulted in consistently larger effect sizes of change than other treatments, including questionnaire measures of sleep quality, sleep self-efficacy, and daytime functioning. The combination treatment group (ISR+SCT) showed trends to outperform other active treatment groups with fewer treatment dropouts, and a greater proportion of treatment responders with 61% reaching "good sleeper" status. Treatment gains achieved at post-treatment in the active treatment groups were largely maintained throughout follow-up periods to 6 months. CONCLUSION This 25-hour intensive conditioning treatment for chronic insomnia can produce rapid improvements in sleep, daytime functioning, and psychological variables. Adding ISR to traditional interventions seems to result in a superior treatment response.
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Affiliation(s)
- Jodie Harris
- School of Psychology, Flinders University, South Australia
- Adelaide Institute for Sleep Health, Repatriation General Hospital, South Australia
| | - Leon Lack
- School of Psychology, Flinders University, South Australia
- Adelaide Institute for Sleep Health, Repatriation General Hospital, South Australia
| | - Kristyn Kemp
- Adelaide Insomnia Clinic, Adelaide, South Australia
| | - Helen Wright
- School of Psychology, Flinders University, South Australia
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Moderate exercise plus sleep education improves self-reported sleep quality, daytime mood, and vitality in adults with chronic sleep complaints: a waiting list-controlled trial. SLEEP DISORDERS 2011; 2011:809312. [PMID: 23471095 PMCID: PMC3581127 DOI: 10.1155/2011/809312] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/13/2011] [Revised: 08/25/2011] [Accepted: 09/07/2011] [Indexed: 12/29/2022]
Abstract
Research indicates that physical exercise can contribute to better sleep quality. This study investigates the six-week influence of a combined intervention on self-rated sleep quality, daytime mood, and quality of life. A nonclinical sample of 114 adults with chronic initiating and the maintaining of sleep complaints participated in the study. The intervention group of 70 adults underwent moderate physical exercise, conducted weekly, plus sleep education sessions. Improvements among participants assigned to the intervention group relative to the waiting-list control group (n = 44) were noted for subjective sleep quality, daytime mood, depressive symptoms and vitality. Derived from PSQI subscores, the intervention group reported increased sleep duration, shortened sleep latency, fewer awakenings after sleep onset, and overall better sleep efficiency compared to controls. The attained scores were well sustained and enhanced over a time that lasted through to the follow-up 18 weeks later. These findings have implications in treatment programs concerning healthy lifestyle approaches for adults with chronic sleep complaints.
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Schlarb AA, Velten-Schurian K, Poets CF, Hautzinger M. First effects of a multicomponent treatment for sleep disorders in children. Nat Sci Sleep 2010; 3:1-11. [PMID: 23616714 PMCID: PMC3630952 DOI: 10.2147/nss.s15254] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Insomnia in children is a common disorder, yet only few child-specific treatment modalities exist so far. The goal of this study was to investigate the effectiveness of a multicomponent intervention program for children with insomnia at 5-10 years of age and their parents. The program was a structured six-session behavioral and hypnotherapeutic group treatment with three sessions for the children and three for their parents. Thirty-eight children (5.1-10.9 years) were randomly assigned to the specific treatment condition or waiting list plus sleep diary control condition. Twenty-two children participated in the treatment group and 16 in the control group. All children suffered from insomnia according to the International Classification of Sleep Disorders criteria. Sleep symptoms were assessed with a sleep diary and the German version of the Children Sleep Habit Questionnaire (CSHQ) and the Sleep Disturbance Scale for Children (SDSC). Although both conditions showed a significant decrease in several sleep symptoms, the treatment group exhibited a significantly greater improvement with regard to CSHQ and SDSC total scores as well as in several sleep parameters, reflecting the most important features of the intervention program, such as bedtime, sleep-related anxiety, night waking, and sleeping in parents' bed. By contrast, the control group's data revealed only unspecific effects. These pilot data suggest that insomnia in childhood can be treated effectively with this child-specific multicomponent group treatment.
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Affiliation(s)
- Angelika A Schlarb
- Faculty of Science, Department of Psychology, University Hospital Tübingen, University of Tübingen, Tübingen, Germany
| | - Kerstin Velten-Schurian
- Faculty of Science, Department of Psychology, University Hospital Tübingen, University of Tübingen, Tübingen, Germany
| | - Christian F Poets
- Department of Neonatology, University Hospital Tübingen, University of Tübingen, Tübingen, Germany
| | - Martin Hautzinger
- Faculty of Science, Department of Psychology, University Hospital Tübingen, University of Tübingen, Tübingen, Germany
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McChargue DE, Sankaranarayanan J, Visovsky CG, Matthews EE, Highland KB, Berger AM. Predictors of adherence to a behavioral therapy sleep intervention during breast cancer chemotherapy. Support Care Cancer 2010; 20:245-52. [PMID: 21174129 DOI: 10.1007/s00520-010-1060-1] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2010] [Accepted: 12/06/2010] [Indexed: 11/26/2022]
Abstract
BACKGROUND This study's purpose was twofold: (1) to establish adherence rates to a behavioral therapy (BT) sleep intervention and (2) to identify psychological and physical symptom predictors of adherence to the intervention in women undergoing breast cancer chemotherapy. METHODS A randomized controlled trial began 48 h before the first of four chemotherapy treatments. Women with stages I-IIIA breast cancer (n = 113) received a BT sleep intervention composed of stimulus control, modified sleep restriction (MSR), relaxation therapy (RT), and sleep hygiene counseling components. A BT plan was developed by a research nurse and each participant, reinforced on day 8, and repeated for chemotherapy cycles 2, 3, and 4. Adherence to the BT plan was measured daily; total adherence score was computed at each chemotherapy cycle by combining adherence estimates of all BT plan components. Psychological and physical symptoms over the past 7 days were measured 2 days prior to and 7 days after each chemotherapy treatment. RESULTS Total adherence rates to the BT plan were 51-52% at all four treatments but adherence varied by component. Sleep disturbance, pain, and anxiety significantly decreased whereas depression significantly increased across chemotherapy. Structural equation modeling revealed a good model fit with decreasing sleep disturbances (0.409) and increasing depression (-0.711) contributing to lower total adherence rates. Increasing depression predicted lower MSR adherence (-0.203) and decreasing sleep disturbances predicted lower RT adherence (1.220). CONCLUSIONS Sleep disturbance and depression significantly impacted adherence rates during chemotherapy. Results warrant attention when promoting adherence to BT sleep interventions during chemotherapy treatment.
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Affiliation(s)
- Dennis E McChargue
- Department of Psychology, University of Nebraska-Lincoln, Lincoln, NE, USA.
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Dzierzewski JM, O'Brien EM, Kay D, McCrae CS. Tackling sleeplessness: psychological treatment options for insomnia in older adults. Nat Sci Sleep 2010; 2:47-61. [PMID: 22323897 PMCID: PMC3273867 DOI: 10.2147/nss.s7064] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
This paper provides a broad review of the extant literature involving the treatment of sleeplessness in older adults with insomnia. First, background information (including information regarding key issues in late-life insomnia and epidemiology of late-life insomnia) pertinent to achieving a general understanding of insomnia in the elderly is presented. Next, theories of insomnia in older adults are examined and discussed in relation to treatment of insomnia in late-life. With a general knowledge base provided, empirical evidence for both pharmacological (briefly) and psychological treatment options for insomnia in late-life are summarized. Recent advances in the psychological treatment of insomnia are provided and future directions are suggested. This review is not meant to be all-inclusive; however, it is meant to provide professionals across multiple disciplines (physicians; psychologists; applied and basic researchers) with a mix of breadth and depth of knowledge related to insomnia in late-life. It is our hope that readers will see the evidence in support of psychological treatments for late-life insomnia, and the utility in continuing to investigate this treatment modality.
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Abstract
Chronic pain and insomnia often occur simultaneously, with the vast majority of chronic pain patients complaining of interrupted or poor quality sleep. The need to improve sleep in these patients is clear, given increasing evidence that sleep disturbance is associated with heightened pain sensitivity and elevated disability. This article evaluates the efficacy of pain management programs (PMPs) based on cognitive-behavioral therapy (CBT) principles and CBT for primary insomnia (CBT-I) in treating pain-related insomnia. Although PMPs effectively enhance pain management skills in patients, they do not adequately address insomnia. CBT-I has demonstrated strong efficacy in treating pain-related insomnia, but sleep improvement is not followed by pain reduction. As both CBT approaches involve strengths and limitations, a hybrid form of treatment is needed that simultaneously addresses pain and sleep.
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Matteson-Rusby SE, Pigeon WR, Gehrman P, Perlis ML. Why treat insomnia? PRIMARY CARE COMPANION TO THE JOURNAL OF CLINICAL PSYCHIATRY 2010; 12:PCC.08r00743. [PMID: 20582296 PMCID: PMC2882812 DOI: 10.4088/pcc.08r00743bro] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/11/2008] [Accepted: 03/06/2009] [Indexed: 10/19/2022]
Abstract
OBJECTIVE To make the case that insomnia is better conceptualized, not as a symptom, but as a primary disorder. DATA SOURCES PubMed was searched from 1975-2009 using the search terms insomnia, insomnia and treatment, insomnia and cost, and insomnia and treatment and safety. STUDY SELECTION English-language articles and other materials were selected to address the following claims: insomnia is unremitting, insomnia is disabling, insomnia is costly, insomnia is pervasive, insomnia is pernicious, and insomnia treatment is safe and effective. DATA EXTRACTION/SYNTHESIS Insomnia, at least when chronic, should be conceptualized as a comorbid condition, one for which effective interventions are available. CONCLUSIONS It is speculated that treatment for insomnia will only become the norm when it has been demonstrated that treatment not only addresses the problem of insomnia but also serves to reduce medical and psychiatric morbidity. At that time, the question will no longer be "Why treat insomnia?" but instead "When isn't insomnia treatment indicated?"
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Affiliation(s)
- Sara E Matteson-Rusby
- Sleep and Neurophysiology Research Laboratory, Department of Psychiatry, University of Rochester, New York and Behavioral Sleep Medicine, Department of Psychiatry, University of Pennsylvania, Philadelphia
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Krakow B, Ulibarri VA, Romero EA. Patients with treatment-resistant insomnia taking nightly prescription medications for sleep: a retrospective assessment of diagnostic and treatment variables. PRIMARY CARE COMPANION TO THE JOURNAL OF CLINICAL PSYCHIATRY 2010; 12:PCC.09m00873. [PMID: 21085555 PMCID: PMC2983459 DOI: 10.4088/pcc.09m00873bro] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/20/2009] [Accepted: 11/24/2009] [Indexed: 10/19/2022]
Abstract
BACKGROUND Some chronic insomnia patients who take nightly prescription medication achieve less than optimal results. The US Food and Drug Administration (FDA) and the American Academy of Sleep Medicine (AASM) recommend reevaluation of this type of patient to assess for potential psychiatric or medical causes to explain this "failure for insomnia to remit." METHOD A retrospective chart review examined a consecutive series of chronic insomnia patients with persistent insomnia complaints despite current nightly use of prescription medication from May 2005 to February 2008. To assess the role of psychiatric influences on insomnia symptoms, our sample (N = 218) was divided into 2 subgroups: a group with a history of psychiatric complaints (psychiatric insomnia, n = 189) and a control group of no psychiatric complaints (insomnia, n = 29). RESULTS The average patient reported insomnia for a decade and took prescription medication for sleep for a mean of 4.5 years. Although 100% of the sample used nightly sleep drugs, only 20% believed medication was the best solution for their condition. As evaluated by self-report and polysomnography, these patients exhibited moderately severe insomnia across most measures. Only a few differences were noted between groups. Subjective perception of insomnia severity was worse in the psychiatric insomnia group, which also reported significantly more insomnia-related interference in daily functioning, symptoms of sleep maintenance insomnia, and a trend toward greater daytime fatigue. The mean Apnea-Hypopnea Index score was 19.5 events/hour, yielding an obstructive sleep apnea diagnosis in 75% of patients per conservative AASM nosology (79% in the insomnia group and 74% in the psychiatric insomnia group, P = .22). CONCLUSIONS In this treatment-seeking sample of patients regularly taking sleep medications, residual insomnia was widespread, and patients with psychiatric insomnia may have perceived their condition as more problematic than a control group of insomnia patients without mental health complaints. Both groups exhibited high rates of objectively diagnosed obstructive sleep apnea, a medical condition associated with pervasive sleep fragmentation. These findings support FDA and AASM guidelines to reassess chronic insomnia patients who manifest residual symptoms despite nightly use of prescription medication for sleep.
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Affiliation(s)
- Barry Krakow
- Sleep and Human Health Institute, Albuquerque, New Mexico, USA.
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Rains JC. Optimizing circadian cycles and behavioral insomnia treatment in migraine. Curr Pain Headache Rep 2009; 12:213-9. [PMID: 18796272 DOI: 10.1007/s11916-008-0037-y] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Sleep regulation may play a key role in headache management for individuals with migraine. At least among individuals with a predisposition to headache, episodes may be provoked by sleep deprivation or excess, as well as by sleep disorders. Chronobiological patterns have been identified in some forms of headache, including migraine. Insomnia is the most common sleep disorder in headache clinic populations, observed in half to two thirds of migraineurs. Recent evidence suggests migraine may improve with regulation of sleep. Because sleep represents a potentially modifiable vulnerability to headache, practitioners may wish to consider strategies that restore sleep homeostasis. Behavioral strategies are effective for regulation of sleep and may be abbreviated for headache medical practice settings. This article discusses the nature and prevalence of sleep complaints in migraineurs, conceptualization, and behavioral management of insomnia in the headache practice setting.
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Affiliation(s)
- Jeanetta C Rains
- Center for Sleep Evaluation, Elliot Hospital, Manchester, NH 03103, USA.
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Abstract
Sleep disturbances are extremely common in the early stages of recovery from alcohol dependence and may persist for several months despite continued abstinence. Studies indicate that sleep disturbances independently increase the risk for relapse to alcohol, suggesting that targeting these problems during recovery may support continued abstinence. However, there is limited information in the addiction literature about available and effective treatments for sleep disturbances in recovering alcoholic patients. The primary goals of this article are to describe the phenomenology of sleep disturbances during recovery from alcohol dependence, to outline the evidence linking sleep problems with alcohol relapse, and to describe available pharmacological and nonpharmacological treatment options, including the evidence regarding their efficacy in recovering alcoholic patients. Recommendations for future research are provided along with special considerations for treating insomnia in this population, including avoiding cross-dependent sedatives, such as benzodiazepines and benzodiazepine receptor agonists (BzRAs).
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ADACHI Y, SATO C, KUNITSUKA K, HAYAMA J, DOI Y. A brief behavior therapy administered by correspondence improves sleep and sleep-related behavior in poor sleepers. Sleep Biol Rhythms 2008. [DOI: 10.1111/j.1479-8425.2007.00329.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Oxman AD, Flottorp S, Håvelsrud K, Fretheim A, Odgaard-Jensen J, Austvoll-Dahlgren A, Carling C, Pallesen S, Bjorvatn B. A televised, web-based randomised trial of an herbal remedy (valerian) for insomnia. PLoS One 2007; 2:e1040. [PMID: 17940604 PMCID: PMC2002515 DOI: 10.1371/journal.pone.0001040] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2007] [Accepted: 10/01/2007] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND This trial was conducted as part of a project that aims to enhance public understanding and use of research in decisions about healthcare by enabling viewers to participate in research and to follow the process, through television reports and on the web. Valerian is an herbal over-the-counter drug that is widely used for insomnia. Systematic reviews have found inconsistent and inconclusive results about its effects. METHODS Participants were recruited through a weekly nationally televised health program in Norway. Enrolment and data collection were over the Internet. 405 participants who were 18 to 75 years old and had insomnia completed a two week diary-keeping run-in period without treatment and were randomised and mailed valerian or placebo tablets for two weeks. All participants and investigators were blind to treatment until after the analysis was completed. FINDINGS For the primary outcome of a minimally important improvement in self-reported sleep quality (> or = 0.5 units on a 7 point scale), the difference between the valerian group (29%) and the placebo group (21%) was not statistically significant (difference 7.5%; 95% CI-0.9 to 15.9; p = 0.08). On the global self-assessment question at the end of the treatment period 5.5% (95% CI 0.2 to 10.8) more participants in the valerian group perceived their sleep as better or much better (p = 0.04). There were similar trends favouring the valerian group for night awakenings (difference = 6.0%, 95% CI-0.5 to 12.5) and sleep duration (difference = 7.5%, 95% CI-1.0 to 16.1). There were no serious adverse events and no important or statistically significant differences in minor adverse events. INTERPRETATION Based on this and previous studies, valerian appears to be safe, but with modest beneficial effects at most on insomnia compared to placebo. The combined use of television and the Internet in randomised trials offers opportunities to answer questions about the effects of health care interventions and to improve public understanding and use of randomised trials. TRIAL REGISTRATION Controlled-Trials.com ISRCTN72748991.
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Affiliation(s)
- Andrew D Oxman
- Norwegian Knowledge Centre for the Health Services, Oslo, Norway.
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Harris J, Lack L, Wright H, Gradisar M, Brooks A. Intensive Sleep Retraining treatment for chronic primary insomnia: a preliminary investigation. J Sleep Res 2007; 16:276-84. [PMID: 17716277 DOI: 10.1111/j.1365-2869.2007.00595.x] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
The aim of this study was to assess the effectiveness of Intensive Sleep Retraining, a novel, short duration behavioural therapy in treating chronic primary insomnia. Seventeen consecutive volunteers from the general public (mean age = 39.1 years), meeting selection criteria for chronic primary insomnia participated in the treatment study. The study was performed as a case replication series. Assessment involved sleep diary, actigraph and questionnaire measures of sleep and daytime functioning for a period of 2 weeks prior to, immediately after, and 6 weeks following the treatment. Treatment involved a single night of sleep deprivation, facilitating short sleep latencies (mean: 6.9 min) to a series of 50 brief nap opportunities. Following treatment, Sleep Onset Latency significantly decreased by a mean of 30.5 min (SD = 28.3), Wake Time after Sleep Onset significantly decreased by a mean of 28 min (SD = 34.0), and Total Sleep Time significantly increased by 64.6 min (SD = 45.5). Significant improvements were also seen in the daytime functioning and psychological measures of fatigue and vigour, cognitive sleep anticipatory anxiety and self-efficacy for sleep. This brief therapy was effective in improving sleep and some daytime functioning and psychological questionnaire measures. These improvements were maintained up to 2 months following the treatment weekend. Further exploration of this brief therapy is needed, with larger, randomized, placebo-controlled trials over longer follow-up periods, and in comparison to other traditional therapies for insomnia.
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Affiliation(s)
- Jodie Harris
- School of Psychology, Flinders University of South Australia, Adelaide, SA, Australia.
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Robertson JA, Broomfield NM, Espie CA. Prospective comparison of subjective arousal during the pre-sleep period in primary sleep-onset insomnia and normal sleepers. J Sleep Res 2007; 16:230-8. [PMID: 17542954 DOI: 10.1111/j.1365-2869.2007.00579.x] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Psychophysiological insomnia (PI) is the most common insomnia subtype, representing 12-15% of all sleep centre referrals. Diagnostic guidelines describe PI as an intrinsic sleep disorder involving both hyperarousal and learned sleep-preventing associations. Whilst evidence for the first component is reasonably compelling, evidence for learned (conditioned) sleep effects is markedly lacking. Indeed, to date no study has attempted to capture directly the conditioned arousal effect assumed to characterize the disorder. Accordingly, the present study explored variations in subjective arousal over time in 15 PI participants (sleep onset type) and 15 normal sleepers (NS). Self-report measures of cognitive arousal, somatic arousal and sleepiness were taken at three time points: 3 h before bedtime (early to mid-evening); 1 h before bedtime (late evening); and in the bedroom at lights out (bedtime) across four, 24-h cycles. Fluctuations in mean arousal and sleepiness values, and in day-to-day variation were examined using analyses of variance. Participants with PI were significantly more cognitive aroused and significantly less sleepy relative to NS, within the bedroom environment. These results support the tenet of conditioned mental arousal to the bedroom, although competing explanations cannot be ruled out. Results are discussed with reference to extant insomnia models.
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Abstract
The aim of this article is to review progress toward developing a cognitive theory of and therapy for chronic insomnia. The article will begin with a brief overview of cognitive behavior therapy for insomnia (CBT-I), the current treatment of choice, which devotes approximately one session to cognitive therapy. On the basis of (a) the conclusion from a recent review of psychological treatments for insomnia that cognitive therapy has received insufficient attention and evaluation and (b) the evidence that cognitive therapy for a range of other psychological disorders has improved treatment outcome, the remainder of the article describes another approach to the treatment of insomnia: cognitive therapy for insomnia (CT-I). This treatment is derived from a cognitive model that specifies five processes that function to maintain insomnia: worry (also known as cognitive arousal), selective attention and monitoring, distorted misperception of sleep and daytime deficits, unhelpful beliefs about sleep, and counterproductive safety behaviors. The aim of the treatment is to reverse all five maintaining processes during both the dayandthe night.
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Gann H, van Calker D, Feige B, Riemann D. [The importance of sleep for healthy alcohol consumers and alcohol dependent patients]. DER NERVENARZT 2004; 75:431-41. [PMID: 15252883 DOI: 10.1007/s00115-003-1637-8] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
This article deals with the effects of alcohol on sleep and sleep EEG of healthy individuals and alcohol-dependent patients during different phases of alcohol dependency. Healthy individuals initially experience an improvement in sleep, although a greater quantity of alcohol can lead to problems of sleep maintenance during the second half of the night. Pre-existing sleep deprivation or sleep restriction potentiates the effects of alcohol. Alcohol-dependent patients are found to be more prone to sleep problems than healthy individuals, which can facilitate the development of alcoholism. These patients experience difficulty falling asleep and suffer from a reduced total sleep time during all phases of the disorder, often accompanied by other sleep disorders such as sleep apnea syndrome or periodic leg movements during sleep. Certain predictors for the risk of relapse in abstinent alcoholics have been identified. Neurobiological findings in sleep and alcohol dependency are discussed. The cholinergic-aminergic reciprocal interaction model of REM and non-REM sleep regulation is significant in this context. Therapeutic implications are discussed.
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Affiliation(s)
- H Gann
- Abteilung für Psychiatrie und Psychotherapie mit Poliklinik, Universitätsklinik für Psychiatrie und Psychosomatik, Freiburg i. Br.
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Krakow B, Melendrez D, Lee SA, Warner TD, Clark JO, Sklar D. Refractory insomnia and sleep-disordered breathing: a pilot study. Sleep Breath 2004; 8:15-29. [PMID: 15026935 DOI: 10.1007/s11325-004-0015-5] [Citation(s) in RCA: 85] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To assess an uncontrolled, open-label trial of sleep-disordered breathing (SDB) treatment on two different samples of chronic insomnia patients. METHOD In Study 1 (Retrospective), data from one diagnostic and one continuous positive airway pressure (CPAP) titration polysomnogram were compiled from 19 chronic insomnia patients with SDB. Objective polysomnogram indicators of sleep and arousal activity and self-reported sleep quality were measured. In Study 2 (Prospective), clinical outcomes were assessed after sequential cognitive-behavioral therapy (CBT) and SDB therapy (CPAP, oral appliances, or bilateral turbinectomy) were provided to 17 chronic insomnia patients with SDB. Repeat measures included the Insomnia Severity Index, Functional Outcomes of Sleep Questionnaire, Pittsburgh Sleep Quality Index, and self-reported insomnia indices and CPAP use. RESULTS In Study 1, seven objective measures of sleep and arousal demonstrated or approached significant improvement during one night of CPAP titration. Sixteen of 19 patients reported improvement in sleep quality. In Study 2, Insomnia Severity Index, Functional Outcomes of Sleep Questionnaire, and Pittsburgh Sleep Quality Index improved markedly with CBT followed by SDB treatment and achieved an average outcome equivalent to curative status. Improvements were large for each treatment phase; however, of 17 patients, only 8 attained a nonclinical level of insomnia after CBT compared with 15 patients after SDB therapy was added. Self-reported insomnia indices also improved markedly, and self-reported SDB therapy compliance was high. CONCLUSIONS In one small sample of chronic insomnia patients with SDB, objective measures of insomnia, arousal, and sleep improved during one night of CPAP titration. In a second small sample, validated measures of insomnia, sleep quality, and sleep impairment demonstrated clinical cures or near-cures after combined CBT and SDB therapies. These pilot results suggest a potential value in researching the pathophysiological relationships between SDB and chronic insomnia, which may be particularly relevant to patients with refractory insomnia.
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Affiliation(s)
- Barry Krakow
- Sleep and Human Health Institute, Albuquerque, New Mexico 87109, USA.
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Riemann D, Fischer J, Mayer G, Peter HJ. The Guidelines for 'Non-Restorative Sleep': Relevance for the Diagnosis and Therapy of Insomnia. Die Leitlinie "Nicht-erholsamer Schlaf": Relevanz fur Diagnostik und Therapie der Insomnie. SOMNOLOGIE 2003. [DOI: 10.1046/j.1439-054x.2003.03201.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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M. Berner M, Berger M, Riemann D. Evidenzbasierte Medizin und die Cochrane Collaboration - Bedeutung fur die Schlafmedizin. The Concept of "Evidence-based Medicine" and the Cochrane Collaboration - Implications for Sleep Medicine. SOMNOLOGIE 2001. [DOI: 10.1046/j.1439-054x.2001.01143.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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