Treating insomnia in depression: Insomnia related factors predict long-term depression trajectories

A systematic review and meta-analysis of psychological treatments to improve sleep quality in university students

OBJECTIVE

This paper reviews the literature evaluating psychological treatments to improve sleep quality in young adult university students.

METHOD

Participants (N = 6179) were young adult (aged 18-30 years) university students. Databases (PubMed, PsychInfo, EMBASE and Medline) were searched for randomized controlled trials evaluating psychological treatments for sleep disturbance in university students. The search date was 20 September 2024.

RESULTS

22 original trials met inclusion criteria. Meta-analysis showed that psychological interventions outperformed control groups (n = 14) on improving sleep quality (g = 0.50, 95%CI:0.26-0.73). There were significantly different effect sizes found between studies that evaluated cognitive behaviour therapy for insomnia (CBT-I; n = 6, g = 0.72, CI: 0.43-1.02) versus studies that evaluated mindfulness interventions (n = 5, g = 0.16, 95% CI: -0.18-0.51).

CONCLUSIONS

Psychological treatments improve sleep quality for young adult university students. While CBT-I showed larger effect sizes than interventions focused on mindfulness, further research is needed to verify if this reflects a true difference in the efficacy of the interventions.

Sleep effort and its measurement: A scoping review

Insomnia disorder is characterized by disruption in sleep continuity and an overall dissatisfaction with sleep. A relevant feature of insomnia is sleep effort, which refers to both cognitive and behavioural conscious attempts to initiate sleep. The Glasgow Sleep Effort Scale is a self-report tool developed to assess this construct. The objective of the current scoping review was to map how sleep effort has been discussed in the literature and operationalized through its respective measure. Medline/PubMed, Scopus, Web of Science and PsycInfo databases were used to search for potential studies. The search query used in databases was the specific name of the self-reported tool itself (Glasgow Sleep Effort Scale) and "sleep effort" term. This scoping review followed JBI guidelines. To be included, records pertaining to any type of study that mentioned the Glasgow Sleep Effort Scale were considered. No language constraint was used. At the end, 166 initial records were retrieved. From those, 46 records met eligibility criteria and were analysed. Among the main findings, it was observed that the Glasgow Sleep Effort Scale has been increasingly used in recent years, with a notable observed upward trend, especially in the last 2 years. In addition to the original measure, only three published adapted versions of the instrument were identified. This suggests that there is limited research on adapting the scale for different populations or contexts. Sleep effort has been increasingly studied in the last few years. Nonetheless, more research on the Glasgow Sleep Effort Scale tool is recommended, including cross-cultural adaptations.

Effects of Sleep Deficiency on Risk, Course, and Treatment of Psychopathology

This article reviews the literature on the relationship between sleep deficiency and unipolar and bipolar depression, anxiety disorders, and posttraumatic stress disorder. We consider the evidence for sleep as a contributory causal factor in the development of psychiatric disorders, as well as sleep as an influential factor related to the outcome and recurrence of psychopathology. A case for sleep deficiency being an important treatment target when sleep and psychiatric disorders are comorbid is also made. Our recommendation is that sleep deficiency is recognized as a means to positively impact the development and course of psychopathology and, as such, is routinely assessed and treated in clinical practice.

Evening Chronotypes With Depression Report Poorer Outcomes of Selective Serotonin Reuptake Inhibitors: A Survey-Based Study of Self-Ratings

BACKGROUND

Preliminary evidence suggests that evening chronotype is related to poorer efficacy of selective serotonin reuptake inhibitors. It is unknown whether this is specific to particular medications, self-rated chronotype, or efficacy.

METHODS

In the Australian Genetics of Depression Study (n = 15,108; 75% women; 18-90 years; 68% with ≥1 other lifetime diagnosis), a survey recorded experiences with 10 antidepressants, and the reduced Morningness-Eveningness Questionnaire was used to estimate chronotype. A chronotype polygenic score was calculated. Age- and sex-adjusted regression models (Bonferroni-corrected) estimated associations among antidepressant variables (how well the antidepressant worked [efficacy], duration of symptom improvement, side effects, discontinuation due to side effects) and self-rated and genetic chronotypes.

RESULTS

The chronotype polygenic score explained 4% of the variance in self-rated chronotype (r = 0.21). Higher self-rated eveningness was associated with poorer efficacy of escitalopram (odds ratio [OR] = 1.04; 95% CI, 1.02 to 1.06; p = .000035), citalopram (OR = 1.03; 95% CI, 1.01 to 1.05; p = .004), fluoxetine (OR = 1.03; 95% CI, 1.01 to 1.05; p = .001), sertraline (OR = 1.02; 95% CI, 1.01 to 1.04; p = .0008), and desvenlafaxine (OR = 1.03; 95% CI, 1.01 to 1.05; p = .004), and a profile of increased side effects (80% of those recorded; ORs = 0.93-0.98), with difficulty getting to sleep the most common. Self-rated chronotype was unrelated to duration of improvement or discontinuation. The chronotype polygenic score was only associated with suicidal thoughts and attempted suicide (self-reported). While our measures are imperfect, and not of circadian phase under controlled conditions, the model coefficients suggest that dysregulation of the phenotypic chronotype relative to its genetic proxy drove relationships with antidepressant outcomes.

CONCLUSIONS

The idea that variation in circadian factors influences response to antidepressants was supported and encourages exploration of circadian mechanisms of depressive disorders and antidepressant treatments.

Insomnia is more likely to persist than remit after a time of stress and uncertainty: a longitudinal cohort study examining trajectories and predictors of insomnia symptoms

STUDY OBJECTIVES

The study aimed to characterize insomnia symptom trajectories over 12 months during a time of stress and uncertainty, the coronavirus disease 2019 (COVID-19) pandemic. It also aimed to investigate sleep and psychological predictors of persistent insomnia symptoms.

METHODS

This longitudinal cohort study comprised 2069 participants with and without insomnia symptoms during the first year of the pandemic. Participants completed online surveys investigating sleep, insomnia, and mental health at four timepoints over 12 months (April 2020-May 2021). Additional trait-level cognitive/psychological questionnaires were administered at 3 months only.

RESULTS

Six distinct classes of insomnia symptoms emerged: (1) severe persistent insomnia symptoms (21.65%), (2) moderate persistent insomnia symptoms (32.62%), (3) persistent good sleep (32.82%), (4) severe insomnia symptoms at baseline but remitting over time (2.27%), (5) moderate insomnia symptoms at baseline but remitting over time (7.78%), and (6) good sleep at baseline but deteriorating into insomnia symptoms over time (2.85%). Persistent insomnia trajectories were predicted by high levels of sleep reactivity, sleep effort, pre-sleep cognitive arousal, and depressive symptoms at baseline. A combination of high sleep reactivity and sleep effort reduced the odds of insomnia remitting. Higher sleep reactivity also predicted the deterioration of good sleep into insomnia symptoms over 12 months. Lastly, intolerance of uncertainty emerged as the only trait-level cognitive/psychological predictor of insomnia trajectory classes.

CONCLUSIONS

Insomnia was more likely to persist than remit over the first year of the COVID-19 pandemic. Addressing sleep reactivity and sleep effort appears critical for reducing insomnia persistence rates after times of stress and uncertainty.

Cognitive behavioural therapy for insomnia reduces actigraphy and diary measured sleep discrepancy for individuals with comorbid insomnia and major depressive disorder: A report from the TRIAD study

OBJECTIVE/BACKGROUND

Discrepancies between sleep diaries and actigraphy occur among individuals with insomnia. Cognitive behavioural therapy for insomnia (CBT-I) improves insomnia but the impact on discrepancy is unclear. This study examined CBT-I's effects on actigraphy-diary discrepancy and explored sleep-related beliefs and attitudes as a mediator.

PATIENTS/METHODS

Participants were 108 (age M±SD = 47.23 ± 12.42, 67.60 % female) adults with insomnia and major depressive disorder from the Treatment of Insomnia and Depression study. They were randomized to 7 sessions of CBT-I or sham Quasi-Desensitization Therapy for Insomnia (DTI), plus 16 weeks of antidepressants. Two weeks of actigraphy and sleep diary were collected at baseline, mid-treatment, end-treatment. Differences between sleep diary and actigraphy total sleep time (TST), sleep onset latency (SOL), wake after sleep onset (WASO), and sleep efficiency (SE) were calculated. Participants completed Dysfunctional Beliefs and Attitudes about Sleep Scale (DBAS) at baseline and mid-treatment.

RESULTS

At baseline, diary (versus actigraphy) TST was shorter (1.1 ± 1.41h), whilst SOL (21.64 ± 41.25min) and WASO (17.45 ± 61.99min) were longer. Mixed effects models using daily data showed that after adjusting for age and sex, participants in the CBT-I group (versus DTI) showed greater reduction in all actigraphy-diary discrepancy domains (all p-values<.01), reductions evident from mid-treatment. Group differences on actigraphy-diary discrepancy reductions in TST, SOL, and SE (not WASO) were mediated by changes in DBAS from baseline to mid-treatment (all p-values<.05). Changes in discrepancy did not mediate insomnia symptom changes (p-values>.39).

CONCLUSIONS

CBT-I reduced actigraphy-diary discrepancy in individuals with comorbid insomnia and depression; this reduction was associated with improved sleep-related attitudes, a therapeutic target of CBT-I.

CLINICAL TRIAL REGISTRATION

TRIAD (Treatment of Insomnia and Depression): Improving Depression Outcome by Adding Insomnia Therapy to Antidepressants. Prospectively registered with Clinical Trials (NCT00767624).

SUPPORT (IF ANY)

MH078924, MH078961, MH079256.

Mindfulness-based cognitive therapy improves insomnia symptoms in individuals with recurrent depression: secondary analyses from a randomized controlled trial

Background

Embedded within a randomized efficacy trial, the present study aimed to investigate whether mindfulness-based cognitive therapy (MBCT) for recurrent depression improved symptoms of insomnia.

Methods

Sixty-eight remitted participants with at least three prior episodes of depression were randomized to 8 weeks of MBCT (n = 33) or a waitlist control condition (n = 35). The Bergen Insomnia Scale was used to screen for insomnia symptoms before and after the intervention. The analyses were conducted using one-way between-groups analyses of covariance.

Results

Twenty-five MBCT participants and 30 waitlist controls completed the study (74.5% females; mean age 40.7 ± 12.9 years). At baseline, 83.6% screened positive for the insomnia diagnosis. Following the intervention and after controlling for corresponding insomnia parameters at baseline, MBCT completers reported significantly less severe insomnia symptoms (p = 0.017), as well as less problems with prolonged sleep onset (p = 0.047) and nocturnal awakenings (p = 0.023), relative to controls. No group differences were found on early morning awakening, daytime impairment, or dissatisfaction with sleep.

Conclusion

The results suggest that MBCT improves certain insomnia symptoms. However, additional sleep-specific interventions may be needed to further improve this population's sleep.Clinical Trial Registration: ISRCTN, ISRCTN18001392, registered 22/11/2018. URL: 10.1186/ISRCTN18001392.

Insomnia and related mental health conditions: Essential neurobiological underpinnings towards reduced polypharmacy utilization rates

Insomnia represents a significant public health burden, with a 10% prevalence in the general population. Reduced sleep affects social and working functioning, productivity, and patient's quality of life, leading to a total of $100 billion per year in direct and indirect healthcare costs. Primary insomnia is unrelated to any other mental or medical illness; secondary insomnia co-occurs with other underlying medical, iatrogenic, or mental conditions. Epidemiological studies found a 40-50% comorbidity prevalence between insomnia and psychiatric disorders, suggesting a high relevance of mental health in insomniacs. Sleep disturbances also worsen the outcomes of several psychiatric disorders, leading to more severe psychopathology and incomplete remission, plausibly contributing to treatment-resistant conditions. Insomnia and psychiatric disorder coexistence can lead to polypharmacy, namely, the concurrent use of two or more medications in the same patient, regardless of their purpose or rationale. Polypharmacy increases the risk of using unnecessary drugs, the likelihood of drug interactions and adverse events, and reduces the patient's compliance due to regimen complexity. The workup of insomnia must consider the patient's sleep habits and inquire about any medical and mental concurrent conditions that must be handled to allow insomnia to be remitted adequately. Monotherapy or limited polypharmacy should be preferred, especially in case of multiple comorbidities, promoting multipurpose molecules with sedative properties and with bedtime administration. Also, non-pharmacological interventions for insomnia, such as sleep hygiene, relaxation training and Cognitive Behavioral Therapy may be useful in secondary insomnia to confront behaviors and thoughts contributing to insomnia and help optimizing the pharmacotherapy. However, insomnia therapy should always be patient-tailored, considering drug indications, contraindications, and pharmacokinetics, besides insomnia phenotype, clinical picture, patient preferences, and side effect profile.

The Relationship of Early Sleep Improvement With Response to Pharmacotherapy in Unipolar Psychotic Depression

BACKGROUND

Since insomnia and depression are interrelated, improved sleep early in antidepressant pharmacotherapy may predict a positive treatment outcome. We investigated whether early insomnia improvement (EII) predicted treatment outcome in psychotic depression (PD) and examined if there was an interaction effect between EII and treatment type to assess if findings were treatment-specific.

METHODS

This study is a secondary analysis of a randomized trial comparing 7 weeks treatment with the antidepressants venlafaxine, imipramine and venlafaxine plus the antipsychotic quetiapine in PD ( n = 114). Early insomnia improvement, defined as ≥20% reduced insomnia after 2 weeks, was assessed by the Hamilton Rating Scale for Depression (HAM-D-17). Associations between EII and treatment outcome were examined using logistic regressions. Subsequently, we added interaction terms between EII and treatment type to assess interaction effects. The predictive value of EII was compared with early response on overall depression (≥20% reduced HAM-D-17 score after 2 weeks).

RESULTS

EII was associated with response (odds ratio [OR], 7.9; 95% confidence interval [CI], 2.7-23.4; P = <0.001), remission of depression (OR, 6.1; 95% CI, 1.6-22.3; P = 0.009), and remission of psychosis (OR, 4.1; 95% CI, 1.6-10.9; P = 0.004). We found no interaction effects between EII and treatment type on depression outcome. Early insomnia improvement and early response on overall depression had a comparable predictive ability for treatment outcome.

CONCLUSIONS

Early insomnia improvement was associated with a positive outcome in pharmacotherapy of PD, regardless of the medication type. Future studies are needed to confirm our findings and to examine the generalizability of EII as predictor in treatment of depression.

Pathways to Anxiety and Depression in Autistic Adolescents and Adults

Individuals diagnosed with autism spectrum disorder (autism) commonly experience co-occurring anxiety and depression, which are significantly associated. These mental health conditions are also variously associated with increased autistic traits, insomnia, intolerance of uncertainty (IU), sensory sensitivity, and autonomic symptoms. However, no research has explored the relationships between IU, sensory sensitivity, autonomic symptoms, insomnia, and autistic traits and how they might be associated with anxiety and depression in autism. This study took a transdiagnostic approach to explore the relationships between anxiety, depression, autistic traits, insomnia, IU, sensory sensitivities, and autonomic arousal in 222 autistic people aged 15-80 years (55.7% female) using path analysis. Four plausible, theoretical models were tested, with model 1 providing best fit and explaining 48% of variance in depression, 37% of variance in anxiety, and 29% of variance in insomnia. Autistic traits and IU were directly associated with anxiety and indirectly associated with depression through anxiety. Anxiety, insomnia, IU, and sensory sensitivity were all directly associated with depression; autonomic arousal and sensory sensitivity were also indirectly associated with depression through insomnia. Thus, multiple pathways can lead to anxiety and depression in autism, not only via known paths such as insomnia and IU but additionally via autonomic arousal and sensory sensitivities which are also elevated in autism. These findings suggest that careful clinical evaluation and individualised treatment plans are needed for autistic adults with anxiety or depression. When considering prevention, programs that help autistic adults reduce arousal, maintain good sleep, and reduce IU may prove fruitful.

Treating postpartum insomnia: a three arm randomised controlled trial of cognitive behavioural therapy and light dark therapy

BACKGROUND

Insomnia symptoms are common during the postpartum period, yet interventions remain scarce. This trial aimed to simultaneously examine the efficacy of cognitive behavioural therapy (CBT) and light dark therapy (LDT), targeting different mechanisms, against treatment-as-usual (TAU), in reducing maternal postpartum insomnia symptoms.

METHODS

This three-arm randomised controlled trial recruited from the general community in Australia. Nulliparous females 4-12 months postpartum with self-reported insomnia symptoms [Insomnia Severity Index (ISI) scores >7] were included; severe medical/psychiatric conditions were excluded. Participants were randomised 1:1:1 to CBT, LDT, or TAU stratified by ISI (< or ⩾14) and infant age (< or ⩾8 months). Participants and principal investigators were unblinded. Six-week interventions were delivered via digital materials and telephone. The primary outcome was insomnia symptoms (ISI), assessed pre-, midpoint-, post- (primary endpoint), and one-month post-intervention. Analyses were intention-to-treat using latent growth models.

RESULTS

114 participants (CBT = 39, LDT = 36, TAU = 39; Mage = 32.20 ± 4.62 years) were randomised. There were significantly greater reductions in ISI scores in CBT and LDT (effect sizes -2.01 and -1.52 respectively, p < 0.001) from baseline to post-intervention compared to TAU; improvements were maintained at follow-up. Similar effects were observed for self-reported sleep disturbance. There were greater reductions in fatigue in CBT (effect size = 0.85, p < 0.001) but not LDT (p = 0.11) compared to TAU. Changes in sleepiness, depression, and anxiety were non-significant compared to TAU (all p > 0.08). Four participants (11%) in the LDT group reported headaches, dizziness, or nausea; no others reported adverse events.

CONCLUSIONS

Therapist-assisted CBT and LDT were feasible during the first postpartum year; data at post-intervention and 1-month follow-up support their safety and efficacy in reducing postpartum insomnia symptoms.

Preferences of University Students for a Psychological Intervention Designed to Improve Sleep: Focus Group Study

BACKGROUND

Many university students have difficulties with sleep; therefore, effective psychological treatments are needed. Most research on psychological treatments to improve sleep has been conducted with middle-aged and older adults, which means it is unclear whether existing psychological treatments are helpful for young adult university students.

OBJECTIVE

This study aimed to discover university student preferences for a psychological intervention to improve sleep quality.

METHODS

Focus groups were conducted over 3 stages to examine students' views regarding content, format, and session duration for a psychological intervention to improve sleep. A thematic analysis was conducted to analyze participant responses.

RESULTS

In total, 30 participants attended small focus group discussions. Three key themes were identified: (1) program development, (2) help-seeking, and (3) student sleep characteristics. Program development subthemes were program format, program content, and engagement facilitators. Help-seeking subthemes were when to seek help, where to access help, stigma, and barriers. Student sleep characteristics subthemes were factors disturbing sleep and consequences of poor sleep.

CONCLUSIONS

Students emphasized the need for a sleep intervention with an in-person and social component, individualized content, and ways to monitor their progress. Participants did not think there was a stigma associated with seeking help for sleep problems. Students identified the lack of routine in their lifestyle, academic workload, and the pressure of multiple demands as key contributors to sleep difficulties.

Sleep and mental health in recruit paramedics: a 6-month longitudinal study

STUDY OBJECTIVES

To explore potential relationships and longitudinal changes in sleep and mental health in recruit paramedics over the first 6 months of work, and whether sleep disturbances pre-emergency work predict future mental health outcomes.

METHODS

Participants (N = 101, 52% female, Mage = 26 years) completed questionnaires prior to (baseline), and after 6 months of emergency work to assess for symptoms of insomnia, obstructive sleep apnea, post-traumatic stress disorder (PTSD), depression, anxiety, and trauma exposure. At each timepoint, participants also completed a sleep diary and wore an actigraph for 14 days to assess sleep patterns. Correlations between baseline sleep and mental health were conducted and changes in these variables across timepoints were examined using linear mixed models. Hierarchical regressions assessed whether sleep at baseline predicted mental health at follow-up.

RESULTS

Insomnia and depression symptoms, and total sleep time increased while sleep onset latency decreased across the first 6 months of emergency work. Participants experienced an average of 1 potentially traumatic event during the 6-month period. Baseline insomnia predicted increased depression symptoms at the 6-month follow-up, while baseline wake after sleep onset predicted follow-up PTSD symptoms.

CONCLUSION

Results highlight an increase in insomnia and depression across the initial months of emergency work, while sleep disturbances before emergency work were identified as potential risk factors for the development of depression and PTSD among paramedics in their early career. Screening and early interventions targeting poor sleep at the beginning of emergency employment may assist in reducing the risk of future mental health outcomes in this high-risk occupation.

Clinical guidelines for the use of lifestyle-based mental health care in major depressive disorder: World Federation of Societies for Biological Psychiatry (WFSBP) and Australasian Society of Lifestyle Medicine (ASLM) taskforce

OBJECTIVES

The primary objectives of these international guidelines were to provide a global audience of clinicians with (a) a series of evidence-based recommendations for the provision of lifestyle-based mental health care in clinical practice for adults with Major Depressive Disorder (MDD) and (b) a series of implementation considerations that may be applicable across a range of settings.

METHODS

Recommendations and associated evidence-based gradings were based on a series of systematic literature searches of published research as well as the clinical expertise of taskforce members. The focus of the guidelines was eight lifestyle domains: physical activity and exercise, smoking cessation, work-directed interventions, mindfulness-based and stress management therapies, diet, sleep, loneliness and social support, and green space interaction. The following electronic bibliographic databases were searched for articles published prior to June 2020: PubMed, EMBASE, The Cochrane Library (Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials (CENTRAL), Cochrane Methodology Register), CINAHL, PsycINFO. Evidence grading was based on the level of evidence specific to MDD and risk of bias, in accordance with the World Federation of Societies for Biological Psychiatry criteria.

RESULTS

Nine recommendations were formed. The recommendations with the highest ratings to improve MDD were the use of physical activity and exercise, relaxation techniques, work-directed interventions, sleep, and mindfulness-based therapies (Grade 2). Interventions related to diet and green space were recommended, but with a lower strength of evidence (Grade 3). Recommendations regarding smoking cessation and loneliness and social support were based on expert opinion. Key implementation considerations included the need for input from allied health professionals and support networks to implement this type of approach, the importance of partnering such recommendations with behaviour change support, and the need to deliver interventions using a biopsychosocial-cultural framework.

CONCLUSIONS

Lifestyle-based interventions are recommended as a foundational component of mental health care in clinical practice for adults with Major Depressive Disorder, where other evidence-based therapies can be added or used in combination. The findings and recommendations of these guidelines support the need for further research to address existing gaps in efficacy and implementation research, especially for emerging lifestyle-based approaches (e.g. green space, loneliness and social support interventions) where data are limited. Further work is also needed to develop innovative approaches for delivery and models of care, and to support the training of health professionals regarding lifestyle-based mental health care.

Baseline symptoms of depression and anxiety negatively impact the effectiveness of CBTi in treating acute insomnia among young adults

Background

Cognitive-behavioural therapy for insomnia (CBTi) is the first-line treatment for those with this sleep disorder. However, depressive and anxiety symptoms often co-occur with acute insomnia, which may affect the effectiveness of CBTi treatment.

Aims

This study aimed to determine the impact of depressive and anxiety symptoms on the efficacy of CBTi in treating acute insomnia.

Methods

A single-arm clinical trial was conducted among individuals who have acute insomnia. Participants underwent self-guided CBTi for 1-week. Their insomnia, depressive symptoms and anxiety symptoms were evaluated using the Insomnia Severity Index and the Hospital Anxiety and Depression Scale at baseline, post-treatment and 3-month follow-up. Repeated measures analysis of variance was used to assess the effectiveness of CBTi in treating insomnia, depressive symptoms and anxiety symptoms. A multivariate Cox regression model was used to determine the impact of depressive and anxiety symptoms on insomnia.

Results

The study found significant reductions in insomnia, depressive symptoms and anxiety symptoms at both post-treatment and 3-month follow-up (F=17.45, p<0.001; F=36.37, p=0.001; and F=81.51, p<0.001, respectively). The duration of CBTi treatment had a positive impact on insomnia recovery (hazard ratio (HR)=0.94, p=0.018). However, baseline depressive symptoms (HR=1.83, p=0.004) and baseline anxiety symptoms (HR=1.99, p=0.001) had significant negative effects on insomnia recovery.

Conclusions

The study showed that a 1-week self-guided CBTi treatment is effective in treating acute insomnia and comorbid depressive and anxiety symptoms. However, baseline depressive and anxiety symptoms negatively impact treatment effectiveness. Therefore, clinicians should assess for depressive and anxiety symptoms before treating acute insomnia with monotherapy CBTi.

Treating depression with a smartphone-delivered self-help cognitive behavioral therapy for insomnia: a parallel-group randomized controlled trial

BACKGROUND

Despite its efficacy in treating comorbid insomnia and depression, cognitive behavioral therapy for insomnia (CBT-I) is limited in its accessibility and, in many countries, cultural compatibility. Smartphone-based treatment is a low-cost, convenient alternative modality. This study evaluated a self-help smartphone-based CBT-I in alleviating major depression and insomnia.

METHODS

A parallel-group randomized, waitlist-controlled trial was conducted with 320 adults with major depression and insomnia. Participants were randomized to receive either a 6-week CBT-I via a smartphone application, proACT-S, or waitlist condition. The primary outcomes included depression severity, insomnia severity, and sleep quality. The secondary outcomes included anxiety severity, subjective health, and acceptability of treatment. Assessments were administered at baseline, post-intervention (week 6) follow-up, and week 12 follow-up. The waitlist group received treatment after the week 6 follow-up.

RESULTS

Intention to treat analysis was conducted with multilevel modeling. In all but one model, the interaction between treatment condition and time at week 6 follow-up was significant. Compared with the waitlist group, the treatment group had lower levels of depression [Center for Epidemiologic Studies Depression Scale (CES-D): Cohen's d = 0.86, 95% CI (-10.11 to -5.37)], insomnia [Insomnia Severity Index (ISI): Cohen's d = 1.00, 95% CI (-5.93 to -3.53)], and anxiety [Hospital Anxiety and Depression Scale - Anxiety subscale (HADS-A): Cohen's d = 0.83, 95% CI (-3.75 to -1.96)]. They also had better sleep quality [Pittsburgh Sleep Quality Index (PSQI): Cohen's d = 0.91, 95% CI (-3.34 to -1.83)]. No differences across any measures were found at week 12, after the waitlist control group received the treatment.

CONCLUSION

proACT-S is an efficacious sleep-focused self-help treatment for major depression and insomnia.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT04228146. Retrospectively registered on 14 January 2020. http://www.w3.org/1999/xlink">https://clinicaltrials.gov/ct2/show/NCT04228146.

ACT-i, an insomnia intervention for autistic adults: a pilot study

BACKGROUND

Insomnia and disturbed sleep are more common in autistic adults compared with non-autistic adults, contributing to significant social, psychological and health burdens. However, sleep intervention research for autistic adults is lacking.

AIMS

The aim of the study was to implement an acceptance and commitment therapy group insomnia intervention (ACT-i) tailored for autistic adults to examine its impact on insomnia and co-occurring mental health symptoms.

METHOD

Eight individuals (6 male, 2 female) aged between 18 and 70 years, with a clinical diagnosis of autism spectrum disorder, and scores ranging from 9 to 26 on the Insomnia Severity Index (ISI) participated in the trial. Participants were assigned to one of two intervention groups (4 per group) within a multiple baseline over time design for group. Participants completed questionnaires pre-intervention, post-intervention, and at 2-month follow-up, actigraphy 1 week prior to intervention and 1 week post-intervention, and a daily sleep diary from baseline to 1 week post-intervention, and 1 week at follow-up.

RESULTS

At a group level there were significant improvements in ISI (λ²=10.17, p=.006) and HADS-A (anxiety) (λ²=8.40, p=.015) scores across the three time points. Clinically reliable improvement occurred for ISI scores (n=5) and HADS-A scores (n=4) following intervention. Client satisfaction indicated that ACT-i was an acceptable intervention to the participants (median 4 out of 5).

CONCLUSIONS

This pilot study with eight autistic adults indicates that ACT-i is both an efficacious and acceptable intervention for reducing self-reported insomnia and anxiety symptoms in autistic adults.

Exercise as a therapeutic modality for the prevention and treatment of depression

While maintaining an active lifestyle and engaging in regular exercise are known to promote cardiovascular (CV) health, increasing evidence has emerged to indicate that these lifestyle behaviors also can promote psychological health and well-being. This has led to research to determine if exercise can serve as a potential therapeutic modality for major depressive disorder (MDD), which is a leading cause of mental-health impairment and overall disability worldwide. The strongest evidence to support this use comes from an increasing number of randomized clinical trials (RCTs) that have compared exercise to usual care, placebo controls, or established therapies in healthy adults and in various clinical populations. The relatively large number of RCTs has led to numerous reviews and meta-analyses, which generally have been concordant in indicating that exercise ameliorates depressive symptoms, improves self-esteem, and enhances various aspects of quality of life. Together, these data indicate that exercise should be considered as a therapeutic modality for improving CV health and psychological well-being. The emerging evidence also has led to a new proposed subspecialty of "lifestyle psychiatry", which promotes the use of exercise as an adjunctive treatment for patients with MDD. Indeed, some medical organizations have now endorsed lifestyle-based approaches as foundational aspects of depression management, with adoption of exercise as a treatment option for MDD. This review summarizes research in the area and provides practical suggestions for the use of exercise in clinical practice.

The impact of sleep quality, fatigue and social well-being on depressive symptomatology in autistic older adolescents and young adults

Depression and poor sleep quality commonly co-occur with autism, and depression has been associated with loneliness and reduced social support. In non-autistic samples, poor sleep quality and daytime fatigue also contribute to depression. However, the contribution of sleep quality and fatigue to depressive symptoms, and how they interact with social factors to influence depression in autism remain unexplored. Our aim was to examine these relationships in 114 young autistic adults aged 15-25 years (57% male) from the SASLA online, longitudinal study (baseline and 2-year follow-up). Hierarchical multiple regression models examined the association between social well-being (social integration and social contribution; T1), sleep quality (T1, T2), and fatigue (T1, T2) on depression (T1, T2). Two mediation models were conducted on T1 data predicting depression from sleep quality though fatigue and sleep quality through social well-being. Depression and fatigue scores did not change over 2 years, but sleep quality worsened. The T1 regression model was significant (R² = 36%) with fatigue and social contribution individually predicting depression symptomatology. The longitudinal regression model was also significant (adjusted R² = 57%) with social contribution (T1) as the only significant predictor of depression (T2). Fatigue trended towards mediating the sleep quality-depression relationship, while social well-being was a significant partial mediator of this relationship. Results highlight that sleep quality, fatigue, and social well-being contribute to depression among young autistic adults. Interestingly, fatigue and social well-being were independently associated with depression. Thus, addressing sleep quality and associated fatigue, and social well-being is important when treating depression in autistic individuals.

Acupuncture for comorbid depression and insomnia in perimenopause: A feasibility patient-assessor-blinded, randomized, and sham-controlled clinical trial

Background and objective

Whilst acupuncture is widely used for treating psychosomatic diseases, there is little high-quality evidence supporting its application in comorbid perimenopausal depression (PMD) and insomnia (PMI) which are common complaints during climacteric. This feasibility, patient-assessor-blinded, randomized, sham-controlled clinical trial addresses this gap by investigating the efficacy and safety of acupuncture on depressed mood and poor sleep in women with comorbid PMD and PMI.

Methods

Seventy eligible participants were randomly assigned to either real-acupuncture (RA) or sham-acupuncture (SA) groups. Either RA or SA treatment were delivered in 17 sessions over 8 weeks. The primary outcomes for mood and sleep were changes on 17-items Hamilton Depression Rating Scale (HAM-D₁₇) and Pittsburgh Sleep Quality Index (PSQI) scores, from baseline to 16-week follow-up. Secondary outcome measures involved anxiety symptoms, perimenopausal symptoms, quality of life, participants' experience of and satisfaction with the acupuncture treatment. Blood samples were taken to measure reproductive hormone levels. Intention-To-Treat and Per-Protocol analyses were conducted with linear mixed-effects models. The James' and Bang's blinding indices were used to assess the adequacy of blinding.

Results

Sixty-five participants completed all treatment sessions, and 54 and 41 participants completed the eight- and 16-week follow-ups, respectively. At post-treatment and 8-week follow-up, the RA group showed a significantly greater reduction in PSQI scores than the SA group did; although the reduction of HAM-D₁₇ scores in RA group was significant, the change was not statistically different from that of SA. There were no significant mean differences between baseline and 16-week follow-up in either HAM-D₁₇ or PSQI in either group. There were no significant between-group differences in serum reproductive hormone levels. All treatments were tolerable and no serious adverse events were reported, and the blinding was successful.

Conclusion

Acupuncture is safe and can contribute to clinically relevant improvements in comorbid PMD and PMI, with satisfactory short-and medium-term effects. Whether the anti-depressive benefit of acupuncture is specific or non-specific remains to be determined. No evidence was found for any longer-term benefit of acupuncture compared to sham at 16 weeks. Further research is required to elucidate mechanisms underlying the short to medium term effects of acupuncture.

Insomnia is a key risk factor for persistent anxiety and depressive symptoms: A 12-month longitudinal cohort study during the COVID-19 pandemic

BACKGROUND

Insomnia is a risk factor for affective disorders. This study examined whether individuals with insomnia symptoms early in the pandemic, either pre-existing or new-onset, were more vulnerable to anxiety and depressive symptoms over time than those who maintained normal sleep. Additionally, sleep-related factors such as pre-sleep arousal were assessed for their influence on clinically significant anxiety and depression risk.

METHODS

Using a global online survey with 3-, 6-, and 12-month follow-ups between April 2020 and May 2021, data from 2069 participants (M = 46.16 ± 13.42 years; 75.3 % female) with pre-existing, new-onset, or no insomnia symptoms was examined using mixed-effects and logistic regression models.

RESULTS

New-onset and pre-existing insomnia predicted persistent anxiety and depressive symptoms longitudinally (p's < 0.001), over other known risk factors, including age, sex, and previous psychiatric diagnoses. Anxiety and depressive symptoms in both insomnia groups remained above clinically significant thresholds at most time points, whereas normal sleepers remained subclinical. Pre-sleep arousal was found to increase the risk of clinically significant anxiety (OR = 1.05) and depressive symptoms (OR = 1.09) at 12-months. Sleep effort contributed to anxiety (OR = 1.06), whereas dysfunctional sleep-related beliefs and attitudes predicted clinically significant depression (OR = 1.22).

LIMITATIONS

Insomnia group categorization was based on self-report at baseline supported by a validated measure. High participant attrition was observed at 3-months (53 %; n = 971), but retention remained steady till 12-months (63 %, n = 779).

CONCLUSIONS

Insomnia is a modifiable risk factor for persistent anxiety and depressive symptoms that needs to be addressed in mental healthcare. Additionally, pre-sleep arousal may be an important transdiagnostic process linking insomnia with affective disorders.

Improving perinatal sleep via a scalable cognitive behavioural intervention: findings from a randomised controlled trial from pregnancy to 2 years postpartum

BACKGROUND

Sleep disturbance is common in gestational parents during pregnancy and postpartum periods. This study evaluated the feasibility and efficacy of a scalable cognitive behavioural therapy (CBT) sleep intervention tailored for these periods.

METHODS

This is a two-arm, parallel-group, single-blind, superiority randomised controlled trial. Nulliparous females without severe medical/psychiatric conditions were randomised 1:1 to CBT or attention- and time-matched control. All participants received a 1 h telephone session and automated multimedia emails from the third trimester until 6 months postpartum. Outcomes were assessed with validated instruments at gestation weeks 30 (baseline) and 35 (pregnancy endpoint), and postpartum months 1.5, 3, 6 (postpartum endpoint), 12 and 24.

RESULTS

In total, 163 eligible participants (age M ± s.d. = 33.35 ± 3.42) were randomised. The CBT intervention was well accepted, with no reported adverse effect. Intention-to-treat analyses showed that compared to control, receiving CBT was associated with lower insomnia severity and sleep disturbance (two primary outcomes), and lower sleep-related impairment at the pregnancy endpoint (p values ⩽ 0.001), as well as at 24 months postpartum (p ranges 0.012-0.052). Group differences across the first postpartum year were non-significant. Participants with elevated insomnia symptoms at baseline benefitted substantially more from CBT (v. control), including having significantly lower insomnia symptoms throughout the first postpartum year. Group differences in symptoms of depression or anxiety were non-significant.

CONCLUSIONS

A scalable CBT sleep intervention is efficacious in buffering against sleep disturbance during pregnancy and benefitted sleep at 2-year postpartum, especially for individuals with insomnia symptoms during pregnancy. The intervention holds promise for implementation into routine perinatal care.

Leading Predictors of COVID-19-Related Poor Mental Health in Adult Asian Indians: An Application of Extreme Gradient Boosting and Shapley Additive Explanations

During the COVID-19 pandemic, an increase in poor mental health among Asian Indians was observed in the United States. However, the leading predictors of poor mental health during the COVID-19 pandemic in Asian Indians remained unknown. A cross-sectional online survey was administered to self-identified Asian Indians aged 18 and older (N = 289). Survey collected information on demographic and socio-economic characteristics and the COVID-19 burden. Two novel machine learning techniques-eXtreme Gradient Boosting and Shapley Additive exPlanations (SHAP) were used to identify the leading predictors and explain their associations with poor mental health. A majority of the study participants were female (65.1%), below 50 years of age (73.3%), and had income ≥ $75,000 (81.0%). The six leading predictors of poor mental health among Asian Indians were sleep disturbance, age, general health, income, wearing a mask, and self-reported discrimination. SHAP plots indicated that higher age, wearing a mask, and maintaining social distancing all the time were negatively associated with poor mental health while having sleep disturbance and imputed income levels were positively associated with poor mental health. The model performance metrics indicated high accuracy (0.77), precision (0.78), F1 score (0.77), recall (0.77), and AUROC (0.87). Nearly one in two adults reported poor mental health, and one in five reported sleep disturbance. Findings from our study suggest a paradoxical relationship between income and poor mental health; further studies are needed to confirm our study findings. Sleep disturbance and perceived discrimination can be targeted through tailored intervention to reduce the risk of poor mental health in Asian Indians.

The role of beliefs about sleep in nightly perceptions of sleep quality across a depression continuum

BACKGROUND

Poor sleep quality is common in depression, but complaints of poor sleep quality are not necessarily tied to objective sleep, and the construct of sleep quality remains poorly understood. Previous work suggests that beliefs about sleep may influence sleep quality appraisals, as might sleep variability from night to night.

OBJECTIVE

We tested whether beliefs about sleep predict daily sleep quality ratings above and beyond nightly variability of actigraphy and diary-assessed sleep over the course of multiple nights.

METHODS

Eighty-eight participants aged 18-65 years across a depressive continuum completed sleep diaries and reported their sleep quality and mood each morning; actigraphy was also completed for 67 of those participants. Multilevel models were used to test previous night's total sleep time and sleep efficiency as predictors of self-reported sleep quality (VAS-SQ) and mood (VAS-M), and whether unhelpful beliefs about sleep predicted VAS-SQ and VAS-M above and beyond the sleep variables.

RESULTS

Individuals across a depression continuum with greater unhelpful beliefs about sleep reported worse sleep quality and worse mood upon awakening, even when accounting for nightly variation in actigraphy or diary assessed total sleep time and sleep efficiency.

CONCLUSIONS

These results suggest that people are influenced by unhelpful sleep beliefs when making judgements about sleep quality and mood, regardless of how well they slept the previous night. Working with these unhelpful sleep beliefs in cognitive behavioral therapy can thus promote better sleep and mood in people across the depressive continuum.

Repeated testing modulates chronic unpredictable mild stress effects in male rats

Depression is a highly prevalent, debilitating mental disorder. Chronic unpredictable mild stress (CUMS) is the most widely applied model to study this affliction in rodents. While studies incorporating CUMS prior to an intervention often require long-lasting stress effects that persist after exposure is ceased, the longevity of these effects is rarely studied. Additionally, it is unclear whether behavioural assessments can be performed before and after interventions without repeated testing effects. In rats, we investigated CUMS effects on components of depressive-like behaviour both acutely after stress cessation and after a recovery period, as well as effects of repeated testing. We observed acute disruptions of the circadian locomotor rhythm and a reduced sucrose preference immediately after CUMS exposure. While circadian locomotor rhythm effects persisted up until four weeks after stress cessation, independently of repeated testing, sucrose preference effects did not. Interestingly, CUMS animals tested once after a recovery period of four weeks showed reduced anxiety-like behaviour in the open field and elevated plus maze compared to their control group and repeatedly-tested CUMS animals. These findings suggest that distinct CUMS-induced components of depressive-like behaviour are affected differentially by recovery time and repeated testing; these aspects should be considered carefully in future study designs.

Effects of Sleep Deficiency on Risk, Course, and Treatment of Psychopathology

This article reviews the literature on the relationship between sleep deficiency and unipolar and bipolar depression, anxiety disorders, and posttraumatic stress disorder. We consider the evidence for sleep as a contributory causal factor in the development of psychiatric disorders, as well as sleep as an influential factor related to the outcome and recurrence of psychopathology. A case for sleep deficiency being an important treatment target when sleep and psychiatric disorders are comorbid is also made. Our recommendation is that sleep deficiency is recognized as a means to positively impact the development and course of psychopathology and, as such, is routinely assessed and treated in clinical practice.

An investigation of cannabis use for insomnia in depression and anxiety in a naturalistic sample

BACKGROUND

Little is known about cannabis use for insomnia in individuals with depression, anxiety, and comorbid depression and anxiety. To develop a better understanding of distinct profiles of cannabis use for insomnia management, a retrospective cohort study was conducted on a large naturalistic sample.

METHODS

Data were collected using the medicinal cannabis tracking app, Strainprint®, which allows users to monitor and track cannabis use for therapeutic purposes. The current study examined users managing insomnia symptoms in depression (n = 100), anxiety (n = 463), and comorbid depression and anxiety (n = 114), for a total of 8476 recorded sessions. Inferential analyses used linear mixed effects modeling to examine self-perceived improvement across demographic variables and cannabis product variables.

RESULTS

Overall, cannabis was perceived to be efficacious across all groups, regardless of age and gender. Dried flower and oral oil were reported as the most used and most efficacious product forms. In the depression group, all strains were perceived to be efficacious and comparisons between strains revealed indica-dominant (M_diff = 1.81, 95% CI 1.26-2.36, P_adj < .001), indica hybrid (M_diff = 1.34, 95% CI 0.46-2.22, P_adj = .045), and sativa-dominant (M_diff = 1.83, 95% CI 0.68-2.99, P_adj = .028) strains were significantly more efficacious than CBD-dominant strains. In anxiety and comorbid conditions, all strain categories were perceived to be efficacious with no significant differences between strains.

CONCLUSIONS

In terms of perceptions, individuals with depression, anxiety, and both conditions who use cannabis for insomnia report significant improvements in symptom severity after cannabis use. The current study highlights the need for placebo-controlled trials investigating symptom improvement and the safety of cannabinoids for sleep in individuals with mood and anxiety disorders.

Effect of Sleep Disturbance Symptoms on Treatment Outcome in Blended Cognitive Behavioral Therapy for Depression (E-COMPARED Study): Secondary Analysis

BACKGROUND

Sleep disturbance symptoms are common in major depressive disorder (MDD) and have been found to hamper the treatment effect of conventional face-to-face psychological treatments such as cognitive behavioral therapy. To increase the dissemination of evidence-based treatment, blended cognitive behavioral therapy (bCBT) consisting of web-based and face-to-face treatment is on the rise for patients with MDD. To date, no study has examined whether sleep disturbance symptoms have an impact on bCBT treatment outcomes and whether it affects bCBT and treatment-as-usual (TAU) equally.

OBJECTIVE

The objectives of this study are to investigate whether baseline sleep disturbance symptoms have an impact on treatment outcomes independent of treatment modality and whether sleep disturbance symptoms impact bCBT and TAU in routine care equally.

METHODS

The study was based on data from the E-COMPARED (European Comparative Effectiveness Research on Blended Depression Treatment Versus Treatment-as-Usual) study, a 2-arm, multisite, parallel randomized controlled, noninferiority trial. A total of 943 outpatients with MDD were randomized to either bCBT (476/943, 50.5%) or TAU consisting of routine clinical MDD treatment (467/943, 49.5%). The primary outcome of this study was the change in depression symptom severity at the 12-month follow-up. The secondary outcomes were the change in depression symptom severity at the 3- and 6-month follow-up and MDD diagnoses at the 12-month follow-up, assessed using the Patient Health Questionnaire-9 and Mini-International Neuropsychiatric Interview, respectively. Mixed effects models were used to examine the association of sleep disturbance symptoms with treatment outcome and treatment modality over time.

RESULTS

Of the 943 patients recruited for the study, 558 (59.2%) completed the 12-month follow-up assessment. In the total sample, baseline sleep disturbance symptoms did not significantly affect change in depressive symptom severity at the 12-month follow-up (β=.16, 95% CI -0.04 to 0.36). However, baseline sleep disturbance symptoms were negatively associated with treatment outcome for bCBT (β=.49, 95% CI 0.22-0.76) but not for TAU (β=-.23, 95% CI -0.50 to 0.05) at the 12-month follow-up, even when adjusting for baseline depression symptom severity. The same result was seen for the effect of sleep disturbance symptoms on the presence of depression measured with Mini-International Neuropsychiatric Interview at the 12-month follow-up. However, for both treatment formats, baseline sleep disturbance symptoms were not associated with depression symptom severity at either the 3- (β=.06, 95% CI -0.11 to 0.23) or 6-month (β=.09, 95% CI -0.10 to 0.28) follow-up.

CONCLUSIONS

Baseline sleep disturbance symptoms may have a negative impact on long-term treatment outcomes in bCBT for MDD. This effect was not observed for TAU. These findings suggest that special attention to sleep disturbance symptoms might be warranted when MDD is treated with bCBT. Future studies should investigate the effect of implementing modules specifically targeting sleep disturbance symptoms in bCBT for MDD to improve long-term prognosis.

Acculturation Stress, Age at Immigration, and Employment Status as Predictors of Sleep Among Latinx Immigrants

Sleep is important for physical and mental health. Latinx individuals are thought to experience worse sleep and associated health outcomes, resulting in health disparities. There is a dearth of research on the factors (e.g., employment status, age at immigration) that predict poor sleep among Latinx immigrants. The present study aimed to (1) examine the link between demographic factors, immigration-related factors, and acculturation stress, and sleep, and (2) identify factors that either attenuate or intensify the link between acculturation stress and sleep among Latinx immigrants in the US South, an immigrant-hostile area that is home to an increasing Latinx population that remains understudied. Hierarchical regressions were used to analyze data from 391 Latinx adult immigrants, examining the link between demographic factors, immigration-related factors, acculturation stress, and two sleep variables (sleep quality, difficulty falling asleep). Employment status and age at immigration were examined as moderators of the link between acculturation stress and sleep. Data were collected through in-person surveys. Regressions showed that acculturation stress was significantly linked to worse sleep quality (β = 0.30, p = 0.001) and more difficulty falling asleep (β = 0.41, p < 0.001), while controlling for participant characteristics. Younger age at immigration (β = - 0.14, p = 0.005) and being unemployed (β = - 0.13, p = 0.006) were associated with more difficulty falling asleep. Age at immigration intensified the relationship between acculturation stress and sleep quality (β = 0.14, p = 0.005), difficulty falling asleep (β = 0.15, p = 0.002). Reducing acculturation stress is a meaningful intervention focus, with important implications for sleep health, particularly for recent Latinx immigrants. Age at immigration and employment status are also important factors to consider when designing targeted interventions.

Insomnia symptoms are associated with impaired resilience in bipolar disorder: Potential links with early life stressors may affect mood features and suicidal risk

AIM

The study aimed to investigate resilience and its association with early exposure to stressful events on the clinical manifestations of bipolar disorders (BDs), such as severity of mood symptoms, suicidal ideation and behaviors focusing on the possible role of insomnia symptoms.

METHOD

A sample of 188 adult participants with BD of type I or II were assessed during depressed phase using the Structural Clinical Interview for DSM-5 (SCID-5), the Beck Depression Inventory-II (BDI-II), the Young Mania Rating Scale (YMRS), the Early Trauma Inventory Self Report-Short Form (ETISR-SF), Resilience Scale for Adults (RSA), the Insomnia Severity Index (ISI) and the Scale for Suicide Ideation (SSI). Participants with or without clinically significant insomnia were compared and we carried out correlations, regression and mediation analyses.

RESULTS

Participants with insomnia showed a greater severity of depressive symptoms as well as of suicidal risk, early life stressors and lower level of resilience. Insomnia symptoms mediated the association between early life stress and low resilience, between low resilience in planning future and depressive symptoms (Z = 2.17, p = 0.029) and low resilience and suicidal risk (Z = 3.05, p = 0.0002) CONCLUSION: Insomnia may be related to the severity of BDs, to higher early life stressors and lower level of resilience. Assessing and targeting insomnia symptoms may potentially promote resilience in BDs in response to early life stressful events. These results should be interpreted in light of several limitations including the cross-sectional design affecting causal interpretations.

Moderators of Cognitive Behavioral Treatment for Insomnia on Depression and Anxiety Outcomes

PURPOSE OF REVIEW

With a focus on reviewing adequately powered randomized controlled trials, we present recent research on the potential of cognitive behavioral therapy for insomnia (CBT-I) to improve depression and anxiety outcomes among patients with insomnia and one of the following comorbid psychiatric disorders: major depressive disorder (MDD), generalized anxiety disorder (GAD), or posttraumatic stress disorder (PTSD). We also examine potential moderators of CBT-I on depression and anxiety outcomes in this population.

RECENT FINDINGS

Despite high comorbidity rates, current behavioral and pharmacological treatments for MDD, GAD, and PTSD do not substantially target or improve insomnia symptoms; residual insomnia is exceedingly common even among patients who experience remission. Insomnia plays a critical role in the onset and maintenance of depression and anxiety, and treating insomnia with CBT-I may improve global outcomes for patients with MDD, GAD, and PTSD. CBT-I is superior to traditional depression/anxiety treatment in improving insomnia symptoms among patients with comorbid psychiatric disorders. Results are mixed on whether CBT-I (either alone or augmented with depression/anxiety treatment) is effective in improving overall MDD, GAD, and PTSD outcomes. Evening circadian preference and depression/anxiety symptom severity may moderate the effect of CBT-I on depression and anxiety outcomes.

Transdiagnostic and functional predictors of depression severity and trajectory in the Penn state psychiatry clinical assessment and rating evaluation system (PCARES) registry

BACKGROUND

Timely, accurate diagnosis and subsequent identification of risk factors for depression that is difficult-to-treat can aid in decreasing the burden of depressive illness and reducing probability of future disability. We aimed to identify sociodemographic, clinical, and functional factors that predict depression severity over one year in a real-world, naturalistic, transdiagnostic clinical sample. A subset sample with moderate depression was examined to determine the magnitude of improvement.

METHODS

The Penn State Psychiatry Clinical Assessment and Rating System (PCARES) Registry houses data from systematically-structured patient-reported outcomes and clinical data from an Electronic Medical Record (EMR) gathered during routine clinical care of patients seeking mental health care at a mid-Atlantic clinic. Self-report symptom and functional measures were obtained, and sociodemographic features and clinical diagnoses were extracted from the EMR from 1,766 patients between 2/6/2016 to 9/30/2019. The Patient Health Questionnaire 9 (PHQ-9) depression scale was obtained at each visit. Using a discrete mixture clustering model, the study population was divided into five longitudinal trajectory groups, termed depression severity groups, based on intra-individual PHQ-9 score trajectories over one year. Multinomial logistic regression models were estimated to evaluate associations between characteristics and the likelihood of depression severity group membership. To determine the magnitude of improvement, predictors of the slope of the PHQ-9 trajectory were examined for patients with moderate depression.

RESULTS

The strongest predictors of high depression severity over one year were poor functioning, high transdiagnostic DSM-5 Level 1 crosscutting symptom score, diagnosis of Post-Traumatic Stress Disorder (PTSD), public/self-pay insurance, female gender, and non-White race. Among the subset of patients with moderate depression, strong predictors of improvement were commercial insurance and exposure to trauma; the strongest predictors of worsening were high functional impairment, high transdiagnostic Level 1 symptom score, diagnosis of PTSD, diagnosis of bipolar disorder, and marital status of single or formerly married; depression-specific symptom measures were not predictive.

LIMITATIONS

Limitations include inferring education and income status from zip code level-data, the non-random missingness of data, and the use of diagnoses collected from the electronic medical record.

CONCLUSION

Functional impairment, transdiagnostic measures of symptom burden, and insurance status are strong predictors of depression severity and poor outcome.

Acupuncture combined with traditional Chinese medicine e-aid cognitive behavioral therapy for insomnia (TCM-eCBT-I) for chronic insomnia: study protocol for a randomized controlled trial

INTRODUCTION

The incidence of insomnia is getting higher and higher. Long-term insomnia seriously affects people's health. Drug use is usually accompanied with adverse events. Both acupuncture and cognitive behavioral therapy for insomnia (CBT-I) have been proven to be safe and effective non-pharmacological treatments for insomnia. As the insomniacs' bad sleep behavior and wrong cognition have not been effectively corrected, acupuncture has a quick effect, high patient compliance but unstable long-term efficacy, while CBT-I is complex, time-consuming, and expensive; additionally, patient compliance is low, and the number of trained therapists is limited, making it difficult to carry out. Therefore, this study aims to use the insomnia TCM system to construct a convenient and feasible traditional Chinese medicine e-aid cognitive behavioral therapy for insomnia (TCM-eCBT-I) for Chinese people, and combine the advantages of acupuncture and TCM-eCBT-I for maintaining long-term efficacy, and three treatments will be evaluated to provide clinicians with a more effective clinical protocol METHODS AND ANALYSIS: This study is a single-center, open-label, randomized controlled trial. Ninety subjects will be recruited and randomly assigned to three groups: the acupuncture group, the TCM-eCBT-I group, and the acupuncture combined with TCM-eCBT-I group, in a ratio of 1:1:1. We will evaluate the Pittsburgh Sleep Quality Index (PSQI) and Dysfunctional Beliefs and Attitudes About Sleep Scale (DBAS), Insomnia Severity Index (ISI), sleep diary, Hamilton Anxiety Scale (HAMA), Hamilton Depression Scale (HAMD), and Fatigue Scale-14 Scale (FS-14) scales. All adverse reactions will be assessed through the ADVERSE event table. All outcomes will be evaluated online at 0 weeks, 4 weeks, 8 weeks, 16 weeks, and 28weeks.

ETHICS AND DISSEMINATION

This study has been approved by the Institutional Review Board of the Affiliated Hospital of Nanjing University of Chinese Medicine (2020 NL-018-02). Informed consent will be obtained from all the subjects. The results will be shared with sleep researchers, public, and relevant academic institutions through high-impact peer-reviewed publications.

TRIAL REGISTRATION

Chinese Clinical Trial Registry ChiCTR2000032960. Registered on 17 May 2020.

The Acute Effects of Aerobic Exercise on Nocturnal and Pre-Sleep Arousal in Patients with Unipolar Depression: Preplanned Secondary Analysis of a Randomized Controlled Trial

Unipolar depression is associated with insomnia and autonomic arousal. The aim of this study was to quantify the effect of a single bout of aerobic exercise on nocturnal heart rate variability and pre-sleep arousal in patients with depression. This study was designed as a two-arm, parallel-group, randomized, outcome assessor-blinded, controlled, superiority trial. Patients with a primary diagnosis of unipolar depression aged 18-65 years were included. The intervention consisted of a single 30 min moderate-intensity aerobic exercise bout. The control group sat and read for 30 min. The primary outcome of interest was RMSSD during the sleep period assessed with polysomnography. Secondary outcomes were additional heart rate variability outcomes during the sleep and pre-sleep period as well as subjective pre-sleep arousal. A total of 92 patients were randomized to either the exercise (N = 46) or the control (N = 46) group. Intent-to-treat analysis ANCOVA of follow-up sleep period RMSSD, adjusted for baseline levels and minimization factors, did not detect a significant effect of the allocation (β = 0.12, p = 0.94). There was no evidence for significant differences between both groups in any other heart rate variability measure nor in measures of cognitive or somatic pre-sleep arousal. As this is the first trial of its kind in this population, the findings need to be confirmed in further studies. Patients with depression should be encouraged to exercise regularly in order to profit from the known benefits on sleep and depressive symptoms, which are supported by extensive literature.

Identifying and characterizing longitudinal patterns of insomnia across the deployment cycle in active duty Army soldiers

STUDY OBJECTIVES

The present study characterized a sample of 4,667 Army soldiers based on their patterns of insomnia before, during, and after deployment, and explored pre-deployment factors predictive of these patterns.

METHODS

Data were analyzed from the Army Study to Assess Risk and Resilience in Service members (STARRS)-Pre/Post Deployment Study (PPDS), using surveys that captured data approximately 1-2 months pre-deployment, and 3- and 9-month post-deployment from soldiers deployed to Afghanistan. Patterns of insomnia across time were examined. Theoretically derived variables linked to sleep disturbance were examined as predictors of the insomnia patterns.

RESULTS

Five longitudinal patterns of insomnia characterized the majority of the sample: "No Insomnia" (no insomnia symptoms at any timepoint; 31%), "Deployment-related Insomnia" (no pre-deployment insomnia, developed insomnia symptoms during deployment and recovered; 40%), "Incident Insomnia" (development insomnia during or shortly after deployment that did not remit; 14%), "Chronic Insomnia" (insomnia both pre- and post-deployment; 11%), and "Other Insomnia" (reported insomnia at ≥1 timepoint, but no clear pattern across the deployment cycle; 4%). Several pre-deployment factors were predictive of insomnia trajectories, including lifetime major depressive episodes, traumatic brain injury history, posttraumatic stress disorder, and past year personal life stressors.

CONCLUSIONS

Distinct longitudinal patterns of insomnia were identified, with more than half of the sample reporting insomnia at some point in the deployment cycle. Identifying mental health conditions that are associated with different insomnia patterns prior to deployment can inform targeted interventions to reduce long-term sleep difficulty.

Association among early life stress, mood features, hopelessness and suicidal risk in bipolar disorder: The potential contribution of insomnia symptoms

AIM

The study aimed to investigate the potential pathways mediating early exposure to stressful events and the clinical manifestations of bipolar disorder (BD), such as severity of mood symptoms, hopelessness and suicidal ideation, focusing on the potential role of insomnia symptoms.

METHOD

A sample of 162 adult participants with BD I or II were assessed during depressed phase using the Structural Clinical Interview for DSM-5 (SCID-5), the Beck Depression Inventory-II (BDI-II), the Young Mania Rating Scale (YMRS), the Early Trauma Inventory Self Report-Short Form (ETISR-SF), the Beck Hopelessness Scale (BHS), the Insomnia Severity Index (ISI) and the Scale for Suicide Ideation (SSI). Participants with or without clinically significant insomnia were compared and we carried out correlations, regression and mediation analyses.

RESULTS

Participants with insomnia showed a greater severity of depressive symptoms,of suicidal risk, of the cognitive component of hopelessness and of early life stressors. Insomnia symptoms mediated the association among early life stress and depressive symptoms (Z = 2.72, p = 0.0006), the cognitive component of hopelessness (Z = 3.02, p = 0.0001) and suicidal ideation and plans (Z = 2.07 p = 0.0006).

CONCLUSION

Insomnia may mediate the relationship between early life stress and clinical manifestations of BD. Assessing the evolution of insomnia symptoms could offer an approach to characterize BD and to formulate treatment strategies. In particular targeting insomnia symptoms might potentially modify the clinical features of BD in response to early life stressful events.

Can changes in multidimensional self-reported interoception be considered as outcome predictors in severely depressed patients? A moderation and mediation analysis

OBJECTIVE

Somatic complaints (e.g. pain) and abnormal self-reported interoception (e.g. maladaptive bodily self-focus) are common features of major depressive disorder (MDD) with sex-specific manifestations. Whereas somatic symptoms are associated with adverse clinical outcomes (e.g. residual symptoms), studies are scarce investigating the role of interoception as an outcome predictor for specific hospital treatment of MDD. Therefore, multivariate associations between changes in multidimensional self-reported interoception, somatic symptoms, and clinical improvements are explored by hypothesizing interactions with sex and an interoceptive mechanism.

METHODS

In this naturalistic study, 87 hospitalized participants suffering from MDD completed questionnaires at pre- and post-treatment assessing multidimensional self-reported interoception (MAIA-2), somatic symptom burden (SCL-90-S® SOMA), and depression severity (BDI-II). We performed a multiple hierarchical regression analysis to test for interaction effects. The mediation hypothesis was path-analytically tested in a parallel mediation model by bootstrapping confidence intervals for (in)direct effects.

RESULTS

Improvements in self-reported interoception independently predicted positive treatment response, ΔR_adj²=8.61%, ΔF(8, 74) = 3.23, p < .01. Prediction effects were moderated by sex, ΔR_adj²=5.54%, ΔF(8, 66) = 2.22, p < .05. Post-hoc analyses revealed significant effects of body confidence in women, B = -4.26, t(28) = -2.78, p < .01, and of self-regulation in men, B = -3.21, t(17) = -2.27, p < .05. Effects of somatic symptom relief on treatment outcome were partially mediated by self-reported interoception, total indirect = 2.94 [95% BCa CI 0.99, 5.69].

CONCLUSION

Interoception patterns changed significantly and predicted outcome of hospital treatment in severely depressed patients. Our study could imply the need to consider body sensations additionally as a target for antidepressive treatments. The development of tailored interoceptive interventions in depressive patients represents a promising vision for the future.

The effects of exercise on sleep in unipolar depression: A systematic review and network meta-analysis

Insomnia predicts the onset, course, and reoccurrence of unipolar depression. However, systematic reviews of treatment options for insomnia in unipolar depression are lacking. After screening 7725 records, 17 trials comprising 1645 patients randomized to 13 treatments were included for quantitative synthesis. Network meta-analysis showed that compared to a passive control condition, all exercise interventions except moderate aerobic exercise alone resulted in significantly better sleep outcomes. Compared with treatment as usual, mind-body exercise plus treatment as usual (SMD: -0.46; 95% CI: -0.80, -0.12) and vigorous strength exercise (SMD: -0.61; 95% CI: -1.12, -0.10) were significantly more effective. Pairwise meta-analyses showed that mind-body exercise (SMD: -0.54; 95% CI: -0.85, -0.23) had beneficial effects compared to passive control. The network meta-analysis is statistically very robust with low heterogeneity, incoherence, and indirectness. However, confidence in the findings was moderate to very low, primarily due to within-study bias. This is the first network meta-analysis to assess exercise's efficacy to improve sleep quality in patients with depression. The findings confirm the benefits of exercise as an add-on treatment for depression. This consolidation of the current state of evidence can help clinicians make evidence-based decisions.

Effect of Sleep Disturbance on Efficacy of Esketamine in Treatment-Resistant Depression: Findings from Randomized Controlled Trials

PURPOSE

To evaluate the relationship of sleep disturbance to the antidepressant effects of esketamine.

MATERIALS AND METHODS

Two double-blind, 4-week studies randomized adults with treatment-resistant depression (TRD) to placebo or esketamine nasal spray, each with newly initiated antidepressant. Sleep was assessed using Montgomery-Åsberg Depression Rating Scale (MADRS) item 4. Change in response (≥50% decrease in MADRS total score) and remission (total MADRS score ≤12) at day 28 was examined by presence/absence of baseline sleep disturbance using logistic regression models. Impact on reported sleep disturbance (MADRS item 4 score) was examined using ANCOVA models.

RESULTS

At baseline, most patients reported disturbed sleep - moderate/severe (65.3%, 369/565), mild (25.3%, 143/565), or none/slightly (9.4%, 53/565) - with similar distribution between treatment groups. A higher proportion of esketamine-treated patients achieved response (OR = 2.05; 95% CI: 1.40-3.02; P < 0.001) and remission (OR = 1.81; 95% CI: 1.23-2.66; P = 0.003) at day 28 compared to antidepressant plus placebo, regardless of presence/severity of sleep disturbance. Consistent with this, sleep (MADRS item 4 score) improved in both groups after the first dose, more so with esketamine by day 8 (between-group difference: P ≤ 0.02 at all time points). Across both treatment groups, 1-point improvement in sleep at day 8 increased the probability of antidepressant response on day 28 by 26% (OR = 1.26, 95% CI: 1.12-1.42; P < 0.001), and remission by 28% (OR = 1.28, 95% CI: 1.14-1.43; P < 0.001).

CONCLUSION

Antidepressant efficacy of esketamine was demonstrated in patients with TRD, regardless of the presence of sleep disturbance. After 8 days of treatment and thereafter, significantly more esketamine-treated patients reported improvement in sleep versus antidepressant plus placebo.

Anxiety predicts dyadic sleep characteristics in couples experiencing insomnia but not in couples without sleep disorders

BACKGROUND

Anxiety and depression are commonly comorbid with sleep problems. Despite growing acknowledgement that bedpartners are important determinants of sleep quality, few studies have explored mental health as a risk factor for disrupted sleep of the bedpartner. We examined whether anxiety or depression symptoms predicted an individual's sleep or their bedpartner's sleep, in couples where one partner experienced insomnia and in couples without sleep disorders.

METHODS

Fifty-two bed-sharing couples where one individual had insomnia ("Patient"), and 55 non-sleep-disordered couples completed the Beck Anxiety Inventory, Patient Health Questionnaire-9, and Insomnia Severity Index (ISI). Sleep was monitored for seven nights. Actor-Partner Interdependence Models assessed whether anxiety or depression symptoms predicted individual or dyadic sleep (wake transmission).

RESULTS

Greater anxiety symptoms predicted increased vulnerability to being woken by their bedpartner, as well as increased frequency of waking their bedpartner up during the night in Patients with insomnia, but not in non-sleep-disordered couples. Neither anxiety nor depression symptoms predicted an individual's or their bedpartner's sleep efficiency in either subsample. However, ISI was positively predicted by own anxiety and depression symptoms for Patients with insomnia and in non-sleep-disordered couples.

LIMITATIONS

The non-sleep-disordered subsample experienced only mild symptoms of anxiety and depression, potentially reducing predictive power.

CONCLUSIONS

Anxiety may help reveal social determinants of sleep in couples experiencing insomnia. These data underscore the importance of considering sleep, the bedpartner, and affective symptoms in mental health and sleep assessments.

The Clinical Effectiveness of Cognitive Behavioral Therapy for Patients with Insomnia and Depression: A Systematic Review and Meta-Analysis

BACKGROUND

Insomnia and depression often co-occurr. However, there is lack of effective treatment for such comorbidity. CBT-I has been recommended as the first-line treatment for insomnia; whether it is also effective for comorbidity of insomnia and depression is still unknown. Therefore, we conducted this meta-analysis of randomized controlled trials to assess the clinical effectiveness and safety of CBT-I for insomnia comorbid with depression. Data Sources. Seven electronic databases, including China National Knowledge Infrastructure (CNKI), Wanfang Database, China Science Technology Journal Database, SinoMed Database, PubMed, the Cochrane Library, and EMBASE, as well as grey literature, were searched from the beginning of each database to July 1, 2019. Study Eligibility Criteria. Randomized controlled trials that compared CBT-I to no treatment or hypnotics (zopiclone, estazolam, and benzodiazepine agonist) for insomnia comorbid with depression and reported both insomnia scales and depression scales. Study Assessment and Synthesis Methods. Cochrane Reviewer's Handbook was used for evaluating the risk of bias of included studies. Review Manager 5.3 software was used for meta-analysis. Online GRADEpro was used to assess the quality of evidence.

RESULTS

The pooled data showed that CBT-I was superior to no treatment for insomnia, while it was unsure whether CBT-I was better than no treatment for depression. And the effectiveness of CBT-I was comparable to hypnotics for both insomnia and depression. CBT-I was likely to be safe due to its noninvasive nature. The methodological quality varied across these trials. The evidence quality varied from moderate to very low, and the recommendation level was low.

CONCLUSIONS

Currently, findings support that CBT-I seems to be effective and safe for insomnia comorbid with depression to improve the insomnia condition, while it is unsure whether CBT-I could improve depression condition. More rigorous trials are needed to confirm our findings.

Association between affective temperaments and mood features in bipolar disorder II: The role of insomnia and chronobiological rhythms desynchronization

BACKGROUND

Bipolar disorders are complex disorders involving the interaction of multiple factors. Affective temperaments, insomnia, and chronobiological rhythms desynchronization may all contribute to bipolar disorder. Since there is a paucity of research examining this topic we aimed to study how they are interrelated and collectively associated with clinical features of bipolar disorder.

METHOD

One-hundred patients with Bipolar Disorder type II depressive episode with and without mixed features were recruited and compared. Subjects were evaluated with SCID -5, the Biological Rhythms Interview of Assessment in Neuropsychiatry (BRIAN), the Insomnia Severity Index (ISI), and the Temperament Evaluation of Memphis, Pisa, Paris, and San Diego Auto-questionnaire (TEMPS-A) while evaluating depressive (Beck Depression Inventory-BDI-II) and manic (Young Mania Rating Scale-YMRS) symptoms. Logistic regression and mediation analyses were conducted.

RESULTS

Subjects with mixed features showed a higher scores in both insomnia and chronobiological rhythms scores. When considering affective temperaments not only depressive, cyclothymic and irritable temperaments predicted mood symptoms but also insomnia (depressive symptoms O.R. 4.17, p = 0.043) and chronobiological sleep de-synchronization (manic symptoms O.R. 8.69, p = 0.001). Insomnia symptoms and chronobiological alterations mediated the association between affective temperaments and mood symptoms.

LIMITATIONS

the cross-sectional design limited any causal interpretation.

CONCLUSION

Subjects with mixed features showed a greater severity of insomnia and chronobiological rhythm de-synchronization compared to subjects without. Insomnia and chronobiological alterations may contribute to mood disorders together with affective temperaments in a complex interplay also mediating their effect on mood. Preventive strategies for bipolars should also act on the dysregulation of sleep and circadian rhythms.

Does objectively-assessed sleep moderate the association between history of major depressive disorder and task-switching?

BACKGROUND

Executive function and psychomotor speed are consistently impaired in patients with major depressive disorder (MDD). Persistent cognitive impairments after depression remission are thought to reflect "scarring" from the neurotoxic effects of hypothalamic-pituitary-adrenal axis activity during a depressive episode. As sleep also deteriorates with depression and restores daytime executive functions, we examined whether adequate sleep could be protective against task-switching and psychomotor impairments associated with a history of MDD.

METHODS

This cross-sectional study tested task-switching associations with MDD history, sleep, and their interaction to determine whether sleep continuity and sleep duration moderate the relationship between MDD history and task-switching performance.

RESULTS

After adjusting for age, sex, education, current depressive symptoms, and use of anti-depressants, a history of MDD, particularly recurrent MDD, was associated with slower response speed and disproportionately lower accuracy on repetition trials compared to switch trials, reflecting impaired adoption of a task-set. Regardless of MDD history, higher wake after sleep onset and shorter total sleep time were associated with slower response times, but neither sleep measure moderated the association between depression history and task-switching performance.

LIMITATIONS

This cross-sectional study cannot assess the causal direction of associations. One night of sleep in the laboratory was used to assess sleep and a single task-switching paradigm was used to assess executive function.

CONCLUSIONS

These results suggest that longer, more continuous sleep is associated with greater psychomotor speed across healthy controls and those with a history of MDD, but MDD-task-switching associations are not mitigated by longer or more continuous sleep.

Is sleep disturbance linked to short- and long-term outcomes following treatments for recurrent depression?

BACKGROUND

Pre-treatment sleep disturbance has been shown to predict antidepressant treatment outcomes. How changes in sleep disturbance during acute treatment affect longitudinal outcomes, or whether continuation-phase treatment further improves sleep disturbance, is unclear.

METHODS

We assessed sleep disturbance repeatedly in: a) 523 adults with recurrent MDD who consented to 12-14 weeks of acute-phase cognitive therapy (A-CT) and b) 241 A-CT responders at elevated risk for depression relapse/recurrence who were randomized to 8 months of continuation-phase treatment (CCT vs. fluoxetine vs. matched pill placebo) and followed protocol-treatment-free for 24 months. Trajectories of change in sleep and depression during and after A-CT were evaluated with multilevel models; individual intercepts and slopes were retained and input into Cox regression models to predict remission, recovery, relapse, and recurrence of MDD.

RESULTS

Sleep disturbance improved over the course of A-CT, but most patients continued to report clinically significant sleep complaints. Response and remission were more likely in patients with less overall sleep disturbance and those with greater reduction in sleep disturbance during A-CT; these patients also achieved post-A-CT remission and recovery sooner. Sleep improvements endured throughout follow-up but were not enhanced by continuation-phase treatment. Sleep disturbance did not predict relapse or recurrence consistently.

LIMITATIONS

Objective sleep disturbance was not assessed. Analyses were not specifically powered to use sleep changes to predict outcomes.

CONCLUSIONS

Improvements in sleep disturbance during A-CT are linked to shorter times to remission and recovery, supporting consideration of monitoring and targeting sleep disturbance in adults with depression.

The Effect of Hypnotics on Sleep Quality and Cognitive Function in Patients with Brain Tumors

Objective

We investigated the effect of hypnotics on sleep quality, cognitive function, and depressive mood in patients with insomnia following brain tumor resection.

Methods

From patients who underwent brain tumor resection, we recruited 10 patients with insomnia who received hypnotics for more than 1 week during a 3-week follow-up period (insomnia group). We also recruited 12 control patients with brain tumors but without insomnia (control group). We evaluated sleep quality at baseline and 3 weeks later using the Insomnia Severity Index (ISI), the Pittsburgh Sleep Quality Index (PSQI), the Stanford Sleepiness Scale (SSS), and the Epworth Sleepiness Scale (ESS) and investigated cognitive function and depression using the Computerized Neuropsychological Test and the Beck Depression Inventory (BDI).

Results

At baseline, SSS, ISI, PSQI, and BDI scores were significantly higher and visual continuous performance test (VCPT) and auditory continuous performance test (ACPT) scores were significantly lower in the insomnia than in the control group. Three weeks later, the patients who had received hypnotics had significantly higher ISI, PSQI, ESS, VCPT, ACPT, visual span forward and backward, and visual recognition test scores, and significantly lower BDI scores.

Conclusion

Quality of sleep in patients with insomnia following brain tumor resection was initially poor but improved significantly after taking hypnotic medication. Further, the hypnotic medications appeared to contribute to the amelioration of cognitive impairments and depressive moods in patients who previously underwent brain tumor resection. We thus recommend the use of hypnotics for patients with brain tumors with insomnia.

Delivering Cognitive Behavioral Therapy for Insomnia in the Real World: Considerations and Controversies

Cognitive-behavioral therapy for insomnia (CBT-I) has emerged as the first-line treatment for chronic insomnia but remains massively underused relative to the prevalence of insomnia disorder. This article focuses on 3 key issues in the delivery of CBT-I in the real world. First, where and how should CBT-I be delivered and who should deliver it? Second, who is an appropriate candidate for CBT-I? Third, how do you measure quality care with CBT-I? These issues give rise to targets for future research aimed at improving the implementation science of CBT-I in the real world.

Impact Of Phenotypic Heterogeneity Of Insomnia On The Patients' Response To Cognitive-Behavioral Therapy For Insomnia: Current Perspectives

Insomnia is one of the most common mental disorders and the most frequent sleep disorder encountered in clinical practice, with a prevalence of about 7% in the European population. Insomnia Disorder (ID) is defined as a disturbance of sleep initiation or maintenance, followed by a feeling of non-restorative sleep and several diurnal consequences ranging from occupational and social difficulties to cognitive impairment. Cognitive-Behavioral Therapy for Insomnia (CBT-I) is considered the first-choice therapy for this disorder because its effectiveness has been proven to be greater in the long term with fewer side effects in comparison to pharmacotherapy. Although its effectiveness has been well established, it has been reported that nearly 40% of patients do not achieve remission after treatment. This finding could be the consequence of heterogeneity of ID between patients. It has been proposed that this heterogeneity might be ascribable to indices that are not related to sleep quality and quantity, such as comorbidities, life events, and personality traits. However, several works focused on the role of sleep markers, in particular objective total sleep time, for the phenotypization of ID and treatment response. The aim of this work is to summarize the available scientific literature regarding the impact of ID subtype on CBT-I response.