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Dietch JR, Manber R, Buysse DJ, Edinger JD, Krystal A. 0533 Age and Education Level are Associated with Dropout from Cognitive-Behavioral Therapy for Insomnia in Participants with Co-Occurring Depression: A Report from the TRIAD Study. Sleep 2020. [DOI: 10.1093/sleep/zsaa056.530] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Introduction
Early termination (i.e., dropout) from cognitive-behavioral therapy for insomnia (CBT-I) likely attenuates benefits and may reduce motivation for future treatment. The aim of the current study was to identify characteristics of participants who dropped out of CBT-I in an RCT of combined treatment for depression and insomnia.
Methods
Participants were 148 adults with comorbid insomnia and depression diagnoses (73% female; M age = 46.6[SD = 12.6]) who were randomly assigned to receive depression pharmacotherapy plus 7 weekly sessions of CBT-I (n = 73) or a credible control therapy for insomnia (n = 75). Receiver operating characteristic curve (ROC) analyses were performed to determine which participant characteristics (i.e., demographics, baseline depression and sleep variables) predicted dropout at session 4 (i.e., minimum dose) and session 7 (i.e., full course of CBT-I).
Results
Early termination (prior to session 4) rate was 28% and ROC analyses indicated participants aged 36 or less were more likely to drop out than those older than 36 (49% vs. 22%). The model did not identify additional predictors for either of the two age categories. Overall termination (prior to session 7) rate was 45% and ROC analyses indicated participants aged 46 or less were more likely to drop out than those older than 46 (61% vs. 34%). The model further found that among participants aged 46 or less, those with less than 14y education were at greater risk for dropout than those with greater than 14y education (79% vs. 46%). No other demographic, depression, or sleep variables were significant predictors of dropout.
Conclusion
Age was associated with elevated rate of dropout from CBT-I among individuals with co-occurring depression and insomnia. It appears that the combination of younger age and lower education level is particularly detrimental to treatment engagement. Better understanding of factors that contribute to dropout from CBT-I in this vulnerable group can guide development of retention strategies.
Support
MH078924, MH078961, MH079256
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Affiliation(s)
- J R Dietch
- VA Palo Alto Health Care System, Palo Alto, CA
| | - R Manber
- Stanford University, Palo Alto, CA
| | - D J Buysse
- University of Pittsburgh, Pittsburgh, PA
| | - J D Edinger
- National Jewish Health, Denver, CO
- Duke University Medical Center, Durham, NC
| | - A Krystal
- University of California, San Francisco, San Francisco, CA
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Atwood ME, Dietch JR, Buysse DJ, Edinger JD, Krystal A, Manber R. 0540 Insomnia Symptom Trajectories During and Following Combined Treatment for Insomnia and Depression: A Report from the Triad Study. Sleep 2020. [DOI: 10.1093/sleep/zsaa056.537] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Introduction
Cognitive behavioral therapy for insomnia (CBT-I) reduces insomnia severity among individuals with insomnia and major depressive disorder (MDD). Understanding the long-term trajectories of insomnia symptom severity has the potential to inform optimization of CBT-I in this population. The objectives of this study were to examine trajectories of change in insomnia severity over a 16-week treatment phase and 2-year naturalistic follow-up, and explore correlates of symptom trajectories.
Methods
148 adults (age 46.6±12.6, 73.0% female) with insomnia and MDD were randomly assigned to receive depression pharmacotherapy plus seven sessions of either CBT-I or control insomnia therapy. Depression and insomnia severity were assessed via the Hamilton Depression Rating Scale and Insomnia Severity Index at baseline, bi-weekly during treatment, and every 4 months over follow-up. Sleep effort and beliefs about sleep were assessed at baseline, midtreatment, and posttreatment.
Results
Latent class linear mixed modeling revealed four insomnia response trajectories: 1) Early Sustained-Responders (16%) showed marked improvement early in treatment, sustained over follow-up; 2) Gradual-Responders (36.7%) achieved substantial symptom reduction by posttreatment, sustained over follow-up; 3) Initial-Responders (25.3%) had substantial symptom reduction during treatment but increased in severity over follow-up; and 4) Partial-Responders (20.7%) achieved minimal improvement over treatment, and maintained moderate symptom severity over follow-up. Chi-square analyses revealed that classes did not differ significantly on sex, ethnicity, employment, relationship status, or treatment received (all ps > .05). One-way ANOVAs with Tukey’s HSD, showed that Partial-Responders consistently endorsed higher depressive symptom severity, sleep effort, and unhelpful beliefs about sleep at baseline, throughout treatment, and follow-up (ps < .05). Early Sustained-Responders endorsed lower sleep effort by midtreatment (ps < .01).
Conclusion
Results suggest four temporal patterns of treatment response and identified clinical correlates. Future work will be needed to determine if addressing sleep effort early in the course of treatment might enhance sustained insomnia outcome.
Support
MH078924, MH078961, MH079256
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Affiliation(s)
| | - J R Dietch
- VA Palo Alto Health Care System, Palo Alto, CA
| | - D J Buysse
- University of Pittsburgh, Pittsburgh, PA
| | | | - A Krystal
- University of California, San Francisco, San Francisco, CA
| | - R Manber
- Stanford University, Palo Alto, CA
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Doghramji K, Davis C, Patroneva A, Schwartz JC, Scart-Grès C, Robert P, Duvauchelle T, Wanaski S, Krystal A. Pitolisant in combination with other medications for the management of narcolepsy. Sleep Med 2019. [DOI: 10.1016/j.sleep.2019.11.258] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Edinger J, Morin C, Beaulieu-Bonneau S, Ivers H, Krystal A, Guay B, Bélanger L, Simmons B, Cartwright A, Busby M. Sequenced therapies for patients with chronic insomnia disorder: findings derived from sleep diary data. Sleep Med 2019. [DOI: 10.1016/j.sleep.2019.11.278] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Osorno RA, Kaplan K, Krystal A, Buysse D, Edinger J, Manber R. 0974 Daytime Insomnia Symptoms Negatively Predict Anhedonia in Patients with Comorbid Major Depressive Disorder and Insomnia Disorder. Sleep 2018. [DOI: 10.1093/sleep/zsy061.973] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- R A Osorno
- PGSP-Stanford Psy.D. Consortium at Palo Alto University, Palo Alto, CA
| | - K Kaplan
- Stanford University, Stanford, CA
| | - A Krystal
- University of California, San Francisco, San Francisco, CA
| | - D Buysse
- University of Pittsburgh, Pittsburgh, PA
| | | | - R Manber
- Stanford University, Stanford, CA
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Asarnow LD, Bei B, Krystal A, Buysse DJ, Thase ME, Edinger JD, Manber R. 0640 CBT-I Enhances Depression Outcome Among Individuals with Evening Chronotype. Sleep 2018. [DOI: 10.1093/sleep/zsy061.639] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
| | - B Bei
- Monash University, Victoria, AUSTRALIA
| | - A Krystal
- University of California, San Francisco, San Francisco, CA
| | - D J Buysse
- Department of Psychiatry, University of Pittsburgh, Pittsburgh, PA
| | - M E Thase
- Department of Psychiatry, University of Pittsburgh, Pittsburgh, PA
| | - J D Edinger
- Department of Medicine, National Jewish Health, Denver, CO
| | - R Manber
- Stanford University, Palo Alto, CA
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Krystal A, Lippa A, Nasiek D, Krusinska E, Purcell R. 0571 OPIOIDS AND SLEEP APNEA: ANTAGONISM OF REMIFENTANIL-INDUCED RESPIRATORY DEPRESSION BY CX1739 IN TWO CLINICAL MODELS OF OPIOID INDUCED RESPIRATORY DEPRESSION. Sleep 2017. [DOI: 10.1093/sleepj/zsx050.570] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Lundeen JS, McCall WV, Rumble M, Krystal A, Case D, Benca R, Looney SW. 0715 SELECTING FUNCTIONAL DATA ANALYSIS SUMMARY MEASURES OF SLEEP ACTIGRAPHY DATA TO REFLECT CLINICAL MORNINGNESS/EVENINGNESS. Sleep 2017. [DOI: 10.1093/sleepj/zsx050.714] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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Bryan MP, Bei B, Rajaratnam SM, Krystal A, Edinger JD, Buysse DJ, Manber R. 0360 COGNITIVE BEHAVIOURAL THERAPY FOR INSOMNIA REDUCES THE DISCREPANCY BETWEEN ACTIGRAPHY AND SELF-REPORT ESTIMATES OF SLEEP QUALITY AND QUANTITY IN COMORBID INSOMNIA AND MAJOR DEPRESSIVE DISORDERS. Sleep 2017. [DOI: 10.1093/sleepj/zsx050.359] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Bei B, Asarnow LD, Krystal A, Edinger JD, Buysse DJ, Manber R. 1093 TREATING DEPRESSION IN INSOMNIA: DISTINCTIVE PATTERNS OF DEPRESSIVE SYMPTOM CHANGE TRAJECTORIES AND THEIR CORRELATES, A REPORT FROM THE TRIAD STUDY. Sleep 2017. [DOI: 10.1093/sleepj/zsx050.1092] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Fava M, Pollack M, Montgomery S, Wessel T, Amato D, Krystal A, Hayduk R, McCall W. Evaluation of the HAM-D17 following eszopiclone treatment in patients with insomnia co-morbid with major depressive disorder or generalized anxiety disorder. Eur Psychiatry 2008. [DOI: 10.1016/j.eurpsy.2008.01.1247] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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Bech P, Krystal A, Walsh J, Rubens R, Caron J, Wessel T, Amato D, Roth T, McCall W, Fava M. Analysis of individual items of the Hamilton depression scale in a study of eszopiclone/fluoxetine co-therapy. Eur Psychiatry 2007. [DOI: 10.1016/j.eurpsy.2007.01.748] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
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Mccall WV, Perlis ML, Tu X, Groman AE, Krystal A, Walsh JK. A comparison of placebo and no-treatment during a hypnotic clinical trial. Int J Clin Pharmacol Ther 2005; 43:355-9. [PMID: 16119510 DOI: 10.5414/cpp43355] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVE Sleep parameters commonly improve during placebo treatment in insomnia clinical trials. We examined whether the improvement seen with placebo was related to taking pills or other non-specific factors. METHOD 95 insomniacs took either a placebo pill (pill+) or no pill (pill-) on nights of their choosing over 12 weeks. RESULTS Pills were consumed on about half of the nights. Consistent improvement was seen with reduced reported sleep latency, wakefulness after sleep onset, number of awakenings, and total sleep time over the 12 weeks for both the pill+ and pill condition. A difference between pill+ and pill- was detected only for total sleep time, and this difference favored pill+. CONCLUSIONS This study suggests that improvement seen during placebo treatment is more related to non-specific factors of participating in clinical trial than to pill taking behavior.
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Affiliation(s)
- W V Mccall
- Department of Psychiatry and Behavioral Medicine, Wake Forest University School of Medicine, Winston-Salem, NC 27157-1071, USA.
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Abstract
To improve our understanding of the physiology of generalized tonic-clonic (GTC) seizures, we have investigated the stationarity and redundancy of 21-electrode EEG data recorded from ten patients during GTC seizures elicited by electroconvulsive therapy (ECT). Stationarity was examined by calculating probability density functions (pdfs) and power spectra over small equal-length non-overlapping time windows and then by studying, visually and quantitatively, the evolution of these quantities over the duration of the seizures. Our analysis shows that some seizures had no demonstrable stationarity, that most seizures had time intervals of at least a few seconds that were statistically stationary by several criteria, and that, in some seizures, there were leads which were delayed in manifesting the statistical changes associated with seizure onset evident in other leads. The redundancy analysis demonstrated for the first time posterior-to-anterior time delays in the mid-ictal region of GTC seizures. The implications of these findings are discussed for the analysis of GTC seizure EEG data, for the physiology of GTC seizures, and for ECT research.
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Affiliation(s)
- S M Zoldi
- Los Alamos National Laboratory, NM, USA
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Asnis GM, Chakraburtty A, DuBoff EA, Krystal A, Londborg PD, Rosenberg R, Roth-Schechter B, Scharf MB, Walsh JK. Zolpidem for persistent insomnia in SSRI-treated depressed patients. J Clin Psychiatry 1999; 60:668-76. [PMID: 10549683 DOI: 10.4088/jcp.v60n1005] [Citation(s) in RCA: 129] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
BACKGROUND Depressed individuals effectively treated with selective serotonin reuptake inhibitors (SSRIs) often report persistent insomnia and require adjunctive sleep-promoting therapy. METHOD Men (N = 40) and women (N = 150) with a mean age of 41.6 years who had persistent insomnia in the presence of effective and stable treatment (at least 2 weeks) with fluoxetine (< or =40 mg/day), sertraline (< or =100 mg/day), or paroxetine (< or =40 mg/day) for DSM-IV major depressive disorder, dysthymic disorder, or minor depressive disorder of mild-to-moderate severity (and score of < or =2 on item 3 of the Hamilton Rating Scale for Depression [HAM-D]) participated in this randomized, double-blind, parallel-group study. At study entry, patients were required to score < or =12 on the HAM-D. During a 1-week single-blind placebo period, patients had to report on at least 3 nights a latency of > or =30 minutes or a sleep time of <6.5 hours and clinically significant daytime impairment. Patients received either placebo (N = 96) or zolpidem, 10 mg (N = 94) nightly, for 4 weeks and single-blind placebo for 1 week thereafter. Sleep was measured with daily questionnaires and during weekly physician visits. RESULTS Compared with placebo, zolpidem was associated with improved sleep: longer sleep times (weeks 1 through 4, p<.05), greater sleep quality (weeks 1 through 4, p<.01), and reduced number of awakenings (weeks 1, 2, and 4; p<.05), together with feeling significantly more refreshed, less sleepy, and more able to concentrate. After placebo substitution, the zolpidem group showed significant worsening relative to pretreatment sleep on the first posttreatment night in total sleep time and sleep quality, reverted to pretreatment insomnia levels on the other hypnotic efficacy measures, or maintained improvement (fewer number of awakenings). There was no evidence of dependence or withdrawal from zolpidem (DSM-IV criteria). Incidence rates of adverse events were similar in both treatment groups (74% and 83% for placebo and zolpidem, respectively), but 7 zolpidem patients discontinued compared with 2 placebo patients. CONCLUSION In this defined patient population, zolpidem, 10 mg, was effectively and safely co-administered with an SSRI, resulting in improved self-rated sleep, daytime functioning, and well-being.
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Affiliation(s)
- G M Asnis
- Department of Psychiatry, Montefiore Medical Center, Bronx, NY 10467, USA
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Krystal A, Carr J, Gavaghan K, Porterfield P, Turner L. Implementing a hospital-wide pain management strategy. Can J Nurs Adm 1997; 10:74-89. [PMID: 9355286] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
The purpose of this article is to describe the process of undertaking a large scale nursing pain management initiative, that we entitled "Pain Month." Several educational resources and strategies were employed in an effort to increase nurse's knowledge on the subject of pain management. Pre and post patient satisfaction surveys were conducted to test the effect of the education on actual pain management. The results showed improvements in actual pain scores and in satisfaction with pain management; however, several more improvements were shown to be necessary to achieve excellent pain management for patients. Follow-up initiatives such as a pain resource nurse program, an interdisciplinary pain committee and continued, patient surveys have been implemented to address some of these existing issues.
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Affiliation(s)
- A Krystal
- Vancouver Hospital & Health Sciences Centre
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Krystal A, Krishnan KR, Raitiere M, Poland R, Ritchie JC, Dunnick NR, Hanada K, Nemeroff CB. Differential diagnosis and pathophysiology of Cushing's syndrome and primary affective disorder. J Neuropsychiatry Clin Neurosci 1990; 2:34-43. [PMID: 1967010 DOI: 10.1176/jnp.2.1.34] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Most patients with major depression have increased 24-hour urinary free cortisol and cortisol nonsuppression after dexamethasone administration, which are cornerstones of a diagnosis of Cushing's syndrome. Similarly, Cushing's syndrome patients often suffer from major psychiatric syndromes, most often depression. These similarities between the two conditions sometimes make it difficult to differentiate them and have led some investigators to suggest they are two points on a spectrum of endocrinologic dysfunction. This article reviews the literature comparing Cushing's syndrome and primary affective disorder and presents two cases that illustrate just how closely these diseases may resemble one another.
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Affiliation(s)
- A Krystal
- Department of Psychiatry, Duke University Medical Center, Durham, North Carolina 27710
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