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Johnsen L, Bird JC, Salkovskis P, James AC, Stratford HJ, Sheaves B. Sleep disruption in adolescent inpatients: prevalence, associations with clinical outcomes, and clinician perspectives. J Sleep Res 2024; 33:e14056. [PMID: 37787462 DOI: 10.1111/jsr.14056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2023] [Revised: 09/12/2023] [Accepted: 09/14/2023] [Indexed: 10/04/2023]
Abstract
Sleep problems are common for adolescents with psychiatric disorders, and sleep treatment may aid mental health recovery. Inpatient admissions are likely a particularly challenging time for sleep. Despite this little is known about the nature of sleep problems, and how sleep treatments could be optimised for this setting. This mixed-methods study set out to better understand sleep disturbances in adolescent inpatients. Study 1 examined the prevalence of Sleep Condition Indicator-assessed insomnia at admission and associations with psychiatric symptoms and admission length in 100 inpatients (aged 11-17 years) on one unit in Oxford. Data were gathered from admission routine measures and medical records. Associations were analysed using linear regressions. Half of the inpatients (n = 50) screened positive for insomnia at admission. Moderate-large significant associations were observed between more severe insomnia and more severe depression (β = -0.56), anxiety (β = -0.51), self-harm (β = -0.49), psychotic experiences (β = -0.32), and conduct problems (β = -0.30), but not admission length. Study 2 gained 12 clinicians' perspectives on sleep problems on the unit via a focus group and semi-structured interviews, analysed using thematic analysis. Ward staff observed insomnia and excessive daytime sleepiness in adolescent inpatients and a reciprocal relationship with mental health symptoms. Ward processes were barriers (e.g., night-time observations) and facilitators (e.g., regular routines) of sleep. Cognitive behavioural therapy for insomnia was not routinely offered but viewed as potentially helpful. Insomnia may be a common problem for adolescent inpatients, associated with greater psychopathology, but not admission length. The possible benefits of psychological sleep interventions for adolescents admitted to psychiatric units now require testing.
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Affiliation(s)
- Laura Johnsen
- Berkshire Healthcare NHS Foundation Trust, Thatcham, UK
| | - Jessica C Bird
- Department of Psychiatry, University of Oxford, Oxford, UK
- South London and Maudsley NHS Foundation Trust, London, UK
| | - Paul Salkovskis
- The Oxford Institute of Clinical Psychology Training and Research, Oxford, UK
- Oxford Health NHS Foundation Trust, Oxford, UK
| | - Anthony C James
- Department of Psychiatry, University of Oxford, Oxford, UK
- Oxford Health NHS Foundation Trust, Oxford, UK
| | | | - Bryony Sheaves
- Oxford Health NHS Foundation Trust, Oxford, UK
- Department of Experimental Psychology, University of Oxford, Oxford, UK
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Henry AL, Miller CB, Emsley R, Sheaves B, Freeman D, Luik AI, Espie CA. Does treating insomnia with digital cognitive behavioural therapy (Sleepio) mediate improvements in anxiety for those with insomnia and comorbid anxiety? An analysis using individual participant data from two large randomised controlled trials. J Affect Disord 2023; 339:58-63. [PMID: 37390923 DOI: 10.1016/j.jad.2023.06.053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Revised: 06/06/2023] [Accepted: 06/26/2023] [Indexed: 07/02/2023]
Abstract
BACKGROUND Considerable comorbidity exists between insomnia and anxiety, and evidence shows that the benefits of CBT for insomnia extend to anxiety. Using data from two large trials of digital CBT (dCBT) for insomnia, we evaluated whether improving sleep is an effective treatment target to reduce both insomnia and anxiety symptoms in individuals with insomnia and clinically significant anxiety. METHODS This was a controlled sub-analysis combining individual participant data from two previous randomised controlled trials of dCBT for insomnia (Sleepio). Participants (N = 2172) with insomnia disorder and clinically significant anxiety symptoms were included in this sub-analysis and received either dCBT or control (usual care or sleep hygiene education). Assessments were evaluated at baseline, post-intervention (week 8 or 10), and follow-up (week 22 or 24). Mediation was evaluated using structural equation models. RESULTS dCBT for insomnia was superior to control at reducing both insomnia (Hedges' g range = 0.77-0.81; both p < 0.001) and anxiety symptoms (Hedges' g range = 0.39-0.44; both p < 0.001) at all time points. Baseline insomnia symptoms moderated the effects of dCBT on insomnia, however no variables moderated treatment effects on anxiety. Reductions in anxiety symptoms at follow-up were mediated by improvements in sleep at post-intervention (% mediated = 84 %), suggesting a causal pathway. LIMITATIONS Participants did not have a formal anxiety disorder diagnosis and so the effects of dCBT for insomnia on anxiety may differ by anxiety disorder. CONCLUSIONS Addressing sleep using dCBT for insomnia may serve as a treatment target from which to improve anxiety in individuals with insomnia and clinically significant comorbid anxiety. CLINICAL TRIAL REGISTRATIONS Digital Insomnia therapy to Assist your Life as well as your Sleep (DIALS) - ISRCTN60530898 http://www.isrctn.com/ISRCTN60530898. Oxford Access for Students Improving Sleep (OASIS) - ISRCTN61272251 http://www.isrctn.com/ISRCTN61272251.
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Affiliation(s)
- Alasdair L Henry
- Big Health Ltd., London, UK/San Francisco, USA; Sir Jules Thorn Sleep and Circadian Neuroscience Institute, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK.
| | - Christopher B Miller
- Big Health Ltd., London, UK/San Francisco, USA; Sir Jules Thorn Sleep and Circadian Neuroscience Institute, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| | - Richard Emsley
- Department of Biostatistics and Health Informatics, King's College London, Institute of Psychiatry, Psychology and Neuroscience, London, UK
| | - Bryony Sheaves
- Department of Psychiatry, University of Oxford, Oxford, UK; Oxford Health NHS Foundation Trust, Oxford, UK
| | - Daniel Freeman
- Department of Psychiatry, University of Oxford, Oxford, UK
| | - Annemarie I Luik
- Department of Epidemiology, Erasmus MC University Medical Centre, Rotterdam, Netherlands; Trimbos Institute, The Netherlands Institute of Mental Health and Addiction, Utrecht, Netherlands
| | - Colin A Espie
- Big Health Ltd., London, UK/San Francisco, USA; Sir Jules Thorn Sleep and Circadian Neuroscience Institute, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
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Sheaves B, Rek S, Freeman D. Nightmares and psychiatric symptoms: A systematic review of longitudinal, experimental, and clinical trial studies. Clin Psychol Rev 2023; 100:102241. [PMID: 36566699 PMCID: PMC10933816 DOI: 10.1016/j.cpr.2022.102241] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Revised: 11/24/2022] [Accepted: 12/14/2022] [Indexed: 12/23/2022]
Abstract
Nightmares occur across a wide range of psychiatric disorders, but outside of PTSD presentations are infrequently considered a treatment priority. We aimed to assess evidence for a contributory causal role of nightmares to the occurrence of psychiatric disorders, and vice versa. A systematic review was conducted of longitudinal, experimental, and clinical trial studies. Twenty-four longitudinal, sixteen trials, and no experimental studies were identified. Methodological shortcomings were common, especially the use of single-item nightmare assessment. Thirty-five studies assessed the path from nightmares to psychiatric symptoms. Depression (n = 10 studies), PTSD (n = 10) and anxiety (n = 5) were the most commonly assessed outcomes in trials. Most were not designed to assess the effect of nightmare treatment on psychiatric symptoms. Treating nightmares led to moderate reductions in PTSD and depression, small to moderate reductions in anxiety, and potentially moderate reductions in paranoia. Nightmares increased the risk of later suicide outcomes (n = 10), but two small pilot trials indicated that treating nightmares might potentially prevent recovery of suicidal ideation. PTSD treatment led to large reductions in trauma-related nightmares (n = 3). The limited literature suggests that treating nightmares may be one route to lessening threat-based disorders in particular, suggestive of a causal relationship. Overall, however, nightmares in most disorders are greatly understudied.
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Affiliation(s)
- Bryony Sheaves
- Department of Psychiatry, University of Oxford, Warneford Hospital, Oxford OX3 7JX, United Kingdom; Oxford Health NHS Foundation Trust, Warneford Hospital, Oxford, OX3 7JX, United Kingdom.
| | - Stephanie Rek
- Department of Psychiatry, University of Oxford, Warneford Hospital, Oxford OX3 7JX, United Kingdom; Department of Psychiatry and Psychotherapy, LMU University Hospital Munich, Munich, Germany; International Max Planck Research School for Translational Psychiatry (IMPRS-TP), Munich, Germany
| | - Daniel Freeman
- Department of Psychiatry, University of Oxford, Warneford Hospital, Oxford OX3 7JX, United Kingdom; Oxford Health NHS Foundation Trust, Warneford Hospital, Oxford, OX3 7JX, United Kingdom
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Sheaves B, Johns L, Loe BS, Bold E, Černis E, Molodynski A, Freeman D. Listening to and Believing Derogatory and Threatening Voices. Schizophr Bull 2022; 49:151-160. [PMID: 35947487 PMCID: PMC9810006 DOI: 10.1093/schbul/sbac101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
BACKGROUND AND HYPOTHESIS A plausible cause of distress for voice hearers is listening to and believing the threats and criticisms heard. Qualitative research indicates that patients have understandable reasons to listen. This study aimed to develop the understanding of distress using this listening and believing framework. Measures were developed of listening and believing voices and the reasons, and associations with distress tested. STUDY DESIGN A cross-sectional study of patients hearing derogatory and threatening voices (N = 591). Listening and Believing-Assessment and Listening and Believing-Reasons item pools were completed, and assessments of distress. Exploratory and confirmatory factor analyses and structural equation modeling (SEM) were conducted. STUDY RESULTS 52% (n = 307) of participants believed their voices most or all the time. Listening and believing had 4 factors: active listening, passive listening, believing, and disregarding. Higher levels of believing, active listening, and particularly passive listening were associated with higher levels of anxiety, depression, and voice distress. Reasons for listening and believing formed 7 factors: to better understand the threat; being too worn down to resist; to learn something insightful; being alone with time to listen; voices trying to capture attention; voices sounding like real people; and voices sounding like known people. Each type of reason was associated with active listening, passive listening, and believing. SEM showed that feeling worn down in particular accounted for listening and believing. Test-retest reliability of measures was excellent. CONCLUSIONS A framework of listening and believing negative voices has the potential to inform the understanding and treatment of voice distress.
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Affiliation(s)
- Bryony Sheaves
- To whom correspondence should be addressed; tel: 01865 618187, e-mail:
| | - Louise Johns
- Department of Psychiatry, University of Oxford, Oxford, UK,Oxford Health NHS Foundation Trust, Oxford, UK
| | - Bao S Loe
- The Psychometrics Centre, University of Cambridge, Cambridge, UK
| | - Emily Bold
- Department of Psychiatry, University of Oxford, Oxford, UK,Oxford Health NHS Foundation Trust, Oxford, UK
| | - Emma Černis
- Department of Psychiatry, University of Oxford, Oxford, UK,Oxford Health NHS Foundation Trust, Oxford, UK
| | | | - Andrew Molodynski
- Department of Psychiatry, University of Oxford, Oxford, UK,Oxford Health NHS Foundation Trust, Oxford, UK
| | - Daniel Freeman
- Department of Psychiatry, University of Oxford, Oxford, UK,Oxford Health NHS Foundation Trust, Oxford, UK
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Alsuhibani A, Shevlin M, Freeman D, Sheaves B, Bentall RP. Why conspiracy theorists are not always paranoid: Conspiracy theories and paranoia form separate factors with distinct psychological predictors. PLoS One 2022; 17:e0259053. [PMID: 35389988 PMCID: PMC8989304 DOI: 10.1371/journal.pone.0259053] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2021] [Accepted: 10/11/2021] [Indexed: 01/12/2023] Open
Abstract
Paranoia and belief in conspiracy theories both involve suspiciousness about the intentions of others but have rarely been studied together. In three studies, one with a mainly student sample (N = 496) and two with more representative UK population samples (N = 1,519, N = 638) we compared single and two-factor models of paranoia and conspiracy theories as well as associations between both belief systems and other psychological constructs. A model with two correlated factors was the best fit in all studies. Both belief systems were associated with poor locus of control (belief in powerful others and chance) and loneliness. Paranoid beliefs were specifically associated with negative self-esteem and, in two studies, insecure attachment; conspiracy theories were associated with positive self-esteem in the two larger studies and narcissistic personality traits in the final study. Conspiracist thinking but not paranoia was associated with poor performance on the Cognitive Reflection Task (poor analytical thinking). The findings suggest that paranoia and belief in conspiracy theories are distinct but correlated belief systems with both common and specific psychological components.
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Affiliation(s)
- Azzam Alsuhibani
- Department of Psychology, King Saud University, Riyadh, Saudi Arabia
| | - Mark Shevlin
- Department of Psychology, University of Ulster, Ulster, United Kingdom
| | - Daniel Freeman
- Department of Psychiatry, University of Oxford, Oxford, United Kingdom
| | - Bryony Sheaves
- Department of Psychiatry, University of Oxford, Oxford, United Kingdom
| | - Richard P. Bentall
- Clinical Psychology Unit, Department of Psychology, University of Sheffield, Sheffield, United Kingdom
- * E-mail:
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Sheaves B, Johns L, Černis E, Griffith L, Freeman D. The challenges and opportunities of social connection when hearing derogatory and threatening voices: A thematic analysis with patients experiencing psychosis. Psychol Psychother 2021; 94:341-356. [PMID: 33124757 PMCID: PMC8247012 DOI: 10.1111/papt.12303] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Revised: 07/20/2020] [Indexed: 11/29/2022]
Abstract
OBJECTIVES Relationships with other people are important determinants of the course of psychosis, yet social isolation is common. This study sought to learn about the patient experience of being around other people when hearing derogatory and threatening voices (DTVs). DESIGN A qualitative interview study. METHODS Fifteen participants with experience of hearing DTVs in the context of non-affective psychosis were recruited from NHS services. Data were obtained by semi-structured interviews and analysed using thematic analysis. RESULTS Three themes were identified: (1) reasons why interacting with people is difficult when hearing DTVs; (2) the relationship between social connection and DTVs; and (3) factors which enable voice hearers to connect with others. A further ten sub-themes are outlined as reasons why hearing DTVs led to lower social connection, including difficulties during conversations (e.g., the concentration required is hard), negative expectations of interactions (e.g., fearing negative judgement from others), and difficulties sharing experiences of voices (e.g., people will be hurt or upset if I tell them about the voices). Isolation was a common response to hearing DTVs but also a time of vulnerability for hearing voices. Managing the challenges of interacting with people led to some improvements in DTVs. CONCLUSIONS There are understandable reasons why hearing DTVs leads to lower social connection. Yet isolating oneself can also be a time of vulnerability for DTVs. Social connection might be one vehicle for disengaging from and disputing derogatory and threatening voice content. The effect on voice hearing of social recovery interventions warrants further investigation. PRACTITIONER POINTS Participants shared 10 reasons why being around people is challenging when hearing derogatory and threatening voices. These typically affected both daily social experiences and contact with clinicians. Common initial responses to hearing DTVs were to reduce contact with people, experience difficulties connecting during conversations and to avoid sharing the experience of voice hearing. However, social isolation was a time of vulnerability to DTVs, and hence, increasing social connection might be a target for interventions. A range of factors enabled voice hearers to manage social situations, for example: the fostering of trust, self-acceptance, learning when it is better to stay at home, and developing a narrative to explain voice hearing to others. Addressing the barriers to connecting with others might have an important role in personal recovery from voice hearing.
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Affiliation(s)
- Bryony Sheaves
- Department of PsychiatryUniversity of OxfordUK,Oxford Health NHS Foundation TrustUK
| | - Louise Johns
- Department of PsychiatryUniversity of OxfordUK,Oxford Health NHS Foundation TrustUK
| | - Emma Černis
- Department of PsychiatryUniversity of OxfordUK,Oxford Health NHS Foundation TrustUK
| | | | | | - Daniel Freeman
- Department of PsychiatryUniversity of OxfordUK,Oxford Health NHS Foundation TrustUK
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Isham L, Griffith L, Boylan A, Hicks A, Wilson N, Byrne R, Sheaves B, Bentall RP, Freeman D. Understanding, treating, and renaming grandiose delusions: A qualitative study. Psychol Psychother 2021; 94:119-140. [PMID: 31785077 PMCID: PMC7984144 DOI: 10.1111/papt.12260] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2019] [Revised: 08/23/2019] [Indexed: 12/01/2022]
Abstract
BACKGROUND Grandiose delusions are arguably the most neglected psychotic experience in research. OBJECTIVES We aimed to discover from patients: whether grandiose delusions have harmful consequences; the psychological mechanisms that maintain them; and what help patients may want from clinical services. DESIGN A qualitative interview design was used to explore patients' experiences of grandiose delusions. METHOD Fifteen patients with past or present experiences of grandiose delusions who were attending psychiatric services were interviewed. Thematic analysis and grounded theory were used to analyse the data. RESULTS Participants reported physical, sexual, social, occupational, and emotional harms from grandiose delusions. All patients described the grandiose belief as highly meaningful: it provided a sense of purpose, belonging, or self-identity, or it made sense of unusual or difficult events. The meaning from the belief was not synonymous with extreme superiority or arrogance. The meaning obtained appeared to be a key driver of the persistence of the beliefs. Other maintenance factors were subjectively anomalous experiences (e.g., voices), symptoms of mania, fantasy elaboration, reasoning biases, and immersive behaviours. Participants described insufficient opportunities to talk about their grandiose beliefs and related experiences and were generally positive about the possibility of a psychological therapy. CONCLUSIONS We conclude that grandiosity is a psychologically rich experience, with a number of maintenance factors that may be amenable to a targeted psychological intervention. Importantly, the term 'grandiose delusion' is an imprecise description of the experience; we suggest 'delusions of exceptionality' may be a credible alternative. PRACTITIONER POINTS Harm from grandiose delusions can occur across multiple domains (including physical, sexual, social, occupational, and emotional) and practitioners should assess accordingly. However, grandiose delusions are experienced by patients as highly meaningful: they provide a sense of purpose, belonging, or self-identity, or make sense of unusual or difficult events. Possible psychological maintenance mechanisms that could be a target for intervention include the meaning of the belief, anomalous experiences, mania, fantasy elaboration, reasoning biases, and immersive behaviours. Patients are keen to have the opportunity to access talking therapies for this experience. Taking extra time to talk at times of distress, 'going the extra mile', and listening carefully can help to facilitate trust.
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Affiliation(s)
- Louise Isham
- Oxford Cognitive Approaches to Psychosis (O‐CAP)Department of PsychiatryUniversity of OxfordUK,Oxford Health NHS Foundation TrustUK
| | - Laura Griffith
- Health Services Management CentreUniversity of BirminghamUK
| | - Anne‐Marie Boylan
- Nuffield Department of Primary Care Health SciencesUniversity of OxfordUK
| | - Alice Hicks
- Patient Advisory GroupOxford Cognitive Approaches to Psychosis (O‐CAP)Department of PsychiatryUniversity of OxfordUK,The McPin FoundationLondonUK
| | - Natalie Wilson
- Patient Advisory GroupOxford Cognitive Approaches to Psychosis (O‐CAP)Department of PsychiatryUniversity of OxfordUK,The McPin FoundationLondonUK
| | - Rory Byrne
- Psychosis Research UnitGreater Manchester Mental Health NHS Foundation TrustUK
| | - Bryony Sheaves
- Oxford Cognitive Approaches to Psychosis (O‐CAP)Department of PsychiatryUniversity of OxfordUK,Oxford Health NHS Foundation TrustUK
| | | | - Daniel Freeman
- Oxford Cognitive Approaches to Psychosis (O‐CAP)Department of PsychiatryUniversity of OxfordUK,Oxford Health NHS Foundation TrustUK
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Abstract
Clinical experience indicates that excessive sleepiness and hypersomnia may be a common issue for patients with psychosis. Excessive sleepiness is typically ascribed to the sedating effects of antipsychotic medications but there may be other potential contributors such as sleep disorders and depression. Furthermore, the impact of excessive sleepiness itself on patients' symptoms and general wellbeing is yet to be examined. The current study reports an exploratory cross-sectional between-groups comparison of patients with early psychosis fulfilling criteria assessed in a diagnostic interview for problematic excessive sleepiness (n = 14), compared with those not reporting excessive sleepiness (n = 46). There were no differences between the groups in diagnosis, medication type, or antipsychotic medication dosage. There were no significant group differences in sleep duration. Significantly lower activity levels were found in the excessive sleepiness group. Insomnia and nightmares were common in those reporting excessive sleepiness. No significant differences were found in psychiatric symptoms, although data did indicate more severe cognitive disorganisation and grandiosity, but less severe paranoia and hallucinations, in the excessive sleepiness group. Wide confidence intervals and small sample size mean that care should be taken interpreting these results. Overall, this study indicates that excessive sleepiness may not be solely related to medication but also to low levels of activity and other sleep disorders. This is a novel finding that, if replicated, could indicate routes of intervention for this clinical issue. Future research should aim to disentangle directions of effect amongst sleepiness, mood, activity, and psychotic symptoms and investigate possible interventions for excessive sleepiness in psychosis.
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Affiliation(s)
- Sarah Reeve
- Department of Clinical, Educational, and Health Psychology, University College London, London, United Kingdom
| | - Bryony Sheaves
- Department of Psychiatry, Warneford Hospital, University of Oxford, Oxford, United Kingdom
- Oxford Health NHS Foundation Trust, Warneford Hospital, Oxford, United Kingdom
| | - Daniel Freeman
- Department of Psychiatry, Warneford Hospital, University of Oxford, Oxford, United Kingdom
- Oxford Health NHS Foundation Trust, Warneford Hospital, Oxford, United Kingdom
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Freeman D, Loe BS, Kingdon D, Startup H, Molodynski A, Rosebrock L, Brown P, Sheaves B, Waite F, Bird JC. The revised Green et al., Paranoid Thoughts Scale (R-GPTS): psychometric properties, severity ranges, and clinical cut-offs. Psychol Med 2021; 51:244-253. [PMID: 31744588 PMCID: PMC7893506 DOI: 10.1017/s0033291719003155] [Citation(s) in RCA: 105] [Impact Index Per Article: 35.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2019] [Revised: 10/02/2019] [Accepted: 10/15/2019] [Indexed: 01/13/2023]
Abstract
BACKGROUND The Green et al., Paranoid Thoughts Scale (GPTS) - comprising two 16-item scales assessing ideas of reference (Part A) and ideas of persecution (Part B) - was developed over a decade ago. Our aim was to conduct the first large-scale psychometric evaluation. METHODS In total, 10 551 individuals provided GPTS data. Four hundred and twenty-two patients with psychosis and 805 non-clinical individuals completed GPTS Parts A and B. An additional 1743 patients with psychosis and 7581 non-clinical individuals completed GPTS Part B. Factor analysis, item response theory, and receiver operating characteristic analyses were conducted. RESULTS The original two-factor structure of the GPTS had an inadequate model fit: Part A did not form a unidimensional scale and multiple items were locally dependant. A Revised-GPTS (R-GPTS) was formed, comprising eight-item ideas of reference and 10-item ideas of persecution subscales, which had an excellent model fit. All items in the new Reference (a = 2.09-3.67) and Persecution (a = 2.37-4.38) scales were strongly discriminative of shifts in paranoia and had high reliability across the spectrum of severity (a > 0.90). The R-GPTS score ranges are: average (Reference: 0-9; Persecution: 0-4); elevated (Reference: 10-15; Persecution: 5-10); moderately severe (Reference: 16-20; Persecution:11-17); severe (Reference: 21-24; Persecution: 18-27); and very severe (Reference: 25+; Persecution: 28+). Recommended cut-offs on the persecution scale are 11 to discriminate clinical levels of persecutory ideation and 18 for a likely persecutory delusion. CONCLUSIONS The psychometric evaluation indicated a need to improve the GPTS. The R-GPTS is a more precise measure, has excellent psychometric properties, and is recommended for future studies of paranoia.
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Affiliation(s)
- Daniel Freeman
- Department of Psychiatry, University of Oxford
- Oxford Health NHS Foundation Trust, Oxford, UK
| | - Bao S. Loe
- The Psychometrics Centre, University of Cambridge, Cambridge, UK
| | - David Kingdon
- Academic Department of Psychiatry, Faculty of Medicine, University of Southampton, Southampton, UK
| | | | | | - Laina Rosebrock
- Department of Psychiatry, University of Oxford
- Oxford Health NHS Foundation Trust, Oxford, UK
| | - Poppy Brown
- Department of Psychiatry, University of Oxford
| | - Bryony Sheaves
- Department of Psychiatry, University of Oxford
- Oxford Health NHS Foundation Trust, Oxford, UK
| | - Felicity Waite
- Department of Psychiatry, University of Oxford
- Oxford Health NHS Foundation Trust, Oxford, UK
| | - Jessica C. Bird
- Department of Psychiatry, University of Oxford
- Oxford Health NHS Foundation Trust, Oxford, UK
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Henry AL, Miller CB, Emsley R, Sheaves B, Freeman D, Luik AI, Littlewood DL, Saunders KEA, Kanady JC, Carl JR, Davis ML, Kyle SD, Espie CA. Insomnia as a mediating therapeutic target for depressive symptoms: A sub-analysis of participant data from two large randomized controlled trials of a digital sleep intervention. J Sleep Res 2020; 30:e13140. [PMID: 32810921 PMCID: PMC8150672 DOI: 10.1111/jsr.13140] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2020] [Revised: 06/19/2020] [Accepted: 06/22/2020] [Indexed: 01/04/2023]
Abstract
Insomnia predicts the onset of depression, commonly co-presents with depression and often persists following depression remission. However, these conditions can be challenging to treat concurrently using depression-specific therapies. Cognitive behavioural therapy for insomnia may be an appropriate treatment to improve both insomnia and depressive symptoms. We examined the effects of a fully-automated digital cognitive behavioural therapy intervention for insomnia (Sleepio) on insomnia and depressive symptoms, and the mediating role of sleep improvement on depressive symptoms in participants from two randomized controlled trials of digital cognitive behavioural therapy for insomnia. We also explored potential moderators of intervention effects. All participants met criteria for probable insomnia disorder and had clinically significant depressive symptomatology (PHQ-9 ≥ 10; n = 3,352). Individuals allocated to treatment in both trials were provided access to digital cognitive behavioural therapy. Digital cognitive behavioural therapy significantly improved insomnia (p < .001; g = 0.76) and depressive symptoms (p < .001; g = 0.48) at post-intervention (weeks 8-10), and increased the odds (OR = 2.9; 95% CI = 2.34, 3.65) of clinically significant improvement in depressive symptoms (PHQ-9 < 10). Improvements in insomnia symptoms at mid-intervention mediated 87% of the effects on depressive symptoms at post-intervention. No variables moderated effectiveness outcomes, suggesting generalizability of these findings. Our results suggest that effects of digital cognitive behavioural therapy for insomnia extend to depressive symptoms in those with clinically significant depressive symptomatology. Insomnia may, therefore, be an important therapeutic target to assist management of depressive symptoms.
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Affiliation(s)
- Alasdair L Henry
- Big Health Inc., San Francisco, California, USA.,Sleep and Circadian Neuroscience Institute, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| | - Christopher B Miller
- Big Health Inc., San Francisco, California, USA.,Sleep and Circadian Neuroscience Institute, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| | - Richard Emsley
- Department of Biostatistics and Health Informatics, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Bryony Sheaves
- Department of Psychiatry, University of Oxford, Oxford, UK
| | - Daniel Freeman
- Department of Psychiatry, University of Oxford, Oxford, UK
| | - Annemarie I Luik
- Department of Epidemiology, Erasmus MC University Medical Centre, Rotterdam, The Netherlands
| | - Donna L Littlewood
- NIHR Greater Manchester Patient Safety Translational Research Centre, University of Manchester, Manchester, UK
| | | | | | | | | | - Simon D Kyle
- Sleep and Circadian Neuroscience Institute, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| | - Colin A Espie
- Big Health Inc., San Francisco, California, USA.,Sleep and Circadian Neuroscience Institute, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
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Waite F, Sheaves B, Isham L, Reeve S, Freeman D. Sleep and schizophrenia: From epiphenomenon to treatable causal target. Schizophr Res 2020; 221:44-56. [PMID: 31831262 PMCID: PMC7327507 DOI: 10.1016/j.schres.2019.11.014] [Citation(s) in RCA: 63] [Impact Index Per Article: 15.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2019] [Revised: 11/08/2019] [Accepted: 11/11/2019] [Indexed: 12/28/2022]
Abstract
BACKGROUND Sleep disturbance is a common clinical issue for patients with psychosis. It has been identified as a putative causal factor in the onset and persistence of psychotic experiences (paranoia and hallucinations). Hence sleep disruption may be a potential treatment target to prevent the onset of psychosis and reduce persistent psychotic experiences. The aim of this review is to describe developments in understanding the nature, causal role, and treatment of sleep disruption in psychosis. METHOD A systematic literature search was conducted to identify studies, published in the last five years, investigating subjective sleep disruption and psychotic experiences. RESULTS Fifty-eight papers were identified: 37 clinical and 21 non-clinical studies. The studies were correlational (n = 38; 20 clinical, 18 non-clinical), treatment (n = 7; 1 non-clinical), qualitative accounts (n = 6 clinical), prevalence estimates (n = 5 clinical), and experimental tests (n = 2 non-clinical). Insomnia (50%) and nightmare disorder (48%) are the most prevalent sleep problems found in patients. Sleep disruption predicts the onset and persistence of psychotic experiences such as paranoia and hallucinations, with negative affect identified as a partial mediator of this relationship. Patients recognise the detrimental effects of disrupted sleep and are keen for treatment. All psychological intervention studies reported large effect size improvements in sleep and there may be modest resultant improvements in psychotic experiences. CONCLUSIONS Sleep disruption is a treatable clinical problem in patients with psychosis. It is important to treat in its own right but may also lessen psychotic experiences. Research is required on how this knowledge can be implemented in clinical services.
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Affiliation(s)
- Felicity Waite
- Department of Psychiatry, University of Oxford, UK; Oxford Health NHS Foundation Trust, UK; Sleep and Circadian Neuroscience Institute, University of Oxford, UK.
| | - Bryony Sheaves
- Department of Psychiatry, University of Oxford, UK,Oxford Health NHS Foundation Trust, UK,Sleep and Circadian Neuroscience Institute, University of Oxford, UK
| | - Louise Isham
- Department of Psychiatry, University of Oxford, UK,Oxford Health NHS Foundation Trust, UK
| | | | - Daniel Freeman
- Department of Psychiatry, University of Oxford, UK,Oxford Health NHS Foundation Trust, UK,Sleep and Circadian Neuroscience Institute, University of Oxford, UK
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12
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Freeman D, Sheaves B, Waite F, Harvey AG, Harrison PJ. Sleep disturbance and psychiatric disorders. Lancet Psychiatry 2020; 7:628-637. [PMID: 32563308 DOI: 10.1016/s2215-0366(20)30136-x] [Citation(s) in RCA: 234] [Impact Index Per Article: 58.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2020] [Revised: 02/22/2020] [Accepted: 03/17/2020] [Indexed: 01/10/2023]
Abstract
Signs of mental ill health that cut across psychiatric diagnostic categories at high rates are typically viewed as non-specific occurrences, downgraded in importance and disregarded. However, problems not associated with particular diagnoses should be expected if there is shared causation across mental health conditions. If dynamic networks of interacting symptoms are the reality of mental health presentations, then particularly disruptive and highly connected problems should be especially common. The non-specific occurrence might be highly consequential. One non-specific occurrence that is often overlooked is patients' chronic difficulty in getting good sleep. In this Review, we consider whether disrupted sleep might be a contributory causal factor in the occurrence of major types of mental health disorders. It is argued that insomnia and other mental health conditions not only share common causes but also show a bidirectional relationship, with typically the strongest pathway being disrupted sleep as a causal factor in the occurrence of other psychiatric problems. Treating insomnia lessens other mental health problems. Intervening on sleep at an early stage might be a preventive strategy for the onset of clinical disorders. Our recommendations are that insomnia is assessed routinely in the occurrence of mental health disorders; that sleep disturbance is treated in services as a problem in its own right, yet also recognised as a pathway to reduce other mental health difficulties; and that access to evidence-based treatment for sleep difficulties is expanded in mental health services.
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Affiliation(s)
- Daniel Freeman
- Department of Psychiatry, University of Oxford, Oxford, UK; Health National Health Service Foundation Trust, Oxford, UK.
| | - Bryony Sheaves
- Department of Psychiatry, University of Oxford, Oxford, UK; Health National Health Service Foundation Trust, Oxford, UK
| | - Felicity Waite
- Department of Psychiatry, University of Oxford, Oxford, UK; Health National Health Service Foundation Trust, Oxford, UK
| | - Allison G Harvey
- Department of Psychology, University of California, Berkeley, CA, USA
| | - Paul J Harrison
- Department of Psychiatry, University of Oxford, Oxford, UK; Health National Health Service Foundation Trust, Oxford, UK
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13
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Sheaves B, Holmes EA, Rek S, Taylor KM, Nickless A, Waite F, Germain A, Espie CA, Harrison PJ, Foster R, Freeman D. Cognitive Behavioural Therapy for Nightmares for Patients with Persecutory Delusions (Nites): An Assessor-Blind, Pilot Randomized Controlled Trial. Can J Psychiatry 2019; 64:686-696. [PMID: 31129983 PMCID: PMC6783669 DOI: 10.1177/0706743719847422] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
OBJECTIVE Nightmares are relatively common in patients experiencing psychosis but rarely assessed or treated. Nightmares may maintain persecutory delusions by portraying fears in sensory-rich detail. We tested the potential benefits of imagery-focused cognitive behavioural therapy (CBT) for nightmares on nightmare severity and persecutory delusions. METHOD This assessor-blind parallel-group pilot trial randomized 24 participants with nightmares and persecutory delusions to receive CBT for nightmares delivered over 4 weeks in addition to treatment as usual (TAU) or TAU alone. Assessments were at 0, 4 (end of treatment), and 8 weeks (follow-up). Feasibility outcomes assessed therapy uptake, techniques used, satisfaction, and attrition. The primary efficacy outcome assessed nightmare severity at week 4. Analyses were intention to treat, estimating treatment effect with 95% confidence intervals (CIs). RESULTS All participants offered CBT completed therapy (mean [SD], 4.8 [0.6] sessions) with high satisfaction, and 20 (83%) participants completed all assessments. Compared with TAU, CBT led to large improvements in nightmares (adjusted mean difference = -7.0; 95% CI, -12.6 to -1.3; d = -1.1) and insomnia (6.3; 95% CI, 2.6 to 10.0; d = 1.4) at week 4. Gains were maintained at follow-up. Suicidal ideation was not exacerbated by CBT but remained stable to follow-up, compared with TAU, which reduced at follow-up (6.8; 95% CI, 0.3 to 3.3; d = 0.7). CBT led to reductions in paranoia (-20.8; 95% CI, -43.2 to 1.7; d = -0.6), although CIs were wide. Three serious adverse events were deemed unrelated to participation (CBT = 2, TAU = 1). CONCLUSIONS CBT for nightmares is feasible and may be efficacious for treating nightmares and comorbid insomnia for patients with persecutory delusions. It shows promise on paranoia but potentially not on suicidal ideation.
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Affiliation(s)
- Bryony Sheaves
- Department of Psychiatry, Warneford Hospital, University of Oxford, Oxford, UK.,Oxford Health NHS Foundation Trust, Warneford Hospital, Oxford, UK
| | - Emily A Holmes
- Department of Psychiatry, Warneford Hospital, University of Oxford, Oxford, UK.,Department of Psychology, Uppsala University, Sweden.,Division of Psychology, Department of Clinical Neuroscience, Karolinska Institutet, Solna, Sweden
| | - Stephanie Rek
- Department of Psychiatry, Warneford Hospital, University of Oxford, Oxford, UK
| | - Kathryn M Taylor
- Nuffield Department of Primary Care Health Sciences, Primary Care Clinical Trials Unit, University of Oxford, Radcliffe Observatory Quarter, Oxford, UK
| | - Alecia Nickless
- Nuffield Department of Primary Care Health Sciences, Primary Care Clinical Trials Unit, University of Oxford, Radcliffe Observatory Quarter, Oxford, UK
| | - Felicity Waite
- Department of Psychiatry, Warneford Hospital, University of Oxford, Oxford, UK.,Oxford Health NHS Foundation Trust, Warneford Hospital, Oxford, UK
| | - Anne Germain
- Department of Psychiatry, University of Pittsburgh School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Colin A Espie
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| | - Paul J Harrison
- Department of Psychiatry, Warneford Hospital, University of Oxford, Oxford, UK.,Oxford Health NHS Foundation Trust, Warneford Hospital, Oxford, UK
| | - Russell Foster
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| | - Daniel Freeman
- Oxford Health NHS Foundation Trust, Warneford Hospital, Oxford, UK.,Nuffield Department of Primary Care Health Sciences, Primary Care Clinical Trials Unit, University of Oxford, Radcliffe Observatory Quarter, Oxford, UK
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14
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Sheaves B, Peters E, Stahl D, Johns L. Changes in care costs associated with cognitive behavioural therapy for psychosis delivered in routine clinical practice. J Ment Health 2019; 29:605-610. [PMID: 30902027 DOI: 10.1080/09638237.2019.1581327] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Background: Schizophrenia spectrum disorders are long-term disabling conditions placing high economic demands on health services.Aim: To investigate whether cognitive behavioural therapy for psychosis (CBTp), delivered in a specialist psychological therapies service, was associated with a reduction in intensive care costs.Methods: Days using inpatient care and out of hours crisis support were recorded (N = 69). Costs associated with high intensity care use in the 12 months pre-referral were compared to during, and 12 months following cessation of therapy.Results: Despite the majority of participants incurring £0 at all time periods, costs of intensive mental health care more than halved with CBTp delivery, with a significant decrease during therapy, and at trend level after therapy (p = 0.07). Post hoc analysis revealed that offsetting the cost of therapy for those who utilised intensive care services at any time point (N = 18) resulted in therapy being cost neutral during therapy and cost effective (at trend level) 12 months following cessation of therapy.Conclusion: CBTp may reduce costs associated with intensive psychiatric care, even in a population where the minority use these services. Investment in therapy may lead to both clinical and financial benefits.
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Affiliation(s)
- Bryony Sheaves
- Department of Psychology, Psychology & Neuroscience (IoPPN), King's College London, Institute of Psychiatry, London, UK.,Department of Psychiatry, Warneford Hospital, University of Oxford, Oxford, UK.,PICuP Clinic, South London and Maudsley NHS Foundation Trust (SLaM), P079, Clinical Treatment Centre, Maudsley Hospital, London, UK
| | - Emmanuelle Peters
- Department of Psychology, Psychology & Neuroscience (IoPPN), King's College London, Institute of Psychiatry, London, UK.,Department of Biostatistics and Health Informatics, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Daniel Stahl
- Oxford Health NHS Foundation Trust, Warneford Hospital, Oxford, UK
| | - Louise Johns
- Department of Psychology, Psychology & Neuroscience (IoPPN), King's College London, Institute of Psychiatry, London, UK.,Department of Psychiatry, Warneford Hospital, University of Oxford, Oxford, UK.,PICuP Clinic, South London and Maudsley NHS Foundation Trust (SLaM), P079, Clinical Treatment Centre, Maudsley Hospital, London, UK
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15
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Abstract
Sleep disturbance is known to be associated with psychosis, but sleep disorders (eg, insomnia, nightmare disorder, sleep apnea) have rarely been investigated. We aimed to provide the first detailed assessment of sleep disorders and their correlates in patients with early psychosis. Sixty outpatients aged between 18 and 30 with nonaffective psychosis were assessed for sleep disorder presence, severity, and treatment using a structured diagnostic interview, sleep diaries, and actigraphy. Psychotic experiences, mood, and psychological wellbeing were also measured. Forty-eight patients (80%) had at least one sleep disorder, with insomnia and nightmare disorder being the most common. Comorbidity of sleep disorders within this group was high, with an average of 3.3 sleep disorders per patient. Over half of the sleep disorders had been discussed with a clinician but almost three-quarters had received no treatment. Treatment according to clinical guidelines was rare, occurring in only 8% of cases (n = 13). Sleep disorders were significantly associated with increased psychotic experiences, depression, anxiety, fatigue, and lower quality of life. Sleep disorders are very common in patients with psychosis, may have wide-ranging negative effects, and merit routine assessment and treatment in psychiatric practice.
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Affiliation(s)
- Sarah Reeve
- Department of Psychiatry, University of Oxford, Warneford Hospital, Oxford, UK,To whom correspondence should be addressed; Oxford Cognitive Approaches to Psychosis, Department of Psychiatry, University of Oxford, Warneford Hospital, Oxford OX3 7JX, UK; tel: +44-0-1865-618298, fax: + 44 (0)1865 793101, e-mail:
| | - Bryony Sheaves
- Department of Psychiatry, University of Oxford, Warneford Hospital, Oxford, UK,Oxford Health NHS Foundation Trust, Oxford, UK
| | - Daniel Freeman
- Department of Psychiatry, University of Oxford, Warneford Hospital, Oxford, UK,Oxford Health NHS Foundation Trust, Oxford, UK
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16
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Reeve S, Nickless A, Sheaves B, Hodgekins J, Stewart SLK, Gumley A, Fowler D, Morrison A, Freeman D. Sleep duration and psychotic experiences in patients at risk of psychosis: A secondary analysis of the EDIE-2 trial. Schizophr Res 2019; 204:326-333. [PMID: 30121185 PMCID: PMC6406020 DOI: 10.1016/j.schres.2018.08.006] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2018] [Revised: 08/06/2018] [Accepted: 08/07/2018] [Indexed: 01/31/2023]
Abstract
Sleep disturbance is common among individuals at risk of psychosis, yet few studies have investigated the relationship between sleep disturbance and clinical trajectory. The Early Detection and Intervention Evaluation (EDIE-2) trial provides longitudinal data on sleep duration and individual psychotic experiences from a cohort of individuals at risk of psychosis, which this study utilises in an opportunistic secondary analysis. Shorter and more variable sleep was hypothesised to be associated with more severe psychotic experiences and lower psychological wellbeing. Mixed effect models were used to test sleep duration and range as predictors of individual psychotic experiences and psychological wellbeing over the 12-24 months (with assessments every 3 months) in 160 participants. Shorter sleep duration was associated with more severe delusional ideas and hallucinations cross-sectionally and longitudinally. The longitudinal relationships did not remain significant after conservative controls were added for the previous severity of psychotic experiences. No significant relationships were found between the sleep variables and other psychotic experiences (e.g. cognitive disorganisation), or psychological wellbeing. The results support a relationship between shorter sleep duration and delusional ideas and hallucinations. Future studies should focus on improving sleep disturbance measurement, and test whether treating sleep improves clinical trajectory in the at-risk group.
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Affiliation(s)
- S Reeve
- Department of Psychiatry, University of Oxford, Warneford Hospital, Oxford, UK.
| | - A Nickless
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Observatory Quarter, Woodstock Road, Oxford, UK
| | - B Sheaves
- Department of Psychiatry, University of Oxford, Warneford Hospital, Oxford, UK; Oxford Health NHS Foundation Trust, Oxford, UK
| | - J Hodgekins
- Norwich Medical School, University of East Anglia, Norwich, UK
| | - S L K Stewart
- Department of Psychology, University of Chester, Parkgate Road, Chester, UK
| | - A Gumley
- Institute of Health and Wellbeing, University of Glasgow, Gartnavel Royal Hospital, Glasgow, UK
| | - D Fowler
- School of Psychology, Pevensey Building, University of Sussex, Falmer, Brighton, UK
| | - A Morrison
- Division of Psychology and Mental Health, University of Manchester, Manchester, UK
| | - D Freeman
- Department of Psychiatry, University of Oxford, Warneford Hospital, Oxford, UK; Oxford Health NHS Foundation Trust, Oxford, UK
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17
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Espie CA, Emsley R, Kyle SD, Gordon C, Drake CL, Siriwardena AN, Cape J, Ong JC, Sheaves B, Foster R, Freeman D, Costa-Font J, Marsden A, Luik AI. Effect of Digital Cognitive Behavioral Therapy for Insomnia on Health, Psychological Well-being, and Sleep-Related Quality of Life: A Randomized Clinical Trial. JAMA Psychiatry 2019; 76:21-30. [PMID: 30264137 PMCID: PMC6583463 DOI: 10.1001/jamapsychiatry.2018.2745] [Citation(s) in RCA: 210] [Impact Index Per Article: 42.0] [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] [Received: 05/08/2018] [Accepted: 08/04/2018] [Indexed: 12/21/2022]
Abstract
Importance Digital cognitive behavioral therapy (dCBT) is a scalable and effective intervention for treating insomnia. Most people with insomnia, however, seek help because of the daytime consequences of poor sleep, which adversely affects quality of life. Objectives To investigate the effect of dCBT for insomnia on functional health, psychological well-being, and sleep-related quality of life and to determine whether a reduction in insomnia symptoms was a mediating factor. Design, Setting, and Participants This online, 2-arm, parallel-group randomized trial comparing dCBT for insomnia with sleep hygiene education (SHE) evaluated 1711 participants with self-reported symptoms of insomnia. Participants were recruited between December 1, 2015, and December 1, 2016, and dCBT was delivered using web and/or mobile channels plus treatment as usual; SHE comprised a website and a downloadable booklet plus treatment as usual. Online assessments took place at 0 (baseline), 4 (midtreatment), 8 (posttreatment), and 24 (follow-up) weeks. Programs were completed within 12 weeks after inclusion. Main Outcomes and Measures Primary outcomes were scores on self-reported measures of functional health (Patient-Reported Outcomes Measurement Information System: Global Health Scale; range, 10-50; higher scores indicate better health); psychological well-being (Warwick-Edinburgh Mental Well-being Scale; range, 14-70; higher scores indicate greater well-being); and sleep-related quality of life (Glasgow Sleep Impact Index; range, 1-100; higher scores indicate greater impairment). Secondary outcomes comprised mood, fatigue, sleepiness, cognitive failures, work productivity, and relationship satisfaction. Insomnia was assessed with the Sleep Condition Indicator (range: 0-32; higher scores indicate better sleep). Results Of the 1711 participants included in the intention-to-treat analysis, 1329 (77.7%) were female, mean (SD) age was 48.0 (13.8) years, and 1558 (91.1%) were white. Use of dCBT was associated with a small improvement in functional health compared with SHE (adjusted difference [95% CI] at week 4, 0.90 [0.40-1.40]; week 8, 1.76 [1.24-2.28]; week 24, 1.76 [1.22-2.30]) and psychological well-being (adjusted difference [95% CI] at week 4, 1.04 [0.28-1.80]; week 8, 2.68 [1.89-3.47]; week 24, 2.95 [2.13-3.76]), and with a large improvement in sleep-related quality of life (at week 4, -8.76 [-11.83 to -5.69]; week 8, -17.60 [-20.81 to -14.39]; week 24, -18.72 [-22.04 to -15.41]) (all P < .01). A large improvement in insomnia mediated these outcomes (range mediated, 45.5%-84.0%). Conclusions and Relevance Use of dCBT is effective in improving functional health, psychological well-being, and sleep-related quality of life in people reporting insomnia symptoms. A reduction in insomnia symptoms mediates these improvements. These results confirm that dCBT improves both daytime and nighttime aspects of insomnia, strengthening existing recommendations of CBT as the treatment of choice for insomnia. Trial Registration isrctn.org identifier: ISRCTN60530898.
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Affiliation(s)
- Colin A. Espie
- Sleep & Circadian Neuroscience Institute, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, United Kingdom
- Big Health Ltd, London, United Kingdom
| | - Richard Emsley
- Biostatistics & Health Informatics Department, Institute of Psychiatry, Psychology & Neuroscience, King’s College London, London, United Kingdom
| | - Simon D. Kyle
- Sleep & Circadian Neuroscience Institute, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, United Kingdom
| | - Christopher Gordon
- Susan Wakil School of Nursing and Midwifery, The University of Sydney, Sydney, Australia
- CIRUS Centre for Integrated Research and Understanding of Sleep, Woolcock Institute of Medical Research, University of Sydney, Sydney, Australia
| | - Christopher L. Drake
- Department of Sleep Disorders and Research Center, Henry Ford Health System, Detroit, Michigan
| | | | - John Cape
- Big Health Ltd, London, United Kingdom
- Division of Psychology and Language Sciences, Faculty of Brain Sciences, University College London, London, United Kingdom
| | - Jason C. Ong
- Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Bryony Sheaves
- Sleep & Circadian Neuroscience Institute, Department of Psychiatry, University of Oxford, Oxford, United Kingdom
| | - Russell Foster
- Sleep & Circadian Neuroscience Institute, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, United Kingdom
| | - Daniel Freeman
- Sleep & Circadian Neuroscience Institute, Department of Psychiatry, University of Oxford, Oxford, United Kingdom
| | - Joan Costa-Font
- Department of Health Policy, The London School of Economics and Political Science, London, United Kingdom
| | - Antonia Marsden
- Centre for Biostatistics, School of Health Sciences, The University of Manchester, Manchester, United Kingdom
| | - Annemarie I. Luik
- Sleep & Circadian Neuroscience Institute, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, United Kingdom
- Big Health Ltd, London, United Kingdom
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18
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Gavriloff D, Sheaves B, Juss A, Espie CA, Miller CB, Kyle SD. Sham sleep feedback delivered via actigraphy biases daytime symptom reports in people with insomnia: Implications for insomnia disorder and wearable devices. J Sleep Res 2018; 27:e12726. [DOI: 10.1111/jsr.12726] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2018] [Revised: 04/27/2018] [Accepted: 05/31/2018] [Indexed: 11/30/2022]
Affiliation(s)
- Dimitri Gavriloff
- Sleep and Circadian Neuroscience Institute (SCNi), Nuffield Department of Clinical Neurosciences; University of Oxford; Oxford UK
- Oxford Health NHS Foundation Trust; Oxford UK
| | - Bryony Sheaves
- Sleep and Circadian Neuroscience Institute (SCNi), Nuffield Department of Clinical Neurosciences; University of Oxford; Oxford UK
- Oxford Health NHS Foundation Trust; Oxford UK
- Department of Psychiatry; University of Oxford; Oxford UK
| | - Amender Juss
- Sleep and Circadian Neuroscience Institute (SCNi), Nuffield Department of Clinical Neurosciences; University of Oxford; Oxford UK
| | - Colin A. Espie
- Sleep and Circadian Neuroscience Institute (SCNi), Nuffield Department of Clinical Neurosciences; University of Oxford; Oxford UK
| | - Christopher B. Miller
- CIRUS, Centre for Sleep and Chronobiology, Woolcock Institute of Medical Research; The University of Sydney; Sydney NSW Australia
| | - Simon D. Kyle
- Sleep and Circadian Neuroscience Institute (SCNi), Nuffield Department of Clinical Neurosciences; University of Oxford; Oxford UK
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19
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Sheaves B, Freeman D, Isham L, McInerney J, Nickless A, Yu LM, Rek S, Bradley J, Reeve S, Attard C, Espie CA, Foster R, Wirz-Justice A, Chadwick E, Barrera A. Stabilising sleep for patients admitted at acute crisis to a psychiatric hospital (OWLS): an assessor-blind pilot randomised controlled trial. Psychol Med 2018; 48:1694-1704. [PMID: 29108526 PMCID: PMC6088775 DOI: 10.1017/s0033291717003191] [Citation(s) in RCA: 42] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2017] [Revised: 09/28/2017] [Accepted: 10/02/2017] [Indexed: 01/18/2023]
Abstract
BACKGROUND When patients are admitted onto psychiatric wards, sleep problems are highly prevalent. We carried out the first trial testing a psychological sleep treatment at acute admission (Oxford Ward sLeep Solution, OWLS). METHODS This assessor-blind parallel-group pilot trial randomised patients to receive sleep treatment at acute crisis [STAC, plus standard care (SC)], or SC alone (1 : 1). STAC included cognitive-behavioural therapy (CBT) for insomnia, sleep monitoring and light/dark exposure for circadian entrainment, delivered over 2 weeks. Assessments took place at 0, 2, 4 and 12 weeks. Feasibility outcomes assessed recruitment, retention of participants and uptake of the therapy. Primary efficacy outcomes were the Insomnia Severity Index and Warwick-Edinburgh Mental Wellbeing Scale at week 2. Analyses were intention-to-treat, estimating treatment effect with 95% confidence intervals. RESULTS Between October 2015 and July 2016, 40 participants were recruited (from 43 assessed eligible). All participants offered STAC completed treatment (mean sessions received = 8.6, s.d. = 1.5). All participants completed the primary end point. Compared with SC, STAC led to large effect size (ES) reductions in insomnia at week 2 (adjusted mean difference -4.6, 95% CI -7.7 to -1.4, ES -0.9), a small improvement in psychological wellbeing (adjusted mean difference 3.7, 95% CI -2.8 to 10.1, ES 0.3) and patients were discharged 8.5 days earlier. One patient in the STAC group had an adverse event, unrelated to participation. CONCLUSIONS In this challenging environment for research, the trial was feasible. Therapy uptake was high. STAC may be a highly effective treatment for sleep disturbance on wards with potential wider benefits on wellbeing and admission length.
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Affiliation(s)
- Bryony Sheaves
- Sleep & Circadian Neuroscience Institute (SCNi), Department of Psychiatry, Warneford Hospital, University of Oxford, Oxford, OX3 7JX, UK
- Oxford Health NHS Foundation Trust, Warneford Hospital, Oxford, OX3 7JX, UK
| | - Daniel Freeman
- Sleep & Circadian Neuroscience Institute (SCNi), Department of Psychiatry, Warneford Hospital, University of Oxford, Oxford, OX3 7JX, UK
- Oxford Health NHS Foundation Trust, Warneford Hospital, Oxford, OX3 7JX, UK
| | - Louise Isham
- Sleep & Circadian Neuroscience Institute (SCNi), Department of Psychiatry, Warneford Hospital, University of Oxford, Oxford, OX3 7JX, UK
- Oxford Health NHS Foundation Trust, Warneford Hospital, Oxford, OX3 7JX, UK
| | - Josephine McInerney
- Oxford Health NHS Foundation Trust, Warneford Hospital, Oxford, OX3 7JX, UK
- Department of Psychiatry, Warneford Hospital, University of Oxford, Oxford, OX3 7JX, UK
| | - Alecia Nickless
- Primary Care Clinical Trials Unit, Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Primary Care Building, Radcliffe Observatory Quarter, Woodstock Road, Oxford, OX2 6GG, UK
| | - Ly-Mee Yu
- Primary Care Clinical Trials Unit, Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Primary Care Building, Radcliffe Observatory Quarter, Woodstock Road, Oxford, OX2 6GG, UK
| | - Stephanie Rek
- Sleep & Circadian Neuroscience Institute (SCNi), Department of Psychiatry, Warneford Hospital, University of Oxford, Oxford, OX3 7JX, UK
| | - Jonathan Bradley
- Sleep & Circadian Neuroscience Institute (SCNi), Department of Psychiatry, Warneford Hospital, University of Oxford, Oxford, OX3 7JX, UK
| | - Sarah Reeve
- Department of Psychiatry, Warneford Hospital, University of Oxford, Oxford, OX3 7JX, UK
| | - Caroline Attard
- Berkshire Healthcare NHS Foundation Trust, Prospect Park Hospital, Honey End Lane, Tilehurst, Reading, Berkshire, RG30 4EJ, UK
| | - Colin A. Espie
- Sleep & Circadian Neuroscience Institute (SCNi), Nuffield Department of Clinical Neurosciences, OMPI, Sir William Dunn School of Pathology, University of Oxford, South Parks Road, Oxford, OX1 3RE, UK
| | - Russell Foster
- Sleep & Circadian Neuroscience Institute (SCNi), Nuffield Department of Clinical Neurosciences, OMPI, Sir William Dunn School of Pathology, University of Oxford, South Parks Road, Oxford, OX1 3RE, UK
| | - Anna Wirz-Justice
- Centre for Chronobiology, Psychiatric Hospital, University of Basel, Wilhelm Klein Strasse 27, CH-4012 Basel, Switzerland
| | - Eleanor Chadwick
- Department of Psychiatry, Warneford Hospital, University of Oxford, Oxford, OX3 7JX, UK
| | - Alvaro Barrera
- Oxford Health NHS Foundation Trust, Warneford Hospital, Oxford, OX3 7JX, UK
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20
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Abstract
Our view is that insomnia may be a causal factor in the occurrence of psychotic experiences such as paranoia and hallucinations. However, the causal relationship is not established. The aim of the study was to investigate the causal role of insomnia in psychotic experiences via a sleep restriction manipulation. The study was a within-subjects crossover design that included a planned mediation analysis. Sixty-eight nonclinical volunteers underwent a sleep loss condition (restricted to 4 h sleep for 3 nights) and a control condition (standard sleep) in randomized order in 2 consecutive weeks, with a weekend washout period. Psychotic experiences (paranoia, hallucinations, grandiosity, and cognitive disorganization) and candidate mediating variables (negative affect and related processes, working memory, decision making, and perceptual processing) were assessed before and after each condition. Actigraphy verified an average sleep duration of 5 h 15 min in the sleep loss condition, vs 6 h 58 min in the control condition. After the sleep loss condition, relative to the control condition, participants reported significant increases in paranoia, hallucinations, and cognitive disorganization, with no significant changes in grandiosity. The sleep loss condition was also associated with significant increases in negative affect, negative self and other cognitions, worry, and working memory impairment. Mediation analyses indicated that changes in psychotic experiences were mediated by changes in negative affect and related processes, but not memory impairment. The overall conclusion is that insomnia has a causal role in the occurrence of certain psychotic experiences, and that a key route is via negative affect.
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Affiliation(s)
- Sarah Reeve
- Department of Psychiatry, University of Oxford, Oxford, UK
| | - Richard Emsley
- Centre for Biostatistics, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
| | - Bryony Sheaves
- Department of Psychiatry, University of Oxford, Oxford, UK
| | - Daniel Freeman
- Department of Psychiatry, University of Oxford, Oxford, UK
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Jones R, Sharkey S, Ford T, Emmens T, Hewis E, Smithson J, Sheaves B, Owens C. Online discussion forums for young people who self-harm: user views. ACTA ACUST UNITED AC 2018. [DOI: 10.1192/pb.bp.110.033449] [Citation(s) in RCA: 49] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Aims and methodTo explore what young people who self-harm think about online self-harm discussion forums. SharpTalk was set up to facilitate shared learning between health professionals and young people who self-harm. We extracted themes and illustrative statements from the online discussion and asked participants to rate statements.ResultsOf 77 young people who participated in the forum, 47 completed the questionnaire. They said they learned more about mental health issues from online discussion forums than from information sites, found it easier to talk about self-harm to strangers than to family or friends, and preferred to talk online than face-to-face or on the telephone. They valued the anonymity the forums provided and reported feeling more able to disclose and less likely to be judged online than in ‘real life’.Clinical implicationsMental health professionals should be aware of the value of anonymous online discussion forums for some young people who self-harm, so that they can talk about them and assess their use with their patients.
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Gavriloff D, Sheaves B, Juss A, Kyle S. False feedback about sleep delivered via actigraphy biases daytime symptom reports: implications for insomnia disorder and wearable devices. Sleep Med 2017. [DOI: 10.1016/j.sleep.2017.11.317] [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: 10/18/2022]
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23
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Freeman D, Sheaves B, Goodwin GM, Yu LM, Nickless A, Harrison PJ, Emsley R, Luik AI, Foster RG, Wadekar V, Hinds C, Gumley A, Jones R, Lightman S, Jones S, Bentall R, Kinderman P, Rowse G, Brugha T, Blagrove M, Gregory AM, Fleming L, Walklet E, Glazebrook C, Davies EB, Hollis C, Haddock G, John B, Coulson M, Fowler D, Pugh K, Cape J, Moseley P, Brown G, Hughes C, Obonsawin M, Coker S, Watkins E, Schwannauer M, MacMahon K, Siriwardena AN, Espie CA. The effects of improving sleep on mental health (OASIS): a randomised controlled trial with mediation analysis. Lancet Psychiatry 2017; 4:749-758. [PMID: 28888927 PMCID: PMC5614772 DOI: 10.1016/s2215-0366(17)30328-0] [Citation(s) in RCA: 365] [Impact Index Per Article: 52.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2017] [Revised: 07/16/2017] [Accepted: 07/19/2017] [Indexed: 12/22/2022]
Abstract
BACKGROUND Sleep difficulties might be a contributory causal factor in the occurrence of mental health problems. If this is true, improving sleep should benefit psychological health. We aimed to determine whether treating insomnia leads to a reduction in paranoia and hallucinations. METHODS We did this single-blind, randomised controlled trial (OASIS) at 26 UK universities. University students with insomnia were randomly assigned (1:1) with simple randomisation to receive digital cognitive behavioural therapy (CBT) for insomnia or usual care, and the research team were masked to the treatment. Online assessments took place at weeks 0, 3, 10 (end of therapy), and 22. The primary outcome measures were for insomnia, paranoia, and hallucinatory experiences. We did intention-to-treat analyses. The trial is registered with the ISRCTN registry, number ISRCTN61272251. FINDINGS Between March 5, 2015, and Feb 17, 2016, we randomly assigned 3755 participants to receive digital CBT for insomnia (n=1891) or usual practice (n=1864). Compared with usual practice, the sleep intervention at 10 weeks reduced insomnia (adjusted difference 4·78, 95% CI 4·29 to 5·26, Cohen's d=1·11; p<0·0001), paranoia (-2·22, -2·98 to -1·45, Cohen's d=0·19; p<0·0001), and hallucinations (-1·58, -1·98 to -1·18, Cohen's d=0·24; p<0·0001). Insomnia was a mediator of change in paranoia and hallucinations. No adverse events were reported. INTERPRETATION To our knowledge, this is the largest randomised controlled trial of a psychological intervention for a mental health problem. It provides strong evidence that insomnia is a causal factor in the occurrence of psychotic experiences and other mental health problems. Whether the results generalise beyond a student population requires testing. The treatment of disrupted sleep might require a higher priority in mental health provision. FUNDING Wellcome Trust.
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Affiliation(s)
- Daniel Freeman
- Department of Psychiatry, University of Oxford, Warneford Hospital, Oxford, UK; Oxford Health National Health Service (NHS) Foundation Trust, Oxford, UK.
| | - Bryony Sheaves
- Department of Psychiatry, University of Oxford, Warneford Hospital, Oxford, UK; Oxford Health National Health Service (NHS) Foundation Trust, Oxford, UK
| | - Guy M Goodwin
- Department of Psychiatry, University of Oxford, Warneford Hospital, Oxford, UK; Oxford Health National Health Service (NHS) Foundation Trust, Oxford, UK
| | - Ly-Mee Yu
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Alecia Nickless
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Paul J Harrison
- Department of Psychiatry, University of Oxford, Warneford Hospital, Oxford, UK; Oxford Health National Health Service (NHS) Foundation Trust, Oxford, UK
| | - Richard Emsley
- Centre for Biostatistics, Institute of Population Health, Manchester University, Manchester Academic Health Centre, Manchester, UK
| | - Annemarie I Luik
- Sleep and Circadian Neuroscience Institute, Nuffield Department of Clinical Neurosciences, University of Oxford, Sir William Dunn School of Pathology, Oxford, UK; Big Health Ltd, London, UK
| | - Russell G Foster
- Sleep and Circadian Neuroscience Institute, Nuffield Department of Clinical Neurosciences, University of Oxford, Sir William Dunn School of Pathology, Oxford, UK
| | - Vanashree Wadekar
- Department of Psychiatry, University of Oxford, Warneford Hospital, Oxford, UK
| | - Christopher Hinds
- Department of Psychiatry, University of Oxford, Warneford Hospital, Oxford, UK
| | - Andrew Gumley
- Institute of Health and Wellbeing, University of Glasgow, Gartnavel Royal Hospital, Glasgow, UK
| | - Ray Jones
- School of Nursing and Midwifery, Faculty of Health and Human Sciences, Plymouth University, Plymouth, UK
| | - Stafford Lightman
- Henry Wellcome Laboratories for Integrative Neuroscience and Endocrinology, University of Bristol, Bristol, UK
| | - Steve Jones
- Spectrum Centre for Mental Health Research, Faculty of Health and Medicine, Lancaster University, Lancaster, UK
| | - Richard Bentall
- Clinical Psychology Unit, Department of Psychology, University of Sheffield, Sheffield, UK
| | - Peter Kinderman
- Psychological Sciences, Institute of Psychology Health and Society, University of Liverpool, Liverpool, UK
| | - Georgina Rowse
- Clinical Psychology Unit, Department of Psychology, University of Sheffield, Sheffield, UK
| | - Traolach Brugha
- Department of Health Sciences, College of Medicine, Biological Sciences and Psychology, Centre for Medicine, University of Leicester, Leicester, UK
| | - Mark Blagrove
- Department of Psychology, University of Swansea, Swansea, UK
| | - Alice M Gregory
- Department of Psychology, Goldsmiths, University of London, London, UK
| | - Leanne Fleming
- Department of Psychology, University of Strathclyde, Glasgow, UK
| | - Elaine Walklet
- Department of Psychology, Institute of Health and Society, University of Worcester, Worcester, UK
| | - Cris Glazebrook
- Division of Psychiatry and Applied Psychology, School of Medicine, University of Nottingham, Nottingham, UK; National Institute for Healthcare Research MindTech Healthcare Technology Co-operative, Institute of Mental Health, University of Nottingham, Nottingham, UK
| | - E Bethan Davies
- National Institute for Healthcare Research MindTech Healthcare Technology Co-operative, Institute of Mental Health, University of Nottingham, Nottingham, UK
| | - Chris Hollis
- Division of Psychiatry and Applied Psychology, School of Medicine, University of Nottingham, Nottingham, UK; National Institute for Healthcare Research MindTech Healthcare Technology Co-operative, Institute of Mental Health, University of Nottingham, Nottingham, UK
| | - Gillian Haddock
- Division of Psychology and Mental Health, School of Health Sciences, University of Manchester, Manchester, UK
| | - Bev John
- School of Psychology and Therapeutic Studies, University of South Wales, Treforest, UK
| | - Mark Coulson
- Department of Psychology, School of Science and Technology, University of Middlesex, London, UK
| | - David Fowler
- Department of Psychology, University of Sussex, Brighton, UK; Sussex Partnership NHS Foundation Trust, Worthing, UK
| | | | - John Cape
- Department of Clinical, Educational and Health Psychology, University College London, London, UK
| | - Peter Moseley
- School of Psychology, University of Central Lancashire, Preston, UK
| | - Gary Brown
- Psychology Department, Royal Holloway, Egham, UK
| | - Claire Hughes
- University of Cambridge Centre for Family Research, Cambridge, UK
| | - Marc Obonsawin
- School of Psychological Sciences and Health, University of Strathclyde, Glasgow UK
| | - Sian Coker
- Department of Clinical Psychology, Norwich Medical School, University of East Anglia, Norwich, UK
| | - Edward Watkins
- SMART Lab, College of Life and Environmental Sciences, Sir Henry Wellcome Building for Mood Disorders Research, University of Exeter, Exeter, UK
| | - Matthias Schwannauer
- School of Health in Social Sciences, University of Edinburgh, Medical School, Edinburgh, UK
| | - Kenneth MacMahon
- School of Health in Social Sciences, University of Edinburgh, Medical School, Edinburgh, UK
| | | | - Colin A Espie
- Sleep and Circadian Neuroscience Institute, Nuffield Department of Clinical Neurosciences, University of Oxford, Sir William Dunn School of Pathology, Oxford, UK; Big Health Ltd, London, UK
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Abstract
BACKGROUND Nightmares are inherently distressing, prevent restorative sleep, and are associated with a number of psychiatric problems, but have rarely been the subject of empirical study. Negative affect, linked to stressful events, is generally considered the key trigger of nightmares; hence nightmares have most often been considered in the context of post-traumatic stress disorder (PTSD). However, many individuals with heightened negative affect do not have nightmares. The objective of this study was to identify mechanistically plausible factors, beyond negative affect, that may explain why individuals experience nightmares. METHOD 846 participants from the UK general population completed an online survey about nightmare occurrence and severity (pre-occupation, distress, and impairment), negative affect, worry, depersonalisation, hallucinatory experiences, paranoia, alcohol use, sleep duration, physical activity levels, PTSD symptoms, and stressful life events. Associations of nightmares with the putative predictive factors were tested controlling for levels of negative affect. Analyses were also repeated controlling for levels of PTSD and the recent occurrence of stressful life events. RESULTS Nightmare occurrence, adjusting for negative affect, was associated with higher levels of worry, depersonalisation, hallucinatory experiences, paranoia, and sleep duration (odds ratios 1.25-1.45). Nightmare severity, controlling for negative affect, was associated with higher levels of worry, depersonalisation, hallucinatory experiences, and paranoia (R 2s: 0.33-0.39). Alcohol use and physical activity levels were not associated with nightmares. DISCUSSION The study identifies a number of potential predictors of the occurrence and severity of nightmares. Causal roles require testing in future longitudinal, experimental, and treatment studies.
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Affiliation(s)
- Stephanie Rek
- Department of Psychiatry, University of Oxford, Warneford Hospital, Oxford, OX3 7JX, UK.
| | - Bryony Sheaves
- Department of Psychiatry, University of Oxford, Warneford Hospital, Oxford, OX3 7JX, UK
| | - Daniel Freeman
- Department of Psychiatry, University of Oxford, Warneford Hospital, Oxford, OX3 7JX, UK
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Sheaves B, Bebbington PE, Goodwin GM, Harrison PJ, Espie CA, Foster RG, Freeman D. Insomnia and hallucinations in the general population: Findings from the 2000 and 2007 British Psychiatric Morbidity Surveys. Psychiatry Res 2016; 241:141-6. [PMID: 27173659 PMCID: PMC4922385 DOI: 10.1016/j.psychres.2016.03.055] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2016] [Revised: 03/02/2016] [Accepted: 03/15/2016] [Indexed: 01/24/2023]
Abstract
Insomnia is common in people experiencing psychosis. It has been identified as a contributory cause of paranoia, but any causal relationship with hallucinations has yet to be established. We tested the hypotheses that insomnia i) has a cross-sectional association with hallucinations ii) predicts new inceptions of hallucinations and iii) that these associations remain after controlling for depression, anxiety, and paranoia. Data from the second (2000, N=8580) and third (2007, N=7403) British Psychiatric Morbidity Surveys were used to assess cross-sectional associations between insomnia and hallucinations. The 2000 dataset included an 18 month follow up of a subsample (N=2406) used to test whether insomnia predicted new inceptions of hallucinations. Insomnia was associated with hallucinations in both cross-sectional datasets. Mild sleep problems were associated with 2-3 times greater odds of reporting hallucinations, whilst chronic insomnia was associated with four times greater odds. Insomnia was also associated with increased odds of hallucinations occurring de novo over the next 18 months. These associations remained significant, although with smaller odds ratios, after controlling for depression, anxiety and paranoia. This is the first longitudinal evidence that insomnia is associated with the development of hallucinatory experiences. Effective treatment of insomnia may lessen the occurrence of hallucinations.
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Affiliation(s)
- Bryony Sheaves
- Department of Psychiatry, University of Oxford, Warneford Hospital, Oxford OX3 7JX, UK.
| | - Paul E Bebbington
- Division of Psychiatry, University College London, 67-73 Riding House Street, London W1W 7EJ, UK
| | - Guy M Goodwin
- Department of Psychiatry, University of Oxford, Warneford Hospital, Oxford OX3 7JX, UK
| | - Paul J Harrison
- Department of Psychiatry, University of Oxford, Warneford Hospital, Oxford OX3 7JX, UK
| | - Colin A Espie
- Sleep and Circadian Neuroscience Institute (SCNi), Oxford Molecular Pathology Institute, Sir William Dunn School of Pathology, South Parks Road, Oxford OX1 3RE, UK
| | - Russell G Foster
- Sleep and Circadian Neuroscience Institute (SCNi), Oxford Molecular Pathology Institute, Sir William Dunn School of Pathology, South Parks Road, Oxford OX1 3RE, UK
| | - Daniel Freeman
- Department of Psychiatry, University of Oxford, Warneford Hospital, Oxford OX3 7JX, UK
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26
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Rehman A, Waite F, Sheaves B, Biello S, Freeman D, Gumley A. Clinician perceptions of sleep problems, and their treatment, in patients with non-affective psychosis. Psychosis 2016; 9:129-139. [PMID: 28670337 PMCID: PMC5470103 DOI: 10.1080/17522439.2016.1206955] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 02/02/2016] [Accepted: 06/24/2016] [Indexed: 12/24/2022]
Abstract
Aims and method: To assess clinicians' views about their understanding and treatment of sleep problems in people with non-affective psychosis. An online survey was emailed to adult mental health teams in two NHS trusts. Results: One hundred and eleven clinicians completed the survey. All clinicians reported disrupted sleep in their patients, and endorsed the view that sleep and psychotic experiences each exacerbate the other. However, most clinicians (n = 92, 82%) assessed sleep problems informally, rather than using standard assessment measures. There was infrequent use of the recommended cognitive-behavioural treatments for sleep problems such as persistent insomnia, with the approaches typically used being sleep hygiene and medications instead. Clinical implications: Clinicians recognise the importance of sleep in psychosis, but the use of formal assessments and recommended treatments is limited. Barriers to treatment implementation identified by the clinicians related to services (e.g. lack of time), patients (e.g. their lifestyle) and environmental features of inpatient settings.
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Affiliation(s)
- Aliyah Rehman
- School of Psychology, University of Glasgow, Glasgow, Scotland
| | - Felicity Waite
- Department of Psychiatry, University of Oxford, Warneford Hospital, Oxford, England
| | - Bryony Sheaves
- Department of Psychiatry, University of Oxford, Warneford Hospital, Oxford, England
| | - Stephany Biello
- School of Psychology, University of Glasgow, Glasgow, Scotland
| | - Daniel Freeman
- Department of Psychiatry, University of Oxford, Warneford Hospital, Oxford, England
| | - Andrew Gumley
- Institute of Health and Wellbeing, University of Glasgow, Glasgow, Scotland
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27
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Freeman D, Bradley J, Antley A, Bourke E, DeWeever N, Evans N, Černis E, Sheaves B, Waite F, Dunn G, Slater M, Clark DM. Virtual reality in the treatment of persecutory delusions: randomised controlled experimental study testing how to reduce delusional conviction. Br J Psychiatry 2016; 209:62-7. [PMID: 27151071 PMCID: PMC4929408 DOI: 10.1192/bjp.bp.115.176438] [Citation(s) in RCA: 112] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2015] [Accepted: 12/16/2015] [Indexed: 11/25/2022]
Abstract
BACKGROUND Persecutory delusions may be unfounded threat beliefs maintained by safety-seeking behaviours that prevent disconfirmatory evidence being successfully processed. Use of virtual reality could facilitate new learning. AIMS To test the hypothesis that enabling patients to test the threat predictions of persecutory delusions in virtual reality social environments with the dropping of safety-seeking behaviours (virtual reality cognitive therapy) would lead to greater delusion reduction than exposure alone (virtual reality exposure). METHOD Conviction in delusions and distress in a real-world situation were assessed in 30 patients with persecutory delusions. Patients were then randomised to virtual reality cognitive therapy or virtual reality exposure, both with 30 min in graded virtual reality social environments. Delusion conviction and real-world distress were then reassessed. RESULTS In comparison with exposure, virtual reality cognitive therapy led to large reductions in delusional conviction (reduction 22.0%, P = 0.024, Cohen's d = 1.3) and real-world distress (reduction 19.6%, P = 0.020, Cohen's d = 0.8). CONCLUSION Cognitive therapy using virtual reality could prove highly effective in treating delusions.
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Affiliation(s)
- Daniel Freeman
- Daniel Freeman, PhD, DClinPsy, Jonathan Bradley, DClinPsy, Department of Psychiatry, University of Oxford, Oxford, UK; Angus Antley, PhD, Department of Psychiatry, University of Oxford and Oxford Health NHS Foundation Trust, Oxford, UK; Emilie Bourke, ScM, Natalie DeWeever, BSc, Nicole Evans, BSc, Emma Černis, MSc, Bryony Sheaves, DClinPsy, Felicity Waite, DClinPsy, Department of Psychiatry, University of Oxford, Oxford, UK; Graham Dunn, PhD, Centre for Biostatistics, Institute of Population Health, University of Manchester, Manchester, UK; Mel Slater, DSc, Department of Computer Science, University College London, London, UK and Institució Catalana de Recerca i Estudis Avançats (ICREA), University of Barcelona, Spain; David M. Clark, DPhil, Department of Experimental Psychology, University of Oxford, Oxford, UK
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Espie CA, Luik AI, Cape J, Drake CL, Siriwardena AN, Ong JC, Gordon C, Bostock S, Hames P, Nisbet M, Sheaves B, G Foster R, Freeman D, Costa-Font J, Emsley R, Kyle SD. Digital Cognitive Behavioural Therapy for Insomnia versus sleep hygiene education: the impact of improved sleep on functional health, quality of life and psychological well-being. Study protocol for a randomised controlled trial. Trials 2016; 17:257. [PMID: 27216112 PMCID: PMC4877942 DOI: 10.1186/s13063-016-1364-7] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2015] [Accepted: 04/24/2016] [Indexed: 01/15/2023] Open
Abstract
BACKGROUND Previous research has demonstrated that digital CBT (dCBT), delivered via the Internet, is a scalable and effective intervention for treating insomnia in otherwise healthy adults and leads to significant improvements in primary outcomes relating to sleep. The majority of people with insomnia, however, seek help because of the functional impact and daytime consequences of poor sleep, not because of sleep discontinuity per se. Although some secondary analyses suggest that dCBT may have wider health benefits, no adequately powered study has investigated these as a primary endpoint. This study specifically aims to investigate the impact of dCBT for insomnia upon health and well-being, and will investigate sleep-related changes as mediating factors. METHODS/DESIGN We propose a pragmatic, parallel-group, randomised controlled trial of 1000 community participants meeting criteria for insomnia disorder. In the DIALS trial (Digital Insomnia therapy to Assist your Life as well as your Sleep), participants will be randomised to dCBT delivered using web and/or mobile channels (in addition to treatment as usual (TAU)) or to sleep hygiene education (SHE), comprising a website plus a downloadable booklet (in addition to TAU). Online assessments will take place at 0 (baseline), 4 (mid-treatment), 8 (post-treatment), and 24 (follow-up) weeks. At week 25 all participants allocated to SHE will be offered dCBT, at which point the controlled element of the trial will be complete. Naturalistic follow-up will be invited at weeks 36 and 48. Primary outcomes are functional health and well-being at 8 weeks. Secondary outcomes are mood, fatigue, sleepiness, cognitive function, productivity and social functioning. All main analyses will be carried out at the end of the final controlled follow-up assessments and will be based on the intention-to-treat principle. Further analyses will determine whether observed changes in functional health and well-being are mediated by changes in sleep. The trial is funded by Big Health Ltd. DISCUSSION This study will be the first large-scale, specifically designed investigation of the health and well-being benefits of CBT for insomnia, and the first examination of the association between CBT-mediated sleep improvement and health status. TRIAL REGISTRATION ISRCTN60530898 .
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Affiliation(s)
- Colin A Espie
- Sleep and Circadian Neuroscience Institute, Nuffield Department of Clinical Neurosciences, University of Oxford, Sir William Dunn School of Pathology, Oxford, UK.
- Big Health Ltd., London, UK.
| | - Annemarie I Luik
- Sleep and Circadian Neuroscience Institute, Nuffield Department of Clinical Neurosciences, University of Oxford, Sir William Dunn School of Pathology, Oxford, UK
- Big Health Ltd., London, UK
| | - John Cape
- Big Health Ltd., London, UK
- Division of Psychology and Language Sciences, Faculty of Brain Sciences, University College London, London, UK
| | - Christopher L Drake
- Department of Sleep Disorders and Research Center, Henry Ford Health System, Detroit, MI, USA
| | | | - Jason C Ong
- Rush University Medical Center, Chicago, IL, USA
| | - Christopher Gordon
- CIRUS Centre for Integrated Research and Understanding of Sleep, Woolcock Institute of Medical Research, University of Sydney, Sydney, Australia
| | | | | | | | - Bryony Sheaves
- Sleep and Circadian Neuroscience Institute, Department of Psychiatry, University of Oxford, Warneford Hospital, Oxford, UK
| | - Russell G Foster
- Sleep and Circadian Neuroscience Institute, Nuffield Department of Clinical Neurosciences, University of Oxford, Sir William Dunn School of Pathology, Oxford, UK
| | - Daniel Freeman
- Sleep and Circadian Neuroscience Institute, Department of Psychiatry, University of Oxford, Warneford Hospital, Oxford, UK
| | - Joan Costa-Font
- The London School of Economics and Political Science, London, UK
| | - Richard Emsley
- Centre for Biostatistics, Institute of Population Health, The University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
| | - Simon D Kyle
- Sleep and Circadian Neuroscience Institute, Nuffield Department of Clinical Neurosciences, University of Oxford, Sir William Dunn School of Pathology, Oxford, UK
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29
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Abstract
BACKGROUND Sleep disturbance is increasingly recognized as a major problem for patients with schizophrenia but it is rarely the direct focus of treatment. The main recommended treatment for insomnia is cognitive behavioural therapy, which we have been evaluating for patients with current delusions and hallucinations in the context of non-affective psychosis. AIMS In this article we describe the lessons we have learned about clinical presentations of sleep problems in schizophrenia and the adaptations to intervention that we recommend for patients with current delusions and hallucinations. METHOD Twelve factors that may particularly contribute to sleep problems in schizophrenia are identified. These include delusions and hallucinations interfering with sleep, attempts to use sleep as an escape from voices, circadian rhythm disruption, insufficient daytime activity, and fear of the bed, based upon past adverse experiences. Specific adaptations for psychological treatment related to each factor are described. CONCLUSIONS Our experience is that patients want help to improve their sleep; sleep problems in schizophrenia should be treated with evidence-based interventions, and that the interventions may have the added benefit of lessening the psychotic experiences. A treatment technique hierarchy is proposed for ease of translation to clinical practice.
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Affiliation(s)
| | | | | | - Colin A. Espie
- Sleep and Circadian Neuroscience Institute, University of Oxford, UK
| | - Helen Startup
- Sussex Partnership NHS Foundation Trust, and University of Oxford, UK
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30
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Sheaves B, Porcheret K, Tsanas A, Espie CA, Foster RG, Freeman D, Harrison PJ, Wulff K, Goodwin GM. Insomnia, Nightmares, and Chronotype as Markers of Risk for Severe Mental Illness: Results from a Student Population. Sleep 2016; 39:173-81. [PMID: 26350467 DOI: 10.5665/sleep.5342] [Citation(s) in RCA: 85] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2015] [Accepted: 07/24/2015] [Indexed: 01/14/2023] Open
Abstract
STUDY OBJECTIVES To group participants according to markers of risk for severe mental illness based on subsyndromal symptoms reported in early adulthood and evaluate attributes of sleep across these risk categories. METHODS An online survey of sleep and psychiatric symptomatology (The Oxford Sleep Survey) was administered to students at one United Kingdom university. 1403 students (undergraduate and postgraduate) completed the survey. The median age was 21 (interquartile range = 20-23) and 55.60% were female. The cross-sectional data were used to cluster participants based on dimensional measures of psychiatric symptoms (hallucinations, paranoia, depression, anxiety, and (hypo)mania). High, medium, and low symptom groups were compared across sleep parameters: insomnia symptoms, nightmares, chronotype, and social jet lag. RESULTS Insomnia symptoms, nightmares frequency, and nightmare-related distress increased in a dose-response manner with higher reported subsyndromal psychiatric symptoms (low, medium, and high). The high-risk group exhibited a later chronotype (mid sleep point for free days) than the medium- or low-risk group. The majority of participants (71.7%) in the high-risk group screened positive for insomnia and the median nightmare frequency was two per 14 days (moderately severe pathology). CONCLUSIONS Insomnia, nightmares, and circadian phase delay are associated with increased subsyndromal psychiatric symptoms in young people. Each is a treatable sleep disorder and might be a target for early intervention to modify the subsequent progression of psychiatric disorder.
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Affiliation(s)
- Bryony Sheaves
- Department of Psychiatry, University of Oxford, Warneford Hospital, Oxford, UK
| | - Kate Porcheret
- Nuffield Department of Clinical Neurosciences, University of Oxford, Sir William Dunn School of Pathology, South Parks Road, Oxford, UK
| | - Athanasios Tsanas
- Institute of Biomedical Engineering, Department of Engineering Science, University of Oxford; Wolfson Centre for Mathematical Biology, Mathematical Institute, University of Oxford, Oxford, UK
| | - Colin A Espie
- Nuffield Department of Clinical Neurosciences, University of Oxford, Sir William Dunn School of Pathology, South Parks Road, Oxford, UK
| | - Russell G Foster
- Nuffield Department of Clinical Neurosciences, University of Oxford, Sir William Dunn School of Pathology, South Parks Road, Oxford, UK
| | - Daniel Freeman
- Department of Psychiatry, University of Oxford, Warneford Hospital, Oxford, UK
| | - Paul J Harrison
- Department of Psychiatry, University of Oxford, Warneford Hospital, Oxford, UK
| | - Katharina Wulff
- Nuffield Department of Clinical Neurosciences, University of Oxford, Sir William Dunn School of Pathology, South Parks Road, Oxford, UK
| | - Guy M Goodwin
- Department of Psychiatry, University of Oxford, Warneford Hospital, Oxford, UK
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Reeve S, Sheaves B, Freeman D. The role of sleep dysfunction in the occurrence of delusions and hallucinations: A systematic review. Clin Psychol Rev 2015; 42:96-115. [PMID: 26407540 PMCID: PMC4786636 DOI: 10.1016/j.cpr.2015.09.001] [Citation(s) in RCA: 155] [Impact Index Per Article: 17.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2015] [Revised: 07/24/2015] [Accepted: 09/03/2015] [Indexed: 12/22/2022]
Abstract
BACKGROUND Sleep dysfunction is extremely common in patients with schizophrenia. Recent research indicates that sleep dysfunction may contribute to psychotic experiences such as delusions and hallucinations. OBJECTIVES The review aims to evaluate the evidence for a relationship between sleep dysfunction and individual psychotic experiences, make links between the theoretical understanding of each, and highlight areas for future research. METHOD A systematic search was conducted to identify studies investigating sleep and psychotic experiences across clinical and non-clinical populations. RESULTS 66 papers were identified. This literature robustly supports the co-occurrence of sleep dysfunction and psychotic experiences, particularly insomnia with paranoia. Sleep dysfunction predicting subsequent psychotic experiences receives support from epidemiological surveys, research on the transition to psychosis, and relapse studies. There is also evidence that reducing sleep elicits psychotic experiences in non-clinical individuals, and that improving sleep in individuals with psychosis may lessen psychotic experiences. Anxiety and depression consistently arise as (partial) mediators of the sleep and psychosis relationship. CONCLUSION Studies are needed that: determine the types of sleep dysfunction linked to individual psychotic experiences; establish a causal connection between sleep and psychotic experiences; and assess treatments for sleep dysfunction in patients with non-affective psychotic disorders such as schizophrenia.
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Affiliation(s)
- Sarah Reeve
- Department of Psychiatry, University of Oxford, UK
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Sheaves B, Onwumere J, Keen N, Stahl D, Kuipers E. Nightmares in Patients With Psychosis: The Relation With Sleep, Psychotic, Affective, and Cognitive Symptoms. Can J Psychiatry 2015; 60:354-61. [PMID: 26454557 PMCID: PMC4542515 DOI: 10.1177/070674371506000804] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/01/2014] [Accepted: 09/01/2014] [Indexed: 12/17/2022]
Abstract
OBJECTIVE To examine the prevalence of nightmares in people with psychosis and to describe the link between nightmares and sleep quality, psychotic, affective, and cognitive symptoms. METHODS Forty participants with psychotic symptoms completed an assessment of nightmares, sleep quality, positive symptoms of psychosis, affect, posttraumatic stress, social functioning, and working memory. RESULTS Among the patients, 55% reported weekly distressing nightmares. Experience of more frequent nightmares was related to poorer sleep quality and sleep efficiency. More distressing nightmares were positively associated with greater delusional severity, depression, anxiety, stress, and difficulties with working memory. CONCLUSIONS Nightmares might be common in those with psychosis and are associated with increased day- and nighttime impairment. Future research should investigate treatments for nightmares, for people presenting with psychotic symptoms.
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Affiliation(s)
- Bryony Sheaves
- Research Clinical Psychologist, Sleep and Circadian Neuroscience Institute, Department of Psychiatry, University of Oxford, Oxford, England
| | - Juliana Onwumere
- Lecturer in Clinical Psychology, Department of Psychology, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, England; Consultant Clinical Psychologist, National Psychosis Unit, South London and Maudsley National Health Service Foundation Trust, England
| | - Nadine Keen
- Consultant Clinical Psychologist, Psychological Interventions Clinic for outpatients with Psychosis, South London and Maudsley National Health Service Foundation Trust, England; Honorary Clinical Psychologist, Department of Psychology, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, England
| | - Daniel Stahl
- Senior Lecturer in Biostatistics, Department of Biostatistics, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, England
| | - Elizabeth Kuipers
- Professor of Clinical Psychology, Department of Psychology, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, England; National Institute for Health Research Biomedical Research Centre, South London and Maudsley National Health Service Foundation Trust, England
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Freeman D, Sheaves B, Goodwin GM, Yu LM, Harrison PJ, Emsley R, Bostock S, Foster RG, Wadekar V, Hinds C, Espie CA. Effects of cognitive behavioural therapy for insomnia on the mental health of university students: study protocol for a randomized controlled trial. Trials 2015; 16:236. [PMID: 26016697 PMCID: PMC4448545 DOI: 10.1186/s13063-015-0756-4] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2015] [Accepted: 05/13/2015] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND Insomnia, defined as repeated difficulties getting or staying asleep, is common in the general population. Such sleep difficulties are a problem in their own right, but increasingly it is being recognised that they may also be a contributory factor in the development of a wide range of mental health problems. Our focus is upon the relationship between insomnia and psychotic experiences, such as paranoia and hallucinations. Psychotic experiences commonly occur in mild forms in the general population and have been linked to disrupted sleep. These psychotic-like experiences raise the risk of development of a clinical disorder. Our aim is to reduce insomnia in a large general population group, and examine the effect on paranoia and hallucinations at the age when mental health problems typically emerge. The primary hypotheses are that cognitive behaviour therapy (CBT) for insomnia will reduce insomnia and also levels of paranoia and hallucinations. The theoretical links will be substantiated by a planned mediation analysis. Improvements in a number of other mental health outcomes are also predicted. METHODS/DESIGN We will carry out a parallel group, randomised controlled trial of 2,614 students with insomnia in universities across the UK. In the Oxford Access for Students Improving Sleep (OASIS) trial, participants will be randomised to digital CBT for insomnia (in addition to treatment as usual) or treatment as usual. Online assessments will take place at zero, three, 10 (post-treatment), and 22 (follow-up) weeks. Primary outcomes are insomnia and psychotic-like experiences (paranoia or hallucinatory experiences) at 10 weeks. Secondary outcomes are levels of mania, depression, anxiety, nightmares, psychological wellbeing, and the development of mental health disorders. All main analyses will be carried out at the end of the last follow-up assessment and will be based on the intention-to-treat principle. The trial is funded by the Wellcome Trust. DISCUSSION This study will be the first large-scale causal test of the relationship between sleep disturbance and psychotic experiences. It will provide evidence concerning the clinical effects of treating insomnia in young adults. TRIAL REGISTRATION This trial was registered with Current Controlled Trials (identifier: ISRCTN61272251 ) on 29 January 2015.
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Affiliation(s)
- Daniel Freeman
- Sleep & Circadian Neuroscience Institute, Department of Psychiatry, University of Oxford, Warneford Hospital, Warneford Lane, Oxford, OX3 7JX, UK.
| | - Bryony Sheaves
- Sleep & Circadian Neuroscience Institute, Department of Psychiatry, University of Oxford, Warneford Hospital, Warneford Lane, Oxford, OX3 7JX, UK.
| | - Guy M Goodwin
- Sleep & Circadian Neuroscience Institute, Department of Psychiatry, University of Oxford, Warneford Hospital, Warneford Lane, Oxford, OX3 7JX, UK.
| | - Ly-Mee Yu
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Gibson Building 1st Floor, Radcliffe Observatory Quarter, Woodstock Road, Oxford, OX2 6GG, UK.
| | - Paul J Harrison
- Sleep & Circadian Neuroscience Institute, Department of Psychiatry, University of Oxford, Warneford Hospital, Warneford Lane, Oxford, OX3 7JX, UK.
| | - Richard Emsley
- Centre for Biostatistics, Institute of Population Health, The University of Manchester, Manchester Academic Health Science Centre, 1.304 Jean McFarlane Building, Oxford Road, Manchester, M13 9PL, UK.
| | - Sophie Bostock
- Sleepio Ltd, 60-62 Commercial Street, London, E1 6LT, UK.
| | - Russell G Foster
- Sleep & Circadian Neuroscience Institute, Nuffield Department of Clinical Neurosciences, University of Oxford, Level 5-6 West Wing, John Radcliffe Hospital, Oxford, OX3 9DU, UK.
| | - Vanashree Wadekar
- Department of Psychiatry, University of Oxford, Warneford Hospital, Warneford Lane, Oxford, OX3 7JX, UK.
| | - Christopher Hinds
- Department of Psychiatry, University of Oxford, Warneford Hospital, Warneford Lane, Oxford, OX3 7JX, UK.
| | - Colin A Espie
- Sleepio Ltd, 60-62 Commercial Street, London, E1 6LT, UK.
- Sleep & Circadian Neuroscience Institute, Nuffield Department of Clinical Neurosciences, University of Oxford, Level 5-6 West Wing, John Radcliffe Hospital, Oxford, OX3 9DU, UK.
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Frank E, Benabou M, Bentzley B, Bianchi M, Goldstein T, Konopka G, Maywood E, Pritchett D, Sheaves B, Thomas J. Influencing circadian and sleep-wake regulation for prevention and intervention in mood and anxiety disorders: what makes a good homeostat? Ann N Y Acad Sci 2014; 1334:1-25. [PMID: 25532787 PMCID: PMC4350368 DOI: 10.1111/nyas.12600] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
All living organisms depend on homeostasis, the complex set of interacting metabolic chemical reactions for maintaining life and well-being. This is no less true for psychiatric well-being than for physical well-being. Indeed, a focus on homeostasis forces us to see how inextricably linked mental and physical well-being are. This paper focuses on these linkages. In particular, it addresses the ways in which understanding of disturbed homeostasis may aid in creating classes of patients with mood and anxiety disorders based on such phenotypes. At the cellular level, we may be able to compensate for the inability to study living brain tissue through the study of homeostatic mechanisms in fibroblasts, pluripotent human cells, and mitochondria and determine how homeostasis is disturbed at the level of these peripheral tissues through exogenous stress. We also emphasize the remarkable opportunities for enhancing knowledge in this area that are offered by advances in technology. The study of human behavior, especially when combined with our greatly improved capacity to study unique but isolated populations, offers particularly clear windows into the relationships among genetic, environmental, and behavioral contributions to homeostasis.
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Affiliation(s)
- Ellen Frank
- Western Psychiatric Institute and Clinic, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Marion Benabou
- Human Genetics and Cognitive Functions, Institut Pasteur, Paris, France
| | - Brandon Bentzley
- Department of Neurosciences, Medical University of South Carolina, Charleston, South Carolina
| | - Matt Bianchi
- Department of Neurology, Sleep Division, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Tina Goldstein
- Western Psychiatric Institute and Clinic, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Genevieve Konopka
- Department of Neuroscience, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Elizabeth Maywood
- Neurobiology Division, MRC Laboratory of Molecular Biology, Cambridge Biomedical Campus, Cambridge, United Kingdom
| | - David Pritchett
- Nuffield Department of Clinical Neurosciences (Nuffield Laboratory of Ophthalmology), University of Oxford, John Radcliffe Hospital, Oxford, United Kingdom
| | - Bryony Sheaves
- Department of Psychiatry, University of Oxford, Warneford Hospital, Oxford, United Kingdom
| | - Jessica Thomas
- Molecular Sleep Laboratory, Glostrup University Hospital, Glostrup, Denmark
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Sheaves B, Jones RB, Williamson GR, Chauhan R. Phase 1 pilot study of e-mail support for people with long term conditions using the Internet. BMC Med Inform Decis Mak 2011; 11:20. [PMID: 21466699 PMCID: PMC3078836 DOI: 10.1186/1472-6947-11-20] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2010] [Accepted: 04/05/2011] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Use of the Internet for people with Long Term Conditions (LTCs) can have a positive effect on knowledge, social support, behavioural and clinical outcomes, yet there is concern that a 'digital divide' prevents some patients from benefitting. While some patients do not have access to the Internet, others that do may still lack expertise or the confidence to make full use of it. The aim of this pilot study was to develop an intervention and test methods for a definitive randomised controlled trial (RCT) of anonymous personal online email support for patients in this latter group. METHODS Recruitment success was evaluated by the number and appropriateness of participants recruited. A personalised e-health support intervention was developed. The provisional primary outcome was the extent to which the Internet affected the participants' confidence in dealing with their LTC. Primary outcome, seven process measures and two secondary outcomes measures were evaluated for completeness of data and sensitivity to detect changes. RESULTS Thirty nine participants were recruited, 29 after personally receiving a leaflet, seven via email advertising, and three via leaflets left in waiting areas. Most participants (61%) were aged over 60. The majority (21/38) rated themselves as experienced Internet users although only 5/38 had used discussion forums for their LTC. Piloting the intervention identified support needed as: (i) technical help with some websites, (ii) advice about issues such as anonymity, (iii) help in judging information quality, (iv) identification of relevant information (via 'Information Prescriptions'), (v) motivational support to try new sites. Attrition was fairly high: 20/39 completed follow up questionnaires. Three process measures showed ceiling effects and two had too many missing values to be useable. CONCLUSION E-health support is a promising way of addressing the problems faced by older generation e-health seekers. Face-to-face leaflet distribution recruited sufficient numbers but additional locations other than hospital should be tried to recruit Internet novices with LTCs. An RCT is feasible and necessary to evaluate the potential benefits of anonymous email support. Our methods could be used by other researchers studying Internet use by people with LTCs.
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Affiliation(s)
- Bryony Sheaves
- Faculty of Health, University of Plymouth, Plymouth, PL4 8AA, UK
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Jones R, Sharkey S, Smithson J, Ford T, Emmens T, Hewis E, Sheaves B, Owens C. Using metrics to describe the participative stances of members within discussion forums. J Med Internet Res 2011; 13:e3. [PMID: 21239373 PMCID: PMC3221352 DOI: 10.2196/jmir.1591] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2010] [Revised: 11/22/2010] [Accepted: 12/20/2010] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Researchers using forums and online focus groups need to ensure they are safe and need tools to make best use of the data. We explored the use of metrics that would allow better forum management and more effective analysis of participant contributions. OBJECTIVE To report retrospectively calculated metrics from self-harm discussion forums and to assess whether metrics add to other methods such as discourse analysis. We asked (1) which metrics are most useful to compare and manage forums, and (2) how metrics can be used to identify the participative stances of members to help manage discussion forums. METHODS We studied the use of metrics in discussion forums on self-harm. SharpTalk comprised five discussion forums, all using the same software but with different forum compositions. SharpTalk forums were similar to most moderated forums but combined support and general social chat with online focus groups discussing issues on self-harm. Routinely recorded time-stamp data were used to derive metrics of episodes, time online, pages read, and postings. We compared metrics from the forums with views from discussion threads and from moderators. We identified patterns of participants' online behavior by plotting scattergrams and identifying outliers and clusters within different metrics. RESULTS In comparing forums, important metrics seem to be number of participants, number of active participants, total time of all participants logged on in each 24 hours, and total number of postings by all participants in 24 hours. In examining participative stances, the important metrics were individuals' time logged per 24 hours, number of episodes, mean length of episodes, number of postings per 24 hours, and location within the forum of those postings. Metric scattergrams identified several participative stances: (1) the "caretaker," who was "always around," logged on for a much greater time than most other participants, posting but mainly in response to others and rarely initiating threads, (2) the "butterfly," who "flitted in and out," had a large number of short episodes, (3) two "discussants," who initiated many more discussion threads than anybody else and posted proportionately less in the support room, (4) "here for you," who posted frequently in the support room in response to other participants' threads, and (5) seven "people in distress," who posted many comments in the support room in comparison with their total postings and tended to post on their own threads. CONCLUSIONS Real-time metrics may be useful: (1) by offering additional ways of comparing different discussion forums helping with their management, and (2) by identifying participative stances of individuals so allowing better moderation and support of forums, and more effective use of the data collected. For this to happen, researchers need to publish metrics for their discussion forums and software developers need to offer more real-time metrics facilities.
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Affiliation(s)
- Ray Jones
- Faculty of Health, University of Plymouth, Plymouth, United Kingdom.
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