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Chaput JP, Tomfohr-Madsen LM, Carney CE, Robillard R, Sampasa-Kanyinga H, Lang JJ. Examining sleep characteristics in Canada through a diversity and equity lens. Sleep Health 2024:S2352-7218(24)00022-6. [PMID: 38519365 DOI: 10.1016/j.sleh.2024.02.001] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Revised: 12/15/2023] [Accepted: 02/01/2024] [Indexed: 03/24/2024]
Abstract
OBJECTIVE To examine specific sleep characteristics of adults living in Canada according to sex, gender, ethnoracial background, socioeconomic status, immigration status, sexual orientation, and language spoken at home. METHODS This cross-sectional and nationally representative study used self-reported data from the 2021 Canadian Community Health Survey (n = 39,346 adults aged 18 years and older). Sleep characteristics (sleep duration, nighttime insomnia symptoms, unrefreshing sleep, and difficulty staying awake) were assessed and compared across groups. RESULTS Females were more likely than males to report nighttime insomnia symptoms (23.1% vs. 14.8%) and unrefreshing sleep (17.2% vs. 13.5%). The same was also observed for gender identity. Although White respondents were more likely to meet sleep duration recommendations (58.3%), they had the highest prevalence of nighttime insomnia symptoms (20.9%) compared to respondents with other ethnoracial backgrounds. Respondents coming from lower socioeconomic backgrounds were more likely to report poorer sleep compared to those coming from higher socioeconomic backgrounds. Insomnia symptoms were lower among immigrants (13.9%) compared to nonimmigrants (21.1%). Respondents with a sexual orientation not classified as heterosexual, gay, or lesbian reported poorer sleep. Finally, for language spoken at home, those who responded "French only" were more likely to meet sleep duration recommendations (64.1%) and were less likely to report unrefreshing sleep (8.8%). Nighttime insomnia symptoms were the lowest among those who reported speaking a language other than French or English at home (9.5%). CONCLUSION This study highlights important sleep disparities among Canadians. Future intervention strategies should aim to reduce sleep health disparities.
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Affiliation(s)
- Jean-Philippe Chaput
- Healthy Active Living and Obesity Research Group, Children's Hospital of Eastern Ontario Research Institute, Ottawa, Ontario, Canada; Department of Pediatrics, Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada; School of Epidemiology and Public Health, Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada.
| | | | - Colleen E Carney
- Department of Psychology, Toronto Metropolitan University, Toronto, Ontario, Canada
| | - Rébecca Robillard
- School of Psychology, University of Ottawa, Ottawa, Ontario, Canada; Sleep Research Unit, University of Ottawa Institute of Mental Health Research at The Royal, Ottawa, Ontario, Canada
| | - Hugues Sampasa-Kanyinga
- Healthy Active Living and Obesity Research Group, Children's Hospital of Eastern Ontario Research Institute, Ottawa, Ontario, Canada; School of Epidemiology and Public Health, Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Justin J Lang
- Healthy Active Living and Obesity Research Group, Children's Hospital of Eastern Ontario Research Institute, Ottawa, Ontario, Canada; School of Epidemiology and Public Health, Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada; Centre for Surveillance and Applied Research, Public Health Agency of Canada, Ottawa, Ontario, Canada; Alliance for Research in Exercise, Nutrition and Activity (ARENA), University of South Australia, Adelaide, South Australia, Australia
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Lau PH, Carney CE. Implementation of a teen sleep app in Canadian high schools: Preliminary evidence of acceptability, engagement, and capacity for supporting healthy sleep habits. J Sleep Res 2024:e14199. [PMID: 38508689 DOI: 10.1111/jsr.14199] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2024] [Revised: 03/02/2024] [Accepted: 03/07/2024] [Indexed: 03/22/2024]
Abstract
High school students suffer from mental health challenges and poorer academic performance resulting from sleep disturbances. Unfortunately, approaches to this problem sometimes focus on increasing sleep duration by going to bed early; a strategy with limited success because teens experience a phase delay in bedtimes. There is a need for approaches that leverage behavioural sleep science and are accessible, scalable, and easily disseminated to students. DOZE (Delivering Online Zzz's with Empirical Support) is a self-management app that is grounded in sleep and circadian basic science. Although initial testing supports it as a feasible and acceptable app in a research context, it has not been tested as a strategy to use in schools. The present study tested DOZE in private high schools in Canada. Two-hundred and twenty-three students downloaded the app and completed daily sleep diaries over 4 weeks. Students reported a more regularised routine for bedtime, Mdiff = -0.43 h, p < 0.001, 95% CI [-0.65, -0.21], and rise time, Mdiff = -0.61 h, p < 0.001, 95% CI [-0.84, -0.38], in addition to a higher total sleep time, Mdiff = 0.18 h, p < 0.008, 95% CI [0.05, 0.31]. Students also rated DOZE to be highly acceptable. The evidence suggests that students find DOZE to be acceptable and engagement in this nonclinical population was reasonably high under minimal researcher supervision. This makes DOZE an attractive option and a step towards broad-based sleep health services. High powered replications with control groups are needed to increase empirical rigour.
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Affiliation(s)
- Parky H Lau
- Department of Psychology, Toronto Metropolitan University, Toronto, Ontario, Canada
| | - Colleen E Carney
- Department of Psychology, Toronto Metropolitan University, Toronto, Ontario, Canada
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Lau PH, Marway OS, Carmona NE, Starick E, Iskenderova I, Carney CE. An Investigation of Further Strategies to Optimize Early Treatment Gains in Brief Therapies for Insomnia. Behav Sleep Med 2024; 22:140-149. [PMID: 37232142 DOI: 10.1080/15402002.2023.2217311] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Abstract
OBJECTIVES Identifying those who are most (and least) likely to benefit from a stepped-care approach to cognitive behavioral therapy for insomnia (CBT-I) increases access to insomnia therapies while minimizing resource consumption. The present study investigates non-targeted factors in a single-session of CBT-I that may act as barriers to early response and remission. METHODS Participants (N = 303) received four sessions of CBT-I and completed measures of subjective insomnia severity, fatigue, sleep-related beliefs, treatment expectations, and sleep diaries. Subjective insomnia severity and sleep diaries were completed between each treatment session. Early response was defined as a 50% reduction in Insomnia Severity Index (ISI) scores and early remission was defined by < 10 on the ISI after the first session. RESULTS A single-session of CBT-I significantly reduced subjective insomnia severity scores and diary total wake time. Logistic regression models indicated that lower baseline fatigue was associated with increased odds of early remission (B = -.05, p = .02), and lower subjective insomnia severity (B = -.13, p = .049). Only fatigue was a significant predictor of early treatment response (B = -.06, p = .003). CONCLUSIONS Fatigue appeared to be an important construct that dictates early changes in perceived insomnia severity. Beliefs about the relationship between sleep and daytime performance may hinder perceived improvements in insomnia symptoms. Incorporating fatigue management strategies and psychoeducation about the relationship between sleep and fatigue may target non-early responders. Future research would benefit from further profiling potential early insomnia responders/remitters.
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Affiliation(s)
- Parky H Lau
- Department of Psychology, Toronto Metropolitan University, Toronto, Ontario, Canada
| | - Onkar S Marway
- Department of Psychology, Toronto Metropolitan University, Toronto, Ontario, Canada
| | - Nicole E Carmona
- Department of Psychology, Toronto Metropolitan University, Toronto, Ontario, Canada
| | - Elisha Starick
- Department of Psychology, Toronto Metropolitan University, Toronto, Ontario, Canada
| | - Irene Iskenderova
- Department of Psychology, Wilfrid Laurier University, Waterloo, Ontario, Canada
| | - Colleen E Carney
- Department of Psychology, Toronto Metropolitan University, Toronto, Ontario, Canada
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Lau P, Starick E, Carney CE. Anxiolytic impact of cognitive behavioural therapy for insomnia in patients with co-morbid insomnia and generalized anxiety disorder. Behav Cogn Psychother 2024:1-5. [PMID: 38282533 DOI: 10.1017/s1352465823000656] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2024]
Abstract
BACKGROUND Cognitive behavioural therapy for insomnia (CBT-I) is an effective treatment for chronic insomnia that also improves non-sleep symptoms, such as mood and anxiety. Identifying sleep-specific variables that predict anxiety change after CBT-I treatment may support alternative strategies when people with generalized anxiety disorder (GAD) do not improve from standard GAD treatment. AIMS To investigate CBT-I on changes in anxiety and evaluate whether changes in sleep-specific variables predict anxiety outcomes. METHODS Seventy-two participants presenting with insomnia and GAD (GAD-I) completed four sessions of CBT-I. Participants completed daily diaries and self-report measures at baseline and post-treatment. RESULTS CBT-I in a co-morbid GAD-I sample was associated with medium reductions in anxiety, and large reductions in insomnia severity. Subjective insomnia severity and tendencies to ruminate in response to fatigue predicted post-treatment anxiety change, in addition to younger age and lower baseline anxiety. CONCLUSIONS The findings suggest that younger GAD-I participants with moderate anxiety symptoms may benefit most from the anxiety-relieving impact of CBT-I. Reducing perceived insomnia severity and the tendency to ruminate in response to fatigue may support reductions in anxiety in those with GAD-I.
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Affiliation(s)
- Parky Lau
- Department of Psychology, Toronto Metropolitan University, Toronto, Canada
| | - Elisha Starick
- Department of Psychology, Toronto Metropolitan University, Toronto, Canada
| | - Colleen E Carney
- Department of Psychology, Toronto Metropolitan University, Toronto, Canada
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Tang NKY, Saconi B, Jansson‐Fröjmark M, Ong JC, Carney CE. Cognitive factors and processes in models of insomnia: A systematic review. J Sleep Res 2023; 32:e13923. [PMID: 37364869 PMCID: PMC10909484 DOI: 10.1111/jsr.13923] [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: 03/31/2023] [Revised: 04/17/2023] [Accepted: 04/17/2023] [Indexed: 06/28/2023]
Abstract
Cognition is central to the experience of insomnia. Although unhelpful thoughts about and around insomnia are a primary treatment target of cognitive behaviour therapy for insomnia, cognitive constructs are termed and conceptualised differently in different theories of insomnia proposed over the past decades. In search of consensus in thinking, the current systematic review identified cognitive factors and processes featured in theoretical models of insomnia and mapped any commonality between models. We systematically searched PsycINFO and PubMed for published theoretical articles on the development, maintenance and remission of insomnia, from inception of databases to February, 2023. A total of 2458 records were identified for title and abstract screening. Of these, 34 were selected for full-text assessment and 12 included for analysis and data synthesis following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. We identified nine distinguishable models of insomnia published between 1982 and 2023 and extracted 20 cognitive factors and processes featured in these models; 39 if sub-factors were counted. After assigning similarity ratings, we observed a high degree of overlap between constructs despite apparent differences in terminologies and measurement methods. As a result, we highlight shifts in thinking around cognitions associated with insomnia and discuss future directions.
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Affiliation(s)
| | - Bruno Saconi
- Department of Population Health Sciences, GeisingerDanvillePennsylvaniaUSA
| | - Markus Jansson‐Fröjmark
- Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet, & Stockholm Health Care Services, Region StockholmStockholmSweden
| | | | - Colleen E. Carney
- Department of PsychologyToronto Metropolitan UniversityTorontoOntarioCanada
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Szabo J, Koerner N, Carney CE. Social problem-solving attitudes and performance as a function of differences in trait and state worry. J Behav Ther Exp Psychiatry 2023; 78:101792. [PMID: 36435552 DOI: 10.1016/j.jbtep.2022.101792] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Revised: 07/29/2022] [Accepted: 09/30/2022] [Indexed: 11/24/2022]
Abstract
BACKGROUND AND OBJECTIVES This study investigated problem-solving attitudes and state-dependent, performance-based problem-solving abilities of individuals with high trait worry as compared to those low in trait worry. Secondary objectives involved investigating the relationship between problem-solving effectiveness and processes hypothesized to influence worry and problem-solving (i.e., working memory, attentional control, emotional dysregulation, and concreteness of thought). METHODS A 2 (group: high worry, n = 68, vs. low worry, n = 66) X 2 (induction type: worry vs. neutral mentation) factorial design was employed to investigate the differential effects of state worry, and neutral mentation for comparison, on performance-based problem-solving effectiveness. Independent samples t-tests tested for group differences in self-reported problem-solving attitudes. Multiple regression analyses were used to investigate if aforementioned processes predict problem-solving effectiveness. RESULTS Previous findings that individuals with high trait worry endorse greater tendencies to self-report unconstructive problem-solving attitudes were replicated. Contrary to predictions, there were no significant within or between group differences on problem-solving performance. Concreteness of problem solutions was the only consistent predictor of problem-solving effectiveness. LIMITATIONS Study did not directly assess problem-solving for personal problems. CONCLUSIONS Disparities in self-appraisal may account for lack of worry-related performance differences. Findings suggest that when employing problem-solving interventions with a high worry population, emphasis should be placed on changing maladaptive problem attitudes. Nonclinical and clinical populations alike may benefit from incorporating training in concreteness in problem-solving therapy.
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Affiliation(s)
- Judit Szabo
- Department of Psychology, Toronto Metropolitan University, Canada
| | - Naomi Koerner
- Department of Psychology, Toronto Metropolitan University, Canada.
| | - Colleen E Carney
- Department of Psychology, Toronto Metropolitan University, Canada
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Chaput JP, Janssen I, Sampasa-Kanyinga H, Carney CE, Dang-Vu TT, Davidson JR, Robillard R, Morin CM. Economic burden of insomnia symptoms in Canada. Sleep Health 2022; 9:185-189. [PMID: 36319579 DOI: 10.1016/j.sleh.2022.09.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Revised: 09/14/2022] [Accepted: 09/24/2022] [Indexed: 11/09/2022]
Abstract
OBJECTIVE To estimate health care and productivity costs associated with insomnia symptoms in Canadian adults. METHODS Three pieces of information were needed to calculate estimates based on a prevalence-based approach: (1) the pooled relative risk estimates of health outcomes consistently associated with insomnia symptoms obtained from recent meta-analyses of prospective cohort studies; (2) the direct (health care) and indirect (lost productivity due to premature mortality) costs of these health outcomes using the Economic Burden of Illness in Canada information; and (3) the prevalence of insomnia symptoms in Canadian men (18.1%) and women (29.5%) obtained from a nationally-representative survey. RESULTS The direct, indirect, and total costs of insomnia symptoms in Canada in 2021 were $1.9 billion, $12.6 million, and $1.9 billion, respectively. This value represents 1.9% of the overall burden of illness costs for 2021 in Canada. The 2 most expensive chronic diseases attributable to insomnia symptoms were type 2 diabetes ($754 million) and depression ($706 million). The main contributor to the costs for type 2 diabetes and depression was prescription drugs. A 5% decrease in insomnia symptoms (from 23.8% to 18.8%) would result in an estimated $353 million in avoided costs while a 5% increase in insomnia symptoms (from 23.8% to 28.8%) would result in an estimated $333 million in additional expenditures yearly. CONCLUSIONS Insomnia symptoms greatly contribute to the economic burden of illness in Canada. Reducing the prevalence of insomnia symptoms would reduce its societal burden.
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Affiliation(s)
- Jean-Philippe Chaput
- Healthy Active Living and Obesity Research Group, CHEO Research Institute, Ottawa, Ontario, Canada; Department of Pediatrics, Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada.
| | - Ian Janssen
- School of Kinesiology and Health Studies, Queen's University, Kingston, Ontario, Canada; Department of Public Health Sciences, Queen's University, Kingston, Ontario, Canada
| | - Hugues Sampasa-Kanyinga
- Healthy Active Living and Obesity Research Group, CHEO Research Institute, Ottawa, Ontario, Canada
| | - Colleen E Carney
- Department of Psychology, Toronto Metropolitan University, Toronto, Ontario, Canada
| | - Thien Thanh Dang-Vu
- Institut Universitaire de Gériatrie de Montréal and CRIUGM, CIUSSS du Centre-Sud-de-l'Île-de-Montréal, Montreal, Quebec, Canada; PERFORM Centre, Center for Studies in Behavioral Neurobiology, Department of Health, Kinesiology and Applied Physiology, Concordia University, Montreal, Quebec, Canada
| | - Judith R Davidson
- Department of Psychology, Queen's University, Kingston, Ontario, Canada
| | - Rebecca Robillard
- The University of Ottawa Institute of Mental Health Research at The Royal, Ottawa, Ontario, Canada; School of Psychology, University of Ottawa, Ottawa, Ontario, Canada
| | - Charles M Morin
- School of Psychology, Laval University, Quebec City, Quebec, Canada
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Lau PH, Marway OS, Carmona NE, Carney CE. Examining whether Changes in Sleep Habits Predict Long-Term Sustainment of Treatment Gains in Individual Remitted from Insomnia after CBT-I. Behav Sleep Med 2022:1-12. [PMID: 36111681 DOI: 10.1080/15402002.2022.2124993] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
OBJECTIVES Providers of Cognitive-Behavioral Therapy for Insomnia (CBT-I) are often asked whether the behavioral recommendations (e.g., stimulus control, sleep restriction) must be adhered to ad infinitum. We examined whether changes in sleep habits/behaviors are a life sentence, or whether patients who remit can relax their adherence while maintaining their treatment gains at 1-year follow-up (FU). METHODS Participants (N = 179) completed 2 weeks of sleep diaries and measures of insomnia severity and safety behaviors at baseline and following four sessions of CBT-I. Of the 137 patients that achieved remission, 77 completed these measures at 1-year FU. RESULTS Improvements in insomnia severity and total wake time (TWT) at post-treatment were maintained at FU (ps ≥ .52). Similarly, reductions in safety behaviors were maintained at FU (p - 1.00), whereas lingering in bed reduced during treatment (p < .001) but increased at FU (p < .001). Changes in sleep habits after treatment did not predict insomnia severity at FU. However, increases in time in bed positively predicted TWT at FU (p = .001). CONCLUSIONS Those who remit after CBT-I may generally relax their adherence to behavioral recommendations without significantly impacting their perceived insomnia symptoms 1 year after treatment despite some increases in TWT. Results increase our confidence in CBT-I as a brief and durable intervention.
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Affiliation(s)
- Parky H Lau
- Department of Psychology, Toronto Metropolitan University, Toronto, Ontario, Canada
| | - Onkar S Marway
- Department of Psychology, Toronto Metropolitan University, Toronto, Ontario, Canada
| | - Nicole E Carmona
- Department of Psychology, Toronto Metropolitan University, Toronto, Ontario, Canada
| | - Colleen E Carney
- Department of Psychology, Toronto Metropolitan University, Toronto, Ontario, Canada
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Carney AE, Wescott DL, Carmona NE, Carney CE, Roecklein KA. The role of beliefs about sleep in nightly perceptions of sleep quality across a depression continuum. J Affect Disord 2022; 311:440-445. [PMID: 35597468 PMCID: PMC9523734 DOI: 10.1016/j.jad.2022.05.092] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [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: 11/20/2021] [Revised: 05/09/2022] [Accepted: 05/15/2022] [Indexed: 10/18/2022]
Abstract
BACKGROUND Poor sleep quality is common in depression, but complaints of poor sleep quality are not necessarily tied to objective sleep, and the construct of sleep quality remains poorly understood. Previous work suggests that beliefs about sleep may influence sleep quality appraisals, as might sleep variability from night to night. OBJECTIVE We tested whether beliefs about sleep predict daily sleep quality ratings above and beyond nightly variability of actigraphy and diary-assessed sleep over the course of multiple nights. METHODS Eighty-eight participants aged 18-65 years across a depressive continuum completed sleep diaries and reported their sleep quality and mood each morning; actigraphy was also completed for 67 of those participants. Multilevel models were used to test previous night's total sleep time and sleep efficiency as predictors of self-reported sleep quality (VAS-SQ) and mood (VAS-M), and whether unhelpful beliefs about sleep predicted VAS-SQ and VAS-M above and beyond the sleep variables. RESULTS Individuals across a depression continuum with greater unhelpful beliefs about sleep reported worse sleep quality and worse mood upon awakening, even when accounting for nightly variation in actigraphy or diary assessed total sleep time and sleep efficiency. CONCLUSIONS These results suggest that people are influenced by unhelpful sleep beliefs when making judgements about sleep quality and mood, regardless of how well they slept the previous night. Working with these unhelpful sleep beliefs in cognitive behavioral therapy can thus promote better sleep and mood in people across the depressive continuum.
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Affiliation(s)
- Alison E Carney
- Department of Psychology, Ryerson University, Toronto, ON, Canada.
| | - Delainey L Wescott
- Department of Psychology, University of Pittsburgh, Pittsburgh, PA, United States of America
| | - Nicole E Carmona
- Department of Psychology, Ryerson University, Toronto, ON, Canada
| | - Colleen E Carney
- Department of Psychology, Ryerson University, Toronto, ON, Canada
| | - Kathryn A Roecklein
- Department of Psychology, University of Pittsburgh, Pittsburgh, PA, United States of America
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Carmona NE, Millett GE, Green SM, Carney CE. Cognitive-behavioral, behavioural and mindfulness-based therapies for insomnia in menopause. Behav Sleep Med 2022:1-12. [PMID: 35942653 DOI: 10.1080/15402002.2022.2109640] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
OBJECTIVES Insomnia is frequently reported by women during menopause due to physiological changes and environmental factors and is associated with negative daytime sequelae. Due to medication side effects and patient preferences, there is increased interest in the use of psychological treatments for menopausal insomnia. The primary objective of this review is to review the efficacy of cognitive-behavioral, behavioral, and mindfulness-based (CBBMB) therapies in treating insomnia in peri- and post-menopausal women. The secondary objective is to review the effect of CBBMB therapies on relevant secondary outcomes to gain a comprehensive understanding of their impacts. METHODS We conducted a narrative review of the literature. A search of PubMed and Google Scholar was conducted between January 2020 and March 2021. RESULTS Cognitive-behavioral therapy (CBT) for insomnia is efficacious, with corollary improvements in mood, functional outcomes and potential mechanistic factors (e.g., unhelpful beliefs). Sleep restriction therapy is also efficacious, with somewhat poorer effects on secondary outcomes relative to CBT. Mindfulness meditation and relaxation for insomnia demonstrated promise, but its long-term effects remain unknown. CONCLUSIONS Research with more diverse samples and head-to-head comparisons is needed. Dissemination of CBBMBs for insomnia in clinics where menopausal women seek care is an important next step.
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Affiliation(s)
- Nicole E Carmona
- Department of Psychology, Toronto Metropolitan University, Toronto, ON, Canada
| | - Geneva E Millett
- Department of Psychology, Toronto Metropolitan University, Toronto, ON, Canada
| | - Sheryl M Green
- Department of Psychiatry and Behavioural Neurosciences, McMaster University, Hamilton, ON, Canada.,Women's Health Concerns Clinic, St. Joseph's Healthcare Hamilton, Hamilton, ON, Canada
| | - Colleen E Carney
- Department of Psychology, Toronto Metropolitan University, Toronto, ON, Canada
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Carney CE, Carmona NE. Author Reply to: Additional Measurement Approaches for Sleep Disturbances. Comment on “Transdiagnostic Self-management Web-Based App for Sleep Disturbance in Adolescents and Young Adults: Feasibility and Acceptability Study (MS 25392)” (Preprint). JMIR Form Res 2022; 6:e39198. [PMID: 35699990 PMCID: PMC9237758 DOI: 10.2196/39198] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Accepted: 05/05/2022] [Indexed: 11/26/2022] Open
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12
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Lau PH, Carney AE, Marway OS, Carmona NE, Amestoy M, Carney CE. Investigating the Antidepressant Effects of CBT-I in Those with Major Depressive and Insomnia Disorders. Journal of Affective Disorders Reports 2022. [DOI: 10.1016/j.jadr.2022.100366] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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Carmona NE, Usyatynsky A, Kutana S, Corkum P, Henderson J, McShane K, Shapiro C, Sidani S, Stinson J, Carney CE. A Transdiagnostic Self-management Web-Based App for Sleep Disturbance in Adolescents and Young Adults: Feasibility and Acceptability Study. JMIR Form Res 2021; 5:e25392. [PMID: 34723820 PMCID: PMC8694239 DOI: 10.2196/25392] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2020] [Revised: 01/06/2021] [Accepted: 09/13/2021] [Indexed: 01/26/2023] Open
Abstract
Background Sleep disturbance and its daytime sequelae, which comprise complex, transdiagnostic sleep problems, are pervasive problems in adolescents and young adults (AYAs) and are associated with negative outcomes. Effective interventions must be both evidence based and individually tailored. Some AYAs prefer self-management and digital approaches. Leveraging these preferences is helpful, given the dearth of AYA treatment providers trained in behavioral sleep medicine. We involved AYAs in the co-design of a behavioral, self-management, transdiagnostic sleep app called DOZE (Delivering Online Zzz’s with Empirical Support). Objective This study tests the feasibility and acceptability of DOZE in a community AYA sample aged 15-24 years. The secondary objective is to evaluate sleep and related outcomes in this nonclinical sample. Methods Participants used DOZE for 4 weeks (2 periods of 2 weeks). They completed sleep diaries, received feedback on their sleep, set goals in identified target areas, and accessed tips to help them achieve their goals. Measures of acceptability and credibility were completed at baseline and end point. Google Analytics was used to understand the patterns of app use to assess feasibility. Participants completed questionnaires assessing fatigue, sleepiness, chronotype, depression, anxiety, and quality of life at baseline and end point. Results In total, 83 participants created a DOZE account, and 51 completed the study. During the study, 2659 app sessions took place with an average duration of 3:02 minutes. AYAs tracked most days in period 1 (mean 10.52, SD 4.87) and period 2 (mean 9.81, SD 6.65), with a modal time of 9 AM (within 2 hours of waking). DOZE was appraised as highly acceptable (mode≥4) on the items “easy to use,” “easy to understand,” “time commitment,” and “overall satisfaction” and was rated as credible (mode≥4) at baseline and end point across all items (logic, confident it would work, confident recommending it to a friend, willingness to undergo, and perceived success in treating others). The most common goals set were decreasing schedule variability (34/83, 41% of participants), naps (17/83, 20%), and morning lingering in bed (16/83, 19%). AYAs accessed tips on difficulty winding down (24/83, 29% of participants), being a night owl (17/83, 20%), difficulty getting up (13/83, 16%), and fatigue (13/83, 16%). There were significant improvements in morning lingering in bed (P=.03); total wake time (P=.02); sleep efficiency (P=.002); total sleep time (P=.03); and self-reported insomnia severity (P=.001), anxiety (P=.002), depression (P=.004), and energy (P=.01). Conclusions Our results support the feasibility, acceptability, credibility, and preliminary efficacy of DOZE. AYAs are able to set and achieve goals based on tailored feedback on their sleep habits, which is consistent with research suggesting that AYAs prefer autonomy in their health care choices and produce good results when given tools that support their autonomy. Trial Registration ClinicalTrials.gov NCT03960294; https://clinicaltrials.gov/ct2/show/NCT03960294
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Affiliation(s)
- Nicole E Carmona
- Department of Psychology, Ryerson University, Toronto, ON, Canada
| | | | - Samlau Kutana
- Department of Psychology, Memorial University of Newfoundland, St. John's, NL, Canada
| | - Penny Corkum
- Department of Psychology and Neuroscience, Dalhousie University, Halifax, NS, Canada.,Department of Psychiatry, Dalhousie University, Halifax, NS, Canada
| | - Joanna Henderson
- Department of Psychiatry, University of Toronto, Toronto, ON, Canada.,Margaret and Wallace McCain Centre for Child, Youth and Family Mental Health, Centre for Addiction and Mental Health, Toronto, ON, Canada
| | - Kelly McShane
- Department of Psychology, Ryerson University, Toronto, ON, Canada.,Human Resource Management and Organizational Behaviour, Ted Rogers School of Management, Ryerson University, Toronto, ON, Canada
| | - Colin Shapiro
- Department of Psychiatry, University of Toronto, Toronto, ON, Canada.,Department of Ophthamology, University of Toronto, Toronto, ON, Canada
| | - Souraya Sidani
- Daphne Cockwell School of Nursing, Ryerson University, Toronto, ON, Canada
| | - Jennifer Stinson
- Chronic Pain Program, Department of Anesthesia and Pain Medicine, The Hospital for Sick Children, Toronto, ON, Canada.,Child Health Evaluative Sciences, Research Institute, The Hospital for Sick Children, Toronto, ON, Canada.,Lawrence S Bloomberg Faculty of Nursing, University of Toronto, Toronto, ON, Canada
| | - Colleen E Carney
- Department of Psychology, Ryerson University, Toronto, ON, Canada
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AminiLari M, Wang L, Neumark S, Adli T, Couban RJ, Giangregorio A, Carney CE, Busse JW. Medical Cannabis and Cannabinoids for Impaired Sleep: A Systematic Review and Meta-Analysis of Randomized Clinical Trials. Sleep 2021; 45:6373351. [PMID: 34546363 DOI: 10.1093/sleep/zsab234] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2021] [Revised: 08/09/2021] [Indexed: 11/12/2022] Open
Abstract
STUDY OBJECTIVES We conducted a systematic review to explore the effectiveness of medical cannabis for impaired sleep. METHODS We searched MEDLINE, EMBASE, CENTRAL and PsychINFO to January 2021 for randomized trials of medical cannabis or cannabinoids for impaired sleep vs. any non-cannabis control. When possible, we pooled effect estimates for all patient-important sleep-related outcomes and used the GRADE approach to appraise the certainty of evidence. RESULTS Thirty-nine trials (5,100 patients) were eligible for review, of which 38 evaluated oral cannabinoids and 1 administered inhaled cannabis. The median follow-up was 35 days, and most trials (33 of 39) enrolled patients living with chronic cancer or noncancer chronic pain. Among patients with chronic pain, moderate certainty evidence found that medical cannabis probably results in a small improvement in sleep quality versus placebo (modeled risk difference [RD] for achieving the minimally important difference [MID], 8% [95% CI, 3 to 12]). Moderate to high certainty evidence shows that medical cannabis vs. placebo results in a small improvement in sleep disturbance for chronic non-cancer pain (modeled RD for achieving the MID, 19% [95% CI, 11 to 28]) and a very small improvement in sleep disturbance for chronic cancer pain (WMD of -0.19cm [95%CI, -0.36 to -0.03cm]; interaction p=0.03). Moderate to high certainty evidence shows medical cannabis, versus placebo, results in a substantial increase in the risk of dizziness (RD 29% [95%CI, 16 to 50], for trials with ≥3 months follow-up), and a small increase in the risk of somnolence, dry mouth, fatigue, and nausea (RDs ranged from 6% to 10%). CONCLUSION Medical cannabis and cannabinoids may improve impaired sleep among people living with chronic pain, but the magnitude of benefit is likely small.
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Affiliation(s)
- Mahmood AminiLari
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada.,The Michael G. DeGroote Institute for Pain Research and Care, McMaster University, Hamilton, Ontario, Canada
| | - Li Wang
- The Michael G. DeGroote Institute for Pain Research and Care, McMaster University, Hamilton, Ontario, Canada
| | - Samuel Neumark
- Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Taranah Adli
- Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada.,Schulich School of Medicine & Dentistry, University of Western Ontario, London, Ontario, Canada
| | - Rachel J Couban
- The Michael G. DeGroote Institute for Pain Research and Care, McMaster University, Hamilton, Ontario, Canada
| | - Aidan Giangregorio
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada.,The Michael G. DeGroote Centre for Medicinal Cannabis Research, McMaster University, Hamilton, Ontario, Canada
| | | | - Jason W Busse
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada.,The Michael G. DeGroote Institute for Pain Research and Care, McMaster University, Hamilton, Ontario, Canada.,The Michael G. DeGroote Centre for Medicinal Cannabis Research, McMaster University, Hamilton, Ontario, Canada.,Department of Anesthesia, McMaster University, Hamilton, Ontario, Canada.,The Chronic Pain Centre of Excellence for Canadian Veterans, Hamilton, Ontario, Canada
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15
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Edinger JD, Arnedt JT, Bertisch SM, Carney CE, Harrington JJ, Lichstein KL, Sateia MJ, Troxel WM, Zhou ES, Kazmi U, Heald JL, Martin JL. Behavioral and psychological treatments for chronic insomnia disorder in adults: an American Academy of Sleep Medicine systematic review, meta-analysis, and GRADE assessment. J Clin Sleep Med 2021; 17:263-298. [PMID: 33164741 DOI: 10.5664/jcsm.8988] [Citation(s) in RCA: 91] [Impact Index Per Article: 30.3] [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: 12/29/2022]
Abstract
INTRODUCTION The purpose of this systematic review is to provide supporting evidence for a clinical practice guideline on the use of behavioral and psychological treatments for chronic insomnia disorder in adult populations. METHODS The American Academy of Sleep Medicine commissioned a task force of 9 experts in sleep medicine and sleep psychology. A systematic review was conducted to identify randomized controlled trials that addressed behavioral and psychological interventions for the treatment of chronic insomnia disorder in adults. Statistical analyses were performed to determine if the treatments produced clinically significant improvements in a range of critical and important outcomes. Finally, the Grading of Recommendations Assessment, Development, and Evaluation process was used to evaluate the evidence for making specific treatment recommendations. RESULTS The literature search identified 1,244 studies; 124 studies met the inclusion criteria, and 89 studies provided data suitable for statistical analyses. Evidence for the following interventions is presented in this review: cognitive-behavioral therapy for insomnia, brief therapies for insomnia, stimulus control, sleep restriction therapy, relaxation training, sleep hygiene, biofeedback, paradoxical intention, intensive sleep retraining, and mindfulness. This review provides a detailed summary of the evidence along with the quality of evidence, the balance of benefits vs harms, patient values and preferences, and resource use considerations.
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Affiliation(s)
- Jack D Edinger
- National Jewish Health, Denver, Colorado.,Duke University Medical Center, Durham, North Carolina
| | - J Todd Arnedt
- Michigan Medicine, University of Michigan, Ann Arbor, Michigan
| | - Suzanne M Bertisch
- Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | | | | | | | | | | | - Eric S Zhou
- Harvard Medical School, Dana-Farber Cancer Institute, Boston Children's Hospital, Boston, Massachusetts
| | - Uzma Kazmi
- American Academy of Sleep Medicine, Darien, Illinois
| | | | - Jennifer L Martin
- David Geffen School of Medicine at the University of California Los Angeles, Los Angeles, California.,VA Greater Los Angeles Healthcare System, Geriatric Research, Education and Clinical Center, Los Angeles, California
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16
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Edinger JD, Arnedt JT, Bertisch SM, Carney CE, Harrington JJ, Lichstein KL, Sateia MJ, Troxel WM, Zhou ES, Kazmi U, Heald JL, Martin JL. Behavioral and psychological treatments for chronic insomnia disorder in adults: an American Academy of Sleep Medicine clinical practice guideline. J Clin Sleep Med 2021; 17:255-262. [PMID: 33164742 DOI: 10.5664/jcsm.8986] [Citation(s) in RCA: 216] [Impact Index Per Article: 72.0] [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: 11/13/2022]
Abstract
INTRODUCTION This guideline establishes clinical practice recommendations for the use of behavioral and psychological treatments for chronic insomnia disorder in adults. METHODS The American Academy of Sleep Medicine (AASM) commissioned a task force of experts in sleep medicine and sleep psychology to develop recommendations and assign strengths based on a systematic review of the literature and an assessment of the evidence using Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology. The task force evaluated a summary of the relevant literature and the quality of evidence, the balance of clinically relevant benefits and harms, patient values and preferences, and resource use considerations that underpin the recommendations. The AASM Board of Directors approved the final recommendations. RECOMMENDATIONS The following recommendations are intended as a guide for clinicians in choosing a specific behavioral and psychological therapy for the treatment of chronic insomnia disorder in adult patients. Each recommendation statement is assigned a strength ("strong" or "conditional"). A "strong" recommendation (ie, "We recommend…") is one that clinicians should follow under most circumstances. A "conditional" recommendation is one that requires that the clinician use clinical knowledge and experience, and to strongly consider the patient's values and preferences to determine the best course of action. 1. We recommend that clinicians use multicomponent cognitive behavioral therapy for insomnia for the treatment of chronic insomnia disorder in adults. (STRONG). 2. We suggest that clinicians use multicomponent brief therapies for insomnia for the treatment of chronic insomnia disorder in adults. (CONDITIONAL). 3. We suggest that clinicians use stimulus control as a single-component therapy for the treatment of chronic insomnia disorder in adults. (CONDITIONAL). 4. We suggest that clinicians use sleep restriction therapy as a single-component therapy for the treatment of chronic insomnia disorder in adults. (CONDITIONAL). 5. We suggest that clinicians use relaxation therapy as a single-component therapy for the treatment of chronic insomnia disorder in adults. (CONDITIONAL). 6. We suggest that clinicians not use sleep hygiene as a single-component therapy for the treatment of chronic insomnia disorder in adults. (CONDITIONAL).
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Affiliation(s)
- Jack D Edinger
- National Jewish Health, Denver, Colorado.,Duke University Medical Center, Durham, North Carolina
| | - J Todd Arnedt
- Michigan Medicine, University of Michigan, Ann Arbor, Michigan
| | - Suzanne M Bertisch
- Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | | | | | | | | | | | - Eric S Zhou
- Harvard Medical School, Dana-Farber Cancer Institute, Boston Children's Hospital, Boston, Massachusetts
| | - Uzma Kazmi
- American Academy of Sleep Medicine, Darien, Illinois
| | | | - Jennifer L Martin
- David Geffen School of Medicine at the University of California Los Angeles, Los Angeles, California.,VA Greater Los Angeles Healthcare System, Geriatric Research, Education and Clinical Center, Los Angeles, California
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17
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Harris AL, Carmona NE, Moss TG, Carney CE. Testing the contiguity of the sleep and fatigue relationship: a daily diary study. Sleep 2021; 44:6007511. [PMID: 33245330 DOI: 10.1093/sleep/zsaa252] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [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: 05/14/2020] [Revised: 09/22/2020] [Indexed: 11/14/2022] Open
Abstract
STUDY OBJECTIVES There is mixed evidence for the relationship between poor sleep and daytime fatigue, and some have suggested that fatigue is simply caused by lack of sleep. Although retrospective measures of insomnia and fatigue tend to correlate, other studies fail to demonstrate a link between objectively disturbed sleep and fatigue. The current study prospectively explored the relationship between sleep and fatigue among those with and without insomnia disorder. METHODS Participants meeting Research Diagnostic Criteria for insomnia disorder (n = 33) or normal sleepers (n = 32) completed the Consensus Sleep Diary (CSD) and daily fatigue ratings for 2 weeks. Baseline questionnaires evaluated cognitive factors including unhelpful beliefs about sleep and rumination about fatigue. Hierarchical linear modeling tested the within- and between-participant relationships between sleep quality, total sleep time, and daily fatigue ratings. Mediation analyses tested if cognitive factors mediated the relationship between insomnia and fatigue. RESULTS Self-reported nightly sleep quality significantly predicted subsequent daily fatigue ratings. Total sleep time was a significant predictor of fatigue within, but not between, participants. Unhelpful sleep beliefs and rumination about fatigue mediated the relationship between insomnia and fatigue reporting. CONCLUSIONS The results suggest that perception of sleep plays an important role in predicting reports of daytime fatigue. These findings could be used in treatment to help shift the focus away from total sleep times, and instead, focus on challenging maladaptive sleep-related cognitions to change fatigue perception.
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Affiliation(s)
- Andrea L Harris
- Department of Psychology, Ryerson University, Toronto, Canada
| | | | - Taryn G Moss
- Department of Psychology, Ryerson University, Toronto, Canada
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18
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Atwood ME, Lachowski AM, Carney CE. Sleep belief change following fatigue induction. Canadian Journal of Behavioural Science / Revue canadienne des sciences du comportement 2021. [DOI: 10.1037/cbs0000186] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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19
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Dias-Barbosa C, Matos R, Vernon M, Carney CE, Krystal A, Puelles J. Correction to: Content validity of a sleep numerical rating scale and a sleep diary in adults and adolescents with moderate-to-severe atopic dermatitis. J Patient Rep Outcomes 2020; 4:107. [PMID: 33373018 PMCID: PMC7772119 DOI: 10.1186/s41687-020-00279-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
An amendment to this paper has been published and can be accessed via the original article.
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20
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Dias-Barbosa C, Matos R, Vernon M, Carney CE, Krystal A, Puelles J. Content validity of a sleep numerical rating scale and a sleep diary in adults and adolescents with moderate-to-severe atopic dermatitis. J Patient Rep Outcomes 2020; 4:100. [PMID: 33226517 PMCID: PMC7683746 DOI: 10.1186/s41687-020-00265-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [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: 04/05/2020] [Accepted: 11/03/2020] [Indexed: 01/06/2023] Open
Abstract
Background The intense itching associated with atopic dermatitis (AD) often causes patients to experience severe sleep disturbance. Here, we describe the results of a two-phase concept elicitation and cognitive interview study to establish the content validity of a sleep disturbance numerical rating scale (SD NRS) and a Consensus Sleep Diary adapted for adults and adolescents with moderate-to-severe AD (CSD-AD©). Results In phase I, a concept elicitation conducted in 20 adults and 10 adolescents with moderate-to-severe AD revealed that the following sleep-related issues were important and relevant: nighttime awakening (87%), trouble falling asleep (73%), feeling unrested (53%), daytime fatigue or sleepiness (53%), and feeling as if they did not get enough sleep (33%). The frequency and extent of sleep disturbance varied substantially from day to day due to varying degrees of itching and flares, medication use, and changes in the weather. All participants understood the SD NRS question, with most finding it easy or very easy to understand (100% of adults and 90% of adolescents) and most understanding the anchors as intended (95% of adults, and 100% of adolescents). Most participants (94% of adults, and 90% of adolescents) indicated that they would consider a one- or two-point change meaningful on the SD NRS. The CSD-AD© was revised based on participant feedback, and tested during phase II in a convenience sample of six adults and four adolescents from phase I. The changes made to the CSD-AD© were confirmed to be relevant and understandable. All patients were able to provide an answer to each item in the CSD-AD©, and most were able to estimate the duration of nighttime awakenings, daytime naps, and dozing. Conclusions The study supported the content validity of the SD NRS and CSD-AD© in adults and adolescents with moderate-to-severe AD. It also emphasized the importance of using these instruments daily when assessing the benefit of a new treatment on sleep quality in this population. Supplementary Information Supplementary information accompanies this paper at 10.1186/s41687-020-00265-y.
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Affiliation(s)
| | - Rodolfo Matos
- Evidera, 7101 Wisconsin Avenue, Suite 1400, Bethesda, MA, 20814, USA.
| | - Margaret Vernon
- Evidera, 7101 Wisconsin Avenue, Suite 1400, Bethesda, MA, 20814, USA
| | - Colleen E Carney
- Ryerson University, 350 Victoria Street, Toronto, ON, M5B 2K3, Canada
| | - Andrew Krystal
- University of California, San Francisco, Weill Institute for Neurosciences, 401 Parnassus Avenue, San Francisco, CA, 94143-0984, USA
| | - Jorge Puelles
- Galderma, World Trade Center, Avenue Gratta-Paille 2, 1018, Lausanne, Switzerland
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21
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Fitzpatrick S, Maich KHG, Carney CE, Kuo JR. Identifying specific insomnia components in borderline personality disorder and their influence on emotion dysregulation. ACTA ACUST UNITED AC 2020; 11:440-450. [DOI: 10.1037/per0000395] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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22
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Abstract
OBJECTIVE AND BACKGROUND Fatigue and insomnia are common debilitating symptoms associated with multiple sclerosis (MS). Negative subjective appraisals of symptoms may influence both insomnia and fatigue severity, but this relationship has not been examined among those with MS. The relationship between insomnia symptoms and both physical and cognitive fatigue were examined. Health-related self-efficacy, fatigue catastrophization, and rumination were examined as potential mediators of the relationship between insomnia symptoms and fatigue. PARTICIPANTS Participants diagnosed with MS (N = 115) were recruited from hospital and community settings in a large metropolitan city. METHODS Participants completed self-report questionnaires, including: Modified Fatigue Impact, Insomnia Severity Index, MS Quality of Life Questionnaire-54, Fatigue Catastrophizing Scale, Multidimensional Health Locus of Control Scale, and the Rumination-Reflection Questionnaire. Two multiple mediation analyses were performed using bootstrapping techniques, examining the cognitive and physical domains of fatigue as separate outcomes. RESULTS AND CONCLUSIONS Mediation analyses revealed a significant association between insomnia symptom severity and the cognitive and physical domains of fatigue. Fatigue catastrophizing was the only significant mediator, accounting for 25% of the variance in the relationship between insomnia symptoms and the cognitive fatigue. However, fatigue catastrophizing did not significantly mediate the relationship between insomnia symptoms and physical fatigue, indicating physical and cognitive fatigue may reflect distinct processes in fatigue expression in those with MS.
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Affiliation(s)
- Crystal J Hare
- a Department of Psychology , Ryerson University , Toronto , Canada
| | | | - Colleen E Carney
- a Department of Psychology , Ryerson University , Toronto , Canada
| | - Tae Hart
- a Department of Psychology , Ryerson University , Toronto , Canada
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23
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Abstract
The Consensus Sleep Diary (CSD) is a standardized, prospective tool for tracking nightly subjective sleep. The current study evaluated the validity and utility of the CSD, with consideration for challenges inherent to psychometric evaluation of diary measures. Results showed that the CSD indices differentiated good sleepers from those with insomnia and were associated with similar objective indices and a subjective insomnia severity measure. The ability to detect treatment improvements after cognitive behavior therapy for insomnia (CBT-I) was tested by comparing pre- and post-CBT-I CSD indices with a subjective rating of insomnia symptom severity. Improvement in insomnia symptom severity was significantly related to improvement on the CSD indices. Completion rate of the CSD amongst participants across all 14 days was 99.8%. These findings provide support for the validity, clinical utility, and usability of the CSD.
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Affiliation(s)
| | | | - Colleen E Carney
- a Department of Psychology , Ryerson University , Toronto , Canada
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24
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Carney CE, Edinger JD, Kuchibhatla M, Lachowski AM, Bogouslavsky O, Krystal AD, Shapiro CM. Cognitive Behavioral Insomnia Therapy for Those With Insomnia and Depression: A Randomized Controlled Clinical Trial. Sleep 2017; 40:2990154. [PMID: 28199710 DOI: 10.1093/sleep/zsx019] [Citation(s) in RCA: 108] [Impact Index Per Article: 15.4] [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: 01/22/2023] Open
Abstract
Study Objective To compare cognitive behavioral therapy for insomnia (CBT-I) + antidepressant medication (AD) against treatments that target solely depression or solely insomnia. Design A blinded, randomized split-plot experimental study. Setting Two urban academic clinical centers. Participants 107 participants (68% female, mean age 42 ± 11) with major depressive disorder and insomnia. Interventions Randomization was to one of three groups: antidepressant (AD; escitalopram) + CBT-I (4 sessions), CBT-I + placebo pill, or AD + 4-session sleep hygiene control (SH). Measurements and Results Subjective sleep was assessed via 2 weeks of daily sleep diaries (use of medication was covaried in all analyses); although there were no statistically significant group differences detected, all groups improved from baseline to posttreatment on subjective sleep efficiency (SE) and total wake time (TWT) and the effect sizes were large. Objective sleep was assessed via overnight polysomnographic monitoring at baseline and posttreatment; analyses revealed both CBT groups improved on TWT (p = .03), but the AD + SH group worsened. There was no statistically significant effect for PSG SE (p = .07). There was a between groups medium effect observed for the AD + SH and CBT + placebo group differences on diary TWT and both PSG variables. All groups improved significantly from baseline to posttreatment on the Hamilton Rating Scale for Depression (HAMD-17); the groups did not differ. Conclusions Although all groups self-reported sleeping better after treatment, only the CBT-I groups improved on objective sleep, and AD + SH's sleep worsened. This suggests that we should be treating sleep in those with depression with an effective insomnia treatment and relying on self-report obscures sleep worsening effects. All groups improved on depression, even a group with absolutely no depression-focused treatment component (CBT-I + placebo). The depression effect in CBT-I only group has been reported in other studies, suggesting that we should further investigate the antidepressant properties of CBT-I.
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25
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Palagini L, Mauri M, Banfi T, Mazzei I, Gronchi A, Bonanni E, Maestri M, Riemann D, Carney CE, Dell'Osso L. Daytime rumination as a feature of Insomnia Disorder: sleep related cognition is not merely a problem of the night. Arch Ital Biol 2016; 153:239-47. [PMID: 26742678 DOI: 10.12871/0003982920152349] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Night-time sleep related cognitions have been shown to play a perpetuating role in insomnia. According to the cognitive model of insomnia day time cognitions (i.e. worry, rumination, etc.) may also contribute to it. The aim of this study was to investigate the possible role of daytime sleep-related rumination in Insomnia Disorder (n= 55, mean age 49.7±16.7 years), Obstructive Sleep Apnea Syndrome (OSAS) (n=33, mean age 58.1±10.2 years) and healthy subjects (n=33, mean age 49.8±13.9), using a set of sleep related variables which included the Daytime Insomnia Symptom Response Scale (DISRS), the Dysfunctional Beliefs about Sleep Scale (DBAS), the Pittsburgh Sleep Quality Index (PSQI) and the Insomnia Severity Index (ISI). Daytime sleep related rumination was higher in insomnia when compared to both OSAS (p<.001) and good sleepers (p<.001). In insomnia, elevated sleep related daytime rumination was best determined by unhelpful sleep related beliefs (coeff=0.3 p=.004), while in OSAS by insomnia symptoms (coeff=0.9, p=.02). These findings suggest that the association between insomnia-specific daytimerumination and unhelpful beliefs may be considered a cognitive feature of insomnia. In insomnia, sleep related cognition may dominate the 24-hour period. This finding might be of use for further investigations studying therapeutic strategies acting on cognitive processes to prevent and treat insomnia disorder and its comorbid conditions.
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Zalai D, Carney CE, Sherman M, Shapiro CM, McShane K. Fatigue in chronic hepatitis C infection: Understanding patients' experience from a cognitive-behavioural perspective. Br J Health Psychol 2015; 21:157-72. [PMID: 26250404 DOI: 10.1111/bjhp.12155] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [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: 12/29/2014] [Revised: 07/11/2015] [Indexed: 12/17/2022]
Abstract
OBJECTIVES Fatigue is a leading concern of patients with chronic hepatitis C virus (HCV) infection. Despite its clinical significance, fatigue in HCV is poorly understood and therefore invariably under-treated. A cognitive-behavioural approach offers a framework to understand and treat fatigue, but the characteristics of fatigue in chronic HCV infection have not been documented from a cognitive-behavioural perspective. This study captured the common and unique aspects of fatigue from a cognitive-behavioural perspective in individuals with HCV infection and clinically significant fatigue. DESIGN Cross-sectional, qualitative using a critical realism approach. METHODS Fourteen individuals (64% women; age >18 years) participated in semi-structured interviews. The interviews documented the features, course, and perceived antecedents of fatigue; fatigue-specific cognitions; fatigue management behaviours; and the functional impact of fatigue. RESULTS Participants' descriptions included the aspects of fatigue that have been targets of cognitive-behavioural therapy in other medical conditions, including attributing fatigue to the illness; expectation of chronicity; low control; and fatigue-driven coping. There were also components of fatigue experience that appear to be unique characteristics of fatigue related to HCV, including predominantly physical fatigue; high acceptance of fatigue; and liver-protective diet as a fatigue management behaviour. CONCLUSIONS This was the first study to document the experience of fatigue in chronic HCV infection in a cognitive-behavioural framework. The findings suggest that the cognitive-behavioural approach can be applied to fatigue in chronic HCV infection. This would open an avenue to alleviate fatigue and thus improve the primary patient-reported outcome of the disease. STATEMENT OF CONTRIBUTION What is already known on this subject? Fatigue is a key patient-reported outcome measure of chronic hepatitis C virus (HCV) infection. Fatigue management is not part of the standard care, because fatigue is poorly characterized in this population. What does this study add? A cognitive-behavioural approach can be applied to understand fatigue in HCV infection. Identified aspects of fatigue (antecedents, consequences, cognitions, behaviours) that can be treatment targets. Cognitive-behavioural therapy would open a new treatment avenue to alleviate fatigue in HCV infection.
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Affiliation(s)
- Dora Zalai
- Department of Psychology, Ryerson University, Toronto, Ontario, Canada
| | - Colleen E Carney
- Department of Psychology, Ryerson University, Toronto, Ontario, Canada
| | - Morris Sherman
- Department of Gastroenterology, University Health Network, University of Toronto, Canada
| | - Colin M Shapiro
- Department of Psychiatry, University Health Network, University of Toronto, Canada.,Department of Ophthalmology, University Health Network, University of Toronto, Canada
| | - Kelly McShane
- Department of Psychology, Ryerson University, Toronto, Ontario, Canada
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27
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Woznica AA, Carney CE, Kuo JR, Moss TG. The insomnia and suicide link: toward an enhanced understanding of this relationship. Sleep Med Rev 2015; 22:37-46. [DOI: 10.1016/j.smrv.2014.10.004] [Citation(s) in RCA: 72] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2014] [Revised: 10/03/2014] [Accepted: 10/06/2014] [Indexed: 11/25/2022]
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28
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Hartmann JA, Carney CE, Lachowski A, Edinger JD. Exploring the construct of subjective sleep quality in patients with insomnia. J Clin Psychiatry 2015; 76:e768-73. [PMID: 26132684 DOI: 10.4088/jcp.14m09066] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [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: 02/16/2014] [Accepted: 07/08/2014] [Indexed: 10/23/2022]
Abstract
OBJECTIVE The construct of subjective sleep quality is poorly understood. One widely used measure of subjective sleep quality is the Pittsburgh Sleep Quality Index (PSQI). The role of psychiatric illness in the association between the PSQI and a prospective, sleep diary-derived sleep quality measure (SDSQ) was investigated plus the degree to which the PSQI may reflect mood states. METHOD A sample of 211 insomnia patients (International Classification of Sleep Disorders, Second Edition) divided by the presence or absence of a comorbid psychiatric disorder (DSM-IV-TR) and recruited between January 2004 and February 2009, completed the PSQI (primary outcome) and 2 weeks of sleep diary monitoring. First, correlations between PSQI and SDSQ were compared; second, regression analyses were used to investigate whether the association between PSQI and SDSQ depends on diagnostic status; third, the differences in sleep quality between the groups, plus the contribution of anxiety and depression in explaining these differences, were explored. RESULTS The correlation between PSQI and SDSQ was significant only in the nonpsychiatric group (P < .001). The association between PSQI and SDSQ was moderated by diagnostic status: it was weaker in psychiatric patients (P = .047). Patients with psychiatric comorbidity scored significantly higher on the PSQI than those without (P < .001); this difference disappeared after controlling for anxiety. There were no group differences for the SDSQ. CONCLUSIONS The present findings suggest that (1) psychiatric patients may be more biased in their retrospective sleep quality ratings, and (2) the PSQI total score may reflect sleep-related distress. The use of a prospective sleep diary measure in patients with a psychiatric disorder is recommended.
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Affiliation(s)
- Jessica A Hartmann
- Orygen, The National Centre of Excellence in Youth Mental Health, University of Melbourne, 35 Poplar Road, Parkville VIC 3052, Australia
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Zalai D, Sherman M, McShane K, Shapiro CM, Carney CE. The importance of fatigue cognitions in chronic hepatitis C infection. J Psychosom Res 2015; 78:193-8. [PMID: 25433976 DOI: 10.1016/j.jpsychores.2014.11.011] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2014] [Revised: 11/09/2014] [Accepted: 11/12/2014] [Indexed: 12/17/2022]
Abstract
UNLABELLED Chronic Hepatitis C virus (HCV) infection is a source of significant public health burden worldwide. Fatigue is a cardinal patient reported consequence of the disease. HCV infection associated fatigue leads to significant impairment in the quality of life and day-to-day functioning. Despite its clinical significance, the factors that contribute to adverse impact of fatigue in HCV infection are largely unknown. OBJECTIVES This study evaluated the contributions of insomnia, depression symptoms, and fatigue-specific cognitions to fatigue-related functional impairment. METHODS Fatigue, insomnia, depression symptoms, as well as fatigue cognitions were assessed in participants (36% females; age>18 years, N=115) with chronic HCV infection at a tertiary hepatitis clinic. RESULTS Sixty percent of participants reported clinically significant fatigue (Fatigue Severity Index FSS ≥ 4). Comorbidities and fatigue perceptions accounted for 61% of the variation of fatigue. Fatigue perceptions were the main predictors of adverse fatigue outcomes (B=.114, 95% CI=.054-.154). Patients with clinically significant fatigue were four-times more likely than less fatigued patients to believe that the main cause of their fatigue was the infection. CONCLUSION Patients' beliefs about their fatigue were the main predictors of adverse fatigue outcomes. These results suggest that fatigue associated with chronic hepatitis C infection can be conceptualized using a cognitive behavioral approach. This was the first study to evaluate the role of both comorbid mood/sleep and cognitive predictors of fatigue in a single model. Integrating the findings into existing treatment strategies could improve patient reported outcomes in chronic hepatitis C infection.
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Affiliation(s)
- Dora Zalai
- Dept. of Psychology, Ryerson University, Toronto, Canada.
| | - Morris Sherman
- Dept. of Gastroenterology, University Health Network, University of Toronto, Toronto, Canada
| | - Kelly McShane
- Dept. of Psychology, Ryerson University, Toronto, Canada
| | - Colin M Shapiro
- Dept. of Psychiatry, University Health Network, University of Toronto, Toronto, Canada; Dept. of Ophthalmology, University Health Network, University of Toronto, Toronto, Canada
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Moss TG, Carney CE, Haynes P, Harris AL. Is daily routine important for sleep? An investigation of social rhythms in a clinical insomnia population. Chronobiol Int 2014; 32:92-102. [PMID: 25187987 DOI: 10.3109/07420528.2014.956361] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [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: 11/13/2022]
Abstract
Social rhythms, also known as daily routines (e.g. exercise, of school or work, recreation, social activities), have been identified as potential time cues to help to regulate the biological clock. Past research has shown links between regularity and healthy sleep. This study examined the regularity and frequency of daytime activities in a clinical insomnia population and a good sleeper comparison group. Participants (N = 69) prospectively monitored their sleep and daily activities for a 2-week period. Although participants with insomnia and good sleepers had similar levels of activity, relative to good sleepers, those with insomnia were less regular in their activities. Findings from this study add to the growing number of studies that highlight the relative importance of the regularity of daytime activities on sleep. Accordingly, future research should test treatment components that focus on regulating daytime activities, which would likely improve treatment outcomes.
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Affiliation(s)
- Taryn G Moss
- Department of Psychology, Ryerson University , Toronto, Ontario , Canada and
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Abstract
Fatigue is a concern for both people with insomnia and with depression, yet it remains poorly understood. Participants (N = 62) included those meeting Diagnostic and Statistical Manual of Mental Disorders (4th ed., text revision) criteria for insomnia and major depressive disorder (MDD). Multiple regression examined sleep, mood, activity, and cognitive factors as predictors of mental and physical fatigue. Only the cognitive factors (i.e., unhelpful beliefs about sleep and symptom-focused rumination) were predictive of both physical and mental fatigue. Beliefs about not being able to function and needing to avoid activities after a poor night of sleep were related to both types of fatigue. Targeting these beliefs via cognitive therapy and encouraging patients to test maladaptive beliefs about sleep may enhance fatigue response in those with MDD and insomnia.
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Affiliation(s)
- Colleen E Carney
- a Department of Psychology Ryerson University , Toronto , Ontario , Canada
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Roecklein KA, Carney CE, Wong PM, Steiner JL, Hasler BP, Franzen PL. The role of beliefs and attitudes about sleep in seasonal and nonseasonal mood disorder, and nondepressed controls. J Affect Disord 2013; 150:466-73. [PMID: 23706838 PMCID: PMC3968775 DOI: 10.1016/j.jad.2013.04.041] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2013] [Accepted: 04/26/2013] [Indexed: 11/30/2022]
Abstract
BACKGROUND Unhelpful sleep-related cognitions play an important role in insomnia and major depressive disorder, but their role in seasonal affective disorder has not yet been explored. Therefore, the purpose of this study was to determine if individuals with seasonal affective disorder (SAD) have sleep-related cognitions similar to those with primary insomnia, and those with insomnia related to comorbid nonseasonal depression. METHODS Participants (n=147) completed the Dysfunctional Beliefs and Attitudes about Sleep 16-item scale (DBAS-16) and the Structured Interview Guide for the Hamilton Depression Rating Scale, Seasonal Affective Disorder Version (SIGH-SAD), which assesses self reported sleep problems including early, middle, or late insomnia, and hypersomnia in the previous week. All participants were assessed in winter, and during an episode for those with a depressive disorder. RESULTS Individuals with SAD were more likely to report hypersomnia on the SIGH-SAD, as well as a combined presentation of hypersomnia and insomnia on the Pittsburgh Sleep Quality Index (PSQI). The SAD group reported DBAS-16 scores in the range associated with clinical sleep disturbance, and DBAS-16 scores were most strongly associated with reports of early insomnia, suggesting circadian misalignment. LIMITATIONS Limitations include the self-report nature of the SIGH-SAD instrument on which insomnia and hypersomnia reports were based. CONCLUSIONS Future work could employ sleep- or chronobiological-focused interventions to improve clinical response in SAD.
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Affiliation(s)
- Kathryn A. Roecklein
- University of Pittsburgh, Department of Psychology, 210 South Bouquet Street, Pittsburgh, PA, 15260
| | - Colleen E. Carney
- Ryerson University, Department of Psychology, JOR-928, Toronto, Ontario, Canada
| | - Patricia M. Wong
- University of Pittsburgh, Department of Psychology, 210 South Bouquet Street, Pittsburgh, PA, 15260
| | - Jessica L. Steiner
- University of Pittsburgh, Department of Psychology, 210 South Bouquet Street, Pittsburgh, PA, 15260
| | - Brant P. Hasler
- University of Pittsburgh School of Medicine, Department of Psychiatry, 3811 O'Hara St., Pittsburgh, PA, 15213
| | - Peter L. Franzen
- University of Pittsburgh School of Medicine, Department of Psychiatry, 3811 O'Hara St., Pittsburgh, PA, 15213
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Abstract
STUDY OBJECTIVES Research suggests that rumination may play an important role in insomnia. Whereas some have suggested that rumination mainly relates to depression, the evidence suggests that there may be insomnia-specific rumination. This paper explores insomnia symptom rumination across two distinct samples of varying levels of depressed mood and insomnia symptom severity. METHODS The first sample consisted of nonclinical participants (N = 327) with a range of insomnia and depressed mood symptoms, and the second sample consisted of those who met both Major Depressive Disorder and Insomnia diagnoses (N = 66). Rather than relying on a measure developed for those with depression, we developed and tested an insomnia-specific measurement scale based on items from previous rumination studies and the addition of items derived from common daytime insomnia symptoms. RESULTS Internal consistency was highly acceptable across the two samples for the new insomnia-specific rumination measure (Cronbach α was 0.93 and 0.94). In the first study, poor sleepers reported significantly higher levels of daytime symptom rumination than did good sleepers. Across both studies, rumination about daytime insomnia symptoms and depression were significantly correlated; however, insomnia rumination scores predicted insomnia even after controlling for depression. Moreover, in Study 2, insomnia-specific rumination was related to insomnia, but general depressive rumination was not predictive of insomnia. CONCLUSIONS The findings provide support for the use of this insomnia-specific rumination scale; moreover the findings support previous observances regarding rumination about daytime insomnia symptoms that are not exclusive to depression.
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Schwartz DR, Carney CE. Mediators of cognitive-behavioral therapy for insomnia: A review of randomized controlled trials and secondary analysis studies. Clin Psychol Rev 2012; 32:664-75. [DOI: 10.1016/j.cpr.2012.06.006] [Citation(s) in RCA: 83] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2012] [Revised: 05/02/2012] [Accepted: 06/25/2012] [Indexed: 11/29/2022]
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Copeland AL, Businelle MS, Stewart DW, Patterson SM, Rash CJ, Carney CE. Identifying Barriers to Entering Smoking Cessation Treatment Among Socioeconomically Disadvantaged Smokers. J Smok Cessat 2012. [DOI: 10.1375/jsc.5.2.164] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
AbstractBackground:Efficacious smoking cessation interventions exist, yet few smokers utilise available resources such as psychosocial treatment programs and pharmacotherapy. The goals of the present study were to (1) identify perceived barriers to entering smoking cessation treatment programs among socioeconomically disadvantaged smokers, who are presently underrepresented in smoking cessation interventions; (2) determine what variables are most important in predicting the barriers identified (i.e., age, gender, ethnicity, income, nicotine dependence level, smoking rate, years smoking, stage of change, presence of smoking-related illness and medical insurance status).Methods:Responses from socioeconomically disadvantaged smokers (N= 343) were collected in 2004–2005 and analysed to develop the Treatment Barriers Questionnaire, a 40-item measure of reasons for not entering smoking cessation programs. Study methods were approved by the Institutional Review Board of Louisiana State University; informed consent procedures were employed.Results:Principal components analysis yielded seven scales named for their theme: (1) Preparedness to Quit Smoking; (2) Work and Time Constraints; (3) Smokers Can or Should Quit on Own; (4) Opinions about Professional Assistance; (5) Mobility Limitations; (6) Insurance Limitations and (7) Misinformation about Professional Assistance. Gender, ethnicity, daily smoking rate, nicotine dependence and stage of change were significant predictors in regression analyses for scales 1,F(10, 201) = 7.83,p< .001,R2= .29, 2F(10, 201) = 2.30,p< .05,R2= .11, and 3,F(10, 201) = 3.58,p< .001,R2= .16. Conclusions: Results can inform efforts to facilitate entry and retention of smokers in cessation programs.
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Carney CE, Buysse DJ, Ancoli-Israel S, Edinger JD, Krystal AD, Lichstein KL, Morin CM. The consensus sleep diary: standardizing prospective sleep self-monitoring. Sleep 2012; 35:287-302. [PMID: 22294820 DOI: 10.5665/sleep.1642] [Citation(s) in RCA: 1092] [Impact Index Per Article: 91.0] [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: 11/03/2022] Open
Abstract
STUDY OBJECTIVES To present an expert consensus, standardized, patient-informed sleep diary. METHODS AND RESULTS Sleep diaries from the original expert panel of 25 attendees of the Pittsburgh Assessment Conference(1) were collected and reviewed. A smaller subset of experts formed a committee and reviewed the compiled diaries. Items deemed essential were included in a Core sleep diary, and those deemed optional were retained for an expanded diary. Secondly, optional items would be available in other versions. A draft of the Core and optional versions along with a feedback questionnaire were sent to members of the Pittsburgh Assessment Conference. The feedback from the group was integrated and the diary drafts were subjected to 6 focus groups composed of good sleepers, people with insomnia, and people with sleep apnea. The data were summarized into themes and changes to the drafts were made in response to the focus groups. The resultant draft was evaluated by another focus group and subjected to lexile analyses. The lexile analyses suggested that the Core diary instructions are at a sixth-grade reading level and the Core diary was written at a third-grade reading level. CONCLUSIONS The Consensus Sleep Diary was the result of collaborations with insomnia experts and potential users. The adoption of a standard sleep diary for insomnia will facilitate comparisons across studies and advance the field. The proposed diary is intended as a living document which still needs to be tested, refined, and validated.
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Hood HK, Carney CE, Harris AL. Rethinking safety behaviors in insomnia: examining the perceived utility of sleep-related safety behaviors. Behav Ther 2011; 42:644-54. [PMID: 22035993 DOI: 10.1016/j.beth.2011.02.004] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2010] [Revised: 02/09/2011] [Accepted: 02/10/2011] [Indexed: 11/19/2022]
Abstract
Harvey's cognitive model of insomnia (2002a) proposes that sleep-related safety behaviors play a central role in the maintenance of insomnia because such maladaptive coping strategies are thought to reinforce threat-based appraisals of the likelihood and consequences of poor sleep. Research to date has assessed the frequency of safety behavior use in those with insomnia only; however, in addition to the frequency of occurrence, the function of safety behaviors (i.e., a belief that they will prevent a feared outcome from occurring), may be an important consideration. The purpose of this study was to examine sleep-related safety behaviors based on an expanded theoretical understanding of such behaviors across psychological disorders; that is, by examining both their frequency and perceived utility. Undergraduate students (N=376) completed an online survey about their sleep, mood, and use of sleep-related safety behaviors. Insomnia severity was associated with a greater perceived need to use safety behaviors (i.e., utility) but not with frequency of safety behavior use. Higher perceived utility of safety behaviors was also associated with unhelpful beliefs about sleep, fear and avoidance of fatigue, and both general and sleep-specific helplessness. These results suggest that these behaviors and the associated underlying maladaptive beliefs may be important targets in cognitive behavioral therapy for insomnia. The current study extends the existing literature and refines the concept of safety behaviors in insomnia to include both the function and frequency of these behaviors.
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Affiliation(s)
- Heather K Hood
- Department of Psychology, Ryerson University, 350 Victoria Street, Toronto, Ontario, Canada M5B 2K3
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Edinger JD, Wyatt JK, Stepanski EJ, Olsen MK, Stechuchak KM, Carney CE, Chiang A, Crisostomo MI, Lineberger MD, Means MK, Radtke RA, Wohlgemuth WK, Krystal AD. Testing the Reliability and Validity of DSM-IV-TR and ICSD-2 Insomnia Diagnoses. ACTA ACUST UNITED AC 2011; 68:992-1002. [PMID: 21646568 DOI: 10.1001/archgenpsychiatry.2011.64] [Citation(s) in RCA: 84] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Jack D Edinger
- Veterans Affairs Medical Center, Durham, North Carolina, USA.
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Carney CE, Moss TG, Harris AL, Edinger JD, Krystal AD. Should we be anxious when assessing anxiety using the Beck Anxiety Inventory in clinical insomnia patients? J Psychiatr Res 2011; 45:1243-9. [PMID: 21482427 PMCID: PMC3157494 DOI: 10.1016/j.jpsychires.2011.03.011] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2010] [Revised: 03/16/2011] [Accepted: 03/17/2011] [Indexed: 10/18/2022]
Abstract
Assessing for clinical levels of anxiety is crucial, as comorbid insomnias far outnumber primary insomnias (PI). Such assessment is complex since those with Anxiety Disorders (AD) and those with PI have overlapping symptoms. Because of this overlap, we need studies that examine the assessment of anxiety in clinical insomnia groups. Participants (N = 207) were classified as having insomnia: 1) without an anxiety disorder (I-ND), or 2) with an anxiety disorder (I-AD). Mean Beck Anxiety Inventory (BAI) item responses were compared using multivariate analysis of variance (MANOVA) and follow-up ANOVAs. As a validity check, a receiver operating characteristic (ROC) curve analysis was conducted to determine if the BAI suggested clinical cutoff was valid for identifying clinical levels of anxiety in this comorbid patient group. The I-ND had lower mean BAI scores than I-AD. There were significant group differences on 12 BAI items. The ROC curve analysis revealed the suggested BAI cutoff (≥16) had 55% sensitivity and 78% specificity. Although anxiety scores were highest in those with insomnia and an anxiety disorder, those with insomnia only had scores in the mild range for anxiety. Nine items did not distinguish between those insomnia sufferers with and without an anxiety disorder. Additionally, published cutoffs for the BAI were not optimal for identifying anxiety disorders in those with insomnia. Such limitations must be considered before using this measure in insomnia patient groups. In addition, the poor specificity and high number of overlapping symptoms between insomnia and anxiety highlight the diagnostic challenges facing clinicians.
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Affiliation(s)
- Colleen E. Carney
- Department of Psychology, Ryerson University 350 Victoria Street, 8th Floor Jorgenson Hall, Toronto, Ontario, M5B 2K3
| | - Taryn G. Moss
- Department of Psychology, Ryerson University 350 Victoria Street, 8th Floor Jorgenson Hall, Toronto, Ontario, M5B 2K3
| | - Andrea L. Harris
- Department of Psychology, Ryerson University 350 Victoria Street, 8th Floor Jorgenson Hall, Toronto, Ontario, M5B 2K3
| | - Jack D. Edinger
- Duke University Medical Center, Durham, NC, United States, Durham VA Medical Center, 508 Fulton Avenue, Durham, NC 27705, United States
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Carney CE, Harris AL, Friedman J, Segal ZV. Residual sleep beliefs and sleep disturbance following Cognitive Behavioral Therapy for major depression. Depress Anxiety 2011; 28:464-70. [PMID: 21400641 DOI: 10.1002/da.20811] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.4] [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: 10/14/2010] [Revised: 02/09/2011] [Accepted: 02/14/2011] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND Sleep disturbance is a commonly reported residual symptom after effective depression treatment. This residual sleep impairment, as well as the presence of problem levels of certain sleep beliefs, may be important for depressive relapse prevention, and as such should be addressed in treatment. The following study examined residual sleep disturbance and residual maladaptive sleep beliefs in those treated with Cognitive Behavior Therapy for depression. METHODS Participants (N = 24) were clinic patients seeking treatment for depression at a community clinic. Repeated measures analyses of variance tested pre- to posttreatment change on depression symptoms, general negative beliefs, sleep quality, and maladaptive sleep beliefs. RESULTS As expected, significant time effects were found for depressive symptoms and general negative beliefs. Sleep quality scores also decreased significantly at posttreatment; however, 92% of those no longer meeting depressive criteria continued to endorse residual sleep disturbance, according to an established clinical cutoff score of > 5 on a validated measure of sleep quality (the Pittsburgh Sleep Quality Index). There were no significant pre- to posttreatment changes for maladaptive sleep beliefs. CONCLUSIONS The results indicate that sleep disturbance and maladaptive sleep-related beliefs remain a problematic residual symptom of remitted depression. These findings are discussed with reference to improving cognitive behavioral treatments for depression in order to help reduce rates of residual sleep problems.
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Affiliation(s)
- Colleen E Carney
- Ryerson University, University of Toronto, Toronto, Ontario, Canada.
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Sánchez-Ortuño MM, Carney CE, Edinger JD, Wyatt JK, Harris A. Moving beyond average values: assessing the night-to-night instability of sleep and arousal in DSM-IV-TR insomnia subtypes. Sleep 2011; 34:531-9. [PMID: 21461332 DOI: 10.1093/sleep/34.4.531] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.2] [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: 11/14/2022] Open
Abstract
STUDY OBJECTIVES We explored differences between individuals with DSM-IV-TR diagnoses of primary insomnia (PI) and insomnia related to a mental disorder (IMD) by using serial measurements of self-reported sleep variables (sleep onset latency, SOL; wake after sleep onset, WASO; total sleep time, TST; sleep efficiency, SE), and visual analogue scale ratings of 2 forms of bedtime arousal (cognitive and emotional). Furthermore, we sought to examine the relationship between sleep and arousal within each diagnostic subgroup. DESIGN Between-group and within-group comparisons. SETTING Duke and Rush University Medical Centers, USA. PARTICIPANTS One hundred eighty-seven insomnia sufferers (126 women, average age 47.15 years) diagnosed by sleep specialists at 2 sleep centers as PI patients (n=126) and IMD patients (n=61). INTERVENTIONS N/A. MEASUREMENTS AND RESULTS Multilevel models for sleep measures indicated that IMD displayed significantly more instability across nights in their TST (i.e., larger changes) than did PI patients. With respect to pre-sleep arousal, IMD patients exhibited higher mean levels of emotional arousal, as well as more instability on the nightly ratings of this measure. Within the PI group, correlational analyses revealed a moderate relationship between the 2 arousal variables and SOL (r values 0.29 and 0.26), whereas the corresponding correlations were negligible and statistically nonsignificant in the IMD group. CONCLUSIONS We found a number of differences on nighttime variables between those diagnosed with primary insomnia and those diagnosed with insomnia related to a mental disorder. These differences imply different perpetuating mechanisms involved in their ongoing sleep difficulties. Additionally, they support the categorical distinctiveness and the concurrent validity of these insomnia subtypes.
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Carney CE, Harris AL, Moss TG, Edinger JD. Distinguishing rumination from worry in clinical insomnia. Behav Res Ther 2010; 48:540-6. [PMID: 20362977 DOI: 10.1016/j.brat.2010.03.004] [Citation(s) in RCA: 114] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2010] [Revised: 03/03/2010] [Accepted: 03/05/2010] [Indexed: 10/19/2022]
Abstract
Research has found that repetitive thought processes, such as worry and rumination, play an important role in several disorders; however, these cognitive processes have not yet been examined in insomnia. This study explores rumination and worry in insomnia by examining: 1) whether those high and low on rumination and worry differ on subjective sleep measures, and 2) whether rumination and worry are distinct processes in insomnia. Participants (N=242) were diagnosed with an insomnia disorder by sleep experts. Participants completed measures of worry and rumination and maintained a 2-week daily sleep log. Results of a multivariate analysis of variance found no main effect of worry; although high and low ruminators differed on several sleep log indices, including sleep efficiency, wakefulness after sleep onset and sleep quality. Factor analysis supported the idea that rumination and worry are separate constructs. Whereas previous research has focused on worry in insomnia, these findings suggest that rumination is important for understanding sleep disturbance. Further, although rumination and worry are both repetitive thought processes, these results indicate that they are distinct processes within insomnia and should be treated as such. The results are discussed with respect to treatment implications for Cognitive Behavioural Therapy for Insomnia.
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Affiliation(s)
- Colleen E Carney
- Sleep and Depression Laboratory, Ryerson University, 350 Victoria Street, Toronto, Ontario, Canada.
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Carney CE, Edinger JD, Morin CM, Manber R, Rybarczyk B, Stepanski EJ, Wright H, Lack L. Examining maladaptive beliefs about sleep across insomnia patient groups. J Psychosom Res 2010; 68:57-65. [PMID: 20004301 PMCID: PMC2796256 DOI: 10.1016/j.jpsychores.2009.08.007] [Citation(s) in RCA: 98] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2008] [Revised: 08/10/2009] [Accepted: 08/11/2009] [Indexed: 10/20/2022]
Abstract
OBJECTIVES Unhelpful beliefs about sleep have been linked to insomnia, and increasing one's cognitive flexibility about sleep has been linked to posttreatment sleep improvement. This study evaluated whether levels of such beliefs differ across insomnia groups and whether there are particular beliefs that differ for specific insomnia subtypes. METHODS Participants (N=1384) were people with insomnia and good sleepers ranging from 18 to 89 years old (mean=42.6; S.D.=19.4). Data from previous studies at five insomnia clinical sites were pooled to examine responses on the Dysfunctional Beliefs and Attitudes about Sleep Scale (DBAS) across differing insomnia groups. RESULTS Group analyses revealed that those from community-based insomnia clinics and those who are hypnotic-dependent generally had the highest levels of unhelpful sleep-related beliefs. With the exception of beliefs about sleep needs (wherein only community sleep clinic patients had high scores relative to good sleepers), all insomnia groups had higher scores on the 16-item DBAS (DBAS-16) than good sleepers. A validity analysis suggested that a DBAS-16 index score of >3.8 represented the level of unhelpful beliefs associated with clinically significant insomnia, although a slightly lower cutoff may be useful for identifying an unhelpful degree of sleep-related beliefs in highly screened primary-insomnia-only and medical patient groups. CONCLUSIONS This study offers descriptive data for the use of DBAS-16 across insomnia subgroups, which will help the user understand what degree of maladaptive sleep beliefs is most strongly associated with clinically significant levels of insomnia. Results also may have implications for cognitive targeting during treatment for particular insomnia groups.
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Affiliation(s)
| | | | | | | | | | | | | | - Leon Lack
- Flinders University, Adelaide, Australia
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Edinger JD, Olsen MK, Stechuchak KM, Means MK, Lineberger MD, Kirby A, Carney CE. Cognitive behavioral therapy for patients with primary insomnia or insomnia associated predominantly with mixed psychiatric disorders: a randomized clinical trial. Sleep 2009; 32:499-510. [PMID: 19413144 DOI: 10.1093/sleep/32.4.499] [Citation(s) in RCA: 166] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE This study was conducted to evaluate the efficacy of cognitive behavioral therapy (CBT) against a sleep hygiene education control therapy in patients with primary or comorbid insomnia. DESIGN AND SETTING Randomized, parallel-group, clinical trial conducted at a single Veterans Affairs medical center, with recruitment from March 2001 to June 2005. PARTICIPANTS Eighty-one adults (n = 11 women; mean age, 54.2 years) with chronic primary (n = 40) or comorbid insomnia associated predominantly with mixed psychiatric disorders (n = 41). INTERVENTIONS Patients, screened via structured interviews and diagnostic polysomnography, were randomly assigned to receive CBT (sleep education, stimulus control, and time-in-bed restrictions; 20 patients with primary and 21 with comorbid insomnia), or sleep hygiene (SH: education about aspects of lifestyle and the bedroom environment that affect sleep; 20 patients with primary and 20 with comorbid insomnia). Outpatient treatment included 4 biweekly sessions with a posttreatment assessment and a follow-up conducted at 6 months. MEASURES AND RESULTS Participants completed actigraphy and sleep diaries for 2 weeks prior to therapy, during a 2-week posttreatment assessment, and during 2 weeks at follow-up. They also completed questionnaires measuring global insomnia symptoms, general sleep quality, and sleep-disruptive beliefs before treatment, immediately following treatment, and at the follow-up time point. Consistent with previous studies, CBT outperformed sleep hygiene across several study outcome measures for the sample as a whole. Statistical analyses showed no significant 3-way interaction of treatment group, time, and insomnia type for any of the sleep or questionnaire measures, suggesting the benefits of CBT over sleep hygiene were comparable for patients with primary insomnia and comorbid insomnia. Moreover, only 1 of several indexes of clinically notable improvement suggested a significantly better response to CBT by patients with primary insomnia, as compared with those with comorbid insomnia. CONCLUSIONS A fixed 4-session "dose" of CBT produced similar benefits for patients with primary and those with comorbid insomnia across most measures examined. Thus, CBT appears to be a viable psychological insomnia therapy both for those with primary insomnia and for groups composed mainly of patients with insomnia and nonpsychotic psychiatric conditions.
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Affiliation(s)
- Jack D Edinger
- Psychology Service, VA Medical Center Durham, NC 27705, USA.
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Carney CE, Ulmer C, Edinger JD, Krystal AD, Knauss F. Assessing depression symptoms in those with insomnia: an examination of the beck depression inventory second edition (BDI-II). J Psychiatr Res 2009; 43:576-82. [PMID: 18954876 PMCID: PMC2677199 DOI: 10.1016/j.jpsychires.2008.09.002] [Citation(s) in RCA: 66] [Impact Index Per Article: 4.4] [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: 03/12/2008] [Revised: 09/03/2008] [Accepted: 09/04/2008] [Indexed: 11/30/2022]
Abstract
BACKGROUND Due to concerns about overlapping symptomatology between medical conditions and depression, the validity of the beck depression inventory (BDI-II) has been assessed in various medical populations. Although major depressive disorder (MDD) and primary insomnia (PI) share some daytime symptoms, the BDI-II has not been evaluated for use with insomnia patients. METHOD Participants (N=140) were screened for the presence of insomnia using the Duke structured clinical interview for sleep disorders (DSISD), and evaluated for diagnosis of MDD using the structured clinical interview for DSM-IV-TR (SCID). Participants' mean BDI-II item responses were compared across two groups [insomnia with or without MDD) using multivariate analysis of variance (MANOVA), and the accuracy rates of suggested clinical cutoffs for the BDI-II were evaluated using a receiver operating characteristic (ROC) curve analysis. RESULTS The insomnia with depression group had significantly higher scores on several items; however, the groups did not differ on insomnia, fatigue, concentration problems, irritability, libido, increased appetite, and thoughts relating to suicide, self-criticism and punishment items. The ROC curve analysis revealed moderate accuracy for the BDI-II's identification of depression in those with insomnia. The suggested BDI cutoff of >or=17 had 81% sensitivity and 79% specificity. Use of the mild cutoff for depression (>or=14) had high sensitivity (91%) but poor specificity (66%). CONCLUSION Several items on the BDI-II might reflect sleep disturbance symptoms rather than depression per se. The recommended BDI-II cutoffs in this population have some support but a lower cutoff could result in an overclassification of depression in insomnia patients, a documented problem in the clinical literature. Understanding which items discriminate insomnia patients without depression may help address this nosological issue.
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Affiliation(s)
| | | | - Jack D. Edinger
- Duke University Medical Center, Durham, NC
- Durham VA Medical Center, NC
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Edinger JD, Carney CE, Wohlgemuth WK. Pretherapy cognitive dispositions and treatment outcome in cognitive behavior therapy for insomnia. Behav Ther 2008; 39:406-16. [PMID: 19027437 DOI: 10.1016/j.beth.2007.12.001] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.1] [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: 07/02/2007] [Revised: 12/02/2007] [Accepted: 12/21/2007] [Indexed: 11/16/2022]
Abstract
This study consisted of secondary analyses of data from 2 randomized clinical trials to test whether pretherapy cognitions predict CBT outcomes. The sample consisted of 155 primary insomnia patients with sleep maintenance complaints. Of these, 98 were randomized to CBT, 23 were assigned to progressive muscle relaxation training (PMR), and 34 were assigned to a control (sham therapy or wait-list) condition (CON). All patients completed the Dysfunctional Beliefs and Attitudes about Sleep Scale (DBAS), a sleep-related Self-Efficacy Scale (SES) and nightly sleep diaries for 2 weeks prior to receiving their assigned treatment. They then completed sleep diaries throughout an 8-week acute treatment period and during a 2-week period at a posttherapy follow-up. A subset of the sample (n=67) also completed polysomnography immediately before and after completing their assigned treatment. Preliminary regression analyses conducted with a small subset (n=15) of the patients receiving CBT showed those with relatively high levels of unhelpful sleep-related beliefs (Type 1 patients), as reflected by their pretherapy responses to the DBAS and SES questionnaires, showed markedly greater reductions in nocturnal wakefulness in response to CBT than did those (Type 2 patients) reporting less pronounced sleep-related beliefs. Given these findings, we used the regression equation derived from our initial analyses to dichotomize our entire sample into Type 1 (n=82; 52.9%) and Type 2 (n=73; 47.1%) subgroups. Subsequent comparisons showed CBT-treated Type 1 patients had significantly less wake time after sleep onset during most of the 8-week treatment phase than did the Type 1 and 2 individuals assigned to either PMR or CON. Relative to patients assigned to the PMR and CON conditions, CBT-treated Type 1 patients showed better performance across multiple subjective and objective benchmarks of clinically significant improvement, whereas the CBT-treated Type 2 patients did not. Results suggest that insomnia patients' pretherapy cognitive dispositions predict CBT outcome, and those with a pronounced sense of sleep-related helplessness are best suited for this treatment which targets this cognitive stance.
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Affiliation(s)
- Jack D Edinger
- VA and Duke University Medical Centers, Durham, NC 27705, USA.
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Edinger JD, Means MK, Carney CE, Krystal AD. Psychomotor performance deficits and their relation to prior nights' sleep among individuals with primary insomnia. Sleep 2008; 31:599-607. [PMID: 18517030 DOI: 10.1093/sleep/31.5.599] [Citation(s) in RCA: 128] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To examine psychomotor (reaction time) performance deficits and their relation to subjective and objective sleep measures among individuals with primary insomnia (PI). DESIGN AND SETTING This study was conducted at affiliated VA and academic medical centers using a matched-groups, cross-sectional research design. PARTICIPANTS Seventy-nine (43 women) individuals with PI (MAge = 50.0 +/- 17.1 y) and 84 (41 women) well-screened normal sleepers (MAge = 48.6 +/- 16.8 y). METHODS AND MEASURES Participants underwent 3 nights of polysomnography (PSG) followed by daytime testing with a 4-trial multiple sleep latency test (MSLT). Before each MSLT nap, they rated their sleepiness and completed a performance battery that included simple reaction time (SRT), continuous performance (CPT), and 4 switching attention (SAT) tests. Performance measures included the mean response latency and the standard deviation of each subject's within-test response latencies. RESULTS PI sufferers reported greater (P = 0.001) daytime sleepiness, but were significantly (P = 0.02), more alert than normal sleepers on the MSLT. Multivariate analyses showed the PI group had significantly longer response latencies and greater response variability across many of the subtests than did the controls. Regression analyses showed that both PSG- and diary-based sleep measures contributed to the prediction of daytime performance indices, although objective wake time after sleep onset appeared the best single predictor of the daytime measures. CONCLUSIONS Results confirm that PI sufferers do show relative psychomotor performance deficits when responding to challenging reaction time tasks, and these deficits appear related to both objective and subjective sleep deficits. Findings support PI patients' diurnal complaints and suggest the usefulness of complex reaction time tasks for assessing them.
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Edinger JD, Wohlgemuth WK, Radtke RA, Coffman CJ, Carney CE. Dose-response effects of cognitive-behavioral insomnia therapy: a randomized clinical trial. Sleep 2007; 30:203-12. [PMID: 17326546 DOI: 10.1093/sleep/30.2.203] [Citation(s) in RCA: 131] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
SUBJECT OBJECTIVE To determine the optimal number of therapist-guided Cognitive-Behavioral Insomnia Therapy (CBT) sessions required for treating primary sleep-maintenance insomnia. DESIGN AND SETTING Randomized, parallel-group, clinical trial at a single academic medical center. Outpatient treatment lasted 8 weeks with final follow-up conducted at 6 months. PARTICIPANTS 86 adults (43 women; mean age 55.4 +/- 9.7 years) with primary sleep-maintenance insomnia (nightly mean wake time after sleep onset [WASO] = 93.4 +/- 44.5 minutes). INTERVENTIONS One (week 1), 2 (weeks 1 and 5), 4 (biweekly), or 8 (weekly) individual CBT sessions scheduled over an 8-week treatment phase, compared with an 8-week no-treatment waiting period (WL). MEASUREMENT Sleep diary and actigraphy measures of total sleep time, onset latency, WASO, total wake time, and sleep efficiency, as well as questionnaire measures of global insomnia symptoms, sleep related self-efficacy, and mood. RESULTS Statistical tests of subjective/objective sleep measures favored the 1- and 4-session CBT doses over the other CBT doses and WL control. However, comparisons of pretreatment data with data acquired at the 6-month follow-up showed only the 4-session group showed significant long-term improvements in objective wake time and sleep efficiency measures. Additionally, 58.3% of the patients receiving 4 CBT sessions met criteria for clinically significant improvement by the end of treatment compared to 43.8% of those receiving 1 CBT session, 22.2% of those provided 2 sessions, 35.3% of those receiving 8 sessions, and 9.1% of those in the control condition. CONCLUSION Findings suggest that 4 individual, biweekly sessions represents the optimal dosing for the CBT intervention tested. Additional dose-response studies are warranted to test CBT models that contain additional treatment components or are delivered via group therapy.
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Carney CE, Segal ZV, Edinger JD, Krystal AD. A comparison of rates of residual insomnia symptoms following pharmacotherapy or cognitive-behavioral therapy for major depressive disorder. J Clin Psychiatry 2007; 68:254-60. [PMID: 17335324 DOI: 10.4088/jcp.v68n0211] [Citation(s) in RCA: 193] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
OBJECTIVE A number of pharmacologic studies have documented that insomnia is among the most commonly reported residual symptoms after remission from depression. Residual symptoms after remission are particularly relevant because these symptoms confer greater risk for subsequent depression. This study was the first to date to examine residual insomnia after cognitive-behavioral therapy (CBT) for depression and to compare CBT with pharmacotherapy for depression on residual insomnia rates. METHOD This naturalistic study examined rates of posttreatment insomnia complaints in patients (N = 94) who had been diagnosed with major depressive disorder (MDD), according to DSM-IV criteria, and who remitted from MDD after completing at least 20 weeks of either CBT or pharmacotherapy at an outpatient clinic specializing in mood disorders. Participants were randomly assigned to the treatment conditions, but only the data from those who completed treatment and remitted were analyzed. Primary outcome measure was the 17-item Hamilton Rating Scale for Depression. Data were collected from October 1, 1999, to September 23, 2003. Groups were compared using a chi(2) for nominal data. RESULTS The rate of posttreatment insomnia was 22% for sleep-onset insomnia, 26% for sleep-maintenance insomnia, and 17% for early morning awakenings, and the rates did not statistically differ across the 2 treatment groups. CONCLUSION Although CBT and pharmacotherapy effectively addressed depression in these patients and addressed insomnia symptoms for many, there were a number of patients with residual insomnia. Whereas there appears to be no difference between CBT and pharmacotherapy with regard to rates of residual insomnia, the rates of such insomnia remaining after these treatments suggest that adjunctive sleep treatment to specifically address insomnia may be necessary for some MDD patients.
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Affiliation(s)
- Colleen E Carney
- Duke Insomnia and Sleep Research Program, Duke University Medical Center, Durham, NC 27710, USA.
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