Sleep health and aging: Recommendations for promoting healthy sleep among older adults: A National Sleep Foundation report

OBJECTIVES

Sleep is a key health indicator in older adults; however, many older adults may experience less than ideal levels of sleep health. The objective of this report is to summarize the proceedings of the National Sleep Foundation's Sleep Health and Aging Conference.

METHODS

The National Sleep Foundation held a Sleep Health and Aging Conference with sleep scientists and stakeholders in the field of aging. The primary goal of this conference was to identify critical sleep health recommendations for older adults.

RESULTS

Essential recommendations aimed at promoting sleep health in older adults focus on light exposure, physical activity, meal timing, environmental conditions, and sleep schedules. Suggestions for promoting sleep health behavior change in older adults include tailored messaging and community support.

CONCLUSIONS

There are unique challenges and opportunities around promoting sleep health in older adults, efforts toward change should include individual, community, and societal foci.

Evaluation of Implementation Strategies for Cognitive Behavioral Therapy (CBT), Acceptance and Commitment Therapy (ACT), and Mindfulness-Based Stress Reduction (MBSR): a Systematic Review

BACKGROUND

Improving access to evidence-based psychotherapies (EBPs) is a Veterans Health Administration (VHA) priority. Cognitive behavioral therapy (CBT), acceptance and commitment therapy (ACT), and mindfulness-based stress reduction (MBSR) are effective for chronic pain and several mental health conditions. We synthesized evidence on implementation strategies to increase EBP access and use.

METHODS

We searched MEDLINE, Embase, PsycINFO, and CINAHL from inception until March 2021 for articles on EBP implementation within integrated health systems to treat chronic pain or chronic mental health conditions. Reviewers independently screened articles, extracted results, coded qualitative findings, and rated quality using modified criteria from Newcastle-Ottawa (quantitative results) or Critical Appraisal Skills Programme (qualitative results). We categorized implementation strategies using the Expert Recommendations for Implementing Change (ERIC) framework and classified outcomes using RE-AIM domains (Reach, Effectiveness, Adoption, Implementation, Maintenance).

RESULTS

Twelve articles (reporting results from 10 studies) evaluated CBT (k = 11) and ACT (k = 1) implementation strategies in large integrated healthcare systems. No studies evaluated MBSR implementation. Eight articles evaluated strategies within VHA. Six articles reported on national VHA EBP implementation programs; all involved training/education, facilitation, and audit/feedback. CBT and ACT implementation demonstrated moderate to large improvements in patient symptoms and quality of life. Trainings increased mental health provider self-efficacy in delivering EBPs, improved provider EBP perceptions, and increased provider EBP use during programs, but had unclear impacts on Reach. It was unclear whether external facilitation added benefit. Provider EBP maintenance was modest; barriers included competing professional time demands and patient barriers.

DISCUSSION

Multi-faceted CBT and ACT implementation programs increased provider EBP Adoption but had unclear impacts on Reach. Future implementation efforts should further evaluate Reach, Adoption, and Maintenance; assess the added value of external facilitation; and consider strategies targeting patient barriers. Future work should use implementation frameworks to guide evaluations of barriers and facilitators, processes of change, and outcomes.

REGISTRATION

PROSPERO registration number CRD42021252038.

Barriers and facilitators of evidence-based psychotherapies for chronic pain in adults: A systematic review

Cognitive behavioral therapy (CBT), acceptance and commitment therapy (ACT), and mindfulness-based stress reduction (MBSR) have demonstrated effectiveness for improving outcomes in chronic pain. These evidence-based psychotherapies (EBPs) remain underutilized in clinical practice, however. To identify research gaps and next steps for improving uptake of EBPs, we conducted a systematic review of patient-, provider-, and system-level barriers and facilitators of their use for chronic pain. We searched MEDLINE, Embase, PsycINFO, and CINAHL databases databases from inception through September 2022. Prespecified eligibility criteria included outpatient treatment of adults with chronic pain; examination of barriers and facilitators and/or evaluation of implementation strategies; conducted in the United States (US), United Kingdom (UK), Ireland, Canada or Australia; and publication in English. Two reviewers independently assessed eligibility and rated quality. We conducted a qualitative synthesis of results using a best-fit framework approach building upon domains of the Consolidated Framework for Implementation Research (CFIR). We identified 34 eligible studies (33 moderate or high quality), most (n=28) of which addressed patient-level factors. Shared barriers across EBPs included variable patient buy-in to therapy rationale and competing responsibilities for patients; shared facilitators included positive group or patient-therapist dynamics. Most studies examining ACT and all examining MBSR assessed only group formats. No studies compared barriers, facilitators, or implementation strategies of group CBT to individual CBT, or of telehealth to in-person EBPs. Conceptual mismatches of patient knowledge and beliefs with therapy principles were largely analyzed qualitatively, and studies did not explore how these mismatches were addressed to support engagement. Future research on EBPs for chronic pain in real-world practice settings is needed to explore provider and system-level barriers and facilitators, heterogeneity of effects and uptake, and both effects and uptake of EBPs delivered in various formats, including group vs. individual therapy and telehealth or asynchronous digital approaches. Perspective This systematic review synthesizes evidence on barriers and facilitators to uptake of cognitive behavioral therapy, acceptance and commitment therapy, and mindfulness-based stress reduction for chronic pain. Findings can guide future implementation work to increase availability and use of evidence-based psychotherapies for treatment of chronic pain. Registration: PROSPERO number CRD42021252038.

"Sign Me Up, I'm Ready!": Helping Patients Prescribed Sleeping Medication Engage with Cognitive Behavioral Therapy for Insomnia (CBT-I)

OBJECTIVE/BACKGROUND

Cognitive behavioral therapy for insomnia (CBT-I) provides safe and effective insomnia care without the risk of harm associated with sleeping medications. Unfortunately, few patients with insomnia engage with CBT-I, with most using sedative hypnotics instead. This study conducted focus groups with patients with insomnia who were treated with sleeping medication, including older adults, women, and patients with chronic pain. The goal was to explore the perspectives of high-risk, CBT-I naïve patients on increasing access and engagement with CBT-I.

PARTICIPANTS

Participants included 29 Veterans with insomnia who had been prescribed sleeping medication in the last year and had not previously engaged with CBT-I.

METHODS

Semi-structured 90-min focus groups were used to 1) explore messages and appropriate channels for a CBT-I social marketing campaign, 2) determine patient preferences for self-management CBT-I tools, and 3) determine patient opinions on alternative provider-delivered forms of CBT-I. Thematic analysis was used to identify conceptual themes.

RESULTS

Three main themes were identified. First, patient education is necessary but not sufficient. Patients recommended multiple outreach attempts through multiple channels to motivate tired and overwhelmed insomnia patients to engage with CBT-I. Second, patients gravitated toward a stepped-care approach. Most would start with self-management CBT-I tools, moving on to provider-delivered CBT-I if needed. Finally, patients appreciated being able to choose from a menu of CBT-I delivery options and would use multiple options simultaneously.

CONCLUSIONS

These findings suggest promising opportunities to increase the use of CBT-I for high-risk patients through patient education and provision of self-management CBT-I tools.

Sleep Disturbance Predicts Less Improvement in Pain Outcomes: Secondary Analysis of the SPACE Randomized Clinical Trial

OBJECTIVE

Sleep disturbance may limit improvement in pain outcomes if not directly addressed in treatment. Moreover, sleep problems may be exacerbated by opioid therapy. This study examined the effects of baseline sleep disturbance on improvement in pain outcomes using data from the Strategies for Prescribing Analgesics Comparative Effectiveness (SPACE) trial, a pragmatic 12-month randomized trial of opioid vs nonopioid medication therapy.

DESIGN

Participants with chronic back pain or hip or knee osteoarthritis pain were randomized to either opioid therapy (N = 120) or nonopioid medication therapy (N = 120).

METHODS

We used mixed models for repeated measures to 1) test whether baseline sleep disturbance scores modified the effect of opioid vs nonopioid treatment on pain outcomes and 2) test baseline sleep disturbance scores as a predictor of less improvement in pain outcomes across both treatment groups.

RESULTS

The tests for interaction of sleep disturbance by treatment group were not significant. Higher sleep disturbance scores at baseline predicted less improvement in Brief Pain Inventory (BPI) interference (β = 0.058, P = 0.0002) and BPI severity (β = 0.026, P = 0.0164).

CONCLUSIONS

Baseline sleep disturbance adversely affects pain response to treatment regardless of analgesic regimen. Recognition and treatment of sleep impairments that frequently co-occur with pain may optimize outcomes.

Exploring the Meaning of Cognitive Behavioral Therapy for Insomnia for Patients with Chronic Pain

OBJECTIVE

Insomnia is one of the most common, persistent, and distressing symptoms associated with chronic pain. Cognitive behavioral therapy for insomnia (CBT-I) is the firstline treatment for insomnia, but patient preferences and perspectives about CBT-I within the context of chronic pain are unknown. The current qualitative study sought to understand the experience of CBT-I among patients with chronic pain, including aspects of CBT-I that were found to be difficult (e.g., pain as a specific barrier to adherence/dropout), changes in sleep and pain functioning after CBT-I, and aspects of CBT-I that were appreciated.

DESIGN

Qualitative semistructured interviews.

METHODS

We conducted individual semistructured interviews with 17 veterans with chronic pain and insomnia who had recently participated in CBT-I, as well as their CBT-I therapists, and used thematic analysis to identify conceptual themes.

RESULTS

Results revealed that patients and CBT-I therapists found changing sleep habits during CBT-I challenging due to anxiety and temporary increases in fatigue, but did not identify major pain-related barriers to adhering to CBT-I recommendations; patients experienced better sleep, mood, energy, and socialization after CBT-I despite minimal changes in pain intensity; and patients highly valued CBT-I as a personalized treatment for sleep and strongly recommended it for other patients with chronic pain.

CONCLUSIONS

Findings of improved sleep and functional outcomes support efforts to incorporate CBT-I into chronic pain treatment, including educating patients and providers about the strong feasibility of improving sleep and quality of life despite ongoing pain.

Provider perspectives of implementation of an evidence-based insomnia treatment in Veterans Affairs (VA) primary care: barriers, existing strategies, and future directions

BACKGROUND

Cognitive behavioral therapy for insomnia (CBT-I) is a highly effective nonpharmacological intervention that is widely considered the gold standard for insomnia treatment. Insomnia is a prevalent and debilitating public health concern. Up to one third of the general population struggles with chronic insomnia, greatly increasing the risk for chronic pain and inflammation, depression and suicide, and cognitive decline. Over the last 10 years, the Veterans Health Administration (VHA) evidence-based psychotherapy training program has trained nearly 1000 providers to deliver CBT-I in hospitals and clinics nationwide. Despite increased access, most patients with insomnia receive sleeping medications instead of CBT-I. This is particularly concerning for vulnerable populations, like older adults, who may be at increased risk of harms from medications. The goal of this study was to obtain a broad range of perspectives on CBT-I implementation from providers who commonly utilize and deliver CBT-I. This work identifies barriers and successful strategies used to overcome these barriers to guide future implementation efforts promoting evidence-based sleep care.

METHODS

Semi-structured interviews, using the Consolidated Framework for Implementation Research (CFIR) as a guide, were conducted with 17 providers from five Veterans Affairs (VA) facilities (8 primary care physicians, 4 primary care psychologists, and 5 CBT-I coordinators). We used a thematic analysis approach in which common ideas were identified across interviews and then grouped into larger conceptual themes. Data were concurrently collected and analyzed with rapid assessment process (RAP) techniques.

RESULTS

Findings suggested implementation barriers and facilitators related to the CFIR constructs of intervention characteristic (e.g., providers unfamiliar with primary evidence of CBT-I effectiveness), inner setting (e.g., sleep as a low relative priority in primary care), and outer setting (e.g., lack of external incentives for increasing CBT-I use), as well as several successful strategies, including use of local champions and supportive opinion leaders.

CONCLUSIONS

These findings suggest promising opportunities to improve implementation of CBT-I, especially at facilities with less well-established CBT-I programs. Formal implementation trials are needed to systematically determine the real-world impact of strategies such as enlisting CBT-I champions, informing opinion leaders about CBT-I services, and promoting network weaving among primary care, mental health, and sleep clinics.

A randomized controlled trial evaluating integrated versus phased application of evidence-based psychotherapies for military veterans with comorbid PTSD and substance use disorders

OBJECTIVE

Recent clinical practice guidelines recommend the delivery of evidence-based psychotherapies for both substance use disorder (SUD) and posttraumatic stress disorder (PTSD) within the same treatment episode for patients with SUD/PTSD comorbidity. This randomized clinical trial evaluated the comparative effectiveness of integrating versus phasing evidence-based psychotherapies for SUD and PTSD among veterans with co-occurring SUD/ PTSD.

METHOD

183 veterans with DSM-IV PTSD and SUD at two VA Medical Centers were randomized to one of two psychotherapies during which Motivational Enhancement Therapy [MET] for SUD and Prolonged Exposure [PE] for PTSD were either phased or integrated throughout treatment. Primary outcomes as evaluated by blinded assessors were percent days with drug use or heavy drinking and PTSD symptomology. We hypothesized integrated MET/PE (n = 95) would yield better SUD and PTSD-related outcomes at posttreatment than phased MET/PE (n = 88).

RESULTS

In intent-to-treat analyses (n=183), both treatment groups achieved clinically (d=0.46 - 1.06) and statistically significant reductions in SUD (p < 0.01) and PTSD (p < 0.01) symptomology; the time by treatment interactions were not significant. Post-hoc analyses could not confirm statistical non-inferiority; between-group effect sizes suggest a lack of clinically-meaningful differences between the two treatment approaches (d=0.08 - 0.27).

CONCLUSIONS

Our hypothesis that integrated MET/PE would result in better outcomes than phased MET/PE across a range of PTSD and SUD measures was not supported; both strategies for combining two single-disorder treatments for co-occurring SUD/PTSD yielded significant symptom reduction.

"You're Missing Out on Something Great": Patient and Provider Perspectives on Increasing the Use of Cognitive Behavioral Therapy for Insomnia

Objective/Background: Cognitive behavioral therapy for insomnia (CBT-I) is the most effective treatment for insomnia but is severely underutilized. One of the key reasons for underuse is lack of knowledge among patients and primary care providers, but effective methods and materials for increasing knowledge are unknown. This study conducted in-depth interviews with CBT-I patients and their CBT-I providers to explore their perceptions on increasing utilization of CBT-I. Participants: Participants included patients who had engaged in CBT-I (N = 17) and CBT-I providers (N = 7). Methods: Semistructured interviews were used to explore the CBT-I referral process, recommendations for increasing uptake of CBT-I, and opinions on CBT-I self-management, with thematic analysis used to identify conceptual themes. Findings were compared and contrasted across patients who completed versus prematurely discontinued therapy and patients versus CBT-I providers. Results: Three main themes of referral, selling, and delivery were identified. Regarding referral, patients had not heard of nor requested CBT-I. Proactive outreach is crucial in populations in which insomnia is so common that it becomes normalized. For selling, patients and CBT-I providers had powerful testimonials that could be used to "sell" treatment using a peer-to-peer approach. Finally, for delivery, patients and CBT-I providers were ambivalent about alternative delivery formats and emphasized the need for personal contact. Although technology may be useful in advertising and delivering CBT-I, it will be important to ensure that these approaches promote rather than discourage engagement in CBT-I. Conclusions: These findings suggest promising opportunities to increase the use of CBT-I, including direct-to-consumer marketing.

Sleep Patterns and Problems Among Army National Guard Soldiers

Introduction

Adequate sleep plays an integral role in the physical and mental health of individuals, while simultaneously influencing their cognitive and work performance. Having recognized this, the U.S. Army has focused efforts on improving soldiers' healthy sleep behaviors. This study examines the extent to which mental health, alcohol use, and certain sleep hygiene behaviors predict sleep problems within an Army National Guard sample (N = 438).

Materials and Methods

This manuscript is part of a larger study approved through the Minneapolis Veterans Affairs Medical Center Institutional Review Board. Mailed surveys were sent to Minnesota Army National Guard soldiers collecting data on sleep hygiene behaviors, mental health symptoms (post-traumatic stress disorder and depression), and alcohol use. Predictors of sleep problems were evaluated with ordinary least squares multiple linear regression analyses, regressing Insomnia Severity Index total scores on demographic variables, post-traumatic stress disorder (PTSD), depression, alcohol use, sleep hygiene factors (routine and consumption activity; both derived from exploratory factor analysis), and technology use (multiple device use and use before bed).

Results

Overall, the majority of participants did not endorse high levels of sleep impairment, while 16.4% screened positive for moderate or even severe levels of clinical insomnia. Bivariate correlations demonstrated that sleep problems were correlated with PTSD symptoms (r = 0.41, p < 0.001), depression (r = 0.49, p < 0.001), Sleep Hygiene Routine (r = -0.34, p < 0.001), and more frequent use of multiple devices before bed (r = 0.15, p = 0.002). The overall regression model predicting sleep problems was significant (R2 = 0.35, adj R2 = 0.34, F[8,408] = 27.58, p < 0.001). Independent predictors of sleep problems included gender (B = 0.99, β = 0.09, t = 2.10, p = 0.036), PTSD (B = 0.89, β = 0.22, t = 4.86, p < 0.001), depression (B = 1.53, β = 0.20, t = 7.56, p < 0.001), and Sleep Hygiene Routine (B = -0.88, β = -0.23, t = -5.473, p < 0.001). Alcohol use, Sleep Hygiene Consumption, and technology use did not emerge as independent predictors.

Conclusion

Although most soldiers denied sleep problems, a sizeable minority met screening criteria for clinical insomnia. Greater numbers of sleep-related complaints were related to psychological distress including depressive and PTSD symptoms, while adherence to a bedtime routine (Sleep Hygiene Routine) showed an inverse relationship. Alcohol use and sleep hygiene consumption activities were not predictive of sleep problems, suggesting that different sleep hygiene behaviors have differential relationships with sleep problems. Screening and intervention for specific sleep problems may be helpful even very early in Army National Guard service members' careers. Particular focus may be needed for those showing signs of emotional distress, such as PTSD or depression. Future research examining the impact of individual sleep hygiene components is warranted.

Clinical Utility of the Inventory of Depression and Anxiety Symptoms (IDAS)

Depressive and anxiety disorders are severe and disabling conditions that result in substantial cost and global societal burden. Accurate and efficient identification is thus vital to proper diagnosis and treatment of these disorders. The Inventory of Depression and Anxiety Symptoms (IDAS) is a reliable and well-validated measure that provides dimensional assessment of both mood and anxiety disorder symptoms. The current study examined the clinical utility of the IDAS by establishing diagnostic cutoff scores and severity ranges using a large mixed sample (N = 5,750). Results indicated that the IDAS scales are good to excellent predictors of their associated Structured Clinical Interview for DSM-IV diagnoses. These findings were replicated using Diagnostic and Statistical Manual of Mental Disorders-Fifth edition (DSM-5) criteria assessed via the Mini-International Neuropsychiatric Interview. We provide three cutoff scores for each scale that can be used differentially depending on the goal of their use: screening, efficiency, or diagnosis confirmation. The identified severity ranges allow users to characterize individuals as mild, moderate, or severe, providing clinical information beyond diagnostic status. Finally, the 10-item IDAS Dysphoria scale and 20-item General Depression scale demonstrate strong ability to predict internalizing diagnoses and may represent an efficient way to screen for the presence of internalizing psychopathology.

Increasing access to and utilization of cognitive behavioral therapy for insomnia (CBT-I): a narrative review

The American College of Physicians (ACP) recently identified cognitive behavioral therapy for insomnia (CBT-I) as the first-line treatment for insomnia. Although CBT-I improves sleep outcomes and reduces the risks associated with reliance on hypnotics, patients are rarely referred to this treatment, especially in primary care where most insomnia treatment is provided. We reviewed the evidence about barriers to CBT-I referrals and efforts to increase the use of CBT-I services. PubMed, PsycINFO, and Embase were searched on January 11, 2018; additional titles were added based on a review of bibliographies and expert opinion and 51 articles were included in the results of this narrative review. Implementation research testing specific interventions to increase routine and sustained use of CBT-I was lacking. Most research focused on pre-implementation work that revealed the complexity of delivering CBT-I in routine healthcare settings due to three distinct categories of barriers. First, system barriers result in limited access to CBT-I and behavioral sleep medicine (BSM) providers. Second, primary care providers are not adequately screening for sleep issues and referring appropriately due to a lack of knowledge, treatment beliefs, and a lack of motivation to assess and treat insomnia. Finally, patient barriers, including a lack of knowledge, treatment beliefs, and limited access, prevent patients from engaging in CBT-I. These findings are organized using a conceptual model to represent the many challenges inherent in providing guideline-concordant insomnia care. We conclude with an agenda for future implementation research to systematically address these challenges.

Provider Types and Outcomes in Obstructive Sleep Apnea Case Finding and Treatment: A Systematic Review

BACKGROUND

Obstructive sleep apnea (OSA) diagnosis and care models rely on sleep specialist physicians (SSPs) and can be expensive and inefficient.

PURPOSE

To assess OSA case-finding accuracy and comparative effectiveness of care by non-sleep specialists (NSSs) and SSPs.

DATA SOURCES

MEDLINE and CINAHL from January 2000 through July 2017.

STUDY SELECTION

English-language trials or observational studies comparing case finding or care by SSPs versus providers not specifically trained as SSPs (NSSs) for adults with suspected or diagnosed OSA.

DATA EXTRACTION

One investigator extracted data and assessed risk of bias and strength of evidence, with confirmation by a second investigator. Primary outcomes were patient-centered (mortality, access to care, quality of life, patient satisfaction, adherence, symptom scores, and adverse events). Intermediate outcomes included resource use, costs, time to initiation of treatment, and case finding.

DATA SYNTHESIS

Four observational studies (n = 580; mean age, 52 years; 77% male) reported good agreement between NSSs and SSPs on appropriate diagnostic testing and classification of OSA severity (low-strength evidence). Five randomized trials and 3 observational studies (n = 1515; mean age, 52 years; 68% male) found that care provided by NSSs and SSPs resulted in similar quality of life, adherence, and symptom scores (low-strength evidence). Evidence was insufficient for access to care and adverse events.

LIMITATIONS

Many outcomes were reported infrequently or not at all. Many NSSs had extensive training or experience in sleep medicine, which limits generalizability of findings to providers with less experience.

CONCLUSION

Care by NSSs and SSPs resulted in similar outcomes in adults with known or suspected OSA. Studies are needed to determine care model implementation and reproducibility of results in nonacademic settings and among less experienced NSSs.

PRIMARY FUNDING SOURCE

Department of Veterans Affairs, Veterans Health Administration, Office of Research and Development, Quality Enhancement Research Initiative. (PROSPERO: CRD42016036810 [full Veterans Affairs Evidence-based Synthesis Program report]).

Resilience and Posttraumatic Stress Disorder Symptoms in National Guard Soldiers Deployed to Iraq: A Prospective Study of Latent Class Trajectories and Their Predictors

This study examined the prospective course of posttraumatic stress disorder (PTSD) symptoms in a cohort of National Guard soldiers (N = 522) deployed to combat operations in Iraq. Participants were assessed 4 times: 1 month before deployment, 2-3 months after returning from deployment, 1 year later, and 2 years postdeployment. Growth mixture modeling revealed 3 distinct trajectories: low-stable symptoms, resilient, 76.4%; new-onset symptoms, 14.2%; and chronic distress, 9.4%. Relative to the resilient class, membership in both the new-onset symptoms and chronic distress trajectory classes was predicted by negative emotionality/neuroticism, odds ratios (ORs) = 1.09, 95% CI [1.02, 1.17], and OR = 1.22, 95% CI [1.09,1.35], respectively; and combat exposure, OR = 1.07, 95% CI [1.02, 1.12], and OR = 1.12, 95% CI [1.02, 1.24], respectively. Membership in the new-onset trajectory class was predicted by predeployment military preparedness, OR = 0.95, 95% CI [0.91, 0.98], perceived threat during deployment, OR = 1.07, 95% CI [1.03, 1.10], and stressful life events following deployment, OR = 1.44, 95% CI [1.05, 1.96]. Prior deployment to Iraq or Afghanistan, OR = 3.85, 95% CI [1.72, 8.69], predeployment depression, OR = 1.27, 95% CI [1.20, 1.36], and predeployment concerns about a deployment's impact on civilian/family life, OR = 1.09, 95% CI [1.02, 1.16], distinguished the chronic distress group relative to the resilient group. Identifying predeployment vulnerability and postdeployment contextual factors provides insight for future efforts to bolster resilience, prevent, and treat posttraumatic symptoms.

Study design, interventions, and baseline characteristics for the Substance use and TRauma Intervention for VEterans (STRIVE) trial

While comorbidity between posttraumatic stress disorder (PTSD) and substance use disorders (SUD) is common among veterans, there is debate regarding how to best treat individuals suffering from both conditions. Despite data supporting the effectiveness of integrated treatments that simultaneously address both disorders, due to concerns that an early focus on trauma may increase dropout and reduce the likelihood of achieving SUD-related goals, providers continue to prefer a sequential approach, where the addiction is treated first and PTSD treatment is instituted following sustained abstinence or reduced use. This project is designed to directly examine these provider concerns by evaluating the benefits and harms of an integrated versus a sequential approach to treating comorbid PTSD and SUD. This paper reviews the study's methodology, treatment approaches, and baseline participant characteristics. In this randomized clinical trial, one hundred eighty-three veterans with co-occurring PTSD and SUD have been randomized to one of two psychotherapies that include the same treatment components for SUD and PTSD (Motivational Enhancement Therapy and Prolonged Exposure respectively), but differ by whether the components are delivered sequentially or are integrated such that PTSD and SUD symptoms are addressed concurrently. We hypothesize that veterans assigned to integrated treatment will show greater improvement in PTSD and SUD symptoms than veterans assigned to sequential treatment. If this hypothesis is supported, the findings have the potential to change clinicians' beliefs and challenge long-standing practice patterns that require participation in SUD treatment prior to initiating trauma-focused therapies for PTSD.

Psychological and Behavioral Interventions for Managing Insomnia Disorder: An Evidence Report for a Clinical Practice Guideline by the American College of Physicians

BACKGROUND

Psychological and behavioral interventions are frequently used for insomnia disorder.

PURPOSE

To assess benefits and harms of psychological and behavioral interventions for insomnia disorder in adults.

DATA SOURCES

Ovid MEDLINE, Embase, the Cochrane Central Register of Controlled Trials, and PsycINFO through September 2015, supplemented with hand-searching.

STUDY SELECTION

Randomized, controlled trials of psychological or behavioral interventions that were published in English and enrolled adults with insomnia disorder lasting 4 or more weeks.

DATA EXTRACTION

Data extraction by single investigator confirmed by a second reviewer; dual investigator assessment of risk of bias; consensus determination of strength of evidence.

DATA SYNTHESIS

Sixty trials with low to moderate risk of bias compared psychological and behavioral interventions with inactive controls or other psychological and behavioral interventions. Cognitive behavioral therapy for insomnia (CBT-I) improved posttreatment global and most sleep outcomes, often compared with information or waitlist controls (moderate-strength evidence). Use of CBT-I improved several sleep outcomes in older adults (low- to moderate-strength evidence). Multicomponent behavioral therapy improved several sleep outcomes in older adults (low- to moderate-strength evidence). Stimulus control improved 1 or 2 sleep outcomes (low-strength evidence). Evidence for other comparisons and for harms was insufficient to permit conclusions.

LIMITATIONS

A wide variety of comparisons limited the ability to pool data. Trials did not always report global outcomes and infrequently conducted remitter or responder analysis. Comparisons were often information or waitlist groups, and publication bias was possible.

CONCLUSION

Use of CBT-I improves most outcomes compared with inactive controls. Multicomponent behavioral therapy and stimulus control may improve some sleep outcomes. Evidence on other outcomes, comparisons, and long-term efficacy were limited.

PRIMARY FUNDING SOURCE

Agency for Healthcare Research and Quality. (

PROSPERO

CRD42014009908).

Pharmacologic Treatment of Insomnia Disorder: An Evidence Report for a Clinical Practice Guideline by the American College of Physicians

BACKGROUND

Pharmacologic interventions are often prescribed for insomnia disorder.

PURPOSE

To assess the benefits, harms, and comparative effectiveness of pharmacologic treatments for adults with insomnia disorder.

DATA SOURCES

Several electronic databases (2004-September 2015), reference lists, and U.S. Food and Drug Administration (FDA) documents.

STUDY SELECTION

35 randomized, controlled trials of at least 4 weeks' duration that evaluated pharmacotherapies available in the United States and that reported global or sleep outcomes; 11 long-term observational studies that reported harm information; FDA review data for nonbenzodiazepine hypnotics and orexin receptor antagonists; and product labels for all agents.

DATA EXTRACTION

Data extraction by single investigator confirmed by a second reviewer; dual-investigator assessment of risk of bias; consensus determination of strength of evidence.

DATA SYNTHESIS

Eszopiclone, zolpidem, and suvorexant improved short-term global and sleep outcomes compared with placebo, although absolute effect sizes were small (low- to moderate-strength evidence). Evidence for benzodiazepine hypnotics, melatonin agonists, and antidepressants, and for most pharmacologic interventions in older adults, was insufficient or low strength. Evidence was also insufficient to compare efficacy within or across pharmacotherapy classes or versus behavioral therapy. Harms evidence reported in trials was judged insufficient or low strength; observational studies suggested that use of hypnotics for insomnia was associated with increased risk for dementia, fractures, and major injury. The FDA documents reported that most pharmacotherapies had risks for cognitive and behavioral changes, including driving impairment, and other adverse effects, and they advised dose reduction in women and in older adults.

LIMITATIONS

Most trials were small and short term and enrolled individuals meeting stringent criteria. Minimum important differences in outcomes were often not established or reported. Data were scant for many treatments.

CONCLUSION

Eszopiclone, zolpidem, and suvorexant may improve short-term global and sleep outcomes for adults with insomnia disorder, but the comparative effectiveness and long-term efficacy of pharmacotherapies for insomnia are not known. Pharmacotherapies for insomnia may cause cognitive and behavioral changes and may be associated with infrequent but serious harms.

PRIMARY FUNDING SOURCE

Agency for Healthcare Research and Quality. (

PROSPERO

CRD42014009908).

A randomized controlled pilot study of CBT-I Coach: Feasibility, acceptability, and potential impact of a mobile phone application for patients in cognitive behavioral therapy for insomnia

There has been growing interest in utilizing mobile phone applications (apps) to enhance traditional psychotherapy. Previous research has suggested that apps may facilitate patients' completion of cognitive behavioral therapy for insomnia (CBT-I) tasks and potentially increase adherence. This randomized clinical trial pilot study ( n = 18) sought to examine the feasibility, acceptability, and potential impact on adherence and sleep outcomes related to CBT-I Coach use. All participants were engaged in CBT-I, with one group receiving the app as a supplement and one non-app group. We found that patients consistently used the app as intended, particularly the sleep diary and reminder functions. They reported that it was highly acceptable to use. Importantly, the app did not compromise or undermine benefits of cognitive behavioral therapy for insomnia and patients in both groups had significantly improved sleep outcomes following treatment.

Sleep Disturbances in Posttraumatic Stress Disorder: Updated Review and Implications for Treatment

Sleep disturbances are common in adults with PTSD and range from insomnia and nightmares to periodic leg movements and disruptive nocturnal behaviors. Together these findings suggest profound disturbances in rapid eye movement (REM) and non-REM (NREM) sleep, although there is a lack of consensus regarding a distinct profile of objective sleep disturbances associated with PTSD. Prospective, longitudinal studies have established that sleep disturbances represent a risk factor for the development and course of PTSD, suggesting that sleep is an important neurobiological mechanism in the etiology and maintenance of this disorder. This research highlights the importance of early identification and treatment of sleep disturbances in at-risk and trauma exposed populations. A number of psychological and pharmacological treatments are effective at treating sleep disturbances in PTSD. Additional research is needed to further develop clinical guidelines informing when and how to integrate sleep-specific treatment with PTSD focused clinical care.

The Unhappy Triad: Pain, Sleep Complaints, and Internalizing Symptoms

There is limited understanding of the etiology and temporal relations of chronic pain, sleep complaints, and depression/anxiety. Several models have been proposed by which sleep disruption represents a common mechanism for the comorbidity of these symptoms. The goals of this study were to 1) clarify the boundaries of these domains and to 2) examine the relations of these symptoms over time following exposure to stressful and potentially traumatic experiences during a combat deployment. We found support for three distinct domains of sleep complaints, internalizing symptoms, and physical complaints. We tested two competing models that have been proposed in the literature, controlling for negative and positive emotionality. Internalizing symptoms strongly mediated the relation between sleep complaints and pain (total effect = .15, direct effect = -.05). The study suggests that increases in sleep complaints immediately following deployment increase the risk of internalizing symptoms and pain several years after deployment.

The bidirectional relationship between sleep complaints and pain: Analysis of data from a randomized trial

OBJECTIVE

The goal of this study was to examine the bidirectional relationship of sleep and pain to determine whether changes in sleep complaints over the course of a chronic pain treatment trial predict pain outcomes and vice versa, controlling for changes in depression and anxiety.

METHODS

Data were analyzed from a 12-month randomized, controlled trial that tested the effectiveness of a collaborative care intervention for veterans with chronic musculoskeletal pain. Participants were 250 veterans from 5 primary care clinics in a Veteran Affairs (VA) medical center. Measures of pain, sleep, and depression/anxiety symptoms were collected at baseline, 3 months, and 12 months. Factor analysis was used to clarify the boundaries of these domains, and structural equation modeling was used to examine whether changes in sleep complaints and depression/anxiety during the trial predicted pain at the end of the trial, controlling for covariates. An alternative model was also tested in which changes in pain predicted sleep complaints.

RESULTS

Changes in sleep complaints at 3 months significantly predicted changes in pain at 12 months (standardized path coefficient = .29, p < .001). To a lesser extent, changes in pain predicted changes in sleep (standardized path coefficient = .15, p < .05). Changes in depression/anxiety did not significantly predict changes in pain or sleep. There was also evidence of differential relations of specific sleep complaints with pain.

CONCLUSIONS

This work helps to further disentangle the complex relationship between pain and sleep. This bidirectional relationship may need to be considered to improve pain outcomes.

Personality traits and combat exposure as predictors of psychopathology over time

BACKGROUND

Research suggests that personality traits have both direct and indirect effects on the development of psychological symptoms, with indirect effects mediated by stressful or traumatic events. This study models the direct influence of personality traits on residualized changes in internalizing and externalizing symptoms following a stressful and potentially traumatic deployment, as well as the indirect influence of personality on symptom levels mediated by combat exposure.

METHOD

We utilized structural equation modeling with a longitudinal prospective study of 522 US National Guard soldiers deployed to Iraq. Analyses were based on self-report measures of personality, combat exposure, and internalizing and externalizing symptoms.

RESULTS

Both pre-deployment Disconstraint and externalizing symptoms predicted combat exposure, which in turn predicted internalizing and externalizing symptoms. There was a significant indirect effect for pre-deployment externalizing symptoms on post-deployment externalizing via combat exposure (p < 0.01). Negative Emotionality and pre-deployment internalizing symptoms directly predicted post-deployment internalizing symptoms, but both were unrelated to combat exposure. No direct effects of personality on residualized changes in externalizing symptoms were found.

CONCLUSIONS

Baseline symptom dimensions had significant direct and indirect effects on post-deployment symptoms. Controlling for both pre-exposure personality and symptoms, combat experiences remained positively related to both internalizing and externalizing symptoms. Implications for diagnostic classification are discussed.

Feasibility and preliminary real-world promise of a manualized group-based cognitive behavioral therapy for insomnia protocol for veterans

Insomnia is increasingly common among the general population, even more so among veterans. Given the adverse impact of insomnia on both mental and physical health of veterans, it is important to provide effective treatments within the Veterans Health Administration (VHA) system. Group-based cognitive behavioral therapy for insomnia (CBT-I) provides a viable option for treatment. This study reports the feasibility, acceptability, initial effectiveness, and durability of group-based CBT-I in a clinical sample of veterans with comorbid medical and mental health diagnoses; the treatment was provided in a real-world VHA hospital setting using a manualized protocol that was explicitly adapted from the existing 1:1 CBT-I VHA protocol. Overall, we found the treatment to be feasible and acceptable to veterans, as well as effective. We found medium to large effect sizes for both questionnaire and sleep diary measures, including sleep onset latency, awakenings during the night, sleep efficiency, insomnia scores, and dysfunctional beliefs about sleep. Improvements in insomnia symptoms were maintained over 1 month.

Pre-deployment daytime and nighttime sleep complaints as predictors of post-deployment PTSD and depression in National Guard troops

There is growing evidence that disturbed sleep is a risk factor for the development of a number of psychiatric diagnoses including depression, PTSD and substance use. The goal of this study was to use a subset of participants from a larger prospective longitudinal study to examine whether preexisting daytime and nighttime sleep disturbances predict depression, PTSD and substance use in US National Guard Soldiers deployed to Iraq. Data on daytime and nighttime sleep complaints, baseline symptoms and personality variables were gathered prior to deployment to Iraq. Measures of psychopathology were collected at three time points post-deployment over the course of two years using both questionnaires and interviews. Multiple regressions were used to predict diagnoses and symptoms of depression, PTSD and substance use. Pre-deployment daytime and nighttime sleep complaints contributed significantly to the prediction of PTSD and depression up to two years after deployment, but not substance use. This study suggests that daytime and nighttime sleep complaints are a risk factor for internalizing disorders including PTSD and depression.

A preliminary investigation of the new and revised symptoms of posttraumatic stress disorder in DSM-5

BACKGROUND

Research has shown that posttraumatic stress disorder (PTSD) is highly comorbid with other mental disorders. The DSM-5 marks an opportunity to increase the differential diagnosis of PTSD by emphasizing symptoms that are specific to PTSD and deemphasizing symptoms that are common to many mental disorders. This study analyzes the new and revised PTSD symptom criteria proposed for DSM-5 by examining their relations with diagnoses and measures of PTSD. In addition, we report the specificity of DSM-5 symptoms with PTSD compared to depressive disorders and substance use.

METHODS

This study utilized pre- and postdeployment data collected from a sample of 213 National Guard Brigade Combat Team soldiers who were deployed to Iraq. Questionnaire data were collected pre- and postdeployment and interview data were collected postdeployment. Scales to measure the DSM-5 symptoms were created using structural analyses and were correlated with interview and self-report measures of PTSD, depression, and substance use.

RESULTS

The DSM-5 symptom of anger shows the most increase from pre- to postdeployment in participants diagnosed with PTSD. In addition, this scale showed the strongest relation to PTSD and showed some evidence of specificity. Other symptom scales, including those measuring negative expectations and aggressive behaviors, showed equivalent correlations with PTSD, depression, and substance use.

CONCLUSIONS

It will be important to continue studying the specificity of anger with PTSD. Several of the other new and revised DSM-5 symptoms appear to be nonspecific, and it is unlikely that their inclusion in the diagnostic criteria for PTSD will improve differential diagnosis.

Development and validation of new anxiety and bipolar symptom scales for an expanded version of the IDAS (the IDAS-II)

The original Inventory of Depression and Anxiety Symptoms (IDAS) contains 11 nonoverlapping scales assessing specific depression and anxiety symptoms. In creating the expanded version of the IDAS (the IDAS-II), our goal was to create new scales assessing other important aspects of the anxiety disorders as well as key symptoms of bipolar disorder. Factor analyses of the IDAS-II item pool led to the creation of seven new scales (Traumatic Avoidance, Checking, Ordering, Cleaning, Claustrophobia, Mania, Euphoria) plus an expanded version of Social Anxiety. These scales are internally consistent and show strong convergent and significant discriminant validity in relation to other self-report and interview-based measures of anxiety, depression, and mania. Furthermore, the scales demonstrate substantial criterion and incremental validity in relation to interview-based measures of DSM-IV (Diagnostic and Statistical Manual of Mental Disorders, fourth edition) symptoms and disorders. Thus, the expanded IDAS-II now assesses a broad range of depression, anxiety, and bipolar symptoms.

Development and initial validation of the Iowa Sleep Disturbances Inventory

The Iowa Sleep Disturbances Inventory (ISDI) is a new measure of self-reported sleep difficulties, which was designed to help facilitate research on the overlap of sleep disturbances and psychopathology. This instrument was developed in two large student samples using principal factor analyses; the psychometric properties of the scales were then examined in three additional samples (students, psychiatric patients, sleep disorder patients). The ISDI consists of 11 specific scales (Nightmares, Initial Insomnia, Fatigue, Fragmented Sleep, Nonrestorative Sleep, Anxiety at Night, Light Sleep, Movement at Night, Sensations at Night, Excessive Sleep, Irregular Schedule) and 1 general scale (Daytime Disturbances). The structure of the ISDI generalizes across both patient and nonpatient samples. In addition, the ISDI scales are internally consistent, show good retest reliability, demonstrate convergent and discriminant validity with widely used measures of sleep disturbances, and display criterion validity in relation to psychiatric patient status and specific symptoms of depression and anxiety.

The two-factor structure of sleep complaints and its relation to depression and anxiety

Although sleep complaints are common in depression and anxiety, there is little agreement as to how they should be organized and assessed. It is also unclear whether sleep complaints show specificity with certain disorders or whether they are nonspecific symptoms. The authors examined the structure of sleep complaints and the relations of these complaints to depression and anxiety in 3 samples: college students, older adults, and psychiatric patients. Exploratory and confirmatory factor analyses indicated that sleep complaints consistently defined 2 distinct dimensions: Insomnia and Lassitude. The Insomnia factor included indicators of early, middle, and late insomnia, as well as poor sleep quality. The Lassitude factor included measures of hypersomnia, fatigue, and sleepiness. Both factors were significantly related to symptoms and diagnoses of depression and anxiety. However, Lassitude was more strongly related to symptoms of depression and anxiety than was Insomnia. In addition, Lassitude showed specificity to measures and diagnoses of depression compared with anxiety disorders. This specificity can be explained by Lassitude's relation with negative and positive emotionality, both of which are components of depression.

Unusual sleep experiences, dissociation, and schizotypy: Evidence for a common domain

This paper reviews studies that have examined associations between unusual sleep experiences (including nightmares, vivid dreaming, narcolepsy symptoms, and complex nighttime behaviors) and dissociation and schizotypy. Using correlational studies and structural analyses, evidence is provided that unusual sleep experiences, dissociation, and schizotypy belong to a common domain. It is demonstrated that unusual sleep experiences show specificity to dissociation and schizotypy compared to other daytime symptoms (e.g., anxiety, depression, substance use) and other sleep disturbances (e.g., insomnia, lassitude/fatigue). The paper also outlines the methodological limitations of the existing evidence and makes suggestions for future research. Finally, three models for the overlap of daytime and nighttime symptoms are reviewed, including biological abnormalities, trauma, and personality traits. Although further research is needed, it is suggested that daytime and nighttime symptoms result from problems with sleep-wake state boundaries, which may be precipitated by stress or trauma. In addition, association between daytime and nighttime symptoms can be attributed to the higher order personality trait of Oddity.

Further validation of the IDAS: evidence of convergent, discriminant, criterion, and incremental validity

The authors explicated the validity of the Inventory of Depression and Anxiety Symptoms (IDAS; D. Watson et al., 2007) in 2 samples (306 college students and 605 psychiatric patients). The IDAS scales showed strong convergent validity in relation to parallel interview-based scores on the Clinician Rating version of the IDAS; the mean convergent correlations were .51 and .62 in the student and patient samples, respectively. With the exception of the Well-Being Scale, the scales also consistently demonstrated significant discriminant validity. Furthermore, the scales displayed substantial criterion validity in relation to Diagnostic and Statistical Manual of Mental Disorders (4th ed.; DSM-IV; American Psychiatric Association, 1994) mood and anxiety disorder diagnoses in the patient sample. The authors identified particularly clear and strong associations between (a) major depression and the IDAS General Depression, Dysphoria and Well-Being scales, (b) panic disorder and IDAS Panic, (c) posttraumatic stress disorder and IDAS Traumatic Intrusions, and (d) social phobia and IDAS Social Anxiety. Finally, in logistic regression analyses, the IDAS scales showed significant incremental validity in predicting several DSM-IV diagnoses when compared against the Beck Depression Inventory-II (A. T. Beck, R. A. Steer, & G. K. Brown, 1996) and the Beck Anxiety Inventory (A. T. Beck & R. A. Steer, 1990).