0153 Patient-Defined Insomnia Severity: How Much Wakefulness is Problematic?

Introduction

While Insomnia Disorder is formally defined in the ICSD-3 and DSM-5, neither diagnostic system adopts quantitative criteria for illness severity. Interestingly, quantitative criteria are provided for frequency and chronicity (i.e., ≥ 3 days / week for ≥ 3 months). For research purposes, illness severity has long been defined using the “30 minute rule” (SL and/or WASO and/or EMA of ≥ 30 minutes is the threshold for clinical relevance). In the present analysis, this threshold was assessed for its significance to patients.

Methods

Sleep continuity disturbance (SCD; SL, WASO, and EMA) and problem endorsement data were collected from an archival/community-based sample (N = 4680; 60% female; Ages 18–89 years; www.sleeplessinphilly.com). Problem endorsement was evaluated through questions that included, “Do you consider this a problem?” after participants reported length of SL, WASO, and EMA. Problem endorsement percentages were calculated for 5 minute bins for between 0 and 65 minutes, with one additional bin for > 65 minutes. The temporal bins were compared for significant deviations using absolute (percent of subjects at 0–5 and 5–10 minutes) and moving references (last significant percent).

Results

The first temporal bin to differ from the absolute reference for SL, WASO, and EMA was the 26–30 minute bin. At this threshold, 87%, 70%, and 94% of the subjects’ identifying SL, WASO and EMA as being problematic (and was deemed statistically different from “normal” [0–10 minute values]).

Conclusion

These data suggest that the “30 minute rule” (which is of unknown provenance) roughly corresponds to the level of illness severity (lowest common threshold) identified by patients as problematic. While the threshold for SL and EMA show a clear majority, the lower percentage of subjects for WASO suggests that people are more tolerant of middle of the night wakefulness.

Support

 

1111 Do Sleep Disorder Symptom Endorsements Differ Between ADHD Subtypes?

Introduction

To date, research on differences in sleep complaints between patients with different subtypes of ADHD has been mixed. On balance, the evidence tends towards ADHD-Combined Presentation (ADHD-C) being associated with more severe sleep and sleep-related daytime complaints than ADHD-Primarily Inattentive (ADHD-I). In order to further assess this issue a surveillance study was undertaken in an active ADHD clinic by adding a comprehensive sleep disorders screener (SDS-CL-25) to the clinical intake procedures. These data were used to ascertain whether the two subtypes differ for any of 13 sleep disorders symptoms.

Methods

Subjects (n = 132; 83 male, 49 female, mean age 32.8, age range 18-79), presenting to the clinic for evaluation for ADHD were given the SDS-CL-25. The SDS-CL-25 is a 25-item instrument developed to screen for multiple sleep disorders at one time (problems are endorsed on a Likert-scale; 0 = never and 4 = more than 5x/week). Endorsements greater than 3x/week were counted as positive for the symptom and less than three days per week was considered negative.

Percent per group was compared using Chi Square Analyses. Cumulative morbidity means were also analyzed using t-tests. The subtype, ADHD-I (n=71) and ADHD-C (N=61), was established using EMR records.

Results

No significant differences between patients with ADHD-I and ADHD-C were detected.

Conclusion

The lack of finding in the present analysis may reflect a lack of difference or a failure to detect differences based on the small sample sizes or lack of statistical control for likely confounders (age, sex, illness severity or chronicity, SES status, etc.). Analyses are ongoing.

Support

No support was provided for this abstract.

1093 Population-level Suicide Ideation: Impact Of Combined Roles Of Sleep Duration, Sleep Disturbance, And Daytime Sleepiness

Introduction

Poor sleep has been shown to be related to suicide ideation and depressed mood, but population-level studies have not been done to explore the specific issues within sleep that effect mood, specifically leading to suicide ideation.

Methods

Data from adults 18 and older in the 2015-2016 National Health and Nutrition Examination Survey (NHANES) who provided complete data were used (N=5,123). Suicide ideation was recorded as the presence of thinking that “you would be better off dead” in the past 2 weeks. Sleep duration was recorded in half-hour increments and transformed to represent absolute distance from 7 hours (to model u-shaped association). Sleep disturbance was recorded as presence of “difficulty falling asleep, staying asleep, or sleeping too much” non, several days, or more than half the days of the past 2 weeks. Sleepiness was frequency feeling “overly sleepy during the day” in the past 12 months. Covariates included age, sex, race/ethnicity, and presence of depressed mood in the past 2 weeks. Additional impact of difficulty thinking/concentrating in the past 2 weeks was explored. NHANES sample weights were used in analyses.

Results

In adjusted analyses, increase likelihood of suicide ideation was associated with distance from 7hrs (OR=1.24/hr, p=0.008), sleep difficulties most of the time (OR=2.46, p=0.001), but not sleepiness. When both sleep variables were adjusted for each other, results remained significant for U-shaped sleep duration (OR=1.21/hr, p=0.02) and sleep disturbance (OR=2.31, p=0.003). These were attenuated but remained significant when difficulty thinking/concentrating was introduced; a significant sobel test (p<0.0001) suggested partial mediation, with this variable accounting for approximately 13% of the variance of the relationship to sleep.

Conclusion

In the population, improper and poor sleep was associated with a greater risk of suicide ideation.

Support

Dr. Grandner is supported by R01MD011600

1174 Assessing Sleep Disorders in Primary Care: A Provider Survey About the Importance of Sleep Health

Introduction

Conditions commonly managed by primary care providers (PCPs) such as depression, diabetes, and heart disease, commonly co-occur with sleep disorders. If PCPs could readily identify comorbid sleep disorders in this context, it may provide a pathway to more effective management of both types of disorders. Currently, it is unknown what might encourage or discourage PCPs from routinely screening their patients for sleep disorders.

Methods

PCPs from UPENN and GHS completed surveys regarding sleep health. The 30-item instrument comprised demographic, 14 VAS (0%-100%=strongly disagree-strongly agree), 4 open-ended, 3 yes/no, and 2 multiple-choice questions.

Results

Ninety-nine PCPs responded and were predominately female (61% F, 37%M, 2% other), Caucasian (81%), on-average 45yrs old (25-70) and in primary care for 16yrs (1-43). Fifty-six percent were MDs, 21%DOs, 17%PAs, and 6%NPs. PCPs rated sleep disorders as highly important for cardiopulmonary, mental, and general health (85, 84, & 83%), with no difference (per linear regression, p>0.05) according to system or provider characteristics. PCPs reported high importance for knowing about and diagnosing sleep disorders (88% & 82%) within their practices. Lower comfort levels were reported for discussing (78%) sleep disorders, overseeing/following (62%), diagnosing (60%), or treating (48%) patients. Eighty percent of PCPs stated an efficient sleep disorders screener would be useful for their practice; this perception varied (per logistic regression) according to provider credentials (Wald=0.037) and Hispanic/Latino ethnicity (Wald=0.025). PCPs reported time constraints limit their responsiveness to sleep disorders

Conclusion

A large disparity exists between the importance PCPs place on sleep disorders and their low comfort levels with following, diagnosing, and treating sleep disorders. PCPs endorsed the need to have available an efficient sleep disorders screener to use in their practice.

Support

No funding was received for this study.

Relationship between insomnia and depression in a community sample depends on habitual sleep duration

Sleep disturbances, such as short sleep duration and insomnia, are core features of depression. However, it is unclear if sleep duration and insomnia have an interactive effect on depression severity or individual symptoms. Data were drawn from a community sample (N = 1007) containing responses on the Insomnia Severity Index, Patient Health Questionnaire-9 (PHQ-9), and average sleep duration. Regression analyses determined the prevalence risks (PR) of symptoms of depression based on insomnia severity and sleep duration. Depression severity was related to insomnia severity (PR 1.09, p < 0.001) and short sleep duration (PR 1.52, p < 0.001), but the interaction between the two was negative (PR 0.97, p < 0.001). Insomnia severity increased the prevalence risk of all individual depression symptoms between 8 and 15%, while sleep duration increased the prevalence risk of appetite dysregulation (PR 1.86, p < 0.001), fatigue (PR 1.51, p < 0.001), difficulty concentrating (PR 1.61, p = 0.003), feelings of failure (PR 1.58, p = 0.002), and suicidal behavior (PR 2.54, p = 0.01). The interaction of sleep duration and insomnia was negative and ranged between 3 and 6%. In clinically significant depression (PHQ >=10), only insomnia severity increased the prevalence risk of depression severity (PR 1.02, p = 0.001). Insomnia and short sleep predict prevalent depression, but their interactive effect was negative. Thus, while insomnia had a greater association with depression severity and symptoms, this association was dependent on habitual sleep duration.

Relationship of Nocturnal Wakefulness to Suicide Risk Across Months and Methods of Suicide

OBJECTIVE

Insomnia is a risk factor for suicide, and the risk of suicide after accounting for population wakefulness is disproportionately highest at night. This study investigated whether this risk varied across months and/or methods of suicide.

METHODS

Time, date, method (eg, firearm, poisoning), and demographic information for 35,338 suicides were collected from the National Violent Death Reporting System for the years 2003-2010. Time of fatal injury was grouped into 1-hour bins and compared to the estimated hourly proportion of the population awake from the American Time Use Survey for 2003-2010. Negative binomial modeling then generated hourly incidence risk ratios (IRRs) of suicide. Risks were then aggregated into 4 categories: morning (6:00 am to 11:59 am), afternoon (noon to 5:59 pm), evening (6:00 pm to 11:59 pm), and night (midnight to 5:59 am).

RESULTS

The risk of suicide was higher at night across all months (P < .001) and methods (P < .001). The mean nocturnal IRR across months was 3.18 (SD = 0.314), with the highest IRR in May (3.90) and the lowest in November (2.74). The mean (SD) nocturnal IRR across methods was 3.09 (0.472), with the highest IRR for fire (3.75) and the lowest for drowning (2.44). Additionally, nocturnal risk was elevated within all demographics (all P < .001). However, there were no month-by-time or method-by-time interactions across demographics (all P > .05).

CONCLUSIONS

Regardless of month or method, the incidence risk of suicide at night is higher than at any other time of day. Additionally, demographic subgroups did not differentially experience higher risks across months or mechanisms at night.

Acute and Chronic Insomnia: What Has Time and/or Hyperarousal Got to Do with It?

Nearly one-third of the population reports new onset or acute insomnia in a given year. Similarly, it is estimated that approximately 10% of the population endorses sleep initiation and maintenance problems consistent with diagnostic criteria for chronic insomnia. For decades, acute and chronic insomnia have been considered variations of the same condition or disorder, only really differentiated in terms of chronicity of symptoms (days/weeks versus months). Whether or not acute and chronic insomnia are part of the same phenomena is an important question, one that has yet to be empirically evaluated. The goal of the present theoretical review was to summarize the definitions of acute and chronic insomnia and discuss the role that hyperarousal may have in explaining how the pathophysiology of acute and chronic insomnia is likely different (i.e., what biopsychological factors precipitate and/or perpetuate acute insomnia, chronic insomnia, or both?).

The European Academy for Cognitive Behavioural Therapy for Insomnia: An initiative of the European Insomnia Network to promote implementation and dissemination of treatment

Insomnia, the most prevalent sleep disorder worldwide, confers marked risks for both physical and mental health. Furthermore, insomnia is associated with considerable direct and indirect healthcare costs. Recent guidelines in the US and Europe unequivocally conclude that cognitive behavioural therapy for insomnia (CBT-I) should be the first-line treatment for the disorder. Current treatment approaches are in stark contrast to these clear recommendations, not least across Europe, where, if any treatment at all is delivered, hypnotic medication still is the dominant therapeutic modality. To address this situation, a Task Force of the European Sleep Research Society and the European Insomnia Network met in May 2018. The Task Force proposed establishing a European CBT-I Academy that would enable a Europe-wide system of standardized CBT-I training and training centre accreditation. This article summarizes the deliberations of the Task Force concerning definition and ingredients of CBT-I, preconditions for health professionals to teach CBT-I, the way in which CBT-I should be taught, who should be taught CBT-I and to whom CBT-I should be administered. Furthermore, diverse aspects of CBT-I care and delivery were discussed and incorporated into a stepped-care model for insomnia.

A secondary analysis of the role of geography in engagement and outcomes in a clinical trial of an efficacious Internet intervention for insomnia

BACKGROUND

Online interventions for insomnia can increase access to treatments for those with limited access to services. What remains unknown is whether individuals from more isolated (vs. more densely populated) regions engage with, and benefit as much from, an online intervention. This secondary analysis examined the relationship of geographical indices with engagement and outcomes of an efficacious, fully automated online cognitive behavioral therapy for insomnia (CBT-I) program (Sleep Healthy Using the Internet-SHUTi).

METHOD

303 participants (M _age  = 43.3; SD = 11.6) were randomly assigned to SHUTi or an online patient education condition and assessed at baseline and post intervention. Rural code of participants was determined using participant zip codes. Distance to the nearest sleep medicine provider was calculated as the distance between the center of the nearest provider's city (from a publicly available list of CBT-I providers) and the center of the participants' zip code. Adherence outcomes were number of intervention core completions, sleep diaries, and logins. Sleep outcomes were insomnia severity as well as sleep onset latency and wake after sleep onset derived from online sleep diaries.

RESULTS

Individuals were from a range of geographic locations. Most lived in fairly densely populated areas; however, there was a large variation in distance to the nearest sleep medicine provider. Findings indicate that the efficacy, adherence, and engagement with SHUTi were not impacted by where people lived. Controlling for age and gender did not impact any of the relationships among geography variables (i.e., distance, ruralness) and adherence or sleep related outcomes.

CONCLUSIONS

Internet interventions must demonstrate that they can overcome obstacles posed by geography. This is the first study to examine the geographic location of participants and its association with engagement with, and outcomes of, online CBT-I.

Doctor-patient sleep discussions for US adults: results from the SHADES study

OBJECTIVES

Determine the current rate of patient-provider sleep discussions and identify factors associated with occurrence of these discussions.

DESIGN

Secondary cross-sectional analysis of self-report data collected during the Sleep and Healthy Activity Diet Environment and Socialization study. Logistic regressions were used.

SETTING

Urban and suburban Southeastern Pennsylvania PARTICIPANTS: A total of n = 998 adults (aged 22-60), 38.6% female, racially and socioeconomically diverse, from urban and suburban Southeastern Pennsylvania.

MEASUREMENTS

Outcome measures were responses to 3 questions: (1) ever discussed sleep with a provider, (2) a provider ever discussed importance of sleep schedule, and (3) a provider ever discussed importance of enough sleep. Descriptive/independent variables included demographic factors and a wide range of patient-reported measures of health and sleep habits.

RESULTS

About a third of individuals have ever discussed sleep with a provider. Factors associated with higher odds of sleep-related discussions included sleep medication use, worse insomnia severity, race (Black/African American, Hispanic, Latino, other/multiracial), female sex, higher education, higher body mass index, and worse depression severity. Factors associated with lower odds were Asian race and low income. Sleep discussions were not associated with certain factors indicative of sleep disorders: sleep duration, snoring, shift work schedule, not working, and anxiety.

CONCLUSIONS

Low rates of patient-provider sleep discussions and factors associated (or not) with their occurrence indicate missed opportunities for improved health outcomes.

Cognitive Behavioral Therapy for Insomnia in Alcohol-Dependent Veterans: A Randomized, Controlled Pilot Study

BACKGROUND

Insomnia is highly prevalent in individuals recovering from alcohol dependence (AD) and increases their risk of relapse. Two studies evaluating cognitive behavior therapy for insomnia (CBT-I) have demonstrated its efficacy in non-Veterans recovering from AD. The aim of this study was to extend these findings in an 8-week trial of CBT-I in Veterans.

METHODS

Veterans recovering from AD were randomly assigned to 8 weeks of treatment with CBT-I (N = 11) or a Monitor-Only (MO; N = 11) condition and were evaluated 3 (N = 21/22) and 6 months posttreatment (N = 18/22). The primary outcome measure was the Insomnia Severity Index (ISI) score. Secondary outcome measures were sleep diary measures, percent days abstinent (PDA), and scores on the Dysfunctional Beliefs and Attitudes About Sleep Scale (DBAS), Sleep Hygiene Index (SHI), Penn Alcohol Craving Scale (PACS), Quick Inventory of Depressive Symptoms (QIDS), State-Trait Anxiety Inventory-Trait (STAI-T) scale, and Short Form 12-item (SF-12). Mixed-effects regression models, adjusted for race, evaluated differences in outcomes between the groups over a 6-month period (clinicaltrials.gov identifier = NCT01603381).

RESULTS

Subjects were male, aged 54.5 (SD = 6.9) years, and had 26.4 (SD = 26.3) days of abstinence before their baseline evaluation. CBT-I produced a significantly greater improvement in model-based estimates than MO (mean change at 6 months compared to their baseline) for ISI, sleep latency from a daily sleep diary, DBAS mean score, and SHI total score. PDA and QIDS improved over time, but there was no difference between the groups. PACS, STAI-T, or SF-12 scale did not show any improvement from their baseline scores.

CONCLUSIONS

CBT-I treatment demonstrated substantial efficacy in reducing insomnia, associated negative cognitions, and improving sleep hygiene in Veterans during early recovery, though it did not reduce drinking behavior.