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Thomas A, Grandner M, Nowakowski S, Nesom G, Corbitt C, Perlis ML. Where are the Behavioral Sleep Medicine Providers and Where are They Needed? A Geographic Assessment. Behav Sleep Med 2016; 14:687-98. [PMID: 27159249 PMCID: PMC5070478 DOI: 10.1080/15402002.2016.1173551] [Citation(s) in RCA: 120] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Although it is widely acknowledged that there are not enough clinicians trained in either Behavioral Sleep Medicine (BSM) in general or in Cognitive Behavioral Therapy for Insomnia (CBT-I) in specific, what is unclear is whether this problem is more acute in some regions relative to others. Accordingly, a geographic approach was taken to assess this issue. Using national directories as well as e-mail listservs (Behavioral Sleep Medicine group and Behavioral Treatment for Insomnia Roster), the present study evaluated geographic patterning of CBSM and BSM providers by city, state, and country. Overall, 88% of 752 BSM providers worldwide live in the United States (n = 659). Of these, 58% reside in 12 states with ≥ 20 providers (CA, NY, PA, IL, MA, TX, FL, OH, MI, MN, WA, and CO), and 19% reside in just 2 states (NY and CA). There were 4 states with no BSM providers (NH, HI, SD, and WY). Of the 167 U.S. cities with a population of > 150,000, 105 cities have no BSM providers. These results clearly suggest that a targeted effort is needed to train individuals in both the unserved and underserved areas.
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Chakravorty S, Siu HYK, Lalley-Chareczko L, Brown GK, Findley JC, Perlis ML, Grandner MA. Sleep Duration and Insomnia Symptoms as Risk Factors for Suicidal Ideation in a Nationally Representative Sample. Prim Care Companion CNS Disord 2015; 17:13m01551. [PMID: 27057399 DOI: 10.4088/pcc.13m01551] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2013] [Accepted: 07/16/2015] [Indexed: 10/22/2022] Open
Abstract
OBJECTIVE Suicidal behavior (suicidal ideation, suicide attempts, and suicide completion) has been increasingly linked with difficulty initiating sleep, maintaining sleep, and early morning awakenings. However, the relationship between suicidal behavior and sleep duration abnormalities is unclear, especially at the population level. The present study used a nationally representative sample to examine the association of suicidal ideation with extreme sleep durations and insomnia symptoms. METHOD Cross-sectional data from adult respondents (≥ 18 years of age, N = 6,228) were extracted from the 2007-2008 wave of the National Health and Nutritional Examination Survey. Ordinal logistic regression analyses were used to evaluate the relationship of suicidal ideation with sleep duration, global insomnia, and individual insomnia symptoms in models adjusted for sociodemographic, socioeconomic, and health-related covariates. RESULTS Suicidal ideation was associated with abnormalities of sleep duration. This relationship ceased to exist once the model was adjusted for depressive symptoms. As expected, an increased level of suicidal ideation was consistently associated with insomnia. Of the insomnia symptoms, difficulty maintaining sleep was found to be the most predictive of suicidal ideation, followed by difficulty initiating sleep (P< .05). CONCLUSIONS Abnormalities of sleep duration and continuity should prompt a clinical assessment for suicide risk.
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Garland SN, Roscoe JA, Heckler CE, Barilla H, Gehrman P, Findley JC, Peoples AR, Morrow GR, Kamen C, Perlis ML. Effects of armodafinil and cognitive behavior therapy for insomnia on sleep continuity and daytime sleepiness in cancer survivors. Sleep Med 2015; 20:18-24. [PMID: 27318221 DOI: 10.1016/j.sleep.2015.12.010] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2015] [Revised: 11/29/2015] [Accepted: 12/22/2015] [Indexed: 12/21/2022]
Abstract
STUDY OBJECTIVES This study involves the analysis of a secondary outcome of a trial examining whether cognitive behavior therapy for insomnia (CBT-I), a wake-promoting medication (armodafinil), or both results in greater improvement in prospectively assessed sleep continuity and daytime sleepiness than a placebo-alone group among a heterogeneous group of cancer survivors. Whether or not armodafinil alone, and/or when combined with CBT-I, affected adherence with CBT-I was evaluated. DESIGN This study is a randomized, placebo-controlled, clinical trial. SETTING This study was conducted at two northeastern academic medical centers. PARTICIPANTS Eighty-eight cancer survivors with chronic insomnia were recruited between October 2008 and November 2012. Participants were assigned to one of four conditions: 1) CBT-I and placebo (CBT-I+P); 2) CBT-I and armodafinil (CBT-I + A); 2) armodafinil alone (ARM); or 4) placebo alone (PLA). INTERVENTIONS CBT-I was delivered in seven weekly individual therapy sessions (three in person, four via telephone). The armodafinil dosage was 50 mg BID. MEASUREMENTS AND RESULTS Sleep continuity was measured with daily sleep diaries assessing sleep latency (SL), wake after sleep onset (WASO), and total sleep time (TST). The Epworth Sleepiness Scale (ESS) measured daytime sleepiness. Compared to the PLA group, the CBT-I+P and CBT-I+A groups reported a significant reduction in SL with effect sizes of 0.67 and 0.58, respectively. A significant reduction was observed in WASO in the CBT-I+A group with an effect size of 0.64. An increasing trend of TST was observed in the CBT-I+P, CBT-I+A, and PLA groups, but not in the ARM group. No statistically significant reductions in daytime sleepiness (ESS) were observed for any of the groups. CONCLUSION CBT-I alone and in combination with armodafinil caused significant improvement in sleep continuity. The addition of armodafinil did not appear to improve daytime sleepiness or enhance adherence to CBT-I.
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Perlis ML, Roalf DR, Kloss JD. A commentary on the “Functioning of three attentional networks and vigilance in primary insomnia”. Sleep Med 2015; 16:1567-8. [DOI: 10.1016/j.sleep.2015.08.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2015] [Accepted: 08/13/2015] [Indexed: 10/23/2022]
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105
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Heckler CE, Garland SN, Peoples AR, Perlis ML, Shayne M, Morrow GR, Kamen C, Hoefler J, Roscoe JA. Cognitive behavioral therapy for insomnia, but not armodafinil, improves fatigue in cancer survivors with insomnia: a randomized placebo-controlled trial. Support Care Cancer 2015; 24:2059-2066. [PMID: 26542272 DOI: 10.1007/s00520-015-2996-y] [Citation(s) in RCA: 52] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2015] [Accepted: 10/26/2015] [Indexed: 11/30/2022]
Abstract
PURPOSE Fatigue is a prevalent, distressing side effect of cancer and cancer treatment which commonly coexists with insomnia. Cognitive behavioral therapy for insomnia (CBT-I) has been shown to improve insomnia in cancer patients, but less is known about its ability to impact fatigue. This work is the analysis for a secondary aim of a four-arm randomized controlled trial (RCT) study assessing the combined and comparative effect of CBT-I and a wakefulness-promoting agent, armodafinil (A), to improve sleep and daytime functioning in cancer survivors. Herein, we examine the effect of CBT-I, with and without A, on fatigue in cancer survivors. PATIENTS AND METHODS This study was a four-arm factorial study with CBTI-I (yes/no) versus A (yes/no). It consisted of 96 cancer survivors (average age 56 years; 88 % female; 68 % breast cancer). Fatigue was assessed by the brief fatigue inventory (BFI) and the FACIT-Fatigue scale. The analysis assessed the additive effects of CBT-I and A and possible non-additive effects where the effect of CBT-I changes depending on the presence or absence of A. RESULTS Analyses adjusting for baseline differences showed that CBT-I improved fatigue as measured by two separate scales (BFI: P = 0.002, Std. error = 0.32, effect size (ES) = 0.46; FACIT-Fatigue: P < 0.001, Std. error = 1.74, ES = 0.64). Armodafinil alone did not show a statistically significant effect on fatigue levels (all Ps > 0.40) nor did the drug influence the efficacy of CBT-I. Structural equation analysis revealed that reductions in insomnia severity were directly responsible for improving cancer-related fatigue. CONCLUSIONS CBT-I with and without armodafinil resulted in a clinically and statistically significant reduction of subjective daytime fatigue in cancer survivors with chronic insomnia. Armodafinil did not improve cancer-related fatigue (CRF) and did not change the efficacy of CBT-I. Patients reporting CRF should be screened and, if indicated, treated for insomnia as part of a comprehensive fatigue management program.
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Perlis ML, Grandner MA, Chakravorty S, Bernert RA, Brown GK, Thase ME. Suicide and sleep: Is it a bad thing to be awake when reason sleeps? Sleep Med Rev 2015; 29:101-7. [PMID: 26706755 DOI: 10.1016/j.smrv.2015.10.003] [Citation(s) in RCA: 94] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2015] [Revised: 10/05/2015] [Accepted: 10/12/2015] [Indexed: 12/11/2022]
Abstract
Suicide is the second leading cause of death, worldwide, for those between the ages of 24 and 44 y old. In 2013, more than 41,000 suicides occurred in the United States. These statistics underscore the need to 1) understand why people die by suicide and 2) identify risk factors that are potentially modifiable. While it has been posited that sleep disturbance may represent one such factor, systematic research in this arena did not begin until the 2000s. Since that time, sleep disturbance has been reliably identified as a risk factor for suicidal ideation, suicide attempts, and suicide. While insomnia, nightmares, and other sleep disorders have each been found to contribute to the risk for suicidal ideation and behavior, it is also possible that these factors share some common variance. One possibility is that sleep disturbance results in being awake at night, and being awake at night also confers risk. The hypothesis proffered here is that being awake when one is not biologically prepared to be so results in "hypofrontality" and diminished executive function, and that this represents a common pathway to suicidal ideation and behavior. Such a proposition is highly testable under a variety of possible protocols. The current review summarizes the extant literature on suicide rates by time-of-day, and discusses circadian, psychosocial, and neurocognitive explanations of risk. Such a focus promises to enhance our understanding of how sleep disturbance may confer risk, allows for the identification of future lines of research, and further justifies the need for interventions that promote good sleep continuity among at-risk individuals.
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Grandner MA, Perlis ML. Treating Insomnia Disorder in the Context of Medical and Psychiatric Comorbidities. JAMA Intern Med 2015; 175:1472-3. [PMID: 26147221 PMCID: PMC4703103 DOI: 10.1001/jamainternmed.2015.3015] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
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108
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Kloss JD, Perlis ML, Zamzow JA, Culnan EJ, Gracia CR. Sleep, sleep disturbance, and fertility in women. Sleep Med Rev 2015; 22:78-87. [PMID: 25458772 PMCID: PMC4402098 DOI: 10.1016/j.smrv.2014.10.005] [Citation(s) in RCA: 102] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2014] [Revised: 10/07/2014] [Accepted: 10/07/2014] [Indexed: 01/27/2023]
Abstract
Sleep and sleep disturbances are increasingly recognized as determinants of women's health and well-being, particularly in the context of the menstrual cycle, pregnancy, and menopause. At present, however, little is known about whether fertility is affected by sleep quantity and quality. That is, to what degree, and by what mechanisms, do sleep and/or its disturbances affect fertility? The purpose of this review is to synthesize what is known about sleep disturbances in relation to reproductive capacity. A model is provided, whereby stress, sleep dysregulation, and circadian misalignment are delineated for their potential relevance to infertility. Ultimately, if it is the case that sleep disturbance is associated with infertility, new avenues for clinical intervention may be possible.
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Watanabe N, Furukawa TA, Shimodera S, Katsuki F, Fujita H, Sasaki M, Sado M, Perlis ML. Cost-effectiveness of cognitive behavioral therapy for insomnia comorbid with depression: Analysis of a randomized controlled trial. Psychiatry Clin Neurosci 2015; 69:335-43. [PMID: 25205008 DOI: 10.1111/pcn.12237] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2014] [Revised: 07/15/2014] [Accepted: 09/03/2014] [Indexed: 11/28/2022]
Abstract
AIM Although the efficacy of cognitive behavioral therapy for insomnia has been confirmed, dissemination depends on the balance of benefits and costs. This study aimed to examine the cost-effectiveness of cognitive behavioral therapy for insomnia consisting of four weekly individual sessions. METHODS We conducted a 4-week randomized controlled trial with a 4-week follow up in outpatient clinics in Japan. Thirty-seven patients diagnosed as having major depressive disorder according to DSM-IV and suffering from chronic insomnia were randomized to receive either treatment as usual (TAU) alone or TAU plus cognitive behavioral therapy for insomnia. Effectiveness was evaluated as quality-adjusted life years (QALY) over 8 weeks' time, estimated by bootstrapping of the observed total scores of the Hamilton Depression Rating Scale. Direct medical costs for cognitive behavioral therapy for insomnia and TAU were also evaluated. We calculated the incremental cost-effectiveness ratio. RESULTS Over the 8 weeks of the study, the group receiving cognitive behavioral therapy for insomnia plus TAU had significantly higher QALY (P = 0.002) than the TAU-alone group with an incremental value of 0.019 (SD 0.006), and had non-significantly higher costs with an incremental value of 254 (SD 203) USD in direct costs. The incremental cost-effectiveness ratio was 13 678 USD (95% confidence interval: -5691 to 71 316). Adding cognitive behavioral therapy for insomnia demonstrated an approximately 95% chance of gaining one more QALY if a decision-maker was willing to pay 60 000 USD, and approximately 90% for 40 000 USD. CONCLUSION Adding cognitive behavioral therapy for insomnia is highly likely to be cost-effective for patients with residual insomnia and concomitant depression.
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Riemann D, Nissen C, Palagini L, Otte A, Perlis ML, Spiegelhalder K. The neurobiology, investigation, and treatment of chronic insomnia. Lancet Neurol 2015; 14:547-58. [PMID: 25895933 DOI: 10.1016/s1474-4422(15)00021-6] [Citation(s) in RCA: 317] [Impact Index Per Article: 35.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2014] [Revised: 01/16/2015] [Accepted: 01/29/2015] [Indexed: 12/31/2022]
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111
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Grandner MA, Nowakowski S, Kloss JD, Perlis ML. Insomnia symptoms predict physical and mental impairments among postmenopausal women. Sleep Med 2015; 16:317-8. [DOI: 10.1016/j.sleep.2015.01.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2014] [Accepted: 01/02/2015] [Indexed: 11/28/2022]
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112
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Chakravorty S, Siu HYK, Lalley-Chareczko L, Brown GK, Findley JC, Perlis ML, Grandner MA. Sleep Duration and Insomnia Symptoms as Risk Factors for Suicidal Ideation in a Nationally Representative Sample. Prim Care Companion CNS Disord 2015. [PMID: 27057399 DOI: 10.4088/pcc.13m01551.] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/29/2022] Open
Abstract
OBJECTIVE Suicidal behavior (suicidal ideation, suicide attempts, and suicide completion) has been increasingly linked with difficulty initiating sleep, maintaining sleep, and early morning awakenings. However, the relationship between suicidal behavior and sleep duration abnormalities is unclear, especially at the population level. The present study used a nationally representative sample to examine the association of suicidal ideation with extreme sleep durations and insomnia symptoms. METHOD Cross-sectional data from adult respondents (≥ 18 years of age, N = 6,228) were extracted from the 2007-2008 wave of the National Health and Nutritional Examination Survey. Ordinal logistic regression analyses were used to evaluate the relationship of suicidal ideation with sleep duration, global insomnia, and individual insomnia symptoms in models adjusted for sociodemographic, socioeconomic, and health-related covariates. RESULTS Suicidal ideation was associated with abnormalities of sleep duration. This relationship ceased to exist once the model was adjusted for depressive symptoms. As expected, an increased level of suicidal ideation was consistently associated with insomnia. Of the insomnia symptoms, difficulty maintaining sleep was found to be the most predictive of suicidal ideation, followed by difficulty initiating sleep (P< .05). CONCLUSIONS Abnormalities of sleep duration and continuity should prompt a clinical assessment for suicide risk.
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Roscoe JA, Garland SN, Heckler CE, Perlis ML, Peoples AR, Shayne M, Savard J, Daniels NP, Morrow GR. Randomized placebo-controlled trial of cognitive behavioral therapy and armodafinil for insomnia after cancer treatment. J Clin Oncol 2014; 33:165-71. [PMID: 25452447 DOI: 10.1200/jco.2014.57.6769] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE Insomnia is a distressing and often persisting consequence of cancer. Although cognitive behavioral therapy for insomnia (CBT-I) is the treatment of choice in the general population, the use of CBT-I in patients with cancer is complicated, because it can result in transient but substantial increases in daytime sleepiness. In this study, we evaluated whether CBT-I, in combination with the wakefulness-promoting agent armodafinil (A), results in better insomnia treatment outcomes in cancer survivors than CBT-I alone. PATIENTS AND METHODS We report on a randomized trial of 96 cancer survivors (mean age, 56 years; female, 87.5%; breast cancer, 68%). The primary analyses examined whether ≥ one of the 7-week intervention conditions (ie, CBT-I, A, or both), when compared with a placebo capsule (P) group, produced significantly greater clinical gains. Insomnia was assessed by the Insomnia Severity Index and sleep quality by the Pittsburgh Sleep Quality Inventory. All patients received sleep hygiene instructions. RESULTS Analyses controlling for baseline differences showed that both the CBT-I plus A (P = .001) and CBT-I plus P (P = .010) groups had significantly greater reductions in insomnia severity postintervention than the P group, with effect sizes of 1.31 and 1.02, respectively. Similar improvements were seen for sleep quality. Gains on both measures persisted 3 months later. CBT-I plus A was not significantly different from CBT-I plus P (P = .421), and A alone was not significantly different from P alone (P = .584). CONCLUSION CBT-I results in significant and durable improvements in insomnia and sleep quality. A did not significantly improve the efficacy of CBT-I or independently affect insomnia or sleep quality.
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Watanabe N, Furukawa TA, Shimodera S, Katsuki F, Fujita H, Sasaki M, Suga Y, Kakeda K, Perlis ML. Can assessors in a psychotherapy trial be successfully blinded? Analysis of a randomized controlled trial on psychotherapy for refractory insomnia in residual depression. PSYCHOTHERAPY AND PSYCHOSOMATICS 2014; 82:401-3. [PMID: 24080757 DOI: 10.1159/000353174] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/13/2013] [Accepted: 05/20/2013] [Indexed: 11/19/2022]
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Shimodera S, Watanabe N, Furukawa TA, Katsuki F, Fujita H, Sasaki M, Perlis ML. Change in quality of life after brief behavioral therapy for insomnia in concurrent depression: analysis of the effects of a randomized controlled trial. J Clin Sleep Med 2014; 10:433-9. [PMID: 24733990 DOI: 10.5664/jcsm.3624] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
STUDY OBJECTIVES The efficacy of cognitive behavioral therapy for insomnia (CBT-I) has been suggested for insomnia concomitant with depression, but its impact on quality of life (QoL) has not been adequately evaluated. The study aimed to determine which aspects of QoL could be affected by CBT-I and how any changes in QoL were mediated by changes in insomnia and depression. METHODS We conducted a 4-week randomized controlled trial with 4-week follow-up in outpatient clinics in Japan. Thirty-seven patients with DSM-IV diagnosis of major depressive disorder concomitant with chronic insomnia were randomly assigned to the treatment-as-usual (TAU) alone arm or the TAU with brief behavioral therapy for insomnia (TAU plus psychotherapy) arm using modified CBT-I consisting of 4 weekly individual sessions. We evaluated QoL using norm-based scoring of the Short Form-36 at baseline and at 8 weeks. We also examined associations between QoL subscales and remission in insomnia or depression while controlling for baseline scores of the entire sample. RESULTS We tested group effects while controlling for baseline scores. TAU plus psychotherapy resulted in significantly better scores on physical functioning (p = 0.006), social functioning (p = 0.002), and mental health (p = 0.041) subscales than TAU alone at 8 weeks. Patients with either remitted insomnia or depression showed higher QoL scores than non-remitted patients; scores approximated those within the normal range. CONCLUSIONS For patients with insomnia in depression, adding CBT-I to TAU can produce substantive benefits in some aspects of QoL. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT00610259, http://www.clinicaltrials.gov/.
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Perlis ML, Zee J, Swinkels C, Kloss J, Morgan K, David B, Morales K. The incidence and temporal patterning of insomnia: a second study. J Sleep Res 2014; 23:499-507. [PMID: 24730977 DOI: 10.1111/jsr.12150] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2013] [Accepted: 03/01/2014] [Indexed: 11/29/2022]
Abstract
Whether subjects with insomnia exhibit good sleep on some interval basis is unclear. Prior research suggests that patients with insomnia are highly variable with respect to night-to-night sleep continuity, that more than 40% of patients exhibit temporal patterning of good sleep, and that nearly 90% of patients exhibit better than average sleep following 1 to 3 nights of relatively poor sleep. The aim of the present study was to replicate and extend the above-noted findings utilizing: (i) a large sample studied over an extended time interval (ii) absolute standards for 'good' and 'poor' sleep; and (iii) a formal statistical methodology to assess temporal patterning and the association of time in bed with bout duration of poor or average sleep. Thirty-three subjects with insomnia and 33 good sleepers completed sleep diaries over the course of 110 days. It was found that subjects with insomnia (compared to good sleepers) had more poor nights (e.g. about 39 versus 7% of the assessed nights), a higher probability of a having a poor night on any given occasion (60% greater probability than good sleepers) and more consecutive nights of poor sleep between good sleep nights (median bout duration of approximately three versus one night). Lastly, it was found that (as would be predicted by both the Spielman model and the two-process model) time in bed moderated bout duration in the insomnia group. That is, longer times in bed were associated with longer bouts of poor sleep.
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Perlis ML, Corbitt CB, Kloss JD. Insomnia research: 3Ps and beyond. Sleep Med Rev 2014; 18:191-3. [PMID: 24685396 DOI: 10.1016/j.smrv.2014.01.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2014] [Accepted: 01/23/2014] [Indexed: 10/25/2022]
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118
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Talbot LS, Maguen S, Metzler TJ, Schmitz M, McCaslin SE, Richards A, Perlis ML, Posner DA, Weiss B, Ruoff L, Varbel J, Neylan TC. Cognitive behavioral therapy for insomnia in posttraumatic stress disorder: a randomized controlled trial. Sleep 2014; 37:327-41. [PMID: 24497661 DOI: 10.5665/sleep.3408] [Citation(s) in RCA: 185] [Impact Index Per Article: 18.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
STUDY OBJECTIVES Examine whether cognitive behavioral therapy for insomnia (CBT-I) improves sleep in posttraumatic stress disorder (PTSD) as well as nightmares, nonsleep PTSD symptoms, depression symptoms, and psychosocial functioning. DESIGN RANDOMIZED CONTROLLED TRIAL WITH TWO ARMS: CBT-I and monitor-only waitlist control. SETTING Department of Veterans Affairs (VA) Medical Center. PARTICIPANTS Forty-five adults (31 females: [mean age 37 y (22-59 y)] with PTSD meeting research diagnostic criteria for insomnia, randomly assigned to CBT-I (n = 29; 22 females) or monitor-only waitlist control (n = 16; nine females). INTERVENTIONS Eight-session weekly individual CBT-I delivered by a licensed clinical psychologist or a board-certified psychiatrist. MEASUREMENTS AND RESULTS Measures included continuous monitoring of sleep with diary and actigraphy; prepolysomnography and postpolysomnography and Clinician-Administered PTSD Scale (CAPS); and pre, mid, and post self-report questionnaires, with follow-up of CBT-I participants 6 mo later. CBT-I was superior to the waitlist control condition in all sleep diary outcomes and in polysomnography-measured total sleep time. Compared to waitlist participants, CBT-I participants reported improved subjective sleep (41% full remission versus 0%), disruptive nocturnal behaviors (based on the Pittsburgh Sleep Quality Index-Addendum), and overall work and interpersonal functioning. These effects were maintained at 6-mo follow-up. Both CBT-I and waitlist control participants reported reductions in PTSD symptoms and CAPS-measured nightmares. CONCLUSIONS Cognitive behavioral therapy for insomnia (CBT-I) improved sleep in individuals with posttraumatic stress disorder, with durable gains at 6 mo. Overall psychosocial functioning improved following CBT-I. The initial evidence regarding CBT-I and nightmares is promising but further research is needed. Results suggest that a comprehensive approach to treatment of posttraumatic stress disorder should include behavioral sleep medicine. CLINICAL TRIAL INFORMATION TRIAL NAME: Cognitive Behavioral Treatment Of Insomnia In Posttraumatic Stress Disorder. URL: http://clinicaltrials.gov/ct2/show/NCT00881647. REGISTRATION NUMBER NCT00881647.
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Chakravorty S, Grandner MA, Mavandadi S, Perlis ML, Sturgis EB, Oslin DW. Suicidal ideation in veterans misusing alcohol: relationships with insomnia symptoms and sleep duration. Addict Behav 2014; 39:399-405. [PMID: 24169371 PMCID: PMC4406056 DOI: 10.1016/j.addbeh.2013.09.022] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2013] [Revised: 09/20/2013] [Accepted: 09/24/2013] [Indexed: 10/26/2022]
Abstract
OBJECTIVE The aim of this investigation was to assess the relationships between suicidal ideation and insomnia symptoms in Veterans misusing alcohol. METHOD Data were extracted in this retrospective chart review of Veterans referred from primary care for a behavioral health evaluation (N=161) based on evidence of heavy drinking, drug use or another behavioral problem. Suicidal ideation (SI) was assessed using the Paykel questionnaire. Insomnia symptoms were assessed with standard diary questions in an interview format and pertained to sleep latency (SL), wake after sleep onset time (WASO), sleep quality (SQ), and habitual sleep duration (HSD). The relations between suicidal ideation and insomnia symptoms were assessed using ordinal regression analyses adjusted for socio-demographic, psychiatric and addiction-related variables. RESULTS Suicidal ideation was reported in 62 (39%) of the Veterans interviewed. In a multivariable model, only inadequate SQ was associated with suicidal ideation. Short sleepers were more likely to endorse suicidal ideation and have attempted suicide in the past year. In addition, older age, inadequate financial status, and the presence of a psychiatric disorder were also significantly associated with suicidal ideation in most of the adjusted models. CONCLUSION Given their association with suicidal ideation, insomnia symptoms in Veterans misusing alcohol should prompt an assessment of underlying psychiatric and social factors.
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Ellis JG, Perlis ML, Bastien CH, Gardani M, Espie CA. The natural history of insomnia: acute insomnia and first-onset depression. Sleep 2014; 37:97-106. [PMID: 24470699 DOI: 10.5665/sleep.3316] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
STUDY OBJECTIVES While many studies have examined the association between insomnia and depression, no studies have evaluated these associations (1) within a narrow time frame, (2) with specific reference to acute and chronic insomnia, and (3) using polysomnography. In the present study, the association between insomnia and first-onset depression was evaluated taking into account these considerations. DESIGN A mixed-model inception design. SETTING Academic research laboratory. PARTICIPANTS Fifty-four individuals (acute insomnia [n = 33], normal sleepers [n = 21]) with no reported history of a sleep disorder, chronic medical condition, or psychiatric illness. INTERVENTIONS N/A. MEASUREMENTS AND RESULTS Participants were assessed at baseline (2 nights of polysomnography and psychometric measures of stress and mood) and insomnia and depression status were reassessed at 3 months. Individuals with acute insomnia exhibited more stress, poorer mood, worse subjective sleep continuity, increased N2 sleep, and decreased N3 sleep. Individuals who transitioned to chronic insomnia exhibited (at baseline) shorter REM latencies and reduced N3 sleep. Individuals who exhibited this pattern in the transition from acute to chronic insomnia were also more likely to develop first-onset depression (9.26%) as compared to those who remitted from insomnia (1.85%) or were normal sleepers (1.85%). CONCLUSION The transition from acute to chronic insomnia is presaged by baseline differences in sleep architecture that have, in the past, been ascribed to Major Depression, either as heritable traits or as acquired traits from prior episodes of depression. The present findings suggest that the "sleep architecture stigmata" of depression may actually develop over the course transitioning from acute to chronic insomnia.
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Grandner MA, Chakravorty S, Perlis ML, Oliver L, Gurubhagavatula I. Habitual sleep duration associated with self-reported and objectively determined cardiometabolic risk factors. Sleep Med 2014; 15:42-50. [PMID: 24333222 PMCID: PMC3947242 DOI: 10.1016/j.sleep.2013.09.012] [Citation(s) in RCA: 193] [Impact Index Per Article: 19.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2013] [Revised: 09/13/2013] [Accepted: 09/19/2013] [Indexed: 12/25/2022]
Abstract
BACKGROUND Self-reported short or long sleep duration has been associated with adverse cardiometabolic health outcomes in laboratory and epidemiologic studies, but interpretation of such data has been limited by methodologic issues. METHODS Adult respondents of the 2007-2008 US National Health and Nutrition Examination Survey (NHANES) were examined in a cross-sectional analysis (N=5649). Self-reported sleep duration was categorized as very short (<5 h), short (5-6 h), normal (7-8 h), or long (≥9 h). Obesity, diabetes mellitus (DM), hypertension, and hyperlipidemia were objectively assessed by self-reported history. Statistical analyses included univariate comparisons across sleep duration categories for all variables. Binary logistic regression analyses and cardiometabolic factor as outcome, with sleep duration category as predictor, were assessed with and without covariates. Observed relationships were further assessed for dependence on race/ethnicity. RESULTS In adjusted analyses, very short sleep was associated with self-reported hypertension (odds ratio [OR], 2.02, [95% confidence interval {CI},1.45-2.81]; P<0.0001), self-reported hyperlipidemia (OR, 1.96 [95% CI, 1.43-2.69]; P<0.0001), objective hyperlipidemia (OR, 1.41 [95% CI, 1.04-1.91]; P=0.03), self-reported DM (OR, 1.76 [95% CI, 1.13-2.74]; P=0.01), and objective obesity (OR, 1.53 [95% CI, 1.03-1.43]; P=0.005). Regarding short sleep (5-6 h), in adjusted analyses, elevated risk was seen for self-reported hypertension (OR, 1.22 [95% CI, 1.02-1.45]; P=0.03) self-reported obesity (OR, 1.21 [95% CI, 1.03-1.43]; P=0.02), and objective obesity (OR, 1.17 [95% CI, 1.00-1.38]; P<0.05). Regarding long sleep (≥9 h), no elevated risk was found for any outcomes. Interactions with race/ethnicity were significant for all outcomes; race/ethnicity differences in patterns of risk varied by outcome studied. In particular, the relationship between very short sleep and obesity was strongest among blacks and the relationship between short sleep and hypertension is strongest among non-Hispanic whites, blacks, and non-Mexican Hispanics/Latinos. CONCLUSIONS Short sleep duration is associated with self-reported and objectively determined adverse cardiometabolic outcomes, even after adjustment for many covariates. Also, these patterns of risk depend on race/ethnicity.
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Chakravorty S, Grandner MA, Kranzler HR, Mavandadi S, Kling MA, Perlis ML, Oslin DW. Insomnia in alcohol dependence: predictors of symptoms in a sample of veterans referred from primary care. Am J Addict 2013; 22:266-70. [PMID: 23617870 DOI: 10.1111/j.1521-0391.2012.12009.x] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2012] [Revised: 03/29/2012] [Accepted: 08/15/2012] [Indexed: 11/28/2022] Open
Abstract
OBJECTIVE Patients with alcohol dependence presenting for treatment may have multiple associated co-morbid conditions and limited social supports, which complicate treatment. Each of these factors has been independently associated with complaints of insomnia. In this preliminary study, we investigated the relations between insomnia complaints and socio-demographic factors and psychiatric co-morbidity in treatment-seeking patients with alcohol dependence. METHOD We conducted a retrospective chart review on 84 consecutive patients referred to the Behavioral Health Laboratory of the Philadelphia Veterans Affairs Medical Center for evaluation of psychiatric and substance use disorders. Patients met DSM-IV diagnostic criteria for alcohol dependence and completed a series of self-assessments of sleep. Univariate and multivariable analyses were used to examine the relations amongst the variables of interest. RESULTS In multivariable models, Sleep Latency was significantly greater in individuals without partners (p = .01), those with psychiatric disorders (p = .03) and smokers (p = .01), with a non-significant trend for those with past-year suicidal ideation. No significant predictor of Wake Time After Sleep Onset was seen. Poor Sleep Quality was predicted by younger age (OR = .93 [.88, .98], p = .004) and the presence of a psychiatric disorder (OR = 20.80 [4, 102], p = .0002), with a non-significant trend for suicidal ideation. CONCLUSIONS Insomnia symptoms in treatment-seeking alcohol dependent patients should prompt consideration of the individuals' psychiatric and psychosocial features.
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Fields BG, Schutte-Rodin S, Perlis ML, Myers M. Master's-level practitioners as cognitive behavioral therapy for insomnia providers: an underutilized resource. J Clin Sleep Med 2013; 9:1093-6. [PMID: 24127157 PMCID: PMC3778184 DOI: 10.5664/jcsm.3096] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Despite the efficacy of cognitive behavioral therapy for insomnia (CBT-I) in treating chronic insomnia, it remains underutilized. Lack of appropriately-trained CBT-I providers is a major reason. Master's-level practitioners (MLPs) may, in addition to doctoral-level psychologists, be uniquely positioned to fill this role, based not only on "goodness of professional fit" but also given a handful of studies showing these individuals' care outcomes meet or exceed standard outcomes. However, the ability of MLPs to provide CBT-I will be significantly restricted until a clear pathway is established that extends from training opportunities to credentialing. Further questions remain about how to attract and incorporate MLPs into established practices.
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Grandner MA, Patel NP, Jean-Louis G, Jackson N, Gehrman PR, Perlis ML, Gooneratne NS. Sleep-related behaviors and beliefs associated with race/ethnicity in women. J Natl Med Assoc 2013; 105:4-15. [PMID: 23862291 PMCID: PMC3759527 DOI: 10.1016/s0027-9684(15)30080-8] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Explore how social factors influence sleep, especially sleep-related beliefs and behaviors. Sleep complaints, sleep hygiene behaviors, and beliefs about sleep were studied in 65 black/African American and white/European American women. Differences were found for snoring and discrepancy between sleep duration and need. Sleep behaviors differed across groups for napping, methods for coping with sleep difficulties, and nonsleep behaviors in bed. Beliefs also distinguished groups, with differences in motivation for sleep and beliefs about sleep being important for health and functioning. These findings have important public health implications in terms of developing effective sleep education interventions that include consideration of cultural aspects.
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