Fatigue and sleep disorders

The role of insomnia in the treatment of chronic fatigue

BACKGROUND

The definition of Chronic Fatigue Syndrome (CFS) overlaps with definitions of insomnia, but there is limited knowledge about the role of insomnia in the treatment of chronic fatigue.

AIMS

To test if improvement of insomnia during treatment of chronic fatigue was associated with improved outcomes on 1) fatigue and 2) cortisol recovery span during a standardized stress exposure.

METHODS

Patients (n = 122) with chronic fatigue received a 3.5-week inpatient return-to-work rehabilitation program based on Acceptance and Commitment Therapy, and had been on paid sick leave>8 weeks due their condition. A physician and a psychologist examined the patients, assessed medication use, and SCID-I diagnoses. Patients completed self-report questionnaires measuring fatigue, pain, depression, anxiety, and insomnia before and after treatment. A subgroup (n = 25) also completed the Trier Social Stress Test for Groups (TSST-G) before and after treatment. Seven cortisol samples were collected during each test and cortisol spans for the TSST-G were calculated.

RESULTS

A hierarchical regression analysis in nine steps showed that insomnia improvement predicted improvement in fatigue, independently of age, gender, improvement in pain intensity, depression and anxiety. A second hierarchical regression analysis showed that improvement in insomnia significantly predicted the cortisol recovery span after the TSST-G independently of improvement in fatigue.

CONCLUSION

Improvement in insomnia severity had a significant impact on both improvement in fatigue and the ability to recover from a stressful situation. Insomnia severity may be a maintaining factor in chronic fatigue and specifically targeting this in treatment could increase treatment response.

The association between daytime napping and cognitive functioning in chronic fatigue syndrome

OBJECTIVES

The precise relationship between sleep and physical and mental functioning in chronic fatigue syndrome (CFS) has not been examined directly, nor has the impact of daytime napping. This study aimed to examine self-reported sleep in patients with CFS and explore whether sleep quality and daytime napping, specific patient characteristics (gender, illness length) and levels of anxiety and depression, predicted daytime fatigue severity, levels of daytime sleepiness and cognitive functioning, all key dimensions of the illness experience.

METHODS

118 adults meeting the 1994 CDC case criteria for CFS completed a standardised sleep diary over 14 days. Momentary functional assessments of fatigue, sleepiness, cognition and mood were completed by patients as part of usual care. Levels of daytime functioning and disability were quantified using symptom assessment tools, measuring fatigue (Chalder Fatigue Scale), sleepiness (Epworth Sleepiness Scale), cognitive functioning (Trail Making Test, Cognitive Failures Questionnaire), and mood (Hospital Anxiety and Depression Scale).

RESULTS

Hierarchical Regressions demonstrated that a shorter time since diagnosis, higher depression and longer wake time after sleep onset predicted 23.4% of the variance in fatigue severity (p <.001). Being male, higher depression and more afternoon naps predicted 25.6% of the variance in objective cognitive dysfunction (p <.001). Higher anxiety and depression and morning napping predicted 32.2% of the variance in subjective cognitive dysfunction (p <.001). When patients were classified into groups of mild and moderate sleepiness, those with longer daytime naps, those who mainly napped in the afternoon, and those with higher levels of anxiety, were more likely to be in the moderately sleepy group.

CONCLUSIONS

Napping, particularly in the afternoon is associated with poorer cognitive functioning and more daytime sleepiness in CFS. These findings have clinical implications for symptom management strategies.

Quantitative measures of nocturnal insomnia symptoms predict greater deficits across multiple daytime impairment domains

This study examined the associations between reported quantitative sleep measures and multiple daytime impairment domains. We collected data from a subsample of adults (n = 513) from the Colorado Longitudinal Twin Study and Community Twin Study. Results revealed that greater insomnia symptom frequency (days per week) significantly predicted greater global sleep-related functional impairment and depressive symptoms. Sleep onset latency was also positively associated with depressive symptoms. Receiver operating characteristic curve analyses indicated 3-4 nights per week and 36-40 min provided optimal sensitivity and specificity for impairment. Thus, insomnia frequency and sleep latency are critical in understanding the impact of insomnia on multiple impairment domains. Using functional impairment as criterion, these findings also support the use of specific quantitative cutoffs for sleep measures in diagnostic systems.

Do sleep, stress, and illness explain daily variations in fatigue? A prospective study

OBJECTIVE

Fatigue is related to a number of serious diseases, as well as to general well-being. It is also a major cause of sickness absence and use of health facilities. Still, the determinants of variations in fatigue are little investigated. The purpose of present study was to investigate the relationships between the daily variations of fatigue with sleep during the previous night, stress or disease symptoms during the same day - across 42 consecutive days of normal life.

METHODS

50 individuals participated and gave diary reports and used an actigraph across the 42days. The data was analyzed using a multilevel approach with mixed model regression.

RESULTS

The analyses showed that the day-to-day variation in fatigue was related to (poor) sleep quality (p<.001) and (reduced) sleep duration (p<.01) the previous night, as well as to higher stress (p<.05), and to the occurrence of a cold or fever (p<.001) during the same day as the fatigue rating. Fatigue was also strongly related to poorer subjective health (p<.001) and sleepiness (p<.001) during the same day.

CONCLUSION

The results indicate that prior sleep (and sleepiness) as well as stress and illness are consistently connected to how fatigue is experienced during normal living conditions.

Predicting uptake of continuous positive airway pressure (CPAP) therapy in obstructive sleep apnoea (OSA): a belief-based theoretical approach

PURPOSE

Obstructive sleep apnoea (OSA) is a common disorder, for which continuous positive airway pressure (CPAP) therapy is a standard treatment. Despite its well-established efficacy, many patients choose not to initiate CPAP treatment. The present study investigated the degree to which biological measures (e.g. Apnoea-Hypopnoea Index [AHI]), symptom experiences (e.g. fatigue) and illness representations (e.g. perceived consequences) predict the decision of individuals newly diagnosed with OSA to undergo a trial of CPAP therapy.

METHODS

Four hundred forty-nine individuals (316 males) newly diagnosed with OSA. Epworth sleepiness scale (ESS), Fatigue Severity Scale, Depression Anxiety Stress Scale and Illness Perception Questionnaire-Revised (IPQ-R) were administered at time of sleep study. These, patient demographics and sleep study variables were used to determine factors predicting patient decision to proceed with a trial of CPAP.

RESULTS

The participants were most likely to attribute their OSA to unchangeable and psychological factors. For those with moderate OSA (AHI, 15 to 30) IPQ-R illness consequence was predictive of decision to initiate CPAP (p = 0.002). For severe OSA (AHI >30) age, ESS and IPQ illness causal beliefs were predictive of decision to initiate CPAP (p < 0.001).

CONCLUSIONS

Illness beliefs are important determinants of the choice of recently diagnosed OSA patients whether or not to undertake a trial of CPAP therapy. Concerns about illness consequences were important in those with moderate OSA. In severe OSA, sleepiness symptoms are more prominent and a more significant determinant of CPAP uptake along with age and causal beliefs.

The Glasgow Sleep Impact Index (GSII): a novel patient-centred measure for assessing sleep-related quality of life impairment in Insomnia Disorder

OBJECTIVES

Daytime dysfunction and quality of life impairment are important and salient consequences of poor sleep in those with insomnia. Existing measurement approaches to functional impact tend to rely on non-specific generic tools, non-validated scales, or ad hoc single scale items. Here we report the development and validation of the Glasgow Sleep Impact Index (GSII), a novel self-report measure which asks patients to generate, and assess, three domains of impairment unique to their own individual context. These three patient-generated areas of impairment are ranked in order of concern (1-3; i.e. 1=the most concerning impairment), and then rated on a visual analogue scale with respect to impact in the past two weeks. Patients re-rate these specified areas of impairment, post-intervention, permitting both individual and group-level analyses.

METHODS

One-hundred and eight patients (71% female; Mean age=45 yrs) meeting Research Diagnostic Criteria for Insomnia Disorder completed the GSII, resulting in the generation of 324 areas (ranks) of sleep-related daytime and quality of life impairment. Fifty-five patients also completed the GSII pre- and post-sleep restriction therapy. The following psychometric properties were assessed: content validity of generated domains; relationship between ranks of impairment; and sensitivity to change post-behavioural intervention.

RESULTS

Content analysis of generated domains support recent DSM-5 proposals for specification of daytime consequences of insomnia; with the most commonly cited areas reflecting impairments in energy/motivation, work performance, cognitive functioning, emotional regulation, health/well-being, social functioning and relationship/family functioning. Preliminary results with 108 patients indicate the GSII to have excellent face and construct validity. The GSII was found to be sensitive to change, post-behavioural treatment (p<0.001; Cohen's d≥0.85 for all three ranks of impairment), and improvements were associated with reductions in insomnia severity in both correlational (range of r=0.28-0.56) and responder versus non-responder analyses (all p<0.05).

CONCLUSIONS

The development of the GSII represents a novel attempt to capture and measure sleep-related quality of life impairment in a valid and meaningful way. Further psychometric and clinical evaluation is suggested.

Younger age, female sex, and high number of awakenings and arousals predict fatigue in patients with sleep disorders: a retrospective polysomnographic observational study

BACKGROUND

The Fatigue Severity Scale (FSS) is widely used to assess fatigue, not only in the context of multiple sclerosis-related fatigue, but also in many other medical conditions. Some polysomnographic studies have shown high FSS values in sleep-disordered patients without multiple sclerosis. The Modified Fatigue Impact Scale (MFIS) has increasingly been used in order to assess fatigue, but polysomnographic data investigating sleep-disordered patients are thus far unavailable. Moreover, the pathophysiological link between sleep architecture and fatigue measured with the MFIS and the FSS has not been previously investigated.

METHODS

This was a retrospective observational study (n = 410) with subgroups classified according to sleep diagnosis. The statistical analysis included nonparametric correlation between questionnaire results and polysomnographic data, age and sex, and univariate and multiple logistic regression.

RESULTS

The multiple logistic regression showed a significant relationship between FSS/MFIS values and younger age and female sex. Moreover, there was a significant relationship between FSS values and number of arousals and between MFIS values and number of awakenings.

CONCLUSION

Younger age, female sex, and high number of awakenings and arousals are predictive of fatigue in sleep-disordered patients. Further investigations are needed to find the pathophysiological explanation for these relationships.

Predictors of perceived sleep quality among men and women with insomnia

The present study determined which self-reported sleep variables and daytime impairment measures are most closely associated with sleep quality ratings (SQR) in men and women with insomnia. The participants were 137 people with insomnia, 56 men and 81 women. Multiple regression found that for men, sleep efficiency best predicted SQR, explaining 26.9% of variance. A similar analysis was conducted for women. After race was entered as a covariate, number of awakenings and total sleep time were significant predictors of SQR. Collectively, race, number of awakenings, and total sleep time explained 35.7% of variance. This suggests that the middle-of-the-night experience predicts sleep quality rating in women with insomnia, whereas the full night experience predicts sleep quality ratings in men with insomnia.

Comparison of polysomnographic data in age-, sex- and Axis I psychiatric diagnosis matched HIV-seropositive and HIV-seronegative insomnia patients

OBJECTIVE

There is a high prevalence of insomnia in HIV-seropositive patients. Insomnia is associated with poorer disease outcomes, cognitive impairment and HIV-associated dementia. However there is limited data characterizing the type of sleep disturbances, and the cause. Previous studies report conflicting results, and observed changes in the distribution of REM and SWS were hypothesized to result from co-morbid mood disorders, although this is not established. We carried out this study to determine if there are differences in polysomnographic (PSG) sleep data in age-, sex- and Axis I diagnoses- matched HIV-seropositive and HIV-seronegative patients.

METHODS

Eighteen HIV-seropositive insomniacs were matched to HIV-seronegative insomniacs based on age, sex and Axis I diagnoses. Participants spent 2 consecutive nights in a sleep lab recording of PSG data.

RESULTS

Multivariate analysis revealed an overall significant match-by-variable interaction (p=0.0126). Follow-up analysis show that compared to HIV-seronegative insomnia controls, HIV-seropositive insomniacs have significantly longer SOL, 8% decreased sleep efficiency, and 8-10% decreased time spent in REM sleep (p's<0.05).

CONCLUSION

This study provides preliminary evidence that even after accounting for differences in age, sex and psychiatric diagnoses, HIV-seropositive patients with insomnia have significantly worse sleep than HIV-seronegative patients with insomnia.

SIGNIFICANCE

Unlike what previous authors have proposed, our results do not support the view that comorbid psychiatric disorders like depression are responsible for the observed differences in PSG findings and the greater incidence of insomnia, in HIV-seropositive patients when compared with other groups of insomnia patients. This suggests the presence of other etiologies including neuronal damage, psychosocial stressors, or comorbid medical conditions. Further studies are needed to determine the extent to which these play a role in insomnia in the HIV-seropositive population.

Transdiagnostic processes in emotional disorders and insomnia: results from a sample of adult outpatients with anxiety and mood disorders

Conceptual similarities between recent models of insomnia and emotional disorders suggest there may be common factors that underlie or maintain these difficulties. Maladaptive cognitive and behavioral processes similar to those described in connection with emotional disorders have been cited as key mechanisms in the maintenance of primary insomnia. Unfortunately, research on this potential overlap is lacking. The present study examined the relationship among anxiety sensitivity (AS), dysfunctional beliefs, fatigue, safety behaviors, and insomnia severity in 59 outpatients with anxiety and mood disorders. Key insomnia processes (dysfunctional beliefs, fatigue, safety behaviors) were all related to insomnia severity in the comorbid sample, although AS was not. However, as hypothesized, AS did moderate the relationship of both dysfunctional beliefs and fatigue with insomnia severity. The relationships between key insomnia processes and insomnia severity was strongest among individuals high in AS. Results support the hypothesis that common mechanisms are involved for insomnia and emotional disorders. AS might function as a mechanism for the maintenance of sleep disturbance in the context of anxiety and mood disorders, suggesting a promising avenue for future research.

The impact of colorectal cancer and self-efficacy beliefs on work ability and employment status: a longitudinal study

We examined how colorectal cancer patients' treatment and symptom management impacted perceptions of work ability and subsequent work decisions. Fifty patients completed questionnaires at baseline (post-surgery/pretreatment), 3 months and 6 months. Questionnaires assessed fatigue, depression, quality-of-life (QoL), cancer self-efficacy, job self-efficacy (JSE) and work ability. Factors related to perceived work ability were occupation (β= 0.31, P= 0.0005) and QoL (β= 0.42, P= 0.01) at baseline, treatment type (β=-0.19, P= 0.05) at 3 months, and JSE at 3 months (β= 0.57, P= 0.0005) and 6 months (β= 0.50, P= 0.006). Factors related to being on sick leave were lower levels of JSE (OR = 2.20, 95% CI: 1.17-4.13) at baseline and being employed in a manual occupation (OR = 0.03, 95% CI: 0.00-0.86), and perceived work ability (OR = 3.05, 95% CI: 1.00-12.80) at 6 months. Along with self-assessed work ability at baseline (β= 0.67, P= 0.0005), receiving chemotherapy or a combination of treatments (β=-0.24, P= 0.05) were the strongest predictors of poorer perceptions of follow-up work ability. Self-efficacy beliefs may add to understanding and should be considered in future research.

The association of fatigue with depression and insomnia in HIV-seropositive patients: a pilot study

OBJECTIVE

Fatigue is a pervasive symptom associated with HIV, resulting in significant functioning impairment; but little is known about its etiology or treatment. In patients with primary insomnia, data have shown improvement in fatigue following successful treatment of insomnia. However, little is known about the role of insomnia in patients with fatigue in HIV. This manuscript seeks to test the hypothesis that insomnia severity is correlated with increased fatigue in HIV-seropositive patients.

METHODS

Fifty-seven ambulatory HIV-seropositive patients, aged 18-60 years, with a DSM-IV-TR diagnosis of insomnia, were administered the Insomnia Severity Index (ISI), Piper Fatigue Scale (PFS), Hospital Anxiety and Depression scale, and Hamilton Depression Rating Scale (HAM-D). Their most recent CD4 count and time since diagnosis of HIV were recorded. Regression analysis was carried out with PFS as the dependent variable.

RESULTS

A higher ISI score correlated with higher PFS score, (R2 = 0.1713, P = 0.0042). Overall depression severity was not significantly correlated with PFS score, except in the most severely depressed subgroup, in which the HADS depression score was the strongest predictor of PFS (R2 = 0.182, P = 0.0009). In participants without depression, ISI accounted for most of the variance in fatigue (R2 = 0.6035, P = 0.0011).

CONCLUSIONS

Greater insomnia severity is associated with greater fatigue severity in HIV seropositive patients. Depression may contribute to both fatigue and insomnia. In the absence of depression, the treatment of insomnia may emerge as a treatment strategy to help alleviate fatigue. Further studies are needed to confirm these data.

CLINICAL TRIAL INFORMATION

Clinical Trials.Gov: The Treatment of Insomnia in Patients with HIV Disease. Registry Number: NCT00465972. URL: http://www.clinicaltrials.gov/ct2/show/NCT00465972?term = HIV+insomnia&rank = 1.

Severe fatigue in narcolepsy with cataplexy

Excessive daytime sleepiness (EDS) is the core symptom of narcolepsy. However, there have been indications that fatigue - which should be separated from EDS--is also a frequent complaint. We determined the prevalence of severe fatigue in a group of narcolepsy patients and its relation with excessive daytime sleepiness, psychological distress, functional impairment and quality of life. We included 80 patients fulfilling the International Classification of Sleep Disorders (ICSD)-2 diagnostic criteria of narcolepsy with cataplexy. Fatigue was measured using the Checklist Individual Strength (CIS). In addition psychological distress, including symptoms of depression, functional impairment and quality of life, were assessed. Comparisons were made between patients with (CIS-fatigue score ≥ 35) and without severe experienced fatigue. Fifty patients (62.5%) reported severe fatigue. There were no sex or age differences between patients with and without severe fatigue. Both fatigued and non-fatigued patients had the same amount of daytime sleepiness (Epworth Sleepiness Score 14.3 ± 4.2 versus 13.1 ± 4.4, P = 0.22), confirming the separation between sleepiness and fatigue. Interestingly, fatigued patients more often used stimulant medication (64% versus 40%, P = 0.02). Severe fatigue was associated with a significantly increased functional impairment, increased depressive symptoms and a lowered general quality of life. In conclusion, a majority of patients with narcolepsy suffer from severe fatigue, which can be distinguished from daytime sleepiness, and results in severe functional impairment.

Problems in functioning from the patient perspective using the International Classification of Functioning, Disability and Health (ICF) as a reference

We conducted a qualitative, multicenter study using a focus group design to explore the lived experiences of persons with any kind of primary sleep disorder with regard to functioning and contextual factors using six open-ended questions related to the International Classification of Functioning, Disability and Health (ICF) components. We classified the results using the ICF as a frame of reference. We identified the meaningful concepts within the transcribed data and then linked them to ICF categories according to established linking rules. The six focus groups with 27 participants yielded a total of 6986 relevant concepts, which were linked to a total of 168 different second-level ICF categories. From the patient perspective, the ICF components: (1) Body Functions; (2) Activities & Participation; and (3) Environmental Factors were equally represented; while (4) Body Structures appeared poignantly less frequently. Out of the total number of concepts, 1843 concepts (26%) were assigned to the ICF component Personal Factors, which is not yet classified but could indicate important aspects of resource management and strategy development of those who have a sleep disorder. Therefore, treatment of patients with sleep disorders must not be limited to anatomical and (patho-)physiological changes, but should also consider a more comprehensive view that includes patient's demands, strategies and resources in daily life and the contextual circumstances surrounding the individual.

Understanding sleep disturbances in African-American breast cancer survivors: a pilot study

OBJECTIVES

The goals of this study were (i) to report the prevalence and nature of sleep disturbances, as determined by clinically significant insomnia symptoms, in a sample of African-American breast cancer survivors; (ii) to assess the extent to which intrusive thoughts about breast cancer and fear of recurrence contributes to insomnia symptoms; and (iii) to assess the extent to which insomnia symptoms contribute to fatigue.

METHODS

African-American breast cancer survivors completed surveys pertaining to demographics, medical history, insomnia symptoms, and intrusive thoughts about breast cancer, fear of cancer recurrence, and fatigue. Hierarchical regression models were performed to investigate the degree to which intrusive thoughts and concerns of cancer recurrence accounted for the severity of insomnia symptoms and insomnia symptom severity's association with fatigue.

RESULTS

Forty-three percent of the sample was classified as having clinically significant sleep disturbances. The most commonly identified sleep complaints among participants were sleep maintenance, dissatisfaction with sleep, difficulty falling asleep, and early morning awakenings. Intrusive thoughts about breast cancer were a significant predictor of insomnia symptoms accounting for 12% of the variance in insomnia symptom severity. After adjusting for covariates, it was found that insomnia symptom severity was independently associated with fatigue accounting for 8% of variance.

CONCLUSIONS

A moderate proportion of African-American breast cancer survivors reported significant problems with sleep. Sleep disturbance was influenced by intrusive thoughts about breast cancer, and fatigue was associated with the severity of participants' insomnia symptoms. This study provides new information about sleep-related issues in African-American breast cancer survivors.

Fatigue: The forgotten symptom of sleep apnea

OBJECTIVE

The present investigation was designed to explore the role and implications of both daytime sleepiness and fatigue in obstructive sleep apnea syndrome with respect to sleep, perceived health quality, and psychological functioning.

METHODS

Our participants consisted of two groups: 124 older community volunteers who completed a polysomnographic sleep study and were diagnosed with sleep apnea, and 19 healthy controls. All participants completed self-report measures of sleepiness, fatigue, sleep quality, health quality, and psychological functioning.

RESULTS

The apnea sample was divided according to clinically relevant cut-offs on sleepiness and fatigue. When those with mid-range scores were ruled out, the following groups remained: low sleepiness/low fatigue (LL, n=23), high sleepiness/high fatigue (HH, n=28), high sleepiness/low fatigue (HS, n=10) and low sleepiness/high fatigue (HF, n=13). The respiratory disturbance index did not differ significantly among these groups and only the two highly fatigued groups (HH and HF) experienced significantly lower average oxygen saturation than the control group. Analyses revealed that the HH group was significantly worse than the LL and control groups on most sleep, health quality, and psychological measures. On these same measures, the groups for whom fatigue was low (LL and HS), regardless of sleepiness, were similar to controls.

CONCLUSION

When patients with sleep apnea are classified into different sleepiness/fatigue categories, the results show that high fatigue is associated with more severe dysfunction than high sleepiness. The current debate on whether to treat apnea patients with low sleepiness needs to consider the impact of fatigue.

Non-essential symptoms of depression and cognitive impairment no dementia (CIND) in community-dwelling elders without dysphoria or anhedonia

BACKGROUND

Several neuropsychiatric symptoms observed in elders with cognitive impairment no dementia (CIND) can be part of a major depressive episode (MDE) or a "subthreshold" depressive episode. Certain neuropsychiatric symptoms of CIND are essential symptoms of MDE (e.g. dysphoria, anhedonia), while other are non-essential symptoms (NESD; e.g. fatigue, insomnia, cognitive complaint). Contrary to essential symptoms, NESD are not specific to MDE and are present in other disorders. It is unknown whether NESD are linked to CIND in absence of MDE or subthreshold MDE. The present study examined the association between NESD and probable CIND in elders without essential MDE symptoms.

METHODS

Participants were 2028 community-dwelling individuals aged 65-96 years who had not experienced dysphoria/anhedonia during the year preceding the interview. Semi-structured in-home interviews evaluated the following NESD: alteration of appetite, sleep disturbance, psychomotor alteration, fatigue/loss of energy, worthlessness/guilt, and cognitive complaints. Probable CIND cases were defined based on the Mini-mental State Examination cut-offs (15th percentile) stratified for age, education and sex.

RESULTS

Symptoms of fatigue/loss of energy (OR: 2.41, 95% CI: 1.42-4.09), sleep disturbance (OR: 3.04 CI: 1.69-5.46) and cognitive complaints (OR: 2.86 CI: 1.71-4.77) were significantly associated with CIND. These associations were not modified after adjustments for potential confounders (age, education level, sex, benzodiazepine use, chronic diseases, and brain disorders).

CONCLUSION

A psychiatric symptomatology occurs in older adults with CIND in the absence of MDE or subthreshold MDE. NESD encountered in the absence of dysphoria/anhedonia should receive particular attention by clinicians since they can be linked to cognitive difficulties.

Maternal postpartum sleepiness and fatigue: associations with objectively measured sleep variables

OBJECTIVE

To explore whether standardized survey instruments and objective performance measures differentiate traditional constructs of sleepiness and fatigue among a sample of postpartum mothers. Additionally, we wanted to explore the independent associations among these measures with actigraphically measured nocturnal sleep variables.

METHOD

Seventy-nine postpartum mothers' subjective sleepiness, fatigue, and performance measures [Stanford Sleepiness Scale (SSS), Epworth Sleepiness Scale (ESS), Visual Analogue of Fatigue Scale (VAS), Profile of Mood States (POMS) subscale items, and the Psychomotor Vigilance Test (PVT)] and objective actigraphically measured sleep were collected during postpartum week 11. A principal components analysis was calculated, then regressions were calculated among resulting factors and among individual measures with total sleep time and sleep efficiency.

RESULTS

Three factors accounted for 83.84% of model variance. Factor 1 (41.41%) included the SSS, ESS, and the VAS. Factor 2 (28.13%) included only PVT variables. Factor 3 (14.30%) included the two POMS subscale items. Factor 1 was associated with nocturnal sleep time and Factor 2 was associated with sleep efficiency. The ESS was independently associated with nocturnal sleep time, whereas, POMS-Vigor subscale and median reaction time, together, were associated with sleep efficiency.

CONCLUSION

Among postpartum mothers, standard instruments used to measure sleepiness, fatigue, and performance were distributed among three distinct factors that did not clearly identify traditional sleepiness and fatigue constructs. Objectively measured sleep time and sleep efficiency were associated with specific factors, as well as specific measures, that correspond to sleepiness and fatigue states.

Psychometric evaluation of the Fatigue Severity Scale in patients with major depression

PURPOSE

This study aimed to investigate the psychometric properties of the Fatigue Severity Scale (FSS), a widely used unidimensional fatigue measure, in patients with major depression.

METHODS

Subjects included were 72 patients with major depressive disorder, diagnosed with the DSM-IV based M.I.N.I. 5.0.0., without comorbid fatigue-associated conditions and Hamilton Depression Rating Scale (HDRS) scores ≥ 17 as well as 40 sex- and age-matched healthy controls. The FSS was administered to patients on two time points separated by a 1-week interval and to controls. The vitality subscale of the 36-item Short Form Health Survey (SF-36vit) and a visual analogue fatigue scale (VASF) were also administered.

RESULTS

A total of 79.2% of patients vs. 15% of controls were fatigue cases according to the M.I.N.I. fatigue/energy loss item. The distribution of FSS scores was negatively skewed in the patient group, demonstrating a ceiling effect. The FSS presented satisfactory test-retest reliability (intraclass correlation coefficient 0.993), internal consistency (Cronbach's α coefficient 0.947), concurrent validity (correlations with SF-36vit, VASF and HDRS were -0.52, 0.73 and 0.32, respectively) and discriminative validity between patients and controls. Factor analysis demonstrated a unidimensional structure. The optimal FSS cutoff score for clinically significant fatigue was 5.4 against the presence of fatigue/energy loss according to the M.I.N.I. as a 'gold standard'.

CONCLUSION

When administered to patients with major depression, the FSS was shown to have satisfactory psychometric properties with the exception of a ceiling effect, which may pose limitations to its use in this population.

A population-based study of associations between current posttraumatic stress symptoms and current fatigue

This study explores current experience with posttraumatic stress disorder (PTSD) symptoms and other variables (sociodemographic, mental distress, somatic morbidity, self-rated health, and quality of life [QoL]) in relation to fatigue. A representative sample of the Norwegian population (N = 3,944) was invited to participate in a mailed survey, and 1,857 (47%) returned valid responses on the questionnaire that included the Fatigue Severity Scale and the Posttraumatic Symptom Scale-10. Posttraumatic stress disorder symptoms showed a strong association with fatigue in univariate (β = .41) and multivariate analyses (β = .33). Associations between psychosocial health variables, QoL, and fatigue were confirmed. However, PTSD symptoms showed the strongest association with fatigue in the analyses. Findings need to be replicated in other population samples and in clinical samples with PTSD and fatigue.

Is sleep in animals affected by prior waking experiences?

Methods to assess changes in the mental state of animals in response to their environment can be used to provide information to enhance animal welfare. One of the most profound changes of mental state observable in mammals is the change between wakefulness and sleep. Sleeping mammals have characteristics that are similar to one another and are measurable, such as specific behaviours, changes in responsiveness to external stimuli and changes in electrophysiology and neurochemistry. Although sleep is a ubiquitous behaviour in the life of mammals, there has been relatively little research on this topic in domesticated animals. All animals are motivated to sleep and this motivation increases after a prolonged period of wakefulness. In humans, sleep can be affected by what has occurred in the prior period of wakefulness and this has also been demonstrated in some non-human mammals. An important aspect of human sleep medicine is the association between stress and subsequent sleep disturbances. Studying changes in amount, bout length, distribution or type of sleep after exposure to potentially stressful events, could help us understand how animals respond to changes in their environment. It is possible that different types of stressors could affect sleep characteristics in different ways and that monitoring and identifying these changes could be useful in providing an additional way of identifying management procedures that have the potential to affect welfare. Sleep measurement is a potentially valuable tool in studies to assess animal welfare.

A population-based association study of candidate genes for depression and sleep disturbance

The clinical manifestation of depression comprises a variety of symptoms, including early morning awakenings and fatigue, features also indicating disturbed sleep. The presence or absence of these symptoms may reflect differences in neurobiological processes leading to prolonged depression. Several neurobiological mechanisms have been indicated in the induction of depression, including disturbances in serotonergic and glutamatergic neurotransmission and in the action of the hypothalamic-pituitary-adrenal (HPA) axis. The same transmitters have also been linked to sleep regulation. We hypothesized that depression without simultaneous symptoms of disturbed sleep would partly have a different genetic background than depression with symptoms of disturbed sleep. We tested this hypothesis using a systematic population-based association study of 14 candidate genes related to depression and disturbed sleep. Association of genetic variants with either depression alone, depression with early morning awakenings, or depression with fatigue was investigated using permutation-based allelic association analysis of a sample of 1,654 adults recruited from Finland's population-based program. The major findings were associations of TPH2 (rs12229394) with depression accompanied by fatigue in women and CREB1 (rs11904814) with depression alone in men. We also found suggestive associations in women for GAD1, GRIA3, and BDNF with depression accompanied by fatigue, and for CRHR1 with depression accompanied by early morning awakenings. The results indicate sex-dependent and symptom-specific differences in the genetic background of depression. These differences may partially explain the broad spectrum of depressive symptoms, and their systematic monitoring could potentially be used for diagnostic purposes.

Systematic analysis of circadian genes in a population-based sample reveals association of TIMELESS with depression and sleep disturbance

Disturbances in the circadian pacemaker system are commonly found in individuals with depression and sleep-related problems. We hypothesized that some of the canonical circadian clock genes would be associated with depression accompanied by signs of disturbed sleep, early morning awakening, or daytime fatigue. We tested this hypothesis in a population-based sample of the Health 2000 dataset from Finland, including 384 depressed individuals and 1270 controls, all with detailed information on sleep and daytime vigilance, and analyzed this set of individuals with regard to 113 single-nucleotide polymorphisms of 18 genes of the circadian system. We found significant association between TIMELESS variants and depression with fatigue (D+FAT+) (rs7486220: pointwise P = 0.000099, OR = 1.66; corrected empirical P for the model of D+FAT+ = 0.0056; haplotype 'C-A-A-C' of rs2291739-rs2291738-rs7486220-rs1082214: P = 0.0000075, OR = 1.72) in females, and association to depression with early morning awakening (D+EMA+) (rs1082214: pointwise P = 0.0009, OR = 2.70; corrected empirical P = 0.0374 for the model D+EMA+; haplotype 'G-T' of rs7486220 and rs1082214: P = 0.0001, OR = 3.01) in males. There was significant interaction of gender and TIMELESS (for example with rs1082214, P = 0.000023 to D+EMA+ and P = 0.005 to D+FAT+). We obtained supported evidence for involvement of TIMELESS in sleeping problems in an independent set of control individuals with seasonal changes in mood, sleep duration, energy level and social activity in females (P = 0.036, = 0.123 for rs1082214) and with early morning awakening or fatigue in males (P = 0.038 and P = 0.0016, respectively, for rs1082214). There was also some evidence of interaction between TIMELESS and PER1 in females to D+FAT+ as well as between TIMELESS and ARNTL, RORA or NR1D1 in males to D+EMA+. These findings support a connection between circadian genes and gender-dependent depression and defective sleep regulation.

Insomnia and health-related quality of life

Health-related Quality of Life (HRQoL) has become an important construct in contemporary medicine and health care, permitting assessment of disorder burden and evaluation of interventions on various aspects of functioning, in a standardized manner. Here we review literature on the measurement of HRQoL in insomnia populations, and the extent to which insomnia treatment improves domains of HRQoL. It is concluded from the relatively small literature that insomnia impacts on diverse areas of HRQoL, and that both pharmacological and non-pharmacological interventions can produce, to varying degrees, improvements in domains spanning physical, social and emotional functioning. Limitations of the current literature are identified; with particular emphasis on measurement and conceptual shortcomings. Suggestions are made in relation to improving the quality of future research, and how to further shed light on the impact of insomnia - and treatment thereof - on both HRQoL and global quality of life.

Arousal frequency is associated with increased fatigue in obstructive sleep apnea

OBJECTIVE

Fatigue is an important and often underemphasized symptom in patients with obstructive sleep apnea (OSA). Sleep fragmentation, i.e., arousals and disruptions in sleep architecture, is common in patients with OSA and may potentially contribute to their fatigue. We hypothesized that arousal frequency and changes in sleep architecture contribute to the fatigue experienced by patients with OSA.

DESIGN

Seventy-three patients with diagnosed but untreated OSA (AHI > or = 15) were enrolled in this study. A baseline polysomnogram was obtained, and fatigue was measured with the Multidimensional Fatigue Symptom Inventory-short form (MFSI-sf). We evaluated the association between fatigue and arousals and various polysomongraphic variables, including sleep stages and sleep efficiency.

RESULTS

Significant correlations between MFSI-sf subscale scores and various arousal indices were noted. Emotional fatigue scores were associated with total arousal index (r = 0.416, p = .021), respiratory movement arousal index (r = 0.346, p = .025), and spontaneous movement arousal index (r = 0.378, p = .025). Physical fatigue scores were associated with total arousal index (r = 0.360, p = .033) and respiratory movement arousal index (r = 0.304, p = .040). Percent of stage 1 sleep and REM sleep were also associated with physical and emotional fatigue scores. Hierarchal linear regression analysis demonstrated that emotional fatigue scores were independently associated with spontaneous movement arousals after controlling for age, body mass index, depression, and sleep apnea severity.

CONCLUSIONS

These findings suggest that arousals may contribute to the fatigue seen in patients with OSA.

Interpreting score differences in the Insomnia Severity Index: using health-related outcomes to define the minimally important difference

OBJECTIVE

To estimate the minimally important difference (MID) for the Insomnia Severity Index (ISI) by examining the association of score differences of the ISI with health-related outcomes including health-related quality of life, productivity, and fatigue.

METHODS

Data came from a randomized, placebo-controlled clinical trial evaluating the long-term efficacy of eszopiclone for primary insomnia (N = 828). Logistic regression models were used to characterize the relationship between ISI change scores (from baseline to 6 months post-treatment) and outcomes/anchors from the SF-36 Health Survey, Work Limitations Questionnaire (WLQ), and Fatigue Severity Scale (FSS). Odds ratios were derived from the regression coefficients to calculate the probability of a given outcome being associated with different ISI change scores. Convergence between anchor- and distribution-based estimates was assessed.

RESULTS

Higher ISI scores (indicating more severe insomnia) were significantly associated with higher probabilities of negative outcome in all models. Individuals with a 6-point score reduction in ISI scores (which corresponded to 1(1/2) standard deviations) were 48% less likely to report 'feeling worn out' (SF-36) at 6 months, 46% less likely to be 'unable to think clearly' (WLQ), and 52% less likely to report 'feeling fatigued' (FSS). Similar results were found across a broad spectrum of all selected anchors.

CONCLUSIONS

Based on results of the study, a 6-point reduction is recommended to represent a clinically meaningful improvement in individuals with primary insomnia. Research on generalizability of the recommended MID in this study to other patient populations and other type of treatment interventions is needed.

An Investigation of Subjective Sleep and Fatigue Measures for Use With Elite Athletes

This study investigated the properties of the Athens Insomnia Scale (Soldatos et al., 2000), the Fatigue Severity Scale (Krupp et al., 1989), and subscales of the SLEEP-50 Questionnaire (Spoormaker et al., 2005) in elite Australian athletes, to determine their appropriateness for this population. Fifty-nine athletes (29 male, 30 female, M = 21.86 yrs, SD = 7.44) from elite basketball, rowing, netball, beach volleyball, and sailing squads completed measures. A subset (n= 20) completed measures again at a 1-month interval, and a further subset (n= 5) were interviewed about their thoughts regarding the measures and their understanding of sleep. All scales and subscales displayed high internal consistency, apart from that which contained items not theoretically related, and all displayed good 1-month test-retest reliability. All measures were significantly correlated, demonstrating convergent validity. Athletes reported few sleep problems, but moderate fatigue. Athletes stated the measures produced accurate reflections of their sleep and fatigue, but also suggested improvements. Research limitations and implications are discussed.

Difficulty in resuming or inability to resume sleep and the links to daytime impairment: definition, prevalence and comorbidity

OBJECTIVES

To assess the chronicity and severity of nocturnal awakenings with difficulty resuming sleep (DRS), its value as an indicator of an ongoing sleep and/or mental disorder and, finally, how it affects on daytime functioning.

METHODS

A cross-sectional telephone study was performed in the non-institutionalized general population of France, the United Kingdom, Germany, Italy and Spain. This representative sample of 22,740 non-institutionalized individuals aged 15 or over was interviewed on their sleeping habits, health, sleep and mental disorders. These five European countries totaled 245.1 million inhabitants. The evaluation of nocturnal awakenings with DRS included duration, frequency (per night, per week and in the previous months) and assessment scale of daytime functioning. DRS was defined as a complaint of difficulty in resuming or inability to resume sleep occurring at least three nights per week and lasting for at least one month.

RESULTS

A total of 16.1% [95% CI: 15.6-16.6] of the sample had DRS. Prevalence was higher in women and increased with age. The average duration of DRS was 40 months. DRS individuals slept on average 30 min less than other subjects with insomnia symptoms and 60 min less than the rest of the sample. Painful physical conditions, anxiety and mood disorders were the most discriminative factors for individuals with DRS distinguishing them from other insomnia subjects and the rest of the sample. Daytime impairment was observed in 52.2% of DRS individuals compared to 32.8% in individuals with classical insomnia symptoms (p < 0.0001).

CONCLUSIONS

(1) DRS affect a large segment of the population; (2) it is a good indicator of an ongoing sleep or mental disorder; (3) it has a stronger impact on daytime functioning than classical insomnia symptoms (OR: 4.7).

Fatigue and health-related quality of life in pediatric inflammatory bowel disease

BACKGROUND & AIMS

Fatigue profoundly impacts quality of life and is a common complaint among patients with chronic disease. This study examined the degree of fatigue and health-related quality of life (HRQOL) in children with inflammatory bowel disease (IBD).

METHODS

Seventy children with IBD and 157 healthy controls and their parents completed age-appropriate measures of fatigue (PedsQL Multidimensional Fatigue Scale) and HRQOL (PedsQL 4.0 Generic Core Scales). Children with IBD completed the IMPACT III Quality of Life Questionnaire, and the Children's Depression Inventory: Short form was completed by children with IBD and healthy controls. Disease activity was determined according to the diagnosis with either the Pediatric Crohn's Disease Activity Index (PCDAI) or a Physician's Global Assessment.

RESULTS

Children with Crohn's disease (N = 52) had a median PCDAI of 0, and 56% with ulcerative colitis (N = 13) or indeterminate colitis (N = 5) were in remission. Mean child self-report PedsQL Multidimensional Fatigue Total Scale scores were 73.9 +/- 16.8 and 82.2 +/- 12.3 for patients with IBD and controls, respectively (P < .001). Mean child self-report PedsQL 4.0 Generic Core Total Scale scores were 76.7 +/- 14.2 and 85.9 +/- 10.4 for patients with IBD and controls, respectively (P < .0001). Children with IBD did not self-report statistically different mean total fatigue and subscale scores compared with children with rheumatologic diseases or cancer.

CONCLUSIONS

In children with primarily inactive IBD, fatigue was significantly higher and HRQOL was significantly lower than in healthy controls. Results among children with IBD were comparable to children with rheumatologic diseases and cancer.

Assessment of fatigue in adults with disabilities

Fatigue is prevalent and can produce major public health consequences. Assessment of fatigue by the PM&R physician begins with a careful history and physical examination, complemented by pertinent rating scales and laboratory studies. In adults with disabilities, a wide variety of etiologies may lead to fatigue. Educating and providing resources about fatigue to patients can help open the discussion about this highly debilitating symptom.

Validation of the fatigue severity scale in a Swiss cohort

BACKGROUND

Fatigue is highly prevalent and has a negative impact on quality of life and performance in a variety of disorders. The 9-item Fatigue Severity Scale (FSS) is one of the most commonly used self-report questionnaires to measure fatigue, but has only been validated in small sample-sized studies and in single disorders.

OBJECTIVE

To validate the FSS in healthy subjects and different disorders known to be commonly associated with fatigue.

MATERIAL AND METHODS

The FSS was administered to 454 healthy subjects, 188 patients with multiple sclerosis (MS), 235 patients with recent ischemic stroke, and 429 patients with sleep-wake disorders including narcolepsy with cataplexy (n=22), restless legs syndrome (RLS) (n=79), sleep apnea (n=108), insomnia (n=62), parasomnia (n=25), excessive daytime sleepiness/hypersomnia of other origin (n=84, and other sleep-wake disorders (n=49.

RESULTS

FSS scores were 4.66 +/- 1.64 (mean +/- SD) in patients with MS, 3.90 +/- 1.85 in patients after ischemic stroke, and 4.34 +/- 1.64 in patients with sleep-wake disorders. Compared to patients, values were significantly lower in healthy subjects (3.00 +/- 1.08, P < 0.01). Scores did not correlate with gender, age, or education. Item analysis showed an excellent internal consistency and reliability (Cronbach alpha = 0.93). Test-retest variability was assessed in 104 healthy subjects, showing stable values over time (2.94 +/- 0.90 vs. 2.90 +/- 0.74; P = 0.27).

CONCLUSIONS

This first validation of a fatigue scale in a large sample size demonstrates that the FSS is a simple and reliable instrument to assess and quantify fatigue for clinical and research purposes.

Sleep problems and associated daytime fatigue in community-dwelling older individuals

BACKGROUND

Reported fatigue has been identified as a component of frailty. The contribution of nighttime sleep quality (duration and complaints) to fatigue symptoms in community-dwelling older adults has not been evaluated.

METHODS

We studied 2264 men and women, aged 75-84 years (mean 77.5 years; standard deviation [SD] 2.9), participating in the Year 5 (2001--2002) clinic visit of the Health, Aging, and Body Composition (Health ABC) study. Fatigue was determined using a subscale of the Modified Piper Fatigue Scale (0-50; higher score indicating higher fatigue). Hours of sleep per night, trouble falling asleep, waking up during the night, and waking up too early in the morning were assessed using interviewer-administered questionnaires.

RESULTS

The average fatigue score was 17.7 (SD 8.4). In multivariate models, women had a 3.8% higher fatigue score than men did. Individuals who slept < or = 6 hours/night had a 4.3% higher fatigue score than did those who slept 7 hours/night. Individuals with complaints of awakening too early in the morning had a 5.5% higher fatigue score than did those without these complaints. These associations remained significant after multivariate adjustment for multiple medical conditions.

CONCLUSION

The association between self-reported short sleep duration (< or = 6 hours), and waking up too early and fatigue symptoms suggests that better and more effective management of sleep behaviors may help reduce fatigue in older adults.

Treatment options for insomnia--pharmacodynamics of zolpidem extended-release to benefit next-day performance

BACKGROUND

Insomnia can manifest as difficulty in falling asleep, in maintaining sleep throughout the night, or waking up too early, with symptoms often unpredictably changing over time. Pharmacologic options for insomnia treatment include prescription hypnotics, such as gamma-amino butyric acid-receptor agonists, sedating antidepressants, over-the-counter antihistamines, melatonin-receptor agonists, and alternative therapies. A concern with insomnia medications is the risk of next-day residual effects, which can impair memory and ability to perform certain tasks, such as driving, and may increase the risk of accidents and falls, especially in the elderly.

OBJECTIVES

To describe the impact of current insomnia treatments on next-day performance.

RESULTS

The longer-acting benzodiazepines are associated with next-day "hangover" effects and, as a result, have been largely replaced by agents in the nonbenzodiazepine class, which typically have shorter half-lives. The hypnotic, sedative activities of these classes of drugs depend on variations in binding characteristics to the alpha1 subunit of the gamma-amino butyric acidA-receptor, which inhibits neuronal activity in broad areas of the brain and is found in areas of the brain responsible for sleep/wakefulness and sedation. However, nonbenzodiazepines with a rapid onset of action and short half-life have shown limited efficacy for maintaining sleep throughout the night. These properties have contributed to the development of modified-release formulations. Zolpidem extended-release is a bilayer tablet that retains the fast onset of action of its parent compound zolpidem while extending the duration of hypnotic activity, owing to a slower-release portion of the tablet.

CONCLUSIONS

Based on clinical evidence, the risk of residual next-day effects of zolpidem extended-release is limited, mainly due to the similarly short half-life in its extended-release formulation.

Sleep disturbances in an arctic population: the Tromsø Study

Background

Prevalence estimates for insomnia range from 10 to 50% in the adult general population. Sleep disturbances cause great impairment in quality of life, which might even rival or exceed the impairment in other chronic medical disorders. The economic implications and use of health-care services related to chronic insomnia represent a clinical concern as well as a pronounced public health problem. Hypnotics are frequently prescribed for insomnia, but alcohol and over-the-counter sleep aids seem to be more widely used by insomniacs than prescription medications. Despite the complex relationship between insomnia and physical and mental health factors, the condition appears to be underrecognized and undertreated by health care providers, probably due to the generally limited knowledge of the causes and natural development of insomnia.

Methods/Design

The Tromsø Study is an ongoing population-based cohort study with five previous health studies undertaken between 1974 and 2001. This protocol outlines a planned study within the sixth Tromsø Study (Tromsø VI), aiming at; 1) describing sleep patterns in a community-based sample representative of the general population of northern Norway, and 2) examining outcome variables of sleep disturbances against possible explanatory and confounding variables, both within a cross-sectional approach, as well as retrospectively in a longitudinal study – exploring sleep patterns in subjects who have attended two or more of the previous Tromsø studies between 1974 and 2009. First, we plan to perform a simple screening in order to identify those participants with probable sleep disturbances, and secondly to investigate these sleep disturbances further, using an extensive sleep-questionnaire. We will also collect biological explanatory variables, i.e. blood samples, weight, height and blood pressure. We plan to merge data on an individual level from the Tromsø VI Study with data from the Norwegian Prescription Database (NorPD), which is a national registry including data for all prescription drugs issued at Norwegian pharmacies. Participants with sleep disturbances will be compared with pair-matched controls without sleep disturbances.

Discussion

Despite ongoing research, many challenges remain in the characterization of sleep disturbances and its correlates. Future mapping of the biological dimensions, natural history, as well as the behavioral and drug-related aspects of sleep disturbances in a representative population samples is clearly needed.

Armodafinil improves wakefulness and long-term episodic memory in nCPAP-adherent patients with excessive sleepiness associated with obstructive sleep apnea

Residual excessive sleepiness (ES) and impaired cognition can occur despite effective and regular nasal continuous positive airway pressure (nCPAP) therapy in some patients with obstructive sleep apnea (OSA). A pooled analysis of two 12-week, randomized, double-blind studies in nCPAP-adherent patients with ES associated with OSA evaluated the effect of armodafinil on wakefulness and cognition. Three hundred and ninety-one patients received armodafinil (150 or 250 mg) and 260 patients received placebo once daily for 12 weeks. Efficacy assessments included the Maintenance of Wakefulness Test (MWT), Cognitive Drug Research cognitive performance battery, Epworth Sleepiness Scale, and Brief Fatigue Inventory. Adverse events were monitored. Armodafinil increased mean MWT sleep latency from baseline to final visit by 2.0 min vs a decrease of 1.5 min with placebo (P < 0.0001). Compared with placebo, armodafinil significantly improved quality of episodic secondary memory (P < 0.05) and patients' ability to engage in activities of daily living (P < 0.0001) and reduced fatigue (P < 0.01). The most common adverse events were headache, nausea, and insomnia. Armodafinil did not adversely affect desired nighttime sleep, and nCPAP use remained high (approximately 7 h/night). Adjunct treatment with armodafinil significantly improved wakefulness, long-term memory, and patients' ability to engage in activities of daily living in nCPAP-adherent individuals with ES associated with OSA. Armodafinil also reduced patient-reported fatigue and was well tolerated.

Vitamins and sleep: an exploratory study

STUDY OBJECTIVE

We analyzed archival data from an epidemiology study to test the association between vitamin use and sleep.

DESIGN

Random digit dialing was used to recruit 772 people ranging in age from 20 to 98 for a study of people's sleep experience. These individuals completed a set of questionnaires about their sleep, health, and daytime functioning. Five hundred and nineteen of these participants had available vitamin use data.

SETTING

Home.

PARTICIPANTS

Five hundred and nineteen people participated. Recruitment applied minimal screening criteria and no attempt was made to favor people with or without sleep disturbance.

INTERVENTIONS

This survey included no intervention. Participants completed 2 weeks of sleep diaries and a set of questionnaires. Of particular salience to the present study, participants reported their vitamin use in listing all medications and nutritional supplements being used currently.

MEASUREMENTS AND RESULTS

For those individuals taking a multivitamin or multiple single vitamins, sleep diaries revealed poorer sleep compared to non-vitamin users in the number and duration of awakenings during the night. After controlling for age, ethnicity, and sex the difference in number of awakenings was still marginally significant. The rate of insomnia, conservatively defined, and consumption of sleep medication were also marginally significantly higher among individuals taking multi-/multiple vitamins compared to those not taking vitamins.

CONCLUSIONS

Disturbed sleep maintenance was associated with multi-/multiple vitamin use. Five equally plausible explanations were advanced to explain this association including vitamins cause poor sleep, poor sleepers seek vitamins, and unidentified factors promote both poor sleep and vitamin use. These data are considered preliminary. Methodological characteristics of future studies were described that hold the promise of more clearly illuminating the association between vitamins and sleep.

Prevalence of temporomandibular disorders in fibromyalgia and failed back syndrome patients: a blinded prospective comparison study

OBJECTIVES

The objective of this study was to determine the prevalence of temporomandibular disorders (TMD) and evaluate psychosocial domains in patients with fibromyalgia (FM) compared with patients with failed back syndrome (FBS).

STUDY DESIGN

The study included 51 (32 FM and 19 FBS) adult patients who were administered orofacial pain and psychological questionnaires before a clinical examination. Presence of TMD was diagnosed according to the Research Diagnostic Criteria for TMD.

RESULTS

Fifty-three percent of the FM patients reported having face pain compared with 11% of the FBS patients. Of those FM patients who reported face pain, 71% fulfilled the criteria for a diagnosable TMD. FM patients had significantly higher subscale scores for somatization, obsessive-compulsive, medication used for sleep, and fatigue compared with FBS patients. Eighty-seven percent of the FM patients reported a stressful event and 42.3% had symptoms indicating posttraumatic stress disorder.

CONCLUSION

The high prevalence of TMD and psychosocial dysfunction among FM patients suggests wide-reaching dysregulation of autonomic and hypothalamic-pituitary-adrenal axis functions.

A longitudinal study of depression, pain, and stress as predictors of sleep disturbance among women with metastatic breast cancer

OBJECTIVE

Sleep disturbances are common among women with breast cancer and can have serious consequences. The present study examined depression, pain, life stress, and participation in group therapy in relation to sleep disturbances in a sample of women with metastatic breast cancer.

METHODS

Ninety-three women with metastatic breast cancer participated in a large intervention trial examining the effect of the group therapy on their symptoms. They completed measures of depression, pain, life stress, and sleep disturbance at baseline, 4, 8 and 12 months.

RESULTS

The results showed that higher initial levels of depression at baseline predicted problems associated with getting up in the morning, waking up during the night, and daytime sleepiness. Increases in depression over the course of 12 months were associated with fewer hours of sleep, more problems with waking up during the night and more daytime sleepiness. Higher levels of pain at baseline predicted more problems getting to sleep. Increases in pain predicted more difficulty getting to sleep and more problems waking up during the night. Greater life stress at baseline predicted more problems getting to sleep and more daytime sleepiness.

CONCLUSIONS

Depression, pain, and life stress scores were each associated with different types of negative change in self-reported sleep disturbances. Depression, especially worsening depression, was associated with the greatest number of types of negative change. The relationships found between sleep disturbance and depression, pain, and life stress suggest specific ways to address the problem of sleep disturbance for women with metastatic breast cancer and show how different types of disturbed sleep may be clinical markers for depression, pain, or life stress in this population.

What predicts patients' perceptions of improvement in insomnia?

Although there has been considerable research into the effectiveness of individual cognitive behavioral treatment for chronic insomnia, less is known about patients' perceptions of what constitutes actual improvement. This study utilized 70 outpatients (mean age = 49.7 years, SD = 12.0) with insomnia who completed a 6-week cognitive behavioral group for sleep. Participants completed a number of primary (Pittsburgh Sleep Quality Index) and secondary measures (the Dysfunctional Beliefs about Sleep Scale, Insomnia Severity Index, Beck Depression Inventory, Penn State Worry Questionnaire) at pre- and post-treatment. Perceived improvement was measured using the Clinical Global Improvement Scale (CGI). Results were analyzed using a combination of Logistic Regression analysis and receiver operating curve characteristic analysis (ROC). Results demonstrated that sleep quality and sleep duration were the most sensitive primary measures, or best predicted perceived improvement, whereas sleep efficiency was the most specific primary measure, or best predicted perceived lack of improvement (defined as only mild improvement). Of the secondary measures, results showed that daytime impairment was the most sensitive predictor of perceived improvement and that mood was the most specific predictor of perceived lack of improvement. Implications of these findings are that sleep quality, sleep duration, and sleep efficiency may offer different types of information and the choice of measure for predicting global improvement in insomnia will depend on the needs of the researcher/clinician.