Cognitive Behavioral Therapy for Insomnia Reduces Depression in Cancer Survivors

STUDY OBJECTIVES

The current archival analyses examine the direct and indirect effects of cognitive behavioral therapy for insomnia (CBT-I) on depression in cancer survivors.

METHODS

We report on 67 cancer survivors from a 2 × 2 randomized controlled trial of CBT-I and armodafinil for insomnia, after collapsing across the noneffective study medication conditions (armodafinil/placebo) to create CBT-I (yes/no). Depression and insomnia were assessed before, during the 7-week CBT-I intervention, at postintervention, and 3 months later by the Patient Health Questionnaire and the Insomnia Severity Index, respectively.

RESULTS

Mean depression at baseline for all participants was 6.44 (standard error = 0.41, range 0-15). Paired t tests showed that depression improved from baseline to postintervention by 48% (P < .001) in the CBT-I group versus 15% (P = .016) in the non-CBT-I group. Analysis of covariance controlling for baseline found that participants receiving CBT-I had significantly less depression at postintervention (effect size = -0.62; P = .001), compared to those who did not receive CBT-I. These benefits were maintained at the 3-month follow-up. Spearman rank correlations showed that changes in insomnia severity from baseline to postintervention were significantly correlated with concurrent changes in depression (r = .73; P < .001). Path analysis revealed that improvement in depression was mediated by improvement in insomnia severity (P < .001).

CONCLUSIONS

Our findings provide preliminary support that in cancer survivors, CBT-I reduces depression via improvement in insomnia. Further, this reduction in depression remained stable 3 months after completing CBT-I. This suggests that a CBT-I intervention has a meaningful effect on depression.

CLINICAL TRIAL REGISTRATION

Registry: ClinicalTrials.gov; Title: Cognitive Behavioral Therapy +/- Armodafinil for Insomnia and Fatigue Following Chemotherapy; Identifier: NCT01091974; URL: https://clinicaltrials.gov/ct2/show/record/NCT01091974.

Effect of insomnia treatments on depression: A systematic review and meta-analysis

BACKGROUND

Insomnia is frequently co-morbid with depression, with a bidirectional relationship between these disorders. There is evidence that insomnia-specific interventions, such as cognitive behavioral therapy for insomnia, may lead to improvements in depression. The purpose of this systematic review and meta-analysis is to determine whether treatment of insomnia leads to improved depression outcomes in individuals with both insomnia and depression.

METHODS

We conduct a systematic review and meta-analysis to explore the effect of treatment for insomnia disorder on depression in patients with both disorders.

RESULTS

Three thousand eight hundred and fifteen studies were reviewed, and 23 studies met inclusion criteria. Although all of the studies suggested a positive clinical effect of insomnia treatment on depression outcomes, most of the results were not statistically significant. Although the interventions and populations were highly variable, the meta-analysis indicates moderate to large effect size (ES) improvement in depression as measured with the Hamilton Depression Rating Scale (ES = -1.29, 95%CI [-2.11, -0.47]) and Beck Depression Inventory (ES = -0.68, 95%CI [-1.29, -0.06]).

CONCLUSIONS

These results support that treating insomnia in patients with depression has a positive effect on mood. Future trials are needed to identify the subtypes of patients whose depression improves during treatment with insomnia-specific interventions, and to identify the mechanisms by which treating insomnia improves mood.

Perceived cognitive deficits and depressive symptoms in patients with multiple sclerosis: Perceived stress and sleep quality as mediators

Multiple Sclerosis (MS), an autoimmune disorder marked by inflammation of the central nervous system, is associated with a myriad of symptoms. Individuals with MS are more likely to experience depressive symptoms, perhaps due to perceived cognitive impairments. Thus, we aimed to explore perceived stress and sleep deficits as potential mediators of the association between perceived cognitive deficits and depressive symptoms. We recruited a sample of 77 MS participants from an outpatient, university-based MS clinic in the United States. Participants ranged in age between 30 and 75 years old (M = 51.12; SD = 9.6), with more females than males (83% female; n = 64). Participants completed the Perceived Deficits Questionnaire, the Pittsburgh Sleep Quality Index, the Perceived Stress Scale, and the Center for Epidemiological Studies Depression Scale - Revised. Correlation analyses and mediation analyses were conducted with bootstrapping technique. Statistical analyses revealed that higher levels of perceived cognitive deficits were associated with lower quality of sleep, more perceived stress, and higher levels of depressive symptoms. Additionally, both perceived stress and sleep quality served as a significant mediator in the perceived cognitive impairments and depressive symptoms linkage. Our novel findings demonstrate the importance of underlying mechanisms (e.g., sleep quality and perceived stress) in the conceptualization of MS. Perceived stress and sleep quality are potentially modifiable factors, perhaps serving as a target for future treatment, to buffer risk of MS patients developing depression.

Does Mid-Treatment Insomnia Severity Mediate between Cognitive Behavioural Therapy for Insomnia and Post-Treatment Depression? An Investigation in a Sample with Comorbid Insomnia and Depressive Symptomatology

Background: Recent treatment studies with cognitive behavioural therapy for insomnia (CBT-I) have demonstrated effects on both sleep problems and depression. Two previous studies have indicated that the beneficial effect from CBT-I on depression may come through improved sleep, although insomnia severity during treatment had not previously been investigated as a mediator. Aims: Our aim was to investigate if insomnia severity during treatment mediated between CBT-I and depression severity after treatment, in a sample with co-morbid insomnia and depressive symptomology. We also examined whether depressive severity during treatment mediated between CBT-I and insomnia after treatment. Method: The participants were recruited from advertisements and fulfilled criteria for insomnia diagnosis, and had depressive symptomatology (Beck Depression Inventory-second edition: BDI-II > 13). Two-thirds of the participants were diagnosed with major depressive disorder. The participants received four biweekly group sessions of CBT-I or relaxation training (active control). Insomnia severity (Insomnia Severity Index) and depressive severity (BDI-II) were measured at baseline, mid-treatment, post-treatment and 6-month follow-up. The mid-treatment measures were used as mediators. Results: Mediational analyses demonstrated a significant reciprocal relationship between insomnia severity and depressive severity throughout CBT-I, although mid-treatment insomnia had a stronger effect on depression than mid-treatment depression had on insomnia. The results were similar for both post-treatment and follow-up. Discussion: Some improvement in depressive severity after CBT-I is explained by improved sleep. The findings emphasize the importance of making comorbid insomnia a treatment focus in its own right.

Improvements of adolescent psychopathology after insomnia treatment: results from a randomized controlled trial over 1 year

BACKGROUND

Adolescent insomnia can be treated effectively with cognitive behavioural therapy for insomnia (CBTI). However, little is known about effects of CBTI on psychopathology in adolescents. This study aimed to investigate whether (a) CBTI improves psychopathology in Internet- (IT) and face-to-face group treatment (GT) compared to waitlist (WL), (b) improvement in psychopathology can be attributed to reduced insomnia, (c) improvement in psychopathology remains stable for up to 1 year.

METHODS

One hundred and sixteen participants (age = 15.6 years, 25% males) with DSM-5 insomnia, were randomly assigned to IT, GT or WL.

CLINICAL TRIAL REGISTRATION

http://www.controlledtrials.com (ISRCTN33922163). Assessments of psychopathology, insomnia and objectively and subjectively measured sleep occurred at baseline, post-treatment, and at 2-, 6- and 12-month follow-up. Multilevel and mediation analyses were run to test hypotheses. The CBTI protocol, 'Sleeping Smart' for both IT and GT consisted of six weekly sessions and a booster session after 2 months.

RESULTS

Psychopathology symptoms, insomnia and sleep problems as measured by actigraphy and sleep logs decreased substantially in IT and GT compared with WL at 2-month follow-up with medium to large effect sizes (ESs). Psychopathology symptoms remained stable or further improved for up to 12-month follow-up. ESs at 12-month follow-up for IT and GT were respectively: affective (d = -0.87 and -0.97), anxiety (d = -0.81 for IT), somatic (d = -0.38 and d = -0.52), oppositional (d = -0.42 for GT) and attention deficit hyperactivity disorder (ADHD) problems (d = -0.47 and -0.46). Mediation analyses indicated that reduction of insomnia symptoms after CBTI fully mediated the effects of CBTI on affective and anxiety problems, and partially mediated the effect on ADHD problems.

CONCLUSIONS

This is the first study demonstrating that Internet and face-to-face CBT for insomnia achieves long-term reduction in adolescent psychopathology and does so by improving insomnia. This finding can have profound implications for youth mental health care.

Chronic parenting stress and mood reactivity: The role of sleep quality

Sleep is a basic biological process supporting emotion regulation. The emotion regulation function of sleep may be particularly important in the context of chronic stress. To better understand how chronic stress and sleep interact to predict mood, 66 parents of children with autism completed daily diaries assessing parenting stress, negative mood, and sleep quality for 6 consecutive days. Hierarchical linear modelling revealed that daily negative mood was predicted by between-person differences in parenting stress and between-person differences in sleep efficiency. Further, between-person differences in sleep efficiency and within-person differences in sleep satisfaction moderated the impact of stress on mood. These data suggest that sleep disturbances may exacerbate the association between stress and mood in the context of chronic parenting stress. Further, high parenting stress appears to heighten the impact of transient sleep disturbances on mood.

Cognitive Behavioural Therapy for Insomnia (CBT-I) to treat depression: A systematic review

INTRODUCTION

Major depressive disorder is one of the most commonly diagnosed psychiatric illnesses, and it has a profound negative impact on an individual's ability to function. Up to 90% of individuals suffering from depression also report sleep and circadian disruptions. If these disruptions are not effectively resolved over the course of treatment, the likelihood of relapse into depression is greatly increased. Cognitive Behavioural Therapy for Insomnia (CBT-I) has shown promise in treating these sleep and circadian disturbances associated with depression, and may be effective as a stand-alone treatment for depression. This may be particularly relevant in cases where antidepressant medications are not ideal (e.g. due to contraindications, cost, or treatment resistance).

METHODS

A systematic literature review was conducted of trials investigating the use of CBT-I to treat depression in adults. Therapy included in-person CBT-I, as well as telehealth and group CBT-I.

RESULTS AND CONCLUSIONS

CBT-I presents a promising treatment for depression comorbid with insomnia. In-person therapy has the most supporting evidence for its efficacy, though treatment effects may not be additive with those of antidepressant medications. Insomnia improvement due to CBT-I may mediate the improvement in depressive symptoms. There is less evidence for the use of telehealth, though a stepped-care approach is indicated based on baseline depressive severity. More research on group therapy and telehealth modalities of delivering CBT-I are required before making recommendations.

The DSM-5 Self-Rated Level 1 Cross-Cutting Symptom Measure identifies high levels of coexistent psychiatric symptomatology in patients referred for insomnia treatment

PURPOSE

Referrals to sleep psychology services, even for a perceived single problem such as insomnia, can present with complex, coexistent psychiatric symptoms and comorbid disorders. This study aimed to assess the feasibility of implementing the DSM-5 Self-Rated Level 1 Cross-Cutting Symptom Measure (CCSM) into a sleep psychology clinic to identify coexistent psychiatric symptomatology in insomnia referrals.

PATIENTS AND METHODS

Patients were 50 consecutive referrals to a private sleep psychology service within a sleep disorders center in Melbourne, Australia. Patients who attended sleep psychology services between June 2015 and January 2017 had their clinical records reviewed. Basic demographic information, comorbidities, and responses to the Insomnia Severity Index were gathered. The Diagnostic and Statistical Manual of Mental Disorders Ed. 5 Task Force and Work Groups created the CCSM in 2013 to deal with the issue of coexistent psychiatric symptomatology across mental health conditions, and this measure was included into the sleep psychology intake procedure and patient responses were reviewed.

RESULTS

The CCSM was simple and quick to administer and score and revealed high levels of psychiatric symptomatology in sleep psychology referrals. Sleep problems were the most common domain of psychiatric symptomatology reported (86%). Anxiety (66%), depression (64%), anger (64%), and somatic symptoms (50%) were also very common. Suicidal ideation was acknowledged by 26% of patients. In addition, 82% of patients had at least one diagnosed comorbidity upon referral (eg, psychiatric, physical health, or other sleep disorder).

CONCLUSION

The findings support the CCSM as a feasible measure for identifying the high levels of coexistent psychiatric symptomatology in patients presenting for insomnia treatment at sleep psychology services.

Effects of cognitive behavioral therapy for depression on improving insomnia and quality of life in Chinese women with breast cancer: results of a randomized, controlled, multicenter trial

PURPOSE

Cognitive behavioral therapy (CBT) for depression had been found to be effective in reducing depressive and anxiety symptoms in breast cancer survivors. It is not known whether CBT for depression would also improve insomnia and quality of life (QOL). The aim of this study was to investigate whether CBT for depression would improve insomnia and QOL in a randomized controlled multicenter trial.

PATIENTS AND METHODS

In this study, breast cancer survivors (n=392) were randomly allocated to the following three groups: CBT (n=98), self-care management (SCM, n=98), and usual care (UC, n=196) in a ratio of 1:1:2. CBT and SCM received a series of nine sessions for 12 weeks, whereas UC received UC only. Insomnia and QOL were evaluated using Athens Insomnia Scale (AIS) and Functional Assessment of Cancer Therapy-Breast (FACT-B) questionnaire at baseline, 4, 12, and 24 weeks.

RESULTS

There was a significant intergroup difference in AIS and FACT-B scores (both P<0.01). CBT showed less insomnia problems and better overall QOL compared with those in SCM and UC (both P<0.01). No significant differences were found between SCM and UC in insomnia problems and overall QOL. Moreover, the effects of CBT on insomnia and QOL were maintained during the follow-up period.

CONCLUSION

CBT for depression can be effective in improving insomnia problems and QOL in the Chinese breast cancer survivors.

CBT-I and HT-I group therapy for adults with insomnia in comparison to those with insomnia and comorbid depression - a pilot study

PURPOSE

The aim of this study was to examine the effectiveness of a combined cognitive-behavioral therapy for insomnia (CBT-I) and hypnotherapy for insomnia (HT-I) program for insomnia patients with or without additional depression regarding depressive symptoms and various sleep parameters.

PATIENTS AND METHODS

A sample of 63 patients suffering from insomnia received a six-session sleep intervention, which combined cognitive-behavioral and hypnotherapeutical elements. Due to violating exclusion criteria, data of 37 patients were analyzed. Ten patients had insomnia comorbid with depression, whereas 27 patients had insomnia only. Sleep diaries were implemented to measure various sleep parameters, whereas depressive symptomatology was assessed with the anxiety and depression scale and Symptom-Checklist-90-R at baseline, before and after the intervention, as well as at 3-months follow-up.

RESULTS

Depressive symptoms decreased from pre to post measurement and follow-up for patients with insomnia comorbid with depression, whereas scores of patients with only insomnia remained relatively on a low level. Both groups showed a significant increase of sleep efficiency and a significant decrease of the duration of wake after sleep onset. However, only patients with insomnia and depression revealed a significant reduction of sleep-onset latency and a higher level of regeneration. Nondepressive insomniacs, on the other hand, showed a significant increase of performance from post measurement to follow-up. For both groups, no change over time was found for number of wake after sleep onset, total sleep time, mood in the morning and evening.

CONCLUSION

Combining CBT-I and HT-I is effective in reducing depressive symptoms and improving sleep. Therefore, nonresponders to other forms of therapy, eg, pharmacological, interpersonal, or cognitive-behavioral therapy, might benefit from the combined CBT-I/HT-I intervention.

Mediators and treatment matching in behavior therapy, cognitive therapy and cognitive behavior therapy for chronic insomnia

OBJECTIVE

To examine the mediators and the potential of treatment matching to improve outcome for cognitive behavior therapy (CBT) for insomnia.

METHOD

Participants were 188 adults (117 women; Mage = 47.4 years, SD = 12.6) meeting the Diagnostic and Statistical Manual of Mental Disorders (4th ed.; text rev.; DSM-IV-TR; American Psychiatric Association [APA], 2000) diagnostic criteria for chronic insomnia (Mduration: 14.5 years, SD: 12.8). Participants were randomized to behavior therapy (BT; n = 63), cognitive therapy (CT; n = 65), or CBT (n = 60). The outcome measure was the Insomnia Severity Index (ISI). Hypothesized BT mediators were sleep-incompatible behaviors, bedtime variability (BTv), risetime variability (RTv) and time in bed (TIB). Hypothesized CT mediators were worry, unhelpful beliefs, and monitoring for sleep-related threat.

RESULTS

The behavioral processes mediated outcome for BT but not CT. The cognitive processes mediated outcome in both BT and CT. The subgroup scoring high on both behavioral and cognitive processes had a marginally significant better outcome if they received CBT relative to BT or CT. The subgroup scoring relatively high on behavioral but low on cognitive processes and received BT or CBT did not differ from those who received CT. The subgroup scoring relatively high on cognitive but low on behavioral processes and received CT or CBT did not differ from those who received BT.

CONCLUSION

The behavioral mediators were specific to BT relative to CT. The cognitive mediators were significant for both BT and CT outcomes. Patients exhibiting high levels of both behavioral and cognitive processes achieve better outcome if they receive CBT relative to BT or CT alone. (PsycINFO Database Record

Trajectories of change and long-term outcomes in a randomised controlled trial of internet-based insomnia treatment to prevent depression

BACKGROUND

Insomnia treatment using an internet-based cognitive-behavioural therapy for insomnia (CBT-I) program reduces depression symptoms, anxiety symptoms and suicidal ideation. However, the speed, longevity and consistency of these effects are unknown.

AIMS

To test the following: whether the efficacy of online CBT-I was sustained over 18 months; how rapidly the effects of CBT-I emerged; evidence for distinct trajectories of change in depressive symptoms; and predictors of these trajectories.

METHOD

A randomised controlled trial compared the 6-week Sleep Healthy Using the Internet (SHUTi) CBT-I program to an attention control program. Adults (N=1149) with clinical insomnia and subclinical depression symptoms were recruited online from the Australian community.

RESULTS

Depression, anxiety and insomnia decreased significantly by week 4 of the intervention period and remained significantly lower relative to control for >18 months (between-group Cohen's d=0.63, 0.47, 0.55, respectively, at 18 months). Effects on suicidal ideation were only short term. Two depression trajectories were identified using growth mixture models: improving (95%) and stable/deteriorating (5%) symptoms. More severe baseline depression, younger age and limited comfort with the internet were associated with reduced odds of improvement.

CONCLUSIONS

Online CBT-I produced rapid and long-term symptom reduction in people with subclinical depressive symptoms, although the initial effect on suicidal ideation was not sustained.

DECLARATION OF INTEREST

P.J.B. has received grants from the National Health and Medical Research Council (NHMRC) during the conduct of the study. H.C. has received grants from the NHMRC and the Australian Research Council during the conduct of the study. L.M.R. receives research funding from the National Institutes of Health (NIH) that, in part, focuses on insomnia. F.P.T. and L.M.R. have equity ownership in BeHealth Solutions (Charlottesville, VA, USA), a company that develops and makes available products related to the research reported in this manuscript. BeHealth Solutions has licensed the SHUTi program and the software platform on which it was built from the University of Virginia. The terms of this arrangement have been reviewed and approved by the University of Virginia in accordance with its conflict of interest policy. N.G. has received grants from the NHMRC during the conduct of the study and personal fees from Lundbeck, Servier and Janssen outside the submitted work.

COPYRIGHT AND USAGE

© The Royal College of Psychiatrists 2017. This is an open access article distributed under the terms of the Creative Commons Non-Commercial, No Derivatives (CC BY-NC-ND) license.

Cognitive behavioural therapy for post-stroke fatigue and sleep disturbance: a pilot randomised controlled trial with blind assessment

The objective of this study was to evaluate the effectiveness of individual cognitive behavioural therapy (CBT) for post-stroke fatigue and sleep disturbance compared to treatment as usual (TAU). In a parallel two-group pilot randomised controlled trial of 15 participants, nine were allocated to eight weekly sessions of adapted CBT and six continued usual care rehabilitation. The primary outcome was the Fatigue Severity Scale (FSS-7) at two and four months from baseline. Secondary outcomes included measures of sleep, mood and quality of life. Outcomes were assessed by a rater who was blind to group membership. At the four-month endpoint, the CBT group demonstrated significantly reduced fatigue relative to TAU (FSS-7 mean difference: 1.92, 95% CI: 0.24 to 3.60). Significant group differences also emerged for sleep quality and depression, favouring the CBT group. Insomnia and physical quality of life improved immediately post-therapy but were no longer superior to TAU at follow-up. Overall, CBT is a promising treatment for improving post-stroke fatigue, sleep quality and depression. Gains were maintained for two months after therapy cessation and represented large treatment effects. These findings highlight the feasibility of the intervention and warrant extension to a phase III clinical trial.

Cognitive Behavior Therapy to Treat Sleep Disturbance and Fatigue After Traumatic Brain Injury: A Pilot Randomized Controlled Trial

OBJECTIVE

To evaluate the efficacy of adapted cognitive behavioral therapy (CBT) for sleep disturbance and fatigue in individuals with traumatic brain injury (TBI).

DESIGN

Parallel 2-group randomized controlled trial.

SETTING

Outpatient therapy.

PARTICIPANTS

Adults (N=24) with history of TBI and clinically significant sleep and/or fatigue complaints were randomly allocated to an 8-session adapted CBT intervention or a treatment as usual (TAU) condition.

INTERVENTIONS

Cognitive behavior therapy.

MAIN OUTCOME MEASURES

The primary outcome was the Pittsburgh Sleep Quality Index (PSQI) posttreatment and at 2-month follow-up. Secondary measures included the Insomnia Severity Index, Fatigue Severity Scale, Brief Fatigue Inventory (BFI), Epworth Sleepiness Scale, and Hospital Anxiety and Depression Scale.

RESULTS

At follow-up, CBT recipients reported better sleep quality than those receiving TAU (PSQI mean difference, 4.85; 95% confidence interval [CI], 2.56-7.14). Daily fatigue levels were significantly reduced in the CBT group (BFI difference, 1.54; 95% CI, 0.66-2.42). Secondary improvements were significant for depression. Large within-group effect sizes were evident across measures (Hedges g=1.14-1.93), with maintenance of gains 2 months after therapy cessation.

CONCLUSIONS

Adapted CBT produced greater and sustained improvements in sleep, daily fatigue levels, and depression compared with TAU. These pilot findings suggest that CBT is a promising treatment for sleep disturbance and fatigue after TBI.

Precision medicine in circadian rhythm sleep-wake disorders: current state and future perspectives

In circadian rhythm sleep-wake disorders precision medicine is less developed than in other medical disciplines mainly because homeostatic sleep and circadian timing have a very complex phenotype with multiple genetic regulation mechanisms. However, biomarkers, phenotyping and psychosocial characteristics are increasingly used. Devices for polysomnography, actigraphy and sleep-tracking applications in mobile phones and other consumer devices with eHealth technologies are increasingly used. Also sleep-related questionnaires and the assessment of co-morbidities influencing sleep in circadian rhythm sleep-wake disorders are major contributors to precision sleep medicine. To further strengthen the (pharmaco-)genetic and biomarker pillar, technology needs to be evolved further. Routinely measuring treatment results using patient-reported outcome measures and clinical neurophysiological instruments will boost precision sleep medicine.

The direction of the relationship between symptoms of insomnia and psychiatric disorders in adolescents

BACKGROUND

This study assessed the direction of the relationship between symptoms of insomnia disorder, depression, various anxiety disorders and obsessive compulsive disorder (OCD) in adolescents after controlling for age, gender, chronotype, and outcome variable at baseline.

METHODS

Data was collected in eight high schools in Adelaide, South Australia, at two time-points approximately 6 months apart. The study was completed by 318 and 255 high school students at baseline and follow-up, respectively, aged 12-18 (M=14.96, SD=1.34) in grades 7-11 at baseline. Hierarchical regression analyses were used to assess each relationship, the first model controlling for age, gender and chronotype, and the second controlling for outcome variable at baseline.

RESULTS

Insomnia symptoms predicted and were predicted by symptoms of each psychiatric disorder in model 1. In model 2, insomnia symptoms predicted symptoms of depression, and vice-versa. Symptoms of insomnia also predicted symptoms of separation anxiety disorder (SAD) once SAD, but not vice-versa, in model 2. Symptoms of obsessive compulsive disorder (OCD) and social phobia (SP) predicted symptoms of insomnia disorder in model 2, but not vice-versa. Insomnia symptoms were no longer related to symptoms of other anxiety disorders in model 2.

LIMITATIONS

The use of self-report measures, and potential predisposing, precipitating, perpetuating or preventative factors were not assessed.

CONCLUSIONS

Symptoms of insomnia disorder are bidirectionally related to depressive symptoms independent from baseline symptoms, and unidirectionally related to symptoms of OCD and SP where OCD and SP are independent risk-factors of the development of insomnia symptoms.

Sleep and mental disorders: A meta-analysis of polysomnographic research

Investigating sleep in mental disorders has the potential to reveal both disorder-specific and transdiagnostic psychophysiological mechanisms. This meta-analysis aimed at determining the polysomnographic (PSG) characteristics of several mental disorders. Relevant studies were searched through standard strategies. Controlled PSG studies evaluating sleep in affective, anxiety, eating, pervasive developmental, borderline and antisocial personality disorders, attention-deficit-hyperactivity disorder (ADHD), and schizophrenia were included. PSG variables of sleep continuity, depth, and architecture, as well as rapid-eye movement (REM) sleep were considered. Calculations were performed with the "Comprehensive Meta-Analysis" and "R" software. Using random effects modeling, for each disorder and each variable, a separate meta-analysis was conducted if at least 3 studies were available for calculation of effect sizes as standardized means (Hedges' g). Sources of variability, that is, sex, age, and mental disorders comorbidity, were evaluated in subgroup analyses. Sleep alterations were evidenced in all disorders, with the exception of ADHD and seasonal affective disorders. Sleep continuity problems were observed in most mental disorders. Sleep depth and REM pressure alterations were associated with affective, anxiety, autism and schizophrenia disorders. Comorbidity was associated with enhanced REM sleep pressure and more inhibition of sleep depth. No sleep parameter was exclusively altered in 1 condition; however, no 2 conditions shared the same PSG profile. Sleep continuity disturbances imply a transdiagnostic imbalance in the arousal system likely representing a basic dimension of mental health. Sleep depth and REM variables might play a key role in psychiatric comorbidity processes. Constellations of sleep alterations may define distinct disorders better than alterations in 1 single variable. (PsycINFO Database Record

The Development of a Clinically Relevant Sleep Modification Protocol for Youth with Type 1 Diabetes

Findings from type 2 diabetes research indicate that sleep is both a predictor of onset and a correlate of disease progression. However, the role sleep plays in glucose regulation and daytime functioning in youth with type 1 diabetes mellitus (T1DM) has not been systematically investigated. Nonetheless, preliminary findings have supported that various sleep parameters are strongly correlated to health-related and neurobehavioral outcomes in youth with T1DM. This suggests that improving sleep might reduce morbidity. A critical step in developing evidence-based guidelines regarding sleep in diabetes management is to first determine that sleep modification in natural settings is possible (i.e., instructing youth to have a healthy sleep opportunity leads to more total sleep time) and that an increased sleep duration impacts disease and psychosocial outcomes in these youth. This article describes the background, design, and feasibility of an ongoing randomized clinical trial that aims to examine if increasing sleep relative to youth's own sleep routines affects glucose control and daytime functioning.

Evidence-Based Applications of Combination Psychotherapy and Pharmacotherapy for Depression

Combination treatment with psychotherapy and antidepressant medication can be provided from the initiation of treatment, sequentially after nonremission with a single-modality treatment or sequentially after remission to buttress the patient's recovery to prevent recurrence. Combination treatment from the initiation of care is best reserved for patients with high depression severity. Sequential addition of treatments, particularly psychotherapy after nonremission to antidepressant medication, is the best supported method of combination, improving remission rates and reducing relapse and recurrence in the long term. However, uncertainty persists around the optimal form of psychotherapy to combine with antidepressant medication for maximizing long-term gains. Better outcomes from combination treatment have been strongest in clinical trials that limited pharmacotherapy to a single antidepressant; benefits of combination treatment have been substantially smaller in trials that allowed flexible use of multiple antidepressant classes. Patients with recurrent major depressive disorder who benefit from combination treatment have better long-term outcomes if an active treatment component is maintained during recovery.

Effectiveness of an online insomnia program (SHUTi) for prevention of depressive episodes (the GoodNight Study): a randomised controlled trial

BACKGROUND

In view of the high co-occurrence of depression and insomnia, a novel way to reduce the risk of escalating depression might be to offer an insomnia intervention. We aimed to assess whether an online self-help insomnia program could reduce depression symptoms.

METHODS

We did this randomised controlled trial at the Australian National University in Canberra, Australia. Internet users (aged 18-64 years) with insomnia and depression symptoms, but who did not meet criteria for major depressive disorder, were randomly assigned (1:1), via computer-generated randomisation, to receive SHUTi, a 6 week, modular, online insomnia program based on cognitive behavioural therapy for insomnia, or HealthWatch, an interactive, attention-matched, internet-based placebo control program. Randomisation was stratified by age and sex. Telephone-based interviewers, statisticians, and chief investigators were masked to group allocation. The primary outcome was depression symptoms at 6 months, as measured with the Patient Health Questionnaire (PHQ-9). The primary analysis was by intention to treat. This trial is registered with the Australian New Zealand Clinical Trials Registry, number ACTRN12611000121965.

FINDINGS

Between April 30, 2013, and June 9, 2014, we randomly assigned 1149 participants to receive SHUTi (n=574) or HealthWatch (n=575), of whom 581 (51%) participants completed the study program assessments at 6 weeks and 504 (44%) participants completed 6 months' follow-up. SHUTi significantly lowered depression symptoms on the PHQ-9 at 6 weeks and 6 months compared with HealthWatch (F[degrees of freedom 2,640·1]=37·2, p<0·0001). Major depressive disorder was diagnosed in 22 (4%) participants at 6 months (n=9 in the SHUTi group and n=13 in the HealthWatch group), with no superior effect of SHUTi versus HealthWatch (Fisher's exact test=0·52; p=0·32). No adverse events were reported.

INTERPRETATION

Online cognitive behaviour therapy for insomnia treatment is a practical and effective way to reduce depression symptoms and could be capable of reducing depression at the population level by use of a fully automatised system with the potential for wide dissemination.

FUNDING

Australian National Health and Medical Research Council.

Insomnia, Nightmares, and Chronotype as Markers of Risk for Severe Mental Illness: Results from a Student Population

STUDY OBJECTIVES

To group participants according to markers of risk for severe mental illness based on subsyndromal symptoms reported in early adulthood and evaluate attributes of sleep across these risk categories.

METHODS

An online survey of sleep and psychiatric symptomatology (The Oxford Sleep Survey) was administered to students at one United Kingdom university. 1403 students (undergraduate and postgraduate) completed the survey. The median age was 21 (interquartile range = 20-23) and 55.60% were female. The cross-sectional data were used to cluster participants based on dimensional measures of psychiatric symptoms (hallucinations, paranoia, depression, anxiety, and (hypo)mania). High, medium, and low symptom groups were compared across sleep parameters: insomnia symptoms, nightmares, chronotype, and social jet lag.

RESULTS

Insomnia symptoms, nightmares frequency, and nightmare-related distress increased in a dose-response manner with higher reported subsyndromal psychiatric symptoms (low, medium, and high). The high-risk group exhibited a later chronotype (mid sleep point for free days) than the medium- or low-risk group. The majority of participants (71.7%) in the high-risk group screened positive for insomnia and the median nightmare frequency was two per 14 days (moderately severe pathology).

CONCLUSIONS

Insomnia, nightmares, and circadian phase delay are associated with increased subsyndromal psychiatric symptoms in young people. Each is a treatable sleep disorder and might be a target for early intervention to modify the subsequent progression of psychiatric disorder.

Internet-Based Cognitive Behavioral Therapy for Insomnia (ICBT-i) Improves Comorbid Anxiety and Depression-A Meta-Analysis of Randomized Controlled Trials

As the internet has become popularized in recent years, cognitive behavioral therapy for insomnia (CBT-i) has shifted from a face-to-face approach to delivery via the internet (internet-based CBT-i, ICBT-i). Several studies have investigated the effects of ICBT-i on comorbid anxiety and depression; however, the results remain inconclusive. Thus, a meta-analysis was conducted to determine the effects of ICBT-i on anxiety and depression. Electronic databases, including PubMed, EMBASE, PsycINFO and the Cochrane Library (throughout May 28, 2015), were systematically searched for randomized controlled trials (RCTs) of ICBT-i. Data were extracted from the qualified studies and pooled together. The standardized mean difference (SMD) and 95% confidence interval (95% CI) were calculated to assess the effects of ICBT-i on comorbid anxiety and depression. Nine records that included ten studies were ultimately qualified. The effect sizes (ESs) were -0.35 [-0.46, -0.25] for anxiety and -0.36 [-0.47, -0.26] for depression, which were stable using a between-group or within-group comparison and suggest positive effects of ICBT-i on both comorbid disorders. Although positive results were identified in this meta-analysis, additional high-quality studies with larger sample sizes are needed in the future.

Cognitive Behavioral Therapy for Chronic Insomnia: A Systematic Review and Meta-analysis

BACKGROUND

Because psychological approaches are likely to produce sustained benefits without the risk for tolerance or adverse effects associated with pharmacologic approaches, cognitive behavioral therapy for insomnia (CBT-i) is now commonly recommended as first-line treatment for chronic insomnia.

PURPOSE

To determine the efficacy of CBT-i on diary measures of overnight sleep in adults with chronic insomnia.

DATA SOURCES

Searches of MEDLINE, EMBASE, PsycINFO, CINAHL, the Cochrane Library, and PubMed Clinical Queries from inception to 31 March 2015, supplemented with manual screening.

STUDY SELECTION

Randomized, controlled trials assessing the efficacy of face-to-face, multimodal CBT-i compared with inactive comparators on overnight sleep in adults with chronic insomnia. Studies of insomnia comorbid with medical, sleep, or psychiatric disorders were excluded.

DATA EXTRACTION

Study characteristics, quality, and data were assessed independently by 2 reviewers. Main outcome measures were sleep onset latency (SOL), wake after sleep onset (WASO), total sleep time (TST), and sleep efficiency (SE%).

DATA SYNTHESIS

Among 292 citations and 91 full-text articles reviewed, 20 studies (1162 participants [64% female; mean age, 56 years]) were included. Approaches to CBT-i incorporated at least 3 of the following: cognitive therapy, stimulus control, sleep restriction, sleep hygiene, and relaxation. At the posttreatment time point, SOL improved by 19.03 (95% CI, 14.12 to 23.93) minutes, WASO improved by 26.00 (CI, 15.48 to 36.52) minutes, TST improved by 7.61 (CI, -0.51 to 15.74) minutes, and SE% improved by 9.91% (CI, 8.09% to 11.73%). Changes seemed to be sustained at later time points. No adverse outcomes were reported.

LIMITATION

Narrow inclusion criteria limited applicability to patients with comorbid insomnia and other sleep problems, and accuracy of estimates at later time points was less clear.

CONCLUSION

CBT-i is an effective treatment for adults with chronic insomnia, with clinically meaningful effect sizes.

PRIMARY FUNDING SOURCE

None. (PROSPERO registration number: CRD42012002863).