Sleep impairment and insomnia in sickle cell disease: a retrospective chart review of clinical and psychological indicators

Psychiatric comorbidities in adults with sickle cell disease: A narrative review

Although descriptions of quality of life and patient reports of mood in sickle cell disease (SCD) have become more common in the literature, less is known about psychiatric illness prevalence, presentation, and treatment, particularly for adults. We provide a narrative review of what is known about common and debilitating psychiatric conditions such as depression, anxiety, and cognitive impairment, specifically for adults with SCD. We discuss the limitations of the current evidence, make provisional recommendations, and identify opportunities for research and improved care.

The Prevalence of Obstructive Sleep Apnea and Associated Symptoms among Patients with Sickle Cell Disease: A Systematic Review and Meta-analysis

Previous studies have shown that patients with sickle cell disease (SCD) are at high risk for obstructive sleep apnea (OSA). In the current study, we aimed to systematically review the literature to address the prevalence of OSA and associated symptoms among patients with SCD. Electronic databases, including Web of Science, Scopus, PubMed, Google Scholar, and Embase were systematically searched to identify the relevant original articles on patients with SCD. Newcastle Ottawa scale was used for quality assessment. Data were pooled by using random effects models. Subgroup analyses were performed by age groups. Thirty-nine studies containing details of 299,358 patients with SCD were included. The pooled results showed that more than half of these patients had OSA with different severities. The prevalence rates of OSA among children with apnea hypopnea index (AHI) cutoffs of above 1, 1.5, and 5 were 51% (95% confidence interval (CI) 36-67%), 29% (95% CI 19-40%), and 18% (95% CI 14-23%), respectively. The prevalence of OSA among adults with AHI cutoff of 5 was 43% (95% CI 21-64%). The pooled rates of snoring, nocturnal enuresis, nocturnal desaturation, and daytime sleepiness were 55% (95% CI 42-69%), 37% (95% CI 33-41%), 49% (95% CI 26-72%), and 21% (95% CI 12-30%), respectively. Given the high prevalence of OSA in patients with SCD, probable greater burden of SCD complications, and irreversible consequences of OSA, screening for OSA symptoms and signs seems useful in these patients. By screening and identifying this heterogeneous disorder earlier, available treatment modalities can be individualized for each patient.

Depressive and Insomnia Symptoms Sequentially Mediate the Association Between Racism-Based Discrimination in Healthcare Settings and Clinical Pain Among Adults With Sickle Cell Disease

Racism-based discrimination in healthcare settings has been associated with clinical pain in adults living with sickle cell disease; however, no studies have examined depressive and insomnia symptoms as mechanisms that may drive this relationship. This secondary data analysis examined associations between depressive and insomnia symptoms, racism-based discrimination, and clinical pain. Seventy-one adults with sickle cell disease (70% female, Mage = 38.79) provided baseline reports of racism-based discrimination, depressive symptoms, insomnia symptoms, and pain (severity, interference, catastrophizing), and they completed daily diaries of pain severity and interference over 3 months. In a sequential mediation model, baseline depressive (1st) and insomnia symptoms (2nd) significantly mediated the association between racism-based discrimination and baseline pain interference, average daily diary pain severity, and average daily diary pain interference. Although the mediation model with baseline pain severity as the outcome was significant, the total and direct effects were not. Results indicate that discrimination in healthcare settings contributes to depression, which may act on pain through sleep disturbance. Findings support the need for systemic and structural changes to eliminate discrimination in healthcare settings and behavioral mood and sleep interventions to reduce the impact of discrimination on clinical pain. PERSPECTIVE: The relationship between discrimination in healthcare settings and pain in adults with sickle cell disease may be driven by depression and sleep disturbance, modifiable risk factors and potential treatment targets. Results suggest that systemic, structural, and institutional changes must be implemented to promote better patient care and health outcomes.

Sleep quality and pain in adolescents and young adults with sickle cell disease

STUDY OBJECTIVES

This study evaluated sleep quality in relation to pain and pain-related impairment in adolescents and young adults with sickle cell disease. The purpose was to examine whether increased age was associated with poorer sleep quality and pain and to examine the sleep quality-pain association in this age group.

METHODS

Eighty-nine adolescents and young adults with sickle cell disease between the ages of 13 and 25 completed ratings of sleep quality, overall pain, and 2 measures of pain-related impairment (pain impact and pain burden) as part of their clinical care. Retrospective chart reviews were completed to match ratings to demographic and medical characteristics. Correlations and multiple regression were used to examine associations between age, sleep quality, and pain variables, including an exploratory analysis of the sleep-pain association by age.

RESULTS

Increased age was associated with poorer sleep quality, worse overall pain, and higher pain burden. Poorer sleep quality was also associated with worse overall pain and pain burden. Using multiple regression, a small, but not statistically significant trend was observed for the interaction of increased age and strengthening of the sleep quality-pain burden association.

CONCLUSIONS

Sleep quality and pain are important challenges for adolescents and young adults with sickle cell disease that may persist or worsen with increased age. Early identification of these difficulties in pediatric populations as well as continued screening and intervention as adolescents transition into adult care is important. Additional longitudinal research is needed to better understand the progression of the sleep-pain relationship over time.

CITATION

Schlenz AM, Thomas SJ, Gloston G, Lebensburger J, Maxwell SL, Kanter J. Sleep quality and pain in adolescents and young adults with sickle cell disease. J Clin Sleep Med. 2022;18(12):2845-2853.

Efficacy of a Contextualized Measurement of Life Satisfaction: A Pilot Study on the Assessment of Progress in Eating Disorder Therapy

Eating disorders strongly affect psychological distress and its perception. However, most of the existing instruments for assessing life satisfaction rely on a point-estimation method that is biased due to the circumstantial conditions around the time of assessment. The main goal of this study was to apply a different kind of instrument-the Life Satisfaction Chart-that situates the current state of life satisfaction in the context of personal history and describes the life stages through a graph. The assessment was applied to a sample of 29 adolescent women (average age of 17.88) who were enrolled in a clinical program to treat their eating disorders. The results showed that their estimation of their current life satisfaction was almost identical to the estimation provided by a therapist for those who were in therapy phases 1, 2, and 3 (of four), while patients' point-estimation satisfaction showed statistically significant differences when compared with the situated estimations. In therapy phase 4, significant discrepancies were observed between the therapist's perception and the patients' perception, because the therapist focused only on eating disorder recovery, whilst the patients evaluated their lives under almost-normal conditions, taking into account further dimensions. The Life Satisfaction Chart is a new approach to life-satisfaction measurement that showed promising measurement and therapeutical properties.

Depression in adults with sickle cell disease: a systematic review of the methodological issues in assessing prevalence of depression

Background

Sickle cell disease (SCD) as other chronic medical conditions is commonly complicated by depression or other psychiatric symptoms. Results reported in studies present a large variation. Thus, synthetic data are needed to understand impact of depression in adults with SCD. The aim of this literature review is to analyse the methodology used in the studies assessing depression and discuss the different prevalence levels reported.

Methods

Studies involving adults with SCD from 1999 to 2018 were included when providing data on prevalence of depression. It was defined by a psychometric assessment, a structured interview, or a medical record review. PRISMA recommendations were followed.

Results

36 studies are included accordingly to our methodology. Prevalence variation is large, from 0% to more than 85%. We find that the type of assessment tool used plays a major role in this between studies variation. Also, methodological issues arise with respect to psychometric assessment. Moreover, differences emerge between continents, setting of recruitment or time of assessment.

Conclusion

All these issues are discussed to provide insight on depression in adults with sickle cell disease.

Trial Registration

PROSPERO Registration CRD42018100684.

A Preliminary Investigation of the Underlying Mechanism Associating Daily Sleep Continuity Disturbance and Prescription Opioid Use Among Individuals With Sickle Cell Disease

BACKGROUND

There are emerging data indicating that sleep disturbance may be linked with an increase in opioid use. The majority of sickle cell disease (SCD) patients experience sleep disturbances, which can elevate pain severity and pain catastrophizing, both of which are important predictors of opioid consumption.

PURPOSE

We conducted a preliminary investigation on the association between previous night sleep disturbance and short-acting opioid use, as well as the potential mediating roles of pain severity and pain catastrophizing. Because sex is associated with sleep disturbance, pain-related experiences, and opioid use, we also explored the potential moderating role of sex.

METHODS

Participants were 45 SCD patients who were prescribed opioids. For 3 months, sleep diaries were collected immediately upon participants' awakening. Daily pain severity, pain catastrophizing, and prescription opioid use measures were collected before bedtime.

RESULTS

Multilevel structural equation modeling revealed that wake time after sleep onset (WASO) during the previous night (Time 1) predicted greater short-acting opioid use during the next day (Time 2). Pain severity and pain catastrophizing measured during the next day (Time 2) also mediated the association between the two. Sex moderation analysis showed that the positive association between WASO and pain severity was largely driven by women.

CONCLUSION

These findings provide some preliminary evidence as to the mechanism linking sleep continuity disturbance and opioid requirement in SCD patients. Future studies should replicate and extend these findings with clearer temporal information and employing more refined measures of sleep continuity and prescription opioid use in a larger sample.

Evaluation of sleep quality and restless legs syndrome in adult patients with sickle cell anemia

PURPOSE

To determine the prevalence of poor sleep quality and RLS in adult patients with sickle cell anemia (SCA). The second aim was to identify the risk factors for RLS and impairment of sleep quality in SCA patients.

MATERIALS AND METHODS

Patients at least 18 years old, with hemoglobin electrophoresis confirmation of sickle cell disease, were included. Restless legs syndrome was diagnosed according to the International Restless Legs Syndrome Study Group criteria. The sleep quality of the patients was determined using the Pittsburgh Sleep Quality Index (PSQI) scale. The Epworth Sleepiness Scale (ESS) was used to assess excessive daytime sleepiness.

RESULTS

Of 72 patients enrolled in the study, the median total PSQI score was 5 (R 1-17). The total PSQI score was significantly associated with increased age and number of acute severe or extremely severe painful crises during the previous year (p < 0.001, r = 0.45; p = 0.013, r = 0.291 respectively). Of 72 patients, 13 (18%) had RLS and 11 (15%) had excessive daytime sleepiness. The presence of RLS was significantly associated with increased age (p = 0.004). The presence of RLS was not associated with fetal hemoglobin, hemoglobin, hematocrit, or ferritin levels (p > 0.05 for all).

CONCLUSION

The prevalence of RLS among this sample of adult patients with sickle cell anemia was much higher than that previously reported for the general Turkish population. The presence of RLS was an important cause of sleep disturbance in these adult patients with SCA.

Do chronic pain and comorbidities affect brain function in sickle cell patients? A systematic review of neuroimaging and treatment approaches

Sickle cell disease (SCD) is a medical condition in which chronic pain is common and negatively impacts psychosocial function and quality of life. Although the brain mechanisms underlying chronic pain are well studied in other painful conditions, the brain mechanisms underlying chronic pain and the associated psychosocial comorbidities are not well established in SCD. A growing literature demonstrates the effect of treatment of chronic pain, including pharmacological and nonpharmacological treatments, on brain function. The present systematic review aimed to (1) determine the effects of chronic pain and psychosocial comorbidities on brain function of patients with SCD; (2) summarize pharmacological and nonpharmacological approaches to treat these symptoms; and (3) identify areas for further investigation of potential beneficial effects of treatments on brain function. Titles were screened using predefined criteria, including SCD, and abstracts and full texts were reviewed by 2 independent reviewers. A total of 1167 SCD articles were identified, and 86 full articles were included covering 3 sections: chronic pain (4 studies), psychosocial comorbidities (11 studies), and pharmacological and nonpharmacological treatments (71 studies). Neuroimaging evidence demonstrates aberrant neural processing related to chronic pain and psychosocial comorbidities in SCD beyond ischemic stroke and cerebral hemorrhage. Although neuroimaging studies show an important role for psychological factors, pain management is nearly exclusively based on opioids. Behavior therapy seems useful to improve psychological symptoms as well as chronic pain and quality of life. Further investigation is required with larger cohorts, matched controls, and examination of treatment-related neural mechanisms.

Identifying Clinical and Research Priorities in Sickle Cell Lung Disease. An Official American Thoracic Society Workshop Report

Background: Pulmonary complications of sickle cell disease (SCD) are diverse and encompass acute and chronic disease. The understanding of the natural history of pulmonary complications of SCD is limited, no specific therapies exist, and these complications are a primary cause of morbidity and mortality.Methods: We gathered a multidisciplinary group of pediatric and adult hematologists, pulmonologists, and emergency medicine physicians with expertise in SCD-related lung disease along with an SCD patient advocate for an American Thoracic Society-sponsored workshop to review the literature and identify key unanswered clinical and research questions. Participants were divided into four subcommittees on the basis of expertise: 1) acute chest syndrome, 2) lower airways disease and pulmonary function, 3) sleep-disordered breathing and hypoxia, and 4) pulmonary vascular complications of SCD. Before the workshop, a comprehensive literature review of each subtopic was conducted. Clinically important questions were developed after literature review and were finalized by group discussion and consensus.Results: Current knowledge is based on small, predominantly observational studies, few multicenter longitudinal studies, and even fewer high-quality interventional trials specifically targeting the pulmonary complications of SCD. Each subcommittee identified the three or four most important unanswered questions in their topic area for researchers to direct the next steps of clinical investigation.Conclusions: Important and clinically relevant questions regarding sickle cell lung disease remain unanswered. High-quality, multicenter, longitudinal studies and randomized clinical trials designed and implemented by teams of multidisciplinary clinician-investigators are needed to improve the care of individuals with SCD.

Use of a depression and sleep impairment treatment guideline to improve quality of life for patients with sickle cell disease

BACKGROUND

Pain in sickle cell disease (SCD) is often joined by other affective disorders such as depression and/or sleep impairment that can impact pain levels and quality of life (QoL).

AIM

To develop a guideline to improve the process of assessment and treatment of depression and sleep impairment in patients admitted with SCD.

METHOD

An interdisciplinary team used the Stetler model to create the Guideline for the Evaluation and Treatment of Depression and Sleep Impairment in Sickle Cell Disease. Patients were assessed, offered treatments and reassessed during the project period.

RESULTS

Both depression and QoL scores showed significant improvement by the end of the project. Significant correlations were found between pain, depression and sleep; depression, pain, sleep and QoL; sleep, pain and depression; and QoL and depression.

CONCLUSIONS

Interdisciplinary teams are effective in creating a guideline to assess and treat depression and sleep impairment and their effects on pain and QoL in patients with SCD.

Development of an Algorithm to Identify Patients with Physician-Documented Insomnia

We developed an insomnia classification algorithm by interrogating an electronic medical records (EMR) database of 314,292 patients. The patients received care at Massachusetts General Hospital (MGH), Brigham and Women’s Hospital (BWH), or both, between 1992 and 2010. Our algorithm combined structured variables (such as International Classification of Diseases 9th Revision [ICD-9] codes, prescriptions, laboratory observations) and unstructured variables (such as text mentions of sleep and psychiatric disorders in clinical narrative notes). The highest classification performance of our algorithm was achieved when it included a combination of structured variables (billing codes for insomnia, common psychiatric conditions, and joint disorders) and unstructured variables (sleep disorders and psychiatric disorders). Our algorithm had superior performance in identifying insomnia patients compared to billing codes alone (area under the receiver operating characteristic curve [AUROC] = 0.83 vs. 0.55 with 95% confidence intervals [CI] of 0.76–0.90 and 0.51–0.58, respectively). When applied to the 314,292-patient population, our algorithm classified 36,810 of the patients with insomnia, of which less than 17% had a billing code for insomnia. In conclusion, an insomnia classification algorithm that incorporates clinical notes is superior to one based solely on billing codes. Compared to traditional methods, our study demonstrates that a classification algorithm that incorporates physician notes can more accurately, comprehensively, and quickly identify large cohorts of insomnia patients.

Acute Pain and Depressive Symptoms: Independent Predictors of Insomnia Symptoms among Adults with Sickle Cell Disease

No studies to date have systematically investigated insomnia symptoms among adults with sickle cell disease (SCD). The purpose of this study was to (1) describe the prevalence of insomnia symptoms and (2) identify biopsychosocial predictors in community-dwelling adults with SCD. Cross-sectional analysis of baseline data from 263 African American adults with SCD (aged 18 years or older). Measures included the Insomnia Severity Index (ISI), Center for Epidemiologic Studies in Depression scale, Urban Life Stress Scale, Brief Pain Inventory, and a chronic pain item. SCD genotype was extracted from the medical record. A slight majority (55%) of the sample reported clinically significant insomnia symptomatology (ISI ≥ 10), which suggests that insomnia symptoms are prevalent among community-dwelling African American adults with SCD. While insomnia symptoms were associated with a number of biopsychosocial characteristics, depressive symptoms and acute pain were the only independent predictors. Given the high number of participants reporting clinically significant insomnia symptoms, nurses should screen for insomnia symptoms and explore interventions to promote better sleep among adults with SCD, with an emphasis on recommending treatment for pain and depression. In addition, current pain and depression interventions in this population could add insomnia measures and assess the effect of the intervention on insomnia symptomatology as a secondary outcome.