The Quest for Mindful Sleep: A Critical Synthesis of the Impact of Mindfulness-Based Interventions for Insomnia

The association between trait mindfulness and sleep problems: A three-level meta-analysis

Trait mindfulness has shown potential in relieving the symptoms related to sleep problems, but the relationship between trait mindfulness and sleep problems varies across studies. To explore this association and obtain reliable estimates, a three-level meta-analysis was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) approach. A comprehensive literature search identified 86 studies involving 87 independent samples and 35,521 participants. A total of 441 effect sizes were analyzed. The study indicated a negative association between trait mindfulness and sleep problems. Furthermore, the meta-analysis revealed significant moderating effects of study design, mindfulness facets, and measurement for trait mindfulness on this relationship. This study suggests that trait mindfulness is closely related to the alleviation of sleep problems. Furthermore, trait mindfulness is vital important in strengthening prevention and intervention measures targeting individuals' sleep problems.

Insomnia in the Veteran Population: A Sleep Health and Wellness Intervention

The purpose of this evidence-based project (EBP) was to determine if an evidence-based sleep health and wellness intervention improved sleep in veterans self-reporting a history of insomnia. Insomnia can negatively affect an individual's physical and psychological well-being, as well as increase health-care costs and decrease the overall quality of life. The intervention utilized a combination of insomnia treatments, delivered to two American Legion veteran participant groups: an Alabama American Legion Retreat and individuals at an American Legion Post site. The holistic-focused modalities used in this intervention included Cognitive Behavioral Therapy for Insomnia (CBT-I) techniques, sleep hygiene principles, and Complementary and Alternative Medicine (CAM) methods. The measurement tool, the Insomnia Severity Index (ISI), indicated statistically significant changes in the severity of participants' self-reported insomnia. Based upon the research evidence and results of the pre- and post-test ISI, a more permanent, ongoing sleep health and wellness intervention is feasible and would have numerous beneficial effects for the veteran's management of insomnia symptoms. Future efforts include implementing sleep hygiene, CAM interventions, and holistic nursing-supported education interventions at other sites and venues within the Alabama American Legion, as well as maintaining long-term community partnerships with veteran groups such as the Alabama American Legion.

Feasibility, appropriateness, and acceptability of a mobile mindfulness meditation intervention to improve sleep quality among a racially/ethnically diverse population

OBJECTIVES

To evaluate the acceptability, appropriateness, and feasibility of using a mindfulness meditation mobile application to improve sleep quality among a diverse group of adults.

METHODS

This explanatory qualitative study used online focus group discussions (N = 4 groups with 17 individuals) to collect information about user experiences with a mindfulness meditation mobile application (Headspace) among participants enrolled in the MINDS study. A rapid analyses approach was used to descriptively compare motivators of app use, barriers and facilitators to app use, and perceived tailoring needs across participants.

RESULTS

Participants on average were 30 years old, 88% female, and identified as Black/African American (52.9%), White (29.4%), Asian (11.8%), and Hispanic (17.6%). All participants felt the app was acceptable and appreciated the ability to personalize their app experience. Individuals with ≥50% intervention adherence (daily use for 30 days) reported being motivated to use the app because it helped them to fall asleep faster, while the remainder of participants used the app to relax throughout the day and faced external barriers to app use (eg, lack of time) and difficulty with app navigation. Only those participants who used the app exclusively in the evenings reported falling asleep faster and staying asleep. Suggestions for tailoring the app differed by race and age. Only Black/African American participants preferred using an instructor based on their race and gender.

CONCLUSION

Using a mobile meditation app to enhance sleep quality is acceptable and feasible, but additional tailoring for Black/African American individuals may improve uptake in this population.

Heart rate variability during mindful breathing meditation

We discuss Heart Rate Variability (HRV) measured during mindful breathing meditation. We provide a pedagogical computation of two commonly used heart rate variability metrics, i.e. the root mean square of successive differences (RMSSD) and the standard deviation of RR intervals (SDRR), in terms of Fourier components. It is shown that the root mean square of successive differences preferentially weights higher frequency Fourier modes, making it unsuitable as a biosignal for mindful breathing meditation which encourages slow breathing. We propose a new metric called the autonomic balance index (ABI) which uses Respiratory Sinus Arrhythmia to quantify the fraction of heart rate variability contributed by the parasympathetic nervous system. We apply this metric to heart rate variability data collected during two different meditation techniques, and show that the autonomic balance index is significantly elevated during mindful breathing, making it a good signal for biofeedback during meditation sessions.

Attentional Bias for Sleep-Related Words as a Function of Severity of Insomnia Symptoms

Attentional bias to sleep-related information is thought to be a core feature for developing and/or maintaining insomnia. This study used a hallmark measure of attentional bias, the dot-probe task, to determine whether this bias toward sleep-related stimuli was a function of the severity of insomnia symptoms. A sample of 231 volunteers (175 females; mean age of 26.91 ± 8.05 years) participated in this online study, filling out the Insomnia Severity Index (ISI) and performing a visual dot-probe task. After categorizing individuals based on the ISI score into normal, subclinical, and moderate/severe sleep groups, we only found a marginally significant interaction between sleep groups and the type of stimuli on RTs, suggesting that subclinical and moderate/severe sleep groups reported slower RTs for sleep-related words than for neutral words. When we calculated the attentional bias score (ABS), we found that ABS significantly differed from zero in the moderate/severe sleep group only, suggesting a disengagement for sleep-related information as a function of the severity of insomnia symptoms. This finding seems to suggest that insomnia is related to greater difficulties in shifting away from sleep-related stimuli.

Internet delivered, non-inferiority, two-arm, assessor-blinded intervention comparing mindfulness-based stress reduction and cognitive-behavioral treatment for insomnia: a protocol study for a randomized controlled trial for nursing staff with insomnia

BACKGROUND

Insomnia and poor sleep quality are highly prevalent conditions related to coronavirus disease 2019 (COVID-19) complications among clinical nurses. Although cognitive behavioral therapy for insomnia (CBT-I) is a first-line treatment, CBT-I suffers from several major drawbacks. This study investigates whether the application of the internet-delivered mindfulness-based stress reduction (iMBSR) intervention will produce effects that are non-inferior to the internet-delivered CBT-I (iCBT-I) intervention in reducing the severity of insomnia in clinical nurses with insomnia at the end of the study.

METHODS

This study protocol presents an internet-delivered, parallel-groups, assessor-blinded, two-arm, non-inferiority randomized controlled trial. The primary outcome is sleep quality, assessed by the Insomnia Severity Index. Secondary outcomes include depression, dysfunctional beliefs, five facets of mindfulness, and client satisfaction.

CONCLUSION

It is expected that this study may address several gaps in the literature. The non-inferiority study design is a novel approach to evaluating whether a standardized, complementary treatment (i.e., MBSR) is as practical as a gold standard treatment rather than its potential benefits. This approach may lead to expanded evidence-based practice and improve patient access to effective treatments.

TRIAL REGISTRATION

Trial registration number: ISRCTN36198096 . Registered on 24th May 2022.

Systematic Review of Clinical Practice Guidelines for Insomnia Disorder

OBJECTIVE

This systematic review assessed the quality of clinical practice guidelines (CPGs) on the treatment of insomnia disorder and their reporting of recommendations, while summarizing the evidence and providing guidance on an algorithmic approach to appropriate pharmacological treatment.

METHODS

The PubMed and EMBASE databases, guideline repositories, and specialist association websites were searched. The quality of the CPGs was assessed using the Appraisal of Guidelines for Research and Evaluation II (AGREE II) instrument, complemented by the AGREE-REX (Appraisal of Guidelines REsearch and Evaluation-Recommendations EXcellence). A multidisciplinary team identified the key clinical questions that a clinician would consider when taking an algorithmic approach to the use of medication for patients with insomnia disorder. By using a meta-synthesis approach, recommendations from the CPGs were characterized and summarized via a recommendation matrix.

RESULTS

A total of 10 records that met the inclusion criteria were included and appraised. Four CPGs were rated as high and 3 CPGs were rated as moderate in overall quality. Most of the CPGs recommended pharmacotherapy only if cognitive behavioral therapy for insomnia or other nonpharmacological interventions were unavailable, unsuccessful, or declined by patients. Recommendations on types of medicines and dose and duration of treatment varied and were nonspecific. Few of the CPGs provided recommendations on pharmacotherapy in special populations.

CONCLUSIONS

Indications for starting medications are the only common thread in all of the reviewed CPGs. The CPGs diverged in the choice of first-line pharmacotherapy, and most of the CPGs did not provide recommendations on all subsequent clinical considerations.

Relationship satisfaction and sleep problems among college students: Serial indirect effects via relationship mindfulness and negative emotional symptoms

ObjectiveThis study examined relationship mindfulness and negative emotional symptoms as serial mediators between relationship satisfaction and sleep problems. Participants: Participants were 242 college students currently in a romantic relationship recruited from a large southeastern university. Methods: Participants completed self-report measures of relationship satisfaction, relationship mindfulness, negative emotional symptoms and sleep disturbances. Serial mediation analyses were conducted, covarying age and attachment orientations. Results: Students who reported higher relationship satisfaction experienced lower sleep problems. Helping explain this association a significant serial mediation model was supported by which relationship mindfulness and subsequent negative emotional symptoms mediated relationship satisfaction and sleep problems. Conclusions: The degree to which a person is more mindful during interactions with a romantic partner appears to play a key role in how relationship satisfaction and negative emotional symptoms are linked to sleep problems.

Insomnia, Time Perspective, and Personality Traits: A Cross-Sectional Study in a Non-Clinical Population

Insomnia disorder is considered a public health problem and additional studies should investigate predisposing and perpetuating factors. This study examined the relationship between Big Five personality traits, time perspective, and insomnia. In a cross-sectional study, 400 participants (227 women; age range 18-74 years) were administered the Big Five Inventory-10 items, the Zimbardo Time Perspective Inventory, and the Insomnia Severity Index (ISI). A measure of chronotype was also included for control purposes. The results show that insomniacs reported lower scores for conscientiousness and extraversion, and for past-positive (PP) and future (F) perspectives, whereas they obtained higher scores for past-negative (PN) perspectives and deviation from a balanced time perspective. The correlations confirmed these findings, but negative correlations between present-hedonistic (PH) perspective and ISI score, and between emotional stability and ISI score, were also found. The mediation analyses showed that F played an indirect role in the relationship between consciousness and ISI score, PN had an indirect effect on the relationship between emotional stability and ISI or between extraversion and insomnia, and PH had an indirect effect on the relationship between extraversion and ISI score. The current outcomes shed light on the mechanisms which serve to mediate the relationship between insomnia and personality traits.

Effectiveness of a 4-Day Mindfulness-Based Intervention in a 2-Month Follow-Up for Chinese Incarcerated People

Mindfulness-based interventions, an evidence-based stress reduction approach, may help incarcerated people cope with stress-related problems in the challenging environment of prison. However, due to their unique living environment, the duration and instructor guidance required by standard mindfulness-based interventions would be infeasible in most prisons. Therefore, the aims of the current study were to test the effects of two different 4-day interventions (i.e., instructor-guided and audio-based) with content similar to Mindfulness-Based Cognitive Therapy for newly incarcerated males, and to compare the effectiveness of the two interventions relative to a no-intervention control group. Using daily assessments, we explored changes in perceived stress, insomnia, and negative affect in the 56 days following the instructor-guided (N = 25), audio-based (N = 21), and control (N = 44) intervention; length of mindfulness practice during the follow-up was also compared between the two intervention groups. Hierarchical linear model results showed significantly greater linear decreases in perceived stress after both mindfulness interventions during the 56-day follow-up (γ₁₁ = -0.011, p < .001, 95% CI [-0.017, -0.004] for instructor-guided intervention; γ₁₂ = -0.013, p < .001, 95% CI [-0.018, -0.006] for audio-based intervention), as compared to the control group. Compared to the control group, the instructor-guided group reported a significantly greater decrease in insomnia (γ₁₁ = -0.007, p < .001, 95% CI [-0.014, -0.002]), but the audio-based group did not (γ₁₂ = -0.002, p = .160, 95% CI [-.007, .004]). Neither mindfulness-based intervention group reported a significantly greater decrease in negative affect compared to the control group (γ₁₁ = -0.002, p = .170, 95% CI [-0.005, 0.001] for instructor-guided intervention; γ₁₂ = -0.002, p = .150, 95% CI [-0.006, 0.002] for audio-based intervention). No significant difference between the two intervention groups was found in the change of outcomes (γ₁₁ = 0.002, -0.005 and 0.000, p = .350, .130 and .390, 95% CI [-0.008, 0.011], 95% CI [-0.014, 0.004] and 95% CI [-0.004, 0.006] subsequently for perceived stress, insomnia and negative affect). Daily mindfulness practice was significantly longer for the audio-based group on the first day of follow-up (γ₀₂ = -0.758, p < .05, 95% CI [-1.333, -0.129]), but it gradually decreased to the same amount as the instructor-guided group (t (32) = 0.051, p = .959). Short-term mindfulness interventions, either instructor-guided or audio-based, appear to be beneficial for Chinese prisoners in reducing stress. Live instruction may have potential benefit in reducing insomnia and sustaining daily practice.

Development of a novel intervention to improve sleep and pain in patients undergoing total knee replacement

Background

Up to 20% of patients experience long-term pain and dissatisfaction after total knee replacement, with a negative impact on their quality of life. New approaches are needed to reduce the proportion of people to go on to experience chronic post-surgical pain. Sleep and pain are bidirectionally linked with poor sleep linked to greater pain. Interventions to improve sleep among people undergoing knee replacement offer a promising avenue. Health beliefs and barriers to engagement were explored using behaviour change theory. This study followed stages 1–4 of the Medical Research Council’s guidance for complex intervention development to develop a novel intervention aimed at improving sleep in pre-operative knee replacement patients.

Methods

Pre-operative focus groups and post-operative telephone interviews were conducted with knee replacement patients. Before surgery, focus groups explored sleep experiences and views about existing sleep interventions (cognitive behavioural therapy for insomnia, exercise, relaxation, mindfulness, sleep hygiene) and barriers to engagement. After surgery, telephone interviews explored any changes in sleep and views about intervention appropriateness. Data were audio-recorded, transcribed, anonymised, and analysed using framework analysis.

Results

Overall, 23 patients took part, 17 patients attended pre-operative focus groups, seven took part in a post-operative telephone interview, and one took part in a focus group and interview. Key sleep issues identified were problems getting to sleep, frequent waking during the night, and problems getting back to sleep after night waking. The main reason for these issues was knee pain and discomfort and a busy mind. Participants felt that the sleep interventions were generally acceptable with no general preference for one intervention over the others. Views of delivery mode varied in relation to digital move and group or one-to-one approaches.

Conclusion

Existing sleep interventions were found to be acceptable to knee replacement patients. Key barriers to engagement related to participants’ health beliefs. Addressing beliefs about the relationship between sleep and pain and enhancing understanding of the bidirectional/cyclical relationship could benefit engagement and motivation. Individuals may also require support to break the fear and avoidance cycle of pain and coping. A future intervention should ensure that patients’ preferences for sleep interventions and delivery mode can be accommodated in a real-world context.

Insomnia as an Unmet Need in Chronic Hematologic Cancer Patients: A study design of a randomized controlled trial evaluating a consumer-based meditation app for treatment of sleep disturbance (Preprint)

Background

To address the need for long-term, accessible, nonpharmacologic interventions targeting sleep in patients with chronic hematological cancer, we propose the first randomized controlled trial to determine the effects of a consumer-based mobile meditation app, Calm, on sleep disturbance in this population.

Objective

This study aims to test the efficacy of daily meditation delivered via Calm compared with a health education podcast control group in improving the primary outcome of self-reported sleep disturbance, as well as secondary sleep outcomes, including sleep impairment and sleep efficiency; test the efficacy of daily meditation delivered via Calm compared with a health education podcast control group on inflammatory markers, fatigue, and emotional distress; and explore free-living use during a 12-week follow-up period and the sustained effects of Calm in patients with chronic hematological cancer.

Methods

In a double-blinded randomized controlled trial, we will recruit 276 patients with chronic hematological cancer to an 8-week app-based wellness intervention—the active, daily, app-based meditation intervention or the health education podcast app control group, followed by a 12-week follow-up period. Participants will be asked to use their assigned app for at least 10 minutes per day during the 8-week intervention period; complete web-based surveys assessing self-reported sleep disturbance, fatigue, and emotional distress at baseline, 8 weeks, and 20 weeks; complete sleep diaries and wear an actigraphy device during the 8-week intervention period and at 20 weeks; and complete blood draws to assess inflammatory markers (tumor necrosis factor-α, interleukin-6, interleukin-8, and C-reactive protein) at baseline, 8 weeks, and 20 weeks.

Results

This project was funded by the National Institutes of Health National Cancer Institute (R01CA262041). The projects began in April 2022, and study recruitment is scheduled to begin in October 2022, with a total project duration of 5 years. We anticipate that we will be able to achieve our enrollment goal of 276 patients with chronic hematological cancers within the allotted project time frame.

Conclusions

This research will contribute to broader public health efforts by providing researchers and clinicians with an evidence-based commercial product to improve sleep in the long term in an underserved and understudied cancer population with a high incidence of sleep disturbance.

Trial Registration

ClinicalTrials.gov NCT05294991; https://clinicaltrials.gov/ct2/show/NCT05294991

International Registered Report Identifier (IRRID)

PRR1-10.2196/39007

The relationship between sleep hygiene, mood, and insomnia symptoms in men with prostate cancer

PURPOSE

Insomnia symptoms are commonly experienced by men after prostate cancer (PCa) treatment. Here we explored how sleep hygiene behaviours and psychological symptoms are associated with insomnia symptoms in PCa patients.

METHODS

An online survey was posted on social media and sent to mailing lists of PCa and general cancer organisations. The survey collected information on demographic, sleep hygiene, and psychological symptoms using validated questionnaires.

RESULTS

Data from 142 participants were compared based on the absence (age = 68.3 ± 8.9 years) and presence (age = 66.6 ± 9.0 years) of insomnia symptoms. Participants with insomnia symptoms had significantly higher levels of anxiety, depression, fatigue, and sleepiness as well as poorer sleep hygiene than those without insomnia symptoms. Control variables (age, number of comorbidities, and BMI) accounted for 11.9% of the variance in insomnia symptoms. Including treatment history contributed to an additional 1.6% of the variance in insomnia symptoms. Adding sleepiness, fatigue, anxiety, and depressive symptoms to the model explained an additional 44.6% of the variance in insomnia symptoms. Furthermore, including the sleep hygiene item 'I think, plan, or worry when I am in bed' and 'I sleep in an uncomfortable bedroom' explained an additional 3.6% of the variance in insomnia symptoms.

CONCLUSIONS

Poor sleep hygiene, fatigue, sleepiness, anxiety, and depressive symptoms were all associated with worse insomnia symptoms in PCa patients. Improving sleep hygiene and treating psychological conditions may potentially help prevent and/or alleviate insomnia symptoms in PCa patients.

Pregnant women’s use of a consumer-based meditation mobile app: A descriptive study

Objective

The objectives of this study were to explore the satisfaction of pregnant or recently pregnant women with the existing Calm app content (i.e. non-pregnancy) and preferences and recommendations for the types of pregnancy-specific content that would be helpful to pregnant women.

Methods

This study was a national cross-sectional survey of subscribers to a meditation mobile app (i.e. Calm). Eligible participants were currently pregnant or recently pregnant (within the past 12 months) and used Calm during their pregnancy. Participants were asked about their Calm usage and perceived benefits of Calm during pregnancy, and interest in pregnancy-specific content. Descriptive statistics were used to characterize the sample.

Results

Participants (N  =  111) were on average 34 years old (SD  =  5.4) and half of the sample was currently pregnant (N  =  55). The most common reasons for using the Calm app during pregnancy was for sleep problems (29%; n  =  31) or anxiety (27%; n  =  29). Women reported Calm was most helpful for improving sleep (32%; n  =  32), anxiety (25%; n  =  25), and stress (21%; n  =  21). Nearly all women wanted pregnancy-specific meditation content within the app (98%; n  =  98) and expressed interest in topics including pregnancy-related anxiety (68%; n  =  67), postpartum (50%; n  =  49), pregnancy-related sleep problems (41%; n  =  40), and labor and delivery (38%; n  =  37).

Conclusion

Women who used the Calm app during pregnancy found it helpful for improving sleep, anxiety, and stress but desire pregnancy-specific content. Future meditation mobile app studies should utilize pregnancy-specific content and test the feasibility and efficacy of sleep and mental health in pregnant women.

A mindfulness meditation mobile app improves depression and anxiety in adults with sleep disturbance: Analysis from a randomized controlled trial

OBJECTIVE

The objective of this study was to 1) determine the effects of a meditation app on depression and anxiety in adults with sleep disturbance, and 2) explore the potential mediating effects of fatigue, daytime sleepiness, and pre-sleep arousal on the relationship between use of the meditation app and changes in depression and anxiety.

METHODS

Participants were 239 adults with elevated insomnia symptoms (i.e., scores ≥ 10 on the Insomnia Severity Index) and limited or no previous experience with meditation. Depression, anxiety, fatigue, daytime sleepiness, and pre-sleep arousal were assessed at baseline, four weeks, and eight weeks. Repeated-measures ANCOVAs assessed intervention effects on depression and anxiety. Mediation models were estimated using the PROCESS macro.

RESULTS

Participants in the meditation group had more improvement in depression and anxiety symptoms during the intervention period than did those in the control group. Changes in somatic and cognitive pre-sleep arousal at mid-intervention fully mediated effects on depression and partially mediated effects on anxiety. There were no significant indirect effects of fatigue and daytime-sleepiness on changes in mental health.

CONCLUSIONS

A meditation app may improve depression and anxiety in adults with sleep disturbance, with effects being driven by improvements in pre-sleep arousal. Future studies should consider targeting pre-sleep arousal to improve mental health in this population.

A Randomized Controlled Trial to Examine the Feasibility and Preliminary Efficacy of a Digital Mindfulness-Based Therapy for Improving Insomnia Symptoms

Objectives

Insomnia has widespread negative implications for health and well-being. Online delivery of mindfulness-based therapy for insomnia (MBTI) has not previously been evaluated. This study investigated the feasibility and preliminary efficacy of a digital MBTI program for improving insomnia symptoms. It was hypothesized that a 6-week digital MBTI program would reduce insomnia symptoms and pre-sleep arousal and improve mood, compared to a waitlist control condition.

Methods

Twenty-seven participants (M = 29.44, SD = 11.97 years) experiencing insomnia symptoms (insomnia severity index [ISI] ≥ 8) were randomized to either a 6-week intervention or waitlist condition. Participants completed the ISI, pre-sleep arousal scale (PSAS), and the positive and negative affect schedule at baseline, mid-, and post-study. Feasibility was assessed across four domains (acceptability, implementation, practicality, and preliminary efficacy) using self-reports, attrition, program completions, and module completions.

Results

Feasibility data for the intervention indicated that there was 22% attrition, and 79% of the modules were completed. There were significantly greater reductions in the severity of insomnia symptoms (p < .001) and both cognitive (p = .03) and somatic (p = .02) subscales of the PSAS, at post-intervention compared to the waitlist group. There were no significant group differences in mood.

Conclusions

This study provides preliminary evidence of the feasibility and efficacy of a digital MBTI, which may assist in the broader dissemination of insomnia treatment.Trial RegistrationAustralian and New Zealand Clinical Trials Registry: ACTRN12620000398909.

Effects of Mindfulness-Based Relapse Prevention on the Chronic use of Hypnotics in Treatment-Seeking Women with Insomnia: a Randomized Controlled Trial

BACKGROUND

Hypnotics are one of the most frequently prescribed drugs worldwide, especially for women, and their chronic use may lead to tolerance, dosage escalation, dependence, withdrawal syndrome, and cognitive impairments, representing a significant public health problem. Consistent evidence from previous studies shows benefits of mindfulness-based interventions (MBIs) for substance use disorders (SUD) and insomnia. However, to date, there is a lack of research about effects of MBIs on reduction/cessation of chronic hypnotic use among women with insomnia.

METHOD

The present randomized trial evaluated the efficacy of the 8-week group-delivered mindfulness-based relapse prevention (MBRP) program in an intervention group (IG, n = 34) compared with weekly phone monitoring only in the control group (CG, n = 36) in reducing hypnotic use and insomnia severity over a 6-month follow-up period.

RESULTS

There were significant differences between groups at baseline regarding hypnotic use but not insomnia. Group effects on hypnotic use were found immediately after the intervention (bT1 = 2.01, p < 0.001) and at the 2-month follow-up (bT2 = 2.21, p < 0.001), favoring the IG. The IG also had a greater reduction from baseline levels than the control group in insomnia severity at the 4-month (bT3 = 0.21, p = 0.045) and 6-month (bT4 = 0.32, p = 0.002) follow-ups.

CONCLUSIONS

The findings provide preliminary evidence of benefits of MBRP for reducing insomnia severity and potentially chronic hypnotic use. However, IG effects on chronic hypnotic use may have resulted from IG and control group differences in chronic hypnotic use at baseline.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02127411.

Acceptance and Commitment Therapy (ACT) Improves Sleep Quality, Experiential Avoidance, and Emotion Regulation in Individuals with Insomnia-Results from a Randomized Interventional Study

Insomnia is a common problem in the general population. To treat insomnia, medication therapies and insomnia-related cognitive-behavioral interventions are often applied. The aim of the present study was to investigate the influence of acceptance and commitment therapy (ACT) on sleep quality, dysfunctional sleep beliefs and attitudes, experiential avoidance, and acceptance of sleep problems in individuals with insomnia, compared to a control condition. A total of 35 participants with diagnosed insomnia (mean age: 41.46 years old; 62.9% females) were randomly assigned to the ACT intervention (weekly group therapy for 60-70 min) or to the active control condition (weekly group meetings for 60-70 min without interventional and psychotherapeutic character). At baseline and after eight weeks (end of the study), and again 12 weeks later at follow-up, participants completed self-rating questionnaires on sleep quality, dysfunctional beliefs and attitudes about sleep, emotion regulation, and experiential avoidance. Furthermore, participants in the intervention condition kept a weekly sleep log for eight consecutive weeks (micro-analysis). Every morning, participants completed the daily sleep log, which consisted of items regarding subjective sleep duration, sleep quality, and the feeling of being restored. Sleep quality, dysfunctional beliefs and attitudes towards sleep, emotion regulation, and experiential avoidance improved over time, but only in the ACT condition compared to the control condition. Improvements remained stable until follow-up. Improvements in experiential avoidance were related to a favorable change in sleep and cognitive-emotional processing. Micro-analyses showed that improvements occurred within the first three weeks of treatment. The pattern of results suggests that ACT appeared to have improved experiential avoidance, which in turn improved both sleep quality and sleep-related cognitive-emotional processes at longer-term in adults with insomnia.

Testing a mindfulness meditation mobile app for the treatment of sleep-related symptoms in adults with sleep disturbance: A randomized controlled trial

The objective of this randomized controlled trial was to test whether a commercially available, mindfulness meditation mobile app, (i.e., Calm app), was effective in reducing fatigue (primary outcome), pre-sleep arousal, and daytime sleepiness (secondary outcomes) in adults with sleep disturbance (Insomnia Severity Index Score >10) as compared to a wait-list control group. Associations between the use of the Calm app (i.e., adherence to the intervention) and changes in sleep quality was also explored in the intervention group only. Adults with sleep disturbance were recruited (N = 640). Eligible and consenting participants (N = 263) were randomly assigned to the intervention (n = 124) or a wait-list control (n = 139) group. Intervention participants were asked to meditate using the Calm app ≥10 minutes/day for eight weeks. Fatigue, daytime sleepiness, and pre-sleep arousal were assessed at baseline, mid- (4-weeks) and post-intervention (8-weeks) in both groups, whereas sleep quality was evaluated only in the intervention group. Findings from intent-to-treat analyses suggest the use of the Calm app for eight weeks significantly decreased daytime fatigue (p = .018) as well as daytime sleepiness (p = .003) and cognitive (p = .005) and somatic (p < .001) pre-sleep arousal as compared to the wait-list control group. Within the intervention group, use of the Calm app was associated with improvements in sleep quality (p < .001). This randomized controlled trial demonstrates that the Calm app can be used to treat fatigue, daytime sleepiness, and pre-sleep arousal in adults with sleep disturbance. Given that the Calm app is affordable and widely accessible, these data have implications for community level dissemination of a mobile app to improve sleep-related symptoms associated with sleep disturbance. Trial registration: ClinicalTrials.gov NCT04045275.

Prevalent Insomnia Concerns and Perceived Need for Sleep Intervention Among Direct-Care Workers in Long-Term Care

This study examined sleep concerns among direct-care workers in long-term care and their perceived need for a sleep intervention. Thirty-five participants reported their sleep concerns and willingness to participate in a sleep intervention with preferred delivery forms/content. Multiple sleep characteristics were assessed via ecological momentary assessment and actigraphy for 2 weeks. Eighty percent reported at least one sleep concern with insomnia-related concerns being most prevalent. Those with insomnia-related concerns tended to have long sleep onset latency, frequent awakenings, suboptimal (long) sleep duration, and long naps. Most participants (66%) expressed interest in participating in a sleep intervention either online or in group sessions; interest was higher in those with insomnia-related concerns. Mindfulness strategies were most preferred, followed by cognitive-behavioral therapy and sleep hygiene education. The high prevalence of insomnia-related concerns in direct-care workers needs to be addressed for the well-being of these workers and for the quality of geriatric care delivery.

Sleep health is associated with next-day mindful attention in healthcare workers

OBJECTIVES

Previous studies have focused on the role of mindfulness in improving sleep health. Sleep health may also increase daily mindfulness; however, this potential directionality is understudied, with a lack of research on healthcare workers who need high-quality sleep and mindful attention for patient care. This study examined whether sleep health predicts next-day mindful attention, and vice versa, in nurses.

DESIGN

Smartphone-based ecological momentary assessment.

SETTING

U.S. hospitals.

PARTICIPANTS

Sixty-one full-time nurses.

MEASUREMENTS

For 2 consecutive weeks, participants provided actigraphy-measured and self-reported daily sleep characteristics. We examined 8 sleep variables across 5 key dimensions: satisfaction (self-report of sleep sufficiency, quality, and insomnia symptoms), alertness (self-report of daytime sleepiness), timing (actigraphy bed- and wake- times), efficiency (actigraphy percentage of time spent asleep during time in bed), and duration (actigraphy sleep duration). Participants reported state mindfulness specific to attention and awareness. Covariates included previous night's sleep, sociodemographics, work shift, workday (vs. nonworkday), and weekend (vs. weekday).

RESULTS

Multilevel modeling revealed that, at the within-person level, after nights with greater sleep sufficiency, better sleep quality, lower efficiency, and longer sleep duration, daily mindful attention was greater than usual. Daily mindful attention was inversely associated with sleepiness, but not predictive of other sleep characteristics. At the between-person level, participants with greater sleep sufficiency, higher sleep quality, and fewer insomnia symptoms reported greater mindful attention overall.

CONCLUSION

Findings show that optimal sleep health is an antecedent of daily mindful attention in nurses. Improving sleep may provide important benefits to their well-being and to the quality of patient care.

Personality traits, stress appraisals and sleep in young elite athletes: A profile approach

The aim of this study was to identify young elite athletes' personality profiles using a person-centred approach and to investigate whether the profiles significantly differ in stress and sleep. 260 athletes from a variety of sports completed a questionnaire package to assess neuroticism and conscientiousness traits, stress appraisals (i.e. intensity and directional interpretation of stress, challenge and threat appraisals), and various indicators of sleep (i.e. sleep quality, social jet lag, Ford insomnia response to stress test (FIRST)). A latent profile analysis (LPA) approach was used to identify personality profiles based on the scores of neuroticism and conscientiousness. A multivariate analysis of variance was performed to examine if the athletes belonging to different personality profiles differ on stress appraisals and indicators of sleep. Three profiles emerged: Maladaptive profile (high levels of conscientiousness and neuroticism); Highly adaptive profile (moderate level of conscientiousness and low level of neuroticism); Adaptive profile (high level of conscientiousness and moderate level of neuroticism). Results showed that athletes from the adaptive profile reported significantly lower scores of stress intensity and threat appraisal than those from other profiles. Athletes from the maladaptive profile reported significantly higher levels of FIRST than those from other profiles as well as worse sleep quality and lower levels of challenge appraisal than the athletes from the highly adaptive profile. These results suggest that investigating personality profile may be useful in identifying athletes at higher risk of stress sensitivity and worsening sleep that are likely to benefit from preventive actions (e.g. cognitive behavioural therapy interventions).

Associations between device use before bed, mood disturbance, and insomnia symptoms in young adults

OBJECTIVES

Young adults (YAs) are vulnerable to insomnia and mood disturbance. YAs also engage in back-lit device use which has been implicated in the development and maintenance of insomnia. This study explored the association between device use, mood disturbance, and insomnia symptoms in YAs.

PARTICIPANTS

Two thousand three hundred and ninety students at a Canadian university, aged 18-35 years.

DESIGN

Cross-sectional online survey MEASUREMENTS: Participants self-reported duration and frequency of back-lit device use before sleep and during the night. The Insomnia Severity Index and the Hospital Anxiety and Depression Scale were used to measure symptoms. Univariate and multivariate logistic regressions explored associations between device use behaviors and insomnia symptoms. A hierarchical regression analysis identified the unique contribution of back-lit device use on insomnia severity adjusting for mood disturbance, age, and sex.

RESULTS

Using a back-lit device for 1-2 hours after lights out (adjusted odds ratio [AOR] = 1.50, p < 0.001), being awakened by a device (AOR = 1.34, p = 0.002), and believing that device use negatively impacts sleep (AOR = 2.27, p < 0.001) were associated with insomnia symptoms. Depression contributed to the greatest unique variance to insomnia (11.8%), followed by anxiety (7.2%). Duration of device use after lights out, being awakened by a device and a negative perception of device use on sleep accounted for an additional 3%.

CONCLUSIONS

Device use contributed to insomnia symptoms over and above mood disturbance, age, and biological sex in YAs. Additional research is needed to determine the direction of effect and inform prevention/intervention programs specific to device use and insomnia symptomology in this population.

Waking up to the problem of sleep: can mindfulness help? A review of theory and evidence for the effects of mindfulness for sleep

The high incidence of poor sleep and associated negative health consequences substantiates the need for effective behavioral sleep interventions. We offer an integrative model of sleep disturbance whereby key risk factors for compromised sleep quality and quantity are targeted through mindfulness practice-namely, experiential awareness, attentional control, and acceptance. Theoretical considerations and burgeoning evidence suggest that mindfulness-based interventions (MBIs) may be promising treatments for improving sleep outcomes. However, evidence is mixed due to heterogeneity in design and methods across studies. More rigorous RCTs are needed to determine the efficacy and underlying mechanisms of MBI's for sleep. MBIs that are affordable, accessible, and scalable are needed to improve sleep outcomes at the population level.

Efficacy of mindfulness-based intervention ('mindfulness-based joyful sleep') in young and middle-aged individuals with insomnia using a biomarker of inflammatory responses: a prospective protocol of a randomised controlled trial in China

INTRODUCTION

Insomnia is a prevalent and significant public health concern. Insomnia can lead to increased inflammatory markers associated with chronic diseases such as cardiovascular disease, diabetes and cancer. Studies suggest that mindfulness-based interventions (MBIs) are more easily delivered within the community than cognitive behavioural therapy for insomnia (CBT-I) which was recommended as the preferred non-pharmacological treatment by the American Academy of Sleep Medicine, are effective in insomnia treatment and can reduce inflammatory markers level in older individuals with insomnia. This study aims to compare the effectiveness of an MBI to CBT-I in young and middle-aged individuals with insomnia disorder and explore its effect on nuclear factor kappa B (NF-κB), a transcription factor that controls the expression of genes involved in inflammation.

METHODS AND ANALYSIS

This report describes a protocol for a randomised controlled trial. Seventy eligible participants will be assigned to mindfulness-based joyful sleep or CBT-I for 2-hour sessions weekly for 8 weeks. The primary outcome is sleep quality assessed by the Pittsburgh Sleep Quality Index, severity of insomnia symptoms assessed by the Insomnia Severity Index and sleep parameters recorded using sleep diary and polysomnography. Secondary outcomes include perceived stress, anxiety and depression. The exploratory outcome is serum level of NF-κB. Outcomes will be evaluated at baseline, the end of the ntervention period and at a 3 month follow-up. Data will be analysed using general linear models, specifically analysis of covariance and analysis of variance will be used.

ETHICS AND DISSEMINATION

Full ethical approval for this study has been obtained from the Ethics Committee of the Third Xiangya Hospital, Central South University, Changsha, China (2018-S236). If Mindfulness-Based Joyful Sleep is proven effective, its dissemination will help bridge the gap between the unmet need and the demand for insomnia interventions in China.

TRIAL REGISTRATION NUMBER

NCT03268629; Pre-results.

Maternal Sleep in Pregnancy and Postpartum Part II: Biomechanisms and Intervention Strategies

PURPOSE OF REVIEW

As described in Part I of this two-part review, maternal sleep has wide-ranging implications for maternal health and overall family functioning. In addition, poor sleep quality and insufficient sleep are highly prevalent and characterized by considerable racial disparities.

RECENT FINDINGS

Part II of this review discusses physiological mechanisms, including inflammation and appetite hormones, by which sleep impacts multiple facets of women's health during pregnancy and postpartum. These mechanisms are increasingly being delineated, but require further study and better integration with studies of behavioral and physical health outcomes. Further, there are multiple potential strategies for improving maternal sleep, providing the opportunity to tailor treatment approaches to individual needs. Ultimately, as a critical health behavior that is amenable to intervention, sleep provides a promising future direction for measurably impacting clinically relevant health parameters in women of childbearing age.

The use of mind-body medicine among US individuals with sleep problems: analysis of the 2017 National Health Interview Survey data

BACKGROUND

Being a major health risk and very prevalent in the population, sleep problems are an important health care issue.

METHODS

We used the 2017 National Health Interview Survey (NHIS) to study the prevalence of sleep problems and the use of mind body medicine (MBM) among individuals with sleep problems in a representative sample of the US population (N = 26,742). Using chi-squared tests and backward stepwise multiple logistic regression analyses, predictors of sleep problems and of MBM use in the past 12 months were identified.

RESULTS

The prevalence of sleep problems was 49.3%, with higher prevalence being associated with higher age, being female, being non-Hispanic White, and higher education. Among individuals with sleep problems, 29.8% used MBM vs. only 17.5% without. Being less than 30 years of age, female, non-Hispanic White, living in the Western US, having a higher education, and being diagnosed with heart disease predicted MBM use among individual's with sleep problems. Yoga (16.3%), spiritual meditation (13.6%), and mindfulness meditation (7.5%) were the most used MBM approaches.

CONCLUSION

The characteristics of individuals with sleep problems were largely in line with the literature, while notably Whites were more prone to sleep problems than other ethnicities. MBM treatments commonly used were yoga, spiritual meditation and mindfulness meditation; although evidence supports its use for sleep problems, tai chi was used rarely by the wider population. Further studies should explore reasons for ethnical differences in MBM use and why some effective MBM approaches are not commonly used.

Internet Mindfulness Meditation Intervention (IMMI) Improves Depression Symptoms in Older Adults

Background: Older adults have fewer physiological reserves and are more likely to be affected by stress. Mindfulness meditation has the potential to be an effective treatment for depression, but little research has been conducted on older adults. The primary objective of this study was to evaluate depression symptom changes in older adults (55–80 years old) taking an Internet Mindfulness Meditation Intervention (IMMI) compared to a waitlist control. The secondary aims were to collect data on pain, perceived stress, resilience, mindfulness, sleep quality, and spirituality. Methods: Fifty older adults were randomized to either the Internet Mindfulness Meditation Intervention, a six-week online intervention with daily home practice, or a waitlist control. Measures were collected at baseline, after the six-week intervention period, and again six weeks later after the waitlist participants completed IMMI. Adherence to home practice was objectively measured with iMINDr. Changes in outcomes for the IMMI and waitlist participants were compared. All participants who completed IMMI were then combined for a within-participant analysis. Results: Adherence to the intervention was low, likely due to a traumatic event in the local area of the participants. Compared to the waitlist participants, those in IMMI had improved depression symptoms (p < 0.00005), perceived stress (p = 0.0007), insomnia symptoms ((p = 0.0009), and pain severity (p = 0.05). In the within-participant analysis of all data before and after IMMI (i.e., those initially randomized to IMMI and waitlist participants who took it), we found improvements in depression symptoms (p = 0.0001), perceived stress (p = 0.0001), insomnia symptoms (p < 0.00005), pain interference (p = 0.003), and spirituality (p = 0.018). A seven-week follow-up after the original six-week IMMI program showed sustained improvements in the IMMI participants. Conclusions: IMMI improved depression and related symptoms compared to controls despite minimal support from study staff. IMMI offers a low-dose, low-cost, easily accessible mindfulness meditation intervention for older adults with depression symptoms.

Effective Insomnia Treatments: Investigation of Processes in Mindfulness and Cognitive Therapy

Understanding the underlying mechanisms of recovery from insomnia is an important goal for improving existing treatments. In a randomised controlled trial, 57 participants with insomnia disorder were given either cognitive therapy (CT) or mindfulness-based therapy (MBT) following 4 sessions of CBT. Each participant was assessed on process measures related to CT and MBT. MBT resulted in improvement on mindfulness process measures and the size of the improvement was significantly greater than achieved in the CT condition. Interestingly, CT and MBT both resulted in significant improvement on the cognitive process measures. Treatment outcome on the primary outcome measure (Insomnia Severity Index) was not predicted by type of treatment but was predicted by posttreatment scores on the cognitive process measures. The results suggest that changes in cognitive processes are especially important in treating insomnia, and that there are different therapeutic modalities through which this can be achieved.

The Role of Mindfulness in the Insomnia Severity of Female Chronic Hypnotic Users

PURPOSE

To investigate dispositional mindfulness, psychiatric symptoms, and their relationship with insomnia severity among female chronic hypnotic users.

METHODS

Observational, cross-sectional study, including 76 women with chronic hypnotic use. Participants completed several self-report questionnaires: sociodemographic characteristics, depressive symptoms (CES-D), anxiety levels (STAI-T), dispositional mindfulness (FFMQ), and insomnia severity (ISI). Exploratory linear regression models were used to identify factors related to insomnia severity.

RESULTS

Multiple linear regression models showed that, for the total sample (N = 76), age (B = - 0.14, p = 0.003), depressive symptoms (B = 0.16, p = 0.005), and the mindfulness facets "observe" (B = 0.21. p = 0.013) and "act with awareness-auto pilot" (B = - 0.48, p = 0.017) were correlated to insomnia severity.

CONCLUSION

Results confirm a relationship between mindfulness and insomnia among female chronic hypnotic users, specifically regarding the ability to observe and act with awareness. A higher score on the "observe" facet was positively correlated with insomnia. This may be because the skill of observing itself, isolated from other mindfulness precepts, does not provide sufficient strategies to cope with the observed discomfort. Increased "acting with awareness-autopilot" was negatively correlated with insomnia severity, arguably because it stimulates breaking automatic patterns of thoughts and behaviors that contribute to the perpetuation of the insomnia cycle.

The role of nonpharmacologic therapies in management of chronic pelvic pain: what to do when surgery fails

PURPOSE OF REVIEW

To provide an update on nonsurgical and nonpharmacologic strategies for the management of chronic pelvic pain (CPP).

RECENT FINDINGS

Effective treatment of patients with CPP requires a multifaceted approach, with thoughtful consideration of surgical, pharmacologic, and nonpharmacologic strategies. Evidence for physical therapy and trigger point injections for treatment of myofascial components of CPP is increasing. Neuromodulation techniques, such as percutaneous tibial nerve stimulation and transcutaneous electrical stimulation, have limited but favorable preliminary data in patients with CPP. Behavioral strategies, such as exercise, cognitive behavioral therapy, and mindfulness, have demonstrated significant improvements in pain, function and quality of life in patients with a variety of chronic pain conditions and are promising avenues for future research in CPP.

SUMMARY

Nonpharmacologic therapies are important adjuncts to surgical and pharmacologic treatment for CPP and should be considered integral to a comprehensive treatment approach.

Australasian Sleep Association position statement regarding the use of psychological/behavioral treatments in the management of insomnia in adults

Insomnia disorder is a high prevalence condition with a high disease burden, which, left untreated, can increase risk of poorer health outcomes. Due to Insomnia's tendency towards having a chronic course, long-term treatment approaches are required to reduce the impact of Insomnia over time. After reviewing the available literature, The Australasian Sleep Association (ASA) recommends Cognitive Behavior Therapy for Insomnia (CBT-I) as a first line treatment in the management of Insomnia. The ASA notes that in addition to CBT-I, there is emerging evidence for the use of Mindfulness Based Therapy for Insomnia when used in combination with behavioural techniques (MBT-I). CBT-I should be used whenever possible, and medications should be limited to the lowest necessary dose and shortest necessary duration. CBT-I, whilst the most effective long-term treatment, does not work for everybody across all circumstances, so there will be circumstances in which other treatments are required (e.g., pharmacotherapy). Improving access to CBT-I is an important issue which will involve raising awareness of the effectiveness of CBT-I, increasing the number of trained practitioners, and the development of effective low intensity treatments that can be offered in the first instance.

The role of sleep duration and sleep disordered breathing in gestational diabetes mellitus

Many women experience sleep problems during pregnancy. This includes difficulty initiating and maintaining sleep due to physiologic changes that occur as pregnancy progresses, as well as increased symptoms of sleep-disordered breathing (SDB). Growing evidence indicates that sleep deficiency alters glucose metabolism and increases risk of diabetes. Poor sleep may exacerbate the progressive increase in insulin resistance that normally occurs during pregnancy, thus contributing to the development of maternal hyperglycemia. Here, we critically review evidence that exposure to short sleep duration or SDB during pregnancy is associated with gestational diabetes mellitus (GDM). Several studies have found that the frequency of GDM is higher in women exposed to short sleep compared with longer sleep durations. Despite mixed evidence regarding whether symptoms of SDB (e.g., frequent snoring) are associated with GDM after adjusting for BMI or obesity, it has been shown that clinically-diagnosed SDB is prospectively associated with GDM. There are multiple mechanisms that may link sleep deprivation and SDB with insulin resistance, including increased levels of oxidative stress, inflammation, sympathetic activity, and cortisol. Despite emerging evidence that sleep deficiency and SDB are associated with increased risk of GDM, it has yet to be demonstrated that improving sleep in pregnant women (e.g., by extending sleep duration or treating SDB) protects against the development of hyperglycemia. If a causal relationship can be established, behavioral therapies for improving sleep can potentially be used to reduce the risk and burden of GDM.

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Many pregnant women experience reduced sleep or sleep-disordered breathing.

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Growing evidence suggests that short sleep is associated with gestational diabetes.

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Sleep-disordered breathing may increase risk of gestational diabetes.

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Poor sleep during pregnancy may promote mechanisms linked with insulin resistance.

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Future studies should test if improving sleep reduces risk of gestational diabetes.

Integrative Medicine for Insomnia

Difficulty initiating and/or maintaining sleep is a common issue. Patients experiencing insomnia symptoms frequently self-treat their symptoms with sleep medications. However, there remains concern regarding the short- and long-term health impacts of sleep medications. This article discusses the evidence supporting integrative approaches to insomnia treatment, including cognitive-behavioral therapy and mind-body therapies (mindfulness meditation, yoga, tai chi), as well as emerging data for use of other less well supported approaches (dietary supplements, acupuncture).