Meta-analytic review of the impact of cognitive-behavior therapy for insomnia on concomitant anxiety

Sleep Health and Anxiety Symptoms in Midlife Women: The Study of Women's Health Across the Nation (SWAN)

Purpose

To investigate the associations between anxiety symptoms in midlife women and sleep features later in life, the aim is to test the hypothesis that poor sleep, as measured by each of six individual dimensions (4 objective actigraphy measures, 2 self-reports) of sleep health, is associated with higher levels of anxiety symptoms in midlife women.

Participants and Methods

The participants in this longitudinal analysis included women from the SWAN Sleep I Study, a subcohort of the community-dwelling midlife women participating in the core Study of Women's Health Across the Nation (SWAN), which was initiated in 1996. Of the 370 participants enrolled in the Sleep Study, 270 were included in the analytic sample, and 100 who did not meet the inclusion criteria were excluded. Baseline measures of six dimensions of multidimensional sleep health (actigraphy measures: efficiency, duration, mid-sleep timing, regularity; self-report measures: alertness, satisfaction) were obtained between 2003 and 2005, corresponding to SWAN core annual/biennial assessments 5-8. Associations of each dimension with self-reported anxiety symptoms (Generalized Anxiety Disorder - 7-item scale; GAD-7), collected during visits 12 (2009-2011), 13 (2011-2013), and 15 (2015-2017), were examined using mixed models. The GAD-7 outcome was measured both continuously and as a categorical variable due to its skewed distribution.

Results

No statistically significant associations were found between any of the six baseline sleep health dimensions and the GAD-7 score after adjustment for covariates.

Conclusion

The reasons for the lack of support for our hypothesis, despite previous evidence supporting an association between sleep and anxiety, are unclear. There is considerable overlap between anxiety and sleep symptoms, which may complicate the interpretation of our the findings. Thus, the failure to identify associations is likely multifactorial, and more studies with shorter follow-up intervals are warranted to better understand these relationships.

An exploration into the relationship between insomnia and repetitive negative thinking among cancer survivors

OBJECTIVE

Insomnia and repetitive negative thinking (RNT) are both prevalent among cancer survivors, yet little work has investigated their interrelationship. To explore the hypothesis that RNT and insomnia are related, we conducted secondary analyses on data from a pilot clinical trial of cognitive behavioral therapy for insomnia (CBT-I) for cancer survivors.

METHODS

This study analyzed survey data from 40 cancer survivors with insomnia who participated in a pilot randomized trial of CBT-I. Correlations and linear regression models were used to determine associations between aspects of RNT and related constructs (fear of cancer recurrence [FCR], cancer-specific rumination, worry, and intolerance of uncertainty) and sleep (insomnia and sleep quality), while accounting for psychiatric symptoms such as anxiety and depression. Treatment-related change in RNT was examined using a series of linear mixed models.

RESULTS

Evidence for an association between RNT and insomnia among cancer survivors emerged. Higher levels of FCR and cancer-related rumination were correlated with more severe insomnia symptoms and worse sleep quality. Notably, FCR levels predicted insomnia, even after controlling for anxiety and depression. Results identified potential benefits and limitations of CBT-I in addressing RNT that should be examined more thoroughly in future research.

CONCLUSIONS

RNT is a potential target to consider in insomnia treatment for cancer survivors.

The effectiveness of stimulus control in cognitive behavioural therapy for insomnia in adults: A systematic review and network meta-analysis

Stimulus control is part of the widely used cognitive behavioural therapy for insomnia. However, there is a lack of knowledge about its mechanisms of action and effectiveness when used alone. This systematic review with network meta-analysis aimed to evaluate stimulus control efficacy when used alone compared with cognitive behavioural therapy for insomnia or its components. The review also documented stimulus control mechanisms of action proposed by the authors. A search was conducted in several bibliographic databases (MEDLINE, PsycINFO, Embase, CINAHL, Psychology Behavioural Sciences Collection, Web of Science, and Cochrane Library) and in two registers from 1972 to June 2022. Randomised studies with adult participants presenting a diagnosis of insomnia and including at least one stimulus control instruction in a treatment group were included. Risk of bias was assessed with the Quality Assessment of Controlled Intervention Studies. Twenty-three studies were included and three network meta-analyses were conducted. The quality of included studies was generally poor. Results indicate that stimulus control is an effective intervention to improve insomnia compared with control conditions. Not all stimulus control instructions seem essential, especially those known to recondition the bedroom for sleep. The review challenges the classical conditioning hypothesis. Results should be interpreted cautiously given the small number of studies included, bias risk, and inconsistencies in the network meta-analysis. Rigorous research is needed in evaluating stimulus control efficacy and mechanisms.

Sleep disorders in a naturalistic cohort of Dutch psychiatric outpatients: prevalence rates and associations with psychopathology symptom severity and well-being

Sleep problems are very common in individuals with a mental disorder. Given the abundant evidence indicating the negative impact of disturbed sleep on mental health outcome, insight into the prevalence of all types of sleep disorders in specific mental disorders and neurodevelopmental conditions is of practical importance. Therefore, we estimated the prevalence of six types of sleep disorders with the Holland Sleep Disorders Questionnaire in an overall mental health sample (n = 1082) and separately for different mental and neurodevelopmental conditions. Furthermore, associations between specific sleep disorders, psychopathology and well-being were studied. The impact of the total number of sleep disorders on these associations was examined. Overall, 46.2% of all participants scored above the cut-off for having a sleep disorder. Specifically, 26.8% scored on insomnia, 12.1% on sleep breathing disorders, 9.7% on hypersomnia, 13.7% on circadian rhythm sleep-wake disorders, 11.2% on parasomnia, and 17.9% on sleep-related movement disorders. Most sleep disorders were associated with greater severity of psychopathology and lower well-being. These associations got stronger with an increasing number of sleep disorders. Our study revealed higher suspected prevalence of most sleep disorders in a mental disorder sample compared to the general population. Moreover, the presence of sleep disorder(s) was strongly associated with symptom severity and reduced well-being. These findings extend the notion that early detection and treatment of sleep disorders in mental health populations is essential for psychiatric outcome.

Sex differences in response to cognitive behavioural therapy for insomnia: A chart review of 455 patients with chronic insomnia

BACKGROUND

Insomnia is more prevalent in females, however studies examining sex differences in response to insomnia treatment are scarce. This study assessed sex-specific differences in cognitive behavioural therapy for insomnia (CBT-I)-related changes in insomnia symptoms in a large clinical cohort.

METHODS

A chart review was conducted of a clinical cohort (females n = 305, males n = 150) referred to a sleep clinic. Participants had a registered psychologist confirm diagnosis of chronic insomnia according to DSM-IV/V criteria and a Level 1 or 2 sleep study. Daily sleep diaries and questionnaires including the Insomnia Severity Index (ISI), Flinders Fatigue Scale (FFS), the Daytime Feelings and Functioning Scale (DFFS), and the Depression, Anxiety and Stress Scale-21 items (DASS), were administered at baseline, post-treatment, and three-month follow-up. Linear mixed models determined interactions between sex and timepoint on symptoms.

RESULTS

Mean (SD) age was 51.7 yrs (15.7, range = 18-90 yrs), and mean BMI was 26.3 kg/m2 (4.9), neither of which differed by sex. At pre-treatment, females demonstrated higher objective total sleep time (min) [343.5 (97.6) vs 323.8 min (92.1), p = 0.044], ISI [19.7 (4.2) vs 18.6 (4.4), p = 0.033], and FFS scores [19.2 (6.0) vs 16.9 (7.2), p = 0.003]. Compared to males, females experienced a greater reduction in FFS and DFFS scores and DASS depressive symptoms (p for interaction: 0.017, 0.043, 0.016 respectively) from baseline to follow-up. The greater reduction in depressive symptoms did not persist after controlling for age, BMI, and sleep apnea severity. Subjective total sleep time similarly increased across treatment for both males [baseline: 335.7 (15.1), post: 357.9 (15.5)] and females [baseline: 318.3 (10.4), post: 354.4 (10.7)], p for interaction: 0.22.

CONCLUSION

Females and males experience similar, substantial benefits from CBT-I after accounting for comorbidities, suggesting the same treatment can resolve insomnia in both sexes.

Investigating a clinically informed sleep disturbance threshold for physical and mental health among Gulf War Illness veterans

Study Objectives

This study (1) assessed sleep quality and health in Gulf War veterans (GWV) meeting the Gulf War Illness (GWI) criteria and (2) compared health associations for both those meeting a "clinically disturbed sleep" threshold, and those below, as determined by the Pittsburgh Sleep Quality Index (PSQI) cutoff for military populations (≥10) on measures of physical, mental, and cognitive health.

Methods

Participant data consisted of questionnaires and assessments completed prior to group assignment in a clinical trial. The sample consisted of 147 GWV, where 81.0% were males, and the median age was 53.4 years.

Results

The mean (SD) PSQI global score was 12.34 (4.00) with 61% of the sample qualifying as clinically disturbed sleepers according to the cutoff (global PSQI ≥ 10). GWI veterans with PSQI scores ≥10 did not differ from others in age (p = 0.20), sex (p = 0.19), or years of education (p = 0.87), but showed worse GW-related symptomology on the Gulf War Kansas questionnaire (p < 0.01), and poorer mental health on the Veterans Rand-36 (p < 0.01).

Conclusions

Disturbed sleep was associated with measures of pain, fatigue, and cognitive health. Our results suggest that a previously determined clinical threshold for clinically disturbed sleep is useful when examining the health status of the study population. Given that GWI is associated with elevated PSQI scores and a high frequency of disturbed sleep, cutoffs determining sleep health should be sensitive to population exposures and health history to improve interpretability.

Impact of sleep disruption on BDD symptoms and treatment response

BACKGROUND

Body dysmorphic disorder (BDD) is severe, undertreated, and relatively common. Although gold-standard cognitive behavioral therapy (CBT) for BDD has strong empirical support, a significant number of patients do not respond. More work is needed to understand BDD's etiology and modifiable barriers to treatment response. Given its high prevalence and impact on the development, maintenance, and treatment of related, frequently comorbid disorders, sleep disruption is a compelling, but not-yet studied factor.

METHODS

Data were drawn from a randomized controlled trial of guided smartphone app-based CBT for BDD. Included participants were offered 12-weeks of treatment, immediately (n = 40) or after a 12-week waitlist (n = 37). Sleep disruption and BDD symptom severity were assessed at baseline, week-6, and week-12.

RESULTS

Hypotheses and analysis plan were pre-registered. Two-thirds of patients reported significant insomnia symptoms at baseline. Baseline severity of sleep disruption and BDD symptoms were not related (r = 0.02). Pre-treatment sleep disruption did not predict BDD symptom reduction across treatment, nor did early sleep improvements predict greater BDD symptom improvement. Early BDD symptom improvement also did not predict later improvements in sleep.

LIMITATIONS

Limitations include the small sample, restricted ranges of BDD symptom severity and treatment response, and few metrics of sleep disruption.

CONCLUSIONS

Although insomnia was disproportionately high in this sample and both BDD symptoms and sleep improved in treatment, results suggest sleep and BDD symptoms may function largely independent of one another. More work is encouraged to replicate and better understand findings as well as potential challenges and benefits of addressing sleep in BDD.

Effect of cognitive behavioural therapy and yoga for generalised anxiety disorder on sleep quality in a randomised controlled trial: the role of worry, mindfulness, and perceived stress as mediators

Sleep disturbances are present in ~65% of individuals with generalised anxiety disorder (GAD). Although both Kundalini yoga (KY) and cognitive behavioural therapy (CBT) are effective treatment options for GAD, little is known about how these treatments compare in improving sleep for GAD and what drives these changes. Accordingly, we examined the effects of CBT, KY, and stress education (SEdu; an attention control condition) on subjective sleep quality (as measured by the Pittsburgh Sleep Quality Index [PSQI] and Insomnia Severity Index [ISI]) in a randomised controlled trial of 226 adults with GAD (mean age 33.37 years; 70% female; 79% White). We hypothesised that both CBT and KY would outperform SEdu in improving sleep disturbances. Three potential mediators of sleep improvement (worry, mindfulness, perceived stress) were also examined. In line with hypotheses, PSQI and ISI scores significantly improved from pre- to post-treatment for all three treatment groups (all p < 0.001, all d > 0.97). However, contrary to predictions, sleep changes were not significantly greater for CBT or KY compared to SEdu. In mediation analyses, within-person deviations in worry, mindfulness, and stress each significantly mediated the effect of time on sleep outcomes. Degree of change in sleep attributable to worry (CBT > KY > SEdu) and perceived stress (CBT, KY > SEdu) was moderated by treatment group. Personalised medicine as well as combined treatment approaches should be studied to help reduce sleep difficulties for patients with GAD who do not respond.

Shift work is associated with extensively disordered sleep, especially when working nights

Background

Shift work is generally associated with working and sleeping out of phase with the endogenous, circadian sleep-wake cycle. This exerts detrimental effects on sleep health. The present study aimed at evaluating the presence of short and long sleep as well as sleep disorders within a broad range of shift work schedules and elucidating the role of sociodemographic factors therein.

Methods

A large dataset containing information on sleep was collected through advertisement in a Belgium newspaper (De Standaard). Adult, working individuals were selected (n = 37,662) and categorized based on their work schedule (regular day, early morning, evening, night, and rotating shift). In this cross-sectional study, prevalence rates of short sleep (≤6 h), long sleep (≥9 h) and sleep disorders (screened with Holland Sleep Disorders Questionnaire), and associations between these sleep variables and sociodemographics (age, sex, education, living companion(s)) were analyzed using binominal logistic regression analyses.

Results

In the total sample all sociodemographic factors affected prevalences of short, long and disordered sleep, consistent with previous studies. Compared to day workers, shift workers more frequently reported short sleep, most prominently night workers (26 vs. 50%) (p < 0.001). Furthermore, all sleep disorders as well as sleep disorder comorbidity were more common in shift workers, again most pronounced in night workers (all p < 0.05). In night shift workers the level of education had the strongest associations with disturbed sleep with a two-fold higher prevalence of short and disordered sleep in low relative to academic educated groups (all p < 0.02).

Conclusion

Shift work is related not only to curtailed sleep and shift work disorder, but also to a plethora of sleep disorders, including insomnia, sleep-related breathing disorders and sleep-related movement disorders. Our findings imply that education on coping strategies may be especially important for young and/or lower educated shift workers.

The European Insomnia Guideline: An update on the diagnosis and treatment of insomnia 2023

Progress in the field of insomnia since 2017 necessitated this update of the European Insomnia Guideline. Recommendations for the diagnostic procedure for insomnia and its comorbidities are: clinical interview (encompassing sleep and medical history); the use of sleep questionnaires and diaries (and physical examination and additional measures where indicated) (A). Actigraphy is not recommended for the routine evaluation of insomnia (C), but may be useful for differential-diagnostic purposes (A). Polysomnography should be used to evaluate other sleep disorders if suspected (i.e. periodic limb movement disorder, sleep-related breathing disorders, etc.), treatment-resistant insomnia (A) and for other indications (B). Cognitive-behavioural therapy for insomnia is recommended as the first-line treatment for chronic insomnia in adults of any age (including patients with comorbidities), either applied in-person or digitally (A). When cognitive-behavioural therapy for insomnia is not sufficiently effective, a pharmacological intervention can be offered (A). Benzodiazepines (A), benzodiazepine receptor agonists (A), daridorexant (A) and low-dose sedating antidepressants (B) can be used for the short-term treatment of insomnia (≤ 4 weeks). Longer-term treatment with these substances may be initiated in some cases, considering advantages and disadvantages (B). Orexin receptor antagonists can be used for periods of up to 3 months or longer in some cases (A). Prolonged-release melatonin can be used for up to 3 months in patients ≥ 55 years (B). Antihistaminergic drugs, antipsychotics, fast-release melatonin, ramelteon and phytotherapeutics are not recommended for insomnia treatment (A). Light therapy and exercise interventions may be useful as adjunct therapies to cognitive-behavioural therapy for insomnia (B).

Does treating insomnia with digital cognitive behavioural therapy (Sleepio) mediate improvements in anxiety for those with insomnia and comorbid anxiety? An analysis using individual participant data from two large randomised controlled trials

BACKGROUND

Considerable comorbidity exists between insomnia and anxiety, and evidence shows that the benefits of CBT for insomnia extend to anxiety. Using data from two large trials of digital CBT (dCBT) for insomnia, we evaluated whether improving sleep is an effective treatment target to reduce both insomnia and anxiety symptoms in individuals with insomnia and clinically significant anxiety.

METHODS

This was a controlled sub-analysis combining individual participant data from two previous randomised controlled trials of dCBT for insomnia (Sleepio). Participants (N = 2172) with insomnia disorder and clinically significant anxiety symptoms were included in this sub-analysis and received either dCBT or control (usual care or sleep hygiene education). Assessments were evaluated at baseline, post-intervention (week 8 or 10), and follow-up (week 22 or 24). Mediation was evaluated using structural equation models.

RESULTS

dCBT for insomnia was superior to control at reducing both insomnia (Hedges' g range = 0.77-0.81; both p < 0.001) and anxiety symptoms (Hedges' g range = 0.39-0.44; both p < 0.001) at all time points. Baseline insomnia symptoms moderated the effects of dCBT on insomnia, however no variables moderated treatment effects on anxiety. Reductions in anxiety symptoms at follow-up were mediated by improvements in sleep at post-intervention (% mediated = 84 %), suggesting a causal pathway.

LIMITATIONS

Participants did not have a formal anxiety disorder diagnosis and so the effects of dCBT for insomnia on anxiety may differ by anxiety disorder.

CONCLUSIONS

Addressing sleep using dCBT for insomnia may serve as a treatment target from which to improve anxiety in individuals with insomnia and clinically significant comorbid anxiety.

CLINICAL TRIAL REGISTRATIONS

Digital Insomnia therapy to Assist your Life as well as your Sleep (DIALS) - ISRCTN60530898 http://www.isrctn.com/ISRCTN60530898. Oxford Access for Students Improving Sleep (OASIS) - ISRCTN61272251 http://www.isrctn.com/ISRCTN61272251.

Postpartum Insomnia and Poor Sleep Quality Are Longitudinally Predictive of Postpartum Mood Symptoms

OBJECTIVE

Insomnia and poor sleep quality are frequently reported by perinatal women. Both are noted to increase the risk of postpartum depression, with less known about their association with postpartum anxiety. This study sought to assess whether perinatal sleep disturbances predicted depression and anxiety symptoms across each month of the first 6 months postpartum in women with a history of depression.

METHODS

Pregnant women without active depression at enrollment ( N = 159), 18 to 45 years of age, were recruited. In late pregnancy and for up to 6 months postpartum, women completed monthly online questionnaires including the Insomnia Symptom Questionnaire, Pittsburgh Sleep Quality Index, Edinburgh Postnatal Depression Scale, and Generalized Anxiety Disorder-7. Repeated-measures multilevel models were used to predict depression and anxiety across the postpartum.

RESULTS

The prevalence of insomnia was 20.4%, and the prevalence of poor sleep quality was 67.8% across the first 6 months postpartum. Postpartum insomnia and poor sleep quality at the between-subject and within-subject levels tended to uniquely predict greater depressive and anxiety symptoms, even after controlling for demographic characteristics, prenatal insomnia, and prenatal poor sleep quality.

CONCLUSIONS

Most of the women in our sample had sleep disturbances across the perinatal period. Consistent with the extant literature, postpartum insomnia and poor sleep quality, but not prenatal measures of sleep, longitudinally predicted greater postpartum depression and anxiety symptoms. The chronic sleep deprivation of insomnia and the subjective experience of poor sleep quality are uniquely relevant risks of postpartum mood disorders. Evaluation and mitigation of perinatal sleep disturbance are ideal opportunities to reduce postpartum mood disorders and subsequent health outcomes.

A Pilot Nurse-Administered CBT Intervention for Insomnia in Patients with Schizophrenic Disorder: A Randomized Clinical Effectiveness Trial

Insomnia is a highly prevalent disorder among the population with schizophrenia and has a significant impact on their quality of life. Cognitive behavioural therapies (CBT) have shown effectiveness in the treatment of insomnia in the general population. The aim of this this pilot study was to evaluate the effectiveness of a group intervention led by nurses in an outpatient mental health centre. The group work combined cognitive behavioural and psychoeducational therapeutic interventions to improve insomnia in patients with schizophrenic disorder and their health-related quality of life. This randomized clinical trial included intervention and control groups with follow-up assessments at 6 and 9 months, using the Insomnia Severity Index (ISI), Pittsburgh Sleep Quality Index (PSQI), and EuroQol-5D (EQ-5D) scales. The inclusion criteria were as follows: over 18 years of age, diagnosis of schizophrenia, and a score of >7 on the ISI scale. The total sample was 40 participants. The ISI scale showed a mean difference of 3.63 (CI 95%: 2.02-5.23) (p = 0.000) and 4.10 (CI 95%: 2.45-5.75) (p = 0.000) and a large effect size (F: 28.36; p = 0.000; ηp2: 0.427). Regarding the PSQI scale, the mean difference was 3.00 (CI 95%: 1.53-4.49) (p = 0.000) and 2.30 (CI 95%: 0.85-3.75) (p = 0.000), with a medium effect size (F: 18.31; p = 0.000 ηp2: 0.325). The EQ-VAS scale showed a difference in mean scores between the groups of 10.48 (CI 95%: -19.66--1.29) (p = 0.027). CBT adapted for populations with mental disorders, carried out by nurses, is effective in improving insomnia and health-related quality of life.

The Use of Evaluation Panels During the Development of a Digital Intervention for Veterans Based on Cognitive Behavioral Therapy for Insomnia: Qualitative Evaluation Study

BACKGROUND

Individuals enrolling in the Veterans Health Administration frequently report symptoms consistent with insomnia disorder. Cognitive behavioral therapy for insomnia (CBT-I) is a gold standard treatment for insomnia disorder. While the Veterans Health Administration has successfully implemented a large dissemination effort to train providers in CBT-I, the limited number of trained CBT-I providers continues to restrict the number of individuals who can receive CBT-I. Digital mental health intervention adaptations of CBT-I have been found to have similar efficacy as traditional CBT-I. To help address the unmet need for insomnia disorder treatment, the VA commissioned the creation of a freely available, internet-delivered digital mental health intervention adaptation of CBT-I known as Path to Better Sleep (PTBS).

OBJECTIVE

We aimed to describe the use of evaluation panels composed of veterans and spouses of veterans during the development of PTBS. Specifically, we report on the methods used to conduct the panels, the feedback they provided on elements of the course relevant to user engagement, and how their feedback influenced the design and content of PTBS.

METHODS

A communications firm was contracted to recruit 3 veteran (n=27) and 2 spouse of veteran (n=18) panels and convene them for three 1-hour meetings. Members of the VA team identified key questions for the panels, and the communications firm prepared facilitator guides to elicit feedback on these key questions. The guides provided a script for facilitators to follow while convening the panels. The panels were telephonically conducted, with visual content displayed via remote presentation software. The communications firm prepared reports summarizing the panelists' feedback during each panel meeting. The qualitative feedback described in these reports served as the raw material for this study.

RESULTS

The panel members provided markedly consistent feedback on several elements of PTBS, including recommendations to emphasize the efficacy of CBT-I techniques; clarify and simplify written content as much as possible; and ensure that content is consistent with the lived experiences of veterans. Their feedback was congruent with previous studies on the factors influencing user engagement with digital mental health interventions. Panelist feedback influenced multiple course design decisions, including reducing the effort required to use the course's sleep diary function, making written content more concise, and selecting veteran testimonial videos that emphasized the benefits of treating chronic insomnia symptoms.

CONCLUSIONS

The veteran and spouse evaluation panels provided useful feedback during the design of PTBS. This feedback was used to make concrete revisions and design decisions consistent with existing research on improving user engagement with digital mental health interventions. We believe that many of the key feedback messages provided by these evaluation panels could prove useful to other digital mental health intervention designers.

Exercise as an Adjunct Treatment to Cognitive Behavior Therapy for Insomnia

The question that guided this review is whether exercise can add to the improvements in insomnia in patients treated with cognitive behavioral therapy for insomnia (CBT-I). CBT-I has long been recommended as the first-line treatment of chronic insomnia. However, CBT-I is not effective for as many as 30% to 40% of patients with insomnia. There is accumulating evidence for positive effects on insomnia following acute and chronic exercise. However, to the best of our knowledge, the effects of CBT-I combined with exercise have not been explored in clinical trials. In this article, we develop a rationale for combining CBT-I with exercise.

A feasibility study to explore the use of digital treatment of sleep as a first-step intervention to improve adolescent mental health

INTRODUCTION

Cognitive behavior therapy for insomnia (CBTi), delivered face-to-face or digitally, can improve the mental health of adults. Although insomnia is common in adolescents, the effects of digital CBTi on adolescent mental health have seldom been investigated.

OBJECTIVES

The aims of this study were to explore: (i) the acceptability of a digital CBTi intervention, Sleepio, as a first-step intervention for adolescents referred to specialist mental health services (CAMHS), (ii) the impact on sleep and mental health and (iii) subsequent CAMHS interventions.

METHOD

Sleepio is a computerized CBTi intervention comprised of six sequentially delivered sessions. Digital Sleepio was offered to new referrals to CAMHS with poor sleep and mental health problems. Results. Of the 75 eligible adolescents, 70 (93%; 95% CI: 85% to 98%) accepted Sleepio with 59 starting the programme and consenting to participate in the study. Of these, 37 (63%; 95% CI: 49% to 75%) completed at least half of the programme. There were post-intervention improvements in sleep, mood, and anxiety; the improvement in sleep was greater for those who completed at least half the programme compared to those who did not. Of those who completed all the programme, 55% (15/29) did not need any subsequent specialist CAMHS input. Of the 11 adolescents who accepted but never started Sleepio, none engaged with other CAMHS interventions and were subsequently discharged.

CONCLUSION

Our study has a number of limitations, in particular the absence of a control group and the loss of follow-up data for programme drop-outs. Nonetheless, these results suggest that digital CBTi may offer a novel and acceptable way of improving the sleep and mental health of adolescents with insomnia. A fully powered randomized controlled trial is required to obtain definitive estimates of the effects of the intervention.

Utility of Wrist-Wearable Data for Assessing Pain, Sleep, and Anxiety Outcomes After Traumatic Stress Exposure

Importance

Adverse posttraumatic neuropsychiatric sequelae after traumatic stress exposure are common and have higher incidence among socioeconomically disadvantaged populations. Pain, depression, avoidance of trauma reminders, reexperiencing trauma, anxiety, hyperarousal, sleep disruption, and nightmares have been reported. Wrist-wearable devices with accelerometers capable of assessing 24-hour rest-activity characteristics are prevalent and may have utility in measuring these outcomes.

Objective

To evaluate whether wrist-wearable devices can provide useful biomarkers for recovery after traumatic stress exposure.

Design, Setting, and Participants

Data were analyzed from a diverse cohort of individuals seen in the emergency department after experiencing a traumatic stress exposure, as part of the Advancing Understanding of Recovery After Trauma (AURORA) study. Participants recruited from 27 emergency departments wore wrist-wearable devices for 8 weeks, beginning in the emergency department, and completed serial assessments of neuropsychiatric symptoms. A total of 19 019 patients were screened. Of these, 3040 patients met study criteria, provided informed consent, and completed baseline assessments. A total of 2021 provided data from wrist-wearable devices, completed the 8-week assessment, and were included in this analysis. The data were randomly divided into 2 equal parts (n = 1010) for biomarker identification and validation. Data were collected from September 2017 to January 2020, and data were analyzed from May 2020 to November 2022.

Exposures

Participants were recruited for the study after experiencing a traumatic stress exposure (most commonly motor vehicle collision).

Main Outcomes and Measures

Rest-activity characteristics were derived and validated from wrist-wearable devices associated with specific self-reported symptom domains at a point in time and changes in symptom severity over time.

Results

Of 2021 included patients, 1257 (62.2%) were female, and the mean (SD) age was 35.8 (13.0) years. Eight wrist-wearable device biomarkers for symptoms of adverse posttraumatic neuropsychiatric sequelae exceeded significance thresholds in the derivation cohort. One of these, reduced 24-hour activity variance, was associated with greater pain severity (r = -0.14; 95% CI, -0.20 to -0.07). Changes in 6 rest-activity measures were associated with changes in pain over time, and changes in the number of transitions between sleep and wake over time were associated with changes in pain, sleep, and anxiety. Simple cutoffs for these biomarkers identified individuals with good recovery for pain (positive predictive value [PPV], 0.85; 95% CI, 0.82-0.88), sleep (PPV, 0.63; 95% CI, 0.59-0.67, and anxiety (PPV, 0.76; 95% CI, 0.72-0.80) with high predictive value.

Conclusions and Relevance

These findings suggest that wrist-wearable device biomarkers may have utility as screening tools for pain, sleep, and anxiety symptom outcomes after trauma exposure in high-risk populations.

Do better nights lead to better days? Guided internet-based cognitive behavioral therapy for insomnia in people suffering from a range of mental health problems: Protocol of a pragmatic randomized clinical trial

BACKGROUND

Insomnia is the transdiagnostically shared most common complaint in disorders of anxiety, stress and emotion regulation. Current cognitive behavioral therapies (CBT) for these disorders do not address sleep, while good sleep is essential for regulating emotions and learning new cognitions and behaviours: the core fundaments of CBT. This transdiagnostic randomized control trial (RCT) evaluates whether guided internet-delivered cognitive behavioral therapy for insomnia (iCBT-I) (1) improves sleep, (2) affects the progression of emotional distress and (3) enhances the effectiveness of regular treatment of people with clinically relevant symptoms of emotional disorders across all mental health care (MHC) echelons.

METHODS

We aim for 576 completers with clinically relevant symptoms of insomnia as well as at least one of the dimensions of generalized anxiety disorder (GAD), social anxiety disorder (SAD), panic disorder (PD), posttraumatic stress disorder (PTSD) or borderline personality disorder (BPD). Participants are either pre-clinical, unattended, or referred to general- or specialized MHC. Using covariate-adaptive randomization, participants will be assigned to a 5 to 8-week iCBT-I (i-Sleep) or a control condition (sleep diary only) and assessed at baseline, and after two and eight months. The primary outcome is insomnia severity. Secondary outcomes address sleep, severity of mental health symptoms, daytime functioning, mental health protective lifestyles, well-being, and process evaluation measures. Analyses use linear mixed-effect regression models.

DISCUSSION

This study can reveal for whom, and at which stage of disease progression, better nights could mean substantially better days.

TRIAL REGISTRATION

International Clinical Trial Registry Platform (NL9776). Registered on 2021-10-07.

Co-occurring insomnia and anxiety: a randomized controlled trial of internet cognitive behavioral therapy for insomnia versus internet cognitive behavioral therapy for anxiety

STUDY OBJECTIVES

Insomnia and anxiety are highly prevalent and frequently co-occur. Given limited therapeutic resources and time constraints, the aim of this study was to compare which treatment-internet cognitive behavioral therapy (CBT) for insomnia or internet CBT for anxiety-leads to the best outcomes in individuals with comorbid insomnia and anxiety.

METHODS

120 participants with comorbid insomnia and clinical anxiety (as defined by scores above the clinical cutoff on the insomnia severity index (ISI) and the generalized anxiety disorder 7-item scale (GAD-7)) were randomized to receive internet-based cognitive behavioral therapy (iCBT) for insomnia or iCBT for anxiety. The primary outcome measures were the ISI and the generalized anxiety disorder 7-item scale. Primary outcome measures were assessed before treatment, at mid-treatment, at post-treatment, and 3 months after treatment. Secondary outcome measures assessed depression symptoms, distress, and sleep diary parameters.

RESULTS

Participants in both groups experienced large reductions in symptoms of insomnia, anxiety, depression, and distress, as well as improvements in sleep efficiency and total sleep time. Improvements were maintained at follow-up. Crucially, at the end of treatment, the insomnia treatment was more effective in reducing symptoms of insomnia than the anxiety treatment, and equally effective in reducing symptoms of anxiety. Treatment gains were maintained at 3-month follow-up, however, there were no differences between groups at that time point.

CONCLUSIONS

These results suggest that in the common case of a patient presenting with comorbid insomnia and anxiety, treatment for insomnia may be the most efficient treatment strategy.

TRIAL REGISTRATION

The trial was registered with the Australian and New Zealand Clinical Trials Registry, https://anzctr.org.au/Trial/Registration/TrialReview.aspx?ACTRN=12618001141235. Trial ID: ACTRN12618001141235. Trial name: a comparison of internet-based CBT for insomnia versus internet-based CBT for anxiety in a comorbid sample.

The Mediating Role of Sleep Quality in the Relationship between Negative Emotional States and Health-Related Quality of Life among Italian Medical Students

Sleep problems have been shown to be related to adverse outcomes concerning physical and mental well-being. Furthermore, mental health issues and sleep problems were reported to be highly prevalent among medical students and physicians, and were found to be associated with worse academic and clinical performance in these populations. This study aims to investigate the prevalence of poor sleep to examine the associations between sleep quality and health-related quality of life (HRQoL), and to explore the possible mediating role of sleep in the relationship between psychological distress and HRQoL itself in a sample of medical and dental students attending a large Italian university. Participants (n = 407, mean age: 24.2 ± 2.4) answered an online questionnaire comprising the 21-item Depression Anxiety Stress Scale, the Pittsburgh Sleep Quality Index, and the Short Form-12 health survey. Up to 62% of the participants reported poor sleep quality. Controlling for psychological distress, sleep quality components were found to be associated with physical and mental HRQoL. Mediation analysis showed that overall sleep quality mediated all the single associations between anxiety, depression, and stress and HRQoL. These preliminary findings suggest that the quality of sleep is important for the well-being of medical students and that targeting sleep issues in this academic population may be beneficial.

Assessing cognitive behavioral therapy for insomnia in individuals with cannabis use disorder utilizing actigraphy and serum biomarkers: A pilot study

OBJECTIVE/BACKGROUND

This pilot study aims to assess the effect of Cognitive Behavioral Therapy for insomnia (CBTi) in individuals with cannabis use disorder and insomnia. It also aims to investigate the effect of CBTi on levels of serum inflammatory markers in relation to insomnia symptoms.

METHODS/PATIENTS

Individuals with cannabis use disorder and insomnia symptoms were recruited over 18 months. Data collected included demographics, self-reported sleep parameters, and cannabis use. Blood samples were drawn to measure IL-2, IL-6, CRP, and cortisol. Participants completed the Insomnia Severity Index questionnaire (ISI) and the Patient Health Questionnaire-4 (PHQ-4), and they were provided with an actigraphy (wrist) device for 1 week before CBTi and a subsequent week after completing the 4 CBTi sessions.

RESULTS

Nineteen participants were enrolled in the study. The mean ISI score decreased from moderately severe insomnia at baseline to no clinically significant insomnia after CBTi with a sustained decrease at 3- and 6-months follow-up. Actigraphy showed a significant decrease in sleep onset latency (SOL) after CBTi. Three months after CBTi, 80% of participants reported a decrease in their cannabis use. There was also a significant and sustained decrease in mean PHQ-4 scores after CBTi. Although only trending towards significance, the levels of three out of four biomarkers (IL-2, IL-6, CRP) were decreased 6 months after CBTi.

CONCLUSIONS

CBTi is effective as a short- and long-term treatment of insomnia and comorbid anxiety/depression in individuals who regularly use cannabis. A potential added benefit is a reduction in cannabis consumption and inflammatory serum biomarkers.

Delayed circadian rhythms and insomnia symptoms in obsessive-compulsive disorder

BACKGROUND

Accumulating evidence implicates sleep and circadian rhythm disturbance in obsessive-compulsive disorder (OCD). However, a multimethod characterization of sleep and circadian rhythms in OCD, their association with symptom severity, and the functional relationship between these variables is lacking.

METHODS

The present study measured multiple indicators of sleep and circadian rhythms in a sample of adults with OCD, adults without OCD, and healthy controls (n = 74). Participants completed measures of morningness-eveningness, delayed sleep-wake phase disorder (DSWPD), insomnia symptoms, and OCD symptoms, as well as one week of sleep monitoring via a sleep diary and actigraphy.

RESULTS

Delayed circadian rhythms (higher eveningness, later mid-sleep timing, and higher rates of DSWPD) and higher insomnia symptoms were observed in those with OCD compared to healthy controls, as well as associations between delayed circadian rhythms and insomnia symptoms and OCD symptom severity across the full sample. Further, insomnia symptoms mediated the relationship between delayed circadian rhythms and OCD symptoms. In contrast, there were no links between total sleep time or sleep quality and OCD.

LIMITATIONS

Data collection during COVID-19 pandemic, correlational data, no physiological measure of circadian rhythms.

CONCLUSIONS

These findings highlight a robust association between delayed circadian rhythms and OCD and suggest insomnia symptoms may be one mechanism in this relationship. Sleep and circadian rhythm disturbance may be novel targets for OCD treatment.

Improving university students' mental health using multi-component and single-component sleep interventions: A systematic review and meta-analysis

University is a time of significant transitions during a young adult's life, with delayed and shortened sleep and poor mental health a common occurrence. This systematic review and meta-analysis examined the effect of both multi-component and single-component sleep interventions on improving university students' sleep and mental health. Five databases (MEDLINE, PsycINFO, Embase, CINAHL and Cochrane Library) were searched for relevant literature published until April 2022. Treatment studies including university students aged 18-24 years, participating in a sleep intervention (multi-component, e.g., CBT-I, or single-component, e.g., sleep hygiene) were eligible. Comparator groups were either active, i.e., alternative intervention, or passive, i.e., waitlist control or treatment-as-usual, with study outcomes to include measures of sleep and mental health. Of 3435 references screened, 11 studies involving 5267 participants, with and without insomnia symptoms, were included for a narrative synthesis on intervention designs and methodology. Six studies eligible for meta-analyses showed a moderate effect of sleep interventions in reducing sleep disturbance (SMD = -0.548 [CI: -0.837, -0.258]) at post-treatment, alongside a small effect in improving anxiety (SMD = -0.226 [CI: -0.421, -0.031]) and depression (SMD = -0.295 [CI: -0.513, -0.077]). Meta-regression examining study and intervention characteristics identified subpopulation (experiencing insomnia or not) as a significant moderator for effects on sleep (p = 0.0003) and depression (p = 0.0063), with larger effects in studies with participants experiencing insomnia. Comparison group type (active or passive) was also a significant moderator (p = 0.0474), with larger effects on sleep in studies using passive comparison groups. Study type, delivery format, and intervention duration were not identified as significant moderators. At follow-ups, small but significant effects were sustained for anxiety and depression. Protecting and promoting sleep amongst university students may help safeguard and advance mental health.

Clinical feasibility of cognitive behavioural therapy for insomnia in a real-world mixed sample at a specialized psychiatric outpatient clinic

BACKGROUND

A majority of psychiatric patients suffer from insomnia or insomnia-like problems. In addition to impairing quality of life, sleep problems can worsen psychiatric conditions, such as depression and anxiety, and can make treatment of various psychiatric conditions less successful. Several international guidelines recommend cognitive behavioural therapy for insomnia (CBT-I) as first line treatment. However, patients in psychiatric care are rarely offered this treatment, and there is a lack of studies evaluating the treatment in regular psychiatric settings. In this pilot study, we aimed to determine the clinical feasibility of a group-based CBT-I intervention in an outpatient clinical setting for patients with depression, bipolar disorder, anxiety disorders and PTSD. We also aimed to investigate if symptoms of insomnia, depression and anxiety changed after CBT-I.

METHODS

Seventeen patients at an out-patient psychiatric clinic for mixed psychiatric problems of anxiety, affective disorders and PTSD, were enrolled in a six-week long group-based CBT-I intervention. Primary outcomes were pre-defined aspects of treatment feasibility. Secondary outcomes were changes in self-reported symptoms of insomnia severity, depression, and anxiety between pre - and post intervention. Assessment of insomnia severity was also performed 3 months after treatment. Feasibility data is reported descriptively, changes in continuous data from pre- to post-treatment were analysed with dependent t-tests.

RESULTS

All feasibility criteria were met; there were enough patients to sustain at least one group per semester (e.g., minimum 8), 88% of included patients attended the first session, mean of attended sessions was 4.9 of 6, and drop-out rate was 5.9%. Therapists, recruited from clinical staff, found the treatment manual credible, and possible to use at the clinic. Symptoms of insomnia decreased after treatment, as well as symptoms of depression and anxiety.

CONCLUSION

CBT-I could prove as a clinically feasible treatment option for insomnia in a psychiatric outpatient setting.

TRIAL REGISTRATION

Clinicaltrials.gov identifier: NCT05379244. Retrospectively registered 18/05/2022.

Effectivity of (Personalized) Cognitive Behavioral Therapy for Insomnia in Mental Health Populations and the Elderly: An Overview

Insomnia is very prevalent in psychiatry and is considered a transdiagnostic symptom of mental disorders. Yet, it is not only a consequence of a mental condition but may also exert detrimental effects on psychiatric symptom severity and therapeutic response; thus, adequate insomnia treatment is particularly important in psychiatric populations. The first choice of intervention is cognitive behavioral therapy for insomnia (CBT-I) as it is rather effective, also in the long run without side effects. It is offered in various forms, ranging from in-person therapy to internet-delivered applications. CBT-I protocols are typically developed for individuals with insomnia disorder without co-occurring conditions. For an optimal therapeutic outcome of CBT-I in individuals with comorbid mental disorders, adaptations of the protocol to tailor the treatment might be beneficial. Based on a literature search using major search engines (Embase; Medline; APA Psych Info; and Cochrane Reviews), this paper provides an overview of the effectiveness of the different CBT-I applications in individuals with diverse comorbid mental conditions and older adults and describes the functionality of CBT-I protocols that have been personalized to specific psychiatric populations, such as depression, substance abuse, and schizophrenia spectrum disorder. Finally, we discuss urgent needs for insomnia therapy targeted to improve both sleep and psychopathologies.

Effects of Sleep Deficiency on Risk, Course, and Treatment of Psychopathology

This article reviews the literature on the relationship between sleep deficiency and unipolar and bipolar depression, anxiety disorders, and posttraumatic stress disorder. We consider the evidence for sleep as a contributory causal factor in the development of psychiatric disorders, as well as sleep as an influential factor related to the outcome and recurrence of psychopathology. A case for sleep deficiency being an important treatment target when sleep and psychiatric disorders are comorbid is also made. Our recommendation is that sleep deficiency is recognized as a means to positively impact the development and course of psychopathology and, as such, is routinely assessed and treated in clinical practice.

Evaluation of a Brief Sleep Intervention Designed to Improve the Sleep, Mood, and Cognitive Performance of Esports Athletes

This study evaluated a brief sleep intervention designed to improve the sleep, mood, and cognitive performance of professional electronic sports (esports) athletes from three major esports regions (i.e., Asia, North America, and Oceania). Fifty-six esports athletes from South Korea (N = 34), the United States (N = 7), and Australia (N = 15) completed the study. Participants completed an initial 2-week pre-intervention phase to establish a baseline, followed by a 2-week intervention phase that involved a group sleep education class, 1:1 session with a trained clinical psychologist, and daily biofeedback. A wrist activity monitor and daily sleep diary were used to monitor sleep during both phases, while at pre- and post-intervention, participants completed a battery of sleep and mood questionnaires and underwent cognitive performance testing. Sleep knowledge increased from pre- to post-intervention (d = 0.83 [95% CI −1.21, −0.43], p =< 0.001), while there were modest improvements in sleep diary estimates (i.e., sleep onset latency (Mdiff = −2.9 min, p = 0.02), sleep onset time (Mdiff = −12 min, p = 0.03), and sleep efficiency (Mdiff = 1.1%, p = 0.004)) and wrist activity monitor estimates (i.e., sleep onset time (Mdiff = −18 min, p = 0.01)). Insomnia severity scores decreased significantly (d = 0.47 [95% CI 0.08, 0.84], p = 0.001), while sleepiness scores increased but not meaningfully (d = 0.23 [95% CI −0.61, 0.14], p = 0.025). However, there was no significant change in mood (i.e., depression and anxiety) or cognitive performance scores (i.e., mean reaction time or lapses). Sleep interventions for esports athletes require further investigation. Future research should examine whether a stepped-care model, whereby increasing therapeutic input is provided as needed, can optimize sleep, mood, and cognitive performance outcomes.

Psychological Interventions to Improve Sleep in Young Adults: A Systematic Review and Meta-analysis of Randomized Controlled Trials

INTRODUCTION

The effects of impaired sleep on the wellbeing of young adults are profound, and the adverse outcomes for mental health are well documented in the research literature.

OBJECTIVE

This systematic review and meta-analysis aimed to identify, summarize, and synthesize the available evidence from randomized-controlled trials (RCTs) investigating psychological interventions aimed at improving sleep and related secondary outcomes such as anxiety and depression in healthy young adults.

METHOD

Nine electronic databases (Cochrane Central Registry of Controlled Trials [CENTRAL], PubMed, Scopus, PsycNET, CINHAL, INFORMIT, Web of Science [Science and Social Citation Index], OpenSigle and EMBASE) were searched, returning 54 full-text papers for assessment, with 13 studies meeting inclusion criteria for the meta-analysis.

RESULTS

A random effects meta-analysis showed that the combined effect of all interventions was moderate (ES = -0.53, 95% CIs [- 0.69, -0.36], p < .01), reflecting the efficacy of psychological interventions at improving sleep scores at post-intervention. Subgroup analyses of individual interventions showed that cognitive-behavioral interventions improved sleep (ES = -0.67, 95% CIs [-0.77, -0.57], p < .01) and secondary outcomes for anxiety (ES = -0.35, 95% CIs [-0.56, -0.15], p < .01) and depression (ES = -0.41, 95% CIs [-0.70, -0.13], p < .01) at post-intervention.

CONCLUSION

The results of the current review support the implementation of cognitive and behavioral interventions for sleep among young adults experiencing both sleep and comorbid mental health problems.

[Sleep disturbances and their associations with disorders in emotional sphere and behavior in children]

The paper addresses associations between sleep disorders and emotional and behavioral disturbances in children. These associations are considered in a view of commonly found co-occurrences of sleep problems, signs of anxiety and depression, oppositional-defiant behavior, and increased aggressiveness. The authors put forward a conception of reciprocal influences of these disturbances and provide information on potential physiological mechanisms responsible for associations between sleep problems and emotional and behavioral disturbances in children. Attention is drawn to hypothalamus-hypophysis-adrenal axis activation, serotonergic and aminergic systems imbalance, impaired melatonin and orexins production. Possibility of an existing pattern encompassing sleep problems, emotional and behavioral disturbances is discussed. Practical recommendations aimed at timely identification and treatment of the mentioned disorders are suggested.

Sleep and anxiety: From mechanisms to interventions

Anxiety is the most common mental health problem worldwide. Epidemiological studies show that sleep disturbances, particularly insomnia, affect ∼50% of individuals with anxiety, and that insufficient sleep can instigate or further exacerbate it. This review outlines brain mechanisms underlying sleep and anxiety, by addressing recent human functional/structural imaging studies on brain networks underlying the anxiogenic impact of sleep loss, and the beneficial effect of sleep on these brain networks. We discuss recent developments from human molecular imaging studies that highlight the role of specific brain neurotransmitter mechanisms, such as the adenosinergic receptor system, on anxiety, arousal, and sleep. This review further discusses frontline sleep interventions aimed at enhancing sleep in individuals experiencing anxiety, such as nonbenzodiazepines/antidepressants, lifestyle and sleep interventions and cognitive behavioral therapy for insomnia. Notwithstanding therapeutic success, up to ∼30% of individuals with anxiety can be nonresponsive to frontline treatments. Thus, we address novel non-invasive brain stimulation techniques that can enhance electroencephalographic slow waves, and might help alleviate sleep and anxiety symptoms. Collectively, these findings contribute to an emerging biological framework that elucidates the interrelationship between sleep and anxiety, and highlight the prospect of slow wave sleep as a potential therapeutic target for reducing anxiety.

Improving sleep quality leads to better mental health: A meta-analysis of randomised controlled trials

The extent to which sleep is causally related to mental health is unclear. One way to test the causal link is to evaluate the extent to which interventions that improve sleep quality also improve mental health. We conducted a meta-analysis of randomised controlled trials that reported the effects of an intervention that improved sleep on composite mental health, as well as on seven specific mental health difficulties. 65 trials comprising 72 interventions and N = 8608 participants were included. Improving sleep led to a significant medium-sized effect on composite mental health (g+ = -0.53), depression (g+ = -0.63), anxiety (g+ = -0.51), and rumination (g+ = -0.49), as well as significant small-to-medium sized effects on stress (g+ = -0.42), and finally small significant effects on positive psychosis symptoms (g+ = -0.26). We also found a dose response relationship, in that greater improvements in sleep quality led to greater improvements in mental health. Our findings suggest that sleep is causally related to the experience of mental health difficulties. Future research might consider how interventions that improve sleep could be incorporated into mental health services, as well as the mechanisms of action that explain how sleep exerts an effect on mental health.

Clinical efficacy and safety of traditional Chinese medicine Xiao Yao San in insomnia combined with anxiety

BACKGROUND

Patients with long-term insomnia generally experience anxiety and depression. Traditional sleeping pills and anti-anxiety drugs have certain limitations. Xiao Yao San (XYS), a complementary and alternative therapy, has been widely used to treat insomnia combined with anxiety. This study aims to evaluate the efficacy and safety of XYS in the treatment of insomnia combined with anxiety.

METHODS

Related literature was retrieved from 8 electronic databases from the establishment time to March 2021. The subjects were diagnosed with insomnia combined with anxiety. We assessed the methodological quality of randomized controlled trials (RCTs) according to the Cochrane Handbook. Data analysis was conducted using RevMan 5.3 software.

RESULTS

The analysis includes 9 RCTs involving 681 patients. Meta-analysis supported that as an auxiliary drug for Western medicine (WM), XYS could enhance the clinical efficacy of insomnia calculated according to the traditional Chinese medicine (TCM) syndrome score scale (risk ratio [RR]: 1.26; 95% confidence interval [CI]: 1.13-1.43; P = .0002) and reduced the scores of Hamilton Anxiety Scale (mean difference [MD]: -5.19; 95% CI: -7.78 to -2.60; P < .001), Pittsburgh Sleep Quality Index (MD: -3.35; 95% CI: -4.86 to -1.84; P < .001), Self-rating Anxiety Scale (MD: -9.38; 95% CI: -10.20 to -8.75; P < .001), TCM syndrome score scale for insomnia (MD: -4.45; 95% CI: -6.65 to -2.24; P < .001), and TCM syndrome score scale for anxiety (MD: -5.54; 95% CI: -9.48 to -1.6; P = .006). The summary analysis also shows that the separate use of XYS was advantageous in reducing the scores of the Hamilton Anxiety Scale (MD: -3.70; 95% CI: -6.31 to -1.09; P = .005), Pittsburgh Sleep Quality Index (MD: -1.82; 95% CI: -2.39 to -1.24; P < .001), and Self-rating Anxiety Scale (MD: -10.79; 95% CI: -14.09 to -7.49; P < .001). The incidence of adverse events with XYS as an ancillary drug or used separately was lower than that in the WM.

CONCLUSION

Our systematic evaluation and meta-analysis showed that XYS combined with WM or XYS alone was beneficial for improving sleep quality and relieving anxiety. Due to the low methodological quality, small sample size, and significant heterogeneity of RCTs, more rigorous and scientific clinical trials are required to further evaluate the efficacy and safety of XYS.

PROSPERO REGISTRATION NUMBER

CRD42020190613.

Do non-pharmacological sleep interventions affect anxiety symptoms? A meta-analysis

Research indicates a bidirectional relationship between sleep and anxiety, with findings suggesting anxiety can precede poor sleep and vice versa. Evidence suggests sleep-related thought processes associated with anxiety are involved in the maintenance of insomnia. Previous meta-analyses provide some evidence to suggest cognitive behavioural therapy for insomnia moderately improves anxiety, yet little research has investigated the effect of other sleep interventions on anxiety symptoms. The aim of this meta-analysis was to review whether non-pharmacological sleep interventions have an impact on anxiety symptoms immediately post-intervention. A systematic search of electronic databases was conducted to identify all randomized control trials (RCTs) investigating non-pharmacological sleep interventions that included anxiety symptoms as an outcome. Forty-three RCTs (n = 5945) met full inclusion criteria and were included in a random-effects meta-analysis model. The combined effect size of non-pharmacological sleep interventions on anxiety symptoms was moderate (Hedges' g = -0.38), indicating a reduction in symptoms. Subgroup analyses found a moderate effect for those with additional physical health difficulties (g = -0.46), a moderate effect for those with additional mental health difficulties (g = -0.47) and a moderate effect for those with elevated levels of anxiety at baseline (g = -0.43). A secondary meta-analysis found a large effect of non-pharmacological sleep interventions on sleep-related thought processes (g = -0.92). These findings indicate non-pharmacological sleep interventions are effective in reducing anxiety and sleep-related thought processes, and these effects may be larger in patients with anxiety. This has clinical implications for considering sleep interventions in the treatment of anxiety.

Cognitive behavioral therapy for insomnia (CBT-i) in patients with fibromyalgia: a systematic review and meta-analysis

PURPOSE

We aimed to evaluate the effectiveness of CBT-i in patients with fibromyalgia in comparison with other non-pharmacological treatments.

METHODS

Randomized controlled trials assessing the effects of CBT-i in adults with fibromyalgia, published in English or Spanish, were eligible. Electronic searches were performed using PubMed, Scopus, The Cochrane Library, WebOfKnowledge and Psicodoc databases in March 2021. The main outcome measures were sleep efficiency and sleep quality. Secondary outcomes included pain, depression, and anxiety.

RESULTS

Of 226 studies reviewed, five were included in the meta-analysis. CBT-i compared with non-pharmacological treatments showed no significant improvements in sleep efficiency (p = 0.05; standardized mean difference (SMD) [95% CI] 0.31 [-0.00 to 0.61]). CBT-i showed significant improvements in sleep quality (p = 0.009; SMD [95% CI] - 0.53 [-0.93 to -0.13]), pain (p = 0.002; SMD [95% CI] - 0.41 [-0.67 to -0.16]), anxiety (p = 0.001; SMD [95% CI] - 0.46 [-0.74 to 0.18]) and depression (p = 0.02; SMD [95% CI] - 0.33 [-0.61 to -0.05]), compared to non-pharmacological treatments. Effect sizes ranged from small to moderate.

CONCLUSIONS

CBT-i was associated with a significant improvement in sleep quality, pain, anxiety, and depression, although these results are retrieved from very few studies with only very low to low quality evidence. Trial registration: The review protocol was registered with PROSPERO (Record ID = CRD42016030161).IMPLICATIONS FOR REHABILITATIONCBT-i has been proven to improve sleep quality, pain, anxiety and depression, although with small effect sizes.Implementing hybrid CBT for pain and sleep or combining CBT and mindfulness may improve symptoms in people diagnosed with FM.This meta-analysis results highlight the need to enhance sleep management skills among people suffering from this health condition.

Treating co-morbid insomnia and social anxiety disorder with sequential CBT protocols: a single-case experimental study

BACKGROUND

Although insomnia disorder and social anxiety disorder are among the most prevalent psychiatric disorders, no studies have yet evaluated the use of sequential evidence-based treatment protocols in the population with co-morbid social anxiety disorder and insomnia disorder.

AIMS

This study aimed to investigate the effects of sequential treatments on co-morbid insomnia disorder and social anxiety disorder. As depression is a common co-morbid syndrome for both insomnia and social anxiety, a secondary aim was to examine depressive symptoms.

METHOD

A single-case repeated crossover AB design was used. Ten participants between 18 and 59 years of age with co-morbid DSM-5 diagnoses of insomnia disorder and social anxiety disorder received sequential treatments with cognitive behavioural therapy (CBT). Seven participants completed the treatment course. The primary outcomes were symptoms of insomnia and social anxiety, and the secondary outcome was symptoms of depression.

RESULTS

The effects of CBT on people with co-morbid social anxiety disorder and insomnia disorder were mixed. The majority of participants improved their sleep quality and lessened symptoms of social anxiety and depression. However, participants differed in their degree of improvement concerning all three disorders.

CONCLUSIONS

Sequential CBT treatments are potentially effective at decreasing symptoms of social anxiety and insomnia for people with co-morbid social anxiety disorder and insomnia disorder. The variation in outcome across participants makes firm conclusions about the treatment efficacy difficult to draw.

The correlation between mental health status, sleep quality, and inflammatory markers, virus negative conversion time among patients confirmed with 2019-nCoV during the COVID-19 outbreak in China: An observational study

The 2019 coronavirus disease (COVID-19) has spread to the whole world. Psychological and sleep problems among confirmed patients have drawn extensive attention which may be highly related to immune function and inflammatory responses of people. The aim of this study is to examine the correlation of mental health status, sleep quality, and inflammatory markers, virus negative conversion time (NCT) among confirmed patients during the COVID-19 outbreak.A cross-sectional survey was conducted in this study. Data from 66 patients assessed with demographic information, anxious symptom, depressive symptom, stress, and sleep quality were collected using a smartphone-based questionnaire platform and then clinical characteristics and laboratory indicators were collected using case review.Nearly 30% of the participants reported depression, anxiety, perceived pressure, and poor sleep quality. Compared with the group without depression, neutrophil count, and ratio of neutrophil count to lymphocyte count (NLR) in the depression disorder group were increased (P = .028, 0.043). There was also a significant difference in NLR and NCT between the anxiety group and the non-anxiety group (P = .021, .024). Similarly, compared with the good sleep quality group, NLR in the poor sleep quality group was increased (P = .011). Correlation analysis indicated that Self-Rating Depression Scale score was positively related to neutrophil count and NLR (r = 0.366, 0.330, P = .016, .031). The total score of Pittsburgh Sleep Quality Index (PSQI) was negatively related to lymphocyte count (r = -0.317, P = .049), and the sleep disturbance as 1 of the 7 dimensions of PSQI scale was positively correlated with NCT and NLR (r = 0.370, 0.340, P = .020, .034).In our study, confirmed patients were prone to have psychological and sleep problems. The level of inflammation in patients with psychological and sleep problems was higher than that in patients without corresponding problems. The inflammatory level increased with the increase of Self-Rating Depression Scale score, and the lymphocyte count decreased with the increase of the PSQI score. NCT was prolonged in the anxiety group and sleep disturbance was positively correlated with NCT.

Trajectories of Insomnia Symptoms and Associations with Mood and Anxiety from Early Pregnancy to the Postpartum

Objective/Background: The current study identified heterogeneous trajectories of insomnia symptoms from early pregnancy to early postpartum. The relationship between demographic and psychological predictors of trajectories and associations between trajectory group membership and symptoms of postpartum depression and anxiety were also explored.Participants: 142 pregnant women were enrolled in a prospective online survey.Method: Women were recruited from a maternity clinic in Calgary, AB and completed measures of insomnia symptoms, depression, generalized anxiety, and interpersonal support at four time-points. Women were recruited and completed the first survey before 20 weeks gestation and were reassessed every 10 weeks. Women were on average 15 weeks gestation, 25 weeks gestation, 35 weeks gestation, and 6 weeks postpartum at the respective time-points. Group-based trajectory analysis was used to determine trajectories of pregnancy insomnia symptoms.Results: Three trajectory groups were identified. A no insomnia group (42.3%) in which women reported consistently low insomnia symptoms. A subclinical insomnia group (44.3%) in which women reported subclinical symptoms which briefly elevated to clinical levels in late-pregnancy, and a clinical insomnia group (13.4%) in which women reported consistently elevated insomnia symptoms. Baseline predictors of membership group included anxiety, depression, and ethnicity such that members of the clinical insomnia group were more likely to also endorse anxiety and depression. Membership in the clinical insomnia group was associated with higher postpartum generalized anxiety and depressive symptoms. Additionally, the clinical insomnia group were more likely to experience symptoms indicative of clinically significant depression.Conclusions: A small group of pregnant women experienced consistently high and elevated insomnia symptoms throughout pregnancy and another larger group endorsed consistently elevated but subthreshold symptoms. Future studies should explore long-term consequences of experiencing high insomnia symptomatology during pregnancy and early postpartum, as well as safe and efficacious interventions.

Altered sleep behavior in a genetic mouse model of impaired fear extinction

Sleep disturbances are a common complaint of anxiety patients and constitute a hallmark feature of post-traumatic stress disorder (PTSD). Emerging evidence suggests that poor sleep is not only a secondary symptom of anxiety- and trauma-related disorders but represents a risk factor in their development, for example by interfering with emotional memory processing. Fear extinction is a critical mechanism for the attenuation of fearful and traumatic memories and multiple studies suggest that healthy sleep is crucial for the formation of extinction memories. However, fear extinction is often impaired in anxiety- and trauma-related disorders—an endophenotype that is perfectly modelled in the 129S1/SvImJ inbred mouse strain. To investigate whether these mice exhibit altered sleep at baseline that could predispose them towards maladaptive fear processing, we compared their circadian sleep/wake patterns to those of typically extinction-competent C57BL/6 mice. We found significant differences regarding diurnal distribution of sleep and wakefulness, but also sleep architecture, spectral features and sleep spindle events. With regard to sleep disturbances reported by anxiety- and PTSD patients, our findings strengthen the 129S1/SvImJ mouse models’ face validity and highlight it as a platform to investigate novel, sleep-focused diagnostic and therapeutic strategies. Whether the identified alterations causally contribute to its pathological anxiety/PTSD-like phenotype will, however, have to be addressed in future studies.

Who Is Seeking Help for Sleep? A Clinical Profile of Patients in a Sleep Psychology Clinic

BACKGROUND

The present study outlines a clinical profile of an ecologically valid population consulting for sleep difficulties at the Sleep Psychology Clinic of the Consultation service of the School of Psychology of Université Laval .

METHOD

Patients self-report to the sleep clinic. Following a phone screening interview, patients present to the clinic for a semi-structured clinical interview for sleep and psychopathology, which is conducted by psychologists and doctorate psychology students. A chart review of adult patients (56% female, M_age = 43.6 years) was conducted (between 2015 and 2018) to record diagnosed sleep, psychiatric, and medical conditions.

RESULTS

There was a high level of comorbidity with an average of 2.85 diagnoses (any diagnosis combined) per patient (SD = 1.76), with 27% of the patients having at least four diagnoses. Reviewing specific types of disorders, 58.5% of patients presented with at least one comorbid psychiatric disorder, 27.5% with one medical comorbidity, or 39.5% with another sleep disorder alongside their primary sleep concern. Insomnia was the main sleep disorder (76%). Anxiety (77.8%) and depression (53.8%) were the predominant psychiatric disorders, while fibromyalgia (10.9%), hypertension (10.9%), and head trauma (9.1%) were the main medical conditions. Of patients with five diagnoses and more, 77.8% were taking on average 3.2 different types of medications. The number of diagnoses predicted the use of prescribed hypnotics and the use of any type of medications.

CONCLUSION

This clinical profile emphasizes the reality of multiple morbidities, which may have implications for clinical decisions. Future research is required to evaluate transdiagnostic approaches for the sleep disorder patient with multiple morbidities.

Sleep Duration and Insomnia in Adolescents Seeking Treatment for Anxiety in Primary Health Care

There is limited knowledge about sleep in adolescents with elevated levels of anxiety treated within primary health care settings, potentially resulting in sleep problems not being sufficiently addressed by primary health care workers. In the current study self-reported anxiety, insomnia, sleep onset latency, sleep duration, and depressive symptoms were assessed in 313 adolescents (12–16 years; mean age 14.0, SD = 0.84, 84.0% girls) referred to treatment for anxiety within primary health care. Results showed that 38.1% of the adolescents met criteria for insomnia, 34.8% reported short sleep duration (<7 h), and 83.1% reported long sleep onset latency (≥30 min). Total anxiety symptoms were related to all sleep variables after controlling for age and sex. Furthermore, all anxiety symptom sub-types were associated with insomnia and sleep onset latency, whereas most anxiety subtypes were associated with sleep duration. Adolescents’ depressive symptoms accounted for most of the anxiety-sleep associations, emphasizing the importance of depressive symptoms for sleep. However, anxiety was associated with insomnia and sleep onset latency also among youth with low levels of depressive symptoms. The findings suggests that primary health care workers should assess sleep duration, sleep onset latency, and insomnia in help-seeking adolescents with anxiety.

Circadian depression: A mood disorder phenotype

Major mood syndromes are among the most common and disabling mental disorders. However, a lack of clear delineation of their underlying pathophysiological mechanisms is a major barrier to prevention and optimised treatments. Dysfunction of the 24-h circadian system is a candidate mechanism that has genetic, behavioural, and neurobiological links to mood syndromes. Here, we outline evidence for a new clinical phenotype, which we have called 'circadian depression'. We propose that key clinical characteristics of circadian depression include disrupted 24-h sleep-wake cycles, reduced motor activity, low subjective energy, and weight gain. The illness course includes early age-of-onset, phenomena suggestive of bipolarity (defined by bidirectional associations between objective motor and subjective energy/mood states), poor response to conventional antidepressant medications, and concurrent cardiometabolic and inflammatory disturbances. Identifying this phenotype could be clinically valuable, as circadian-targeted strategies show promise for reducing depressive symptoms and stabilising illness course. Further investigation of underlying circadian disturbances in mood syndromes is needed to evaluate the clinical utility of this phenotype and guide the optimal use of circadian-targeted interventions.

Insomnia - A Heterogenic Disorder Often Comorbid With Psychological and Somatic Disorders and Diseases: A Narrative Review With Focus on Diagnostic and Treatment Challenges

Patients with insomnia complain of problems with sleep onset or sleep maintenance or early morning awakenings, or a combination of these, despite adequate opportunity and circumstances for sleep. In addition, to fulfill the diagnostic criteria for insomnia the complaints need to be associated with negative daytime consequences. For chronic insomnia, the symptoms are required to be present at least 3 days per week for a duration of at least 3 months. Lastly, for insomnia to be defined as a disorder, the sleep complaints and daytime symptoms should not be better explained by another sleep disorder. This criterion represents a diagnostic challenge, since patients suffering from other sleep disorders often complain of insomnia symptoms. For instance, insomnia symptoms are common in e.g., obstructive sleep apnea and circadian rhythm sleep-wake disorders. It may sometimes be difficult to disentangle whether the patient suffers from insomnia disorder or whether the insomnia symptoms are purely due to another sleep disorder. Furthermore, insomnia disorder may be comorbid with other sleep disorders in some patients, e.g., comorbid insomnia and sleep apnea (COMISA). In addition, insomnia disorder is often comorbid with psychological or somatic disorders and diseases. Thus, a thorough assessment is necessary for correct diagnostics. For chronic insomnia disorder, treatment-of-choice is cognitive behavioral therapy, and such treatment is also effective when the insomnia disorder appears comorbid with other diagnoses. Furthermore, studies suggest that insomnia is a heterogenic disorder with many different phenotypes or subtypes. Different insomnia subtypes may respond differently to treatment, but more research on this issue is warranted. Also, the role of comorbidity on treatment outcome is understudied. This review is part of a Research Topic on insomnia launched by Frontiers and focuses on diagnostic and treatment challenges of the disorder. The review aims to stimulate to more research into the bidirectional associations and interactions between insomnia disorder and other sleep, psychological, and somatic disorders/diseases.

Insomnia disorder and its reciprocal relation with psychopathology

Sleep is crucial for daytime functioning. In populations with psychiatric conditions, many people suffer from insomnia symptoms or an insomnia disorder. Emerging evidence suggests a bidirectional relationship between insomnia and various psychopathologies, implying that insomnia not only may be a consequence of mental disorders but also may contribute to new development, symptom severity, and reoccurrence of diverse mental disorders. Research on potential mechanisms underlying the insomnia psychopathology association is important, both from the preventive and treatment perspective. Most hypotheses concern the influence of insomnia on emotion regulation and on shared pathophysiological pathways, ranging from gut microbiome composition to genetic and specific neurotransmitter system aberrations.

Non-pharmacological Approaches for Management of Insomnia

Insomnia is a prevalent sleep problem associated with a constellation of negative health-related outcomes and significant socioeconomic burden. It commonly co-occurs with psychiatric and medical conditions, which may further exacerbate these comorbid conditions and hinder treatment response. There is much empirical evidence to support the clinical efficacy of non-pharmacological treatment for insomnia, especially cognitive behavioral therapy for insomnia (CBT-I), in managing insomnia in a wide range of populations. This article reviews the research on the efficacy of CBT-I for primary insomnia and insomnia comorbid with other psychiatric and medical conditions, the empirical evidence regarding different CBT-I treatment modalities, the implementation of CBT-I across different age groups, and some initial evidence on the sequential combination of insomnia treatments. A brief overview of other non-pharmacological treatment with regard to complementary alternative medicine is also provided.

The Association between Insomnia and Anxiety Symptoms in a Naturalistic Anxiety Treatment Setting

Objective/Background: Few studies have examined the relationship between insomnia and anxiety treatment outcomes in naturalistic settings. Furthermore, prior studies typically examine insomnia within a single anxiety diagnosis without accounting for the high overlap between disorders. Here we investigate the association between insomnia and multiple anxiety disorders over a course of cognitive behavioral treatment (CBT) in a naturalistic treatment setting. Participants: Insomnia was assessed in 326 patients seeking treatment at a clinic specializing in CBT for anxiety. Methods: Multilevel modeling was used to investigate whether insomnia moderated reductions in anxiety symptoms. A cross-lagged analysis tested for bidirectional effects between insomnia and anxiety. Multiple regression was used to investigate the relationship between insomnia and anxiety while controlling for the other anxiety disorders and depression. Results: While there was a significant reduction in insomnia during treatment in all anxiety disorders, the majority of the most severe patients remained in the clinical range at post-treatment. Baseline insomnia did not significantly moderate anxiety outcomes, suggesting that patients with high or low levels of insomnia will do equally well in CBT for anxiety. The bidirectional effect between insomnia and anxiety did not reach significance. Additionally, posttraumatic stress disorder, generalized anxiety disorder, and panic disorder were associated with the greatest endorsement of insomnia, after controlling for the overlap between disorders. Conclusions: Sleep problems may persist after anxiety treatment, suggesting that CBT for insomnia may be warranted during or after a course of CBT for anxiety. Importantly, baseline insomnia does not impede anxiety reduction during CBT.

An Evaluation of Cognitive Behavioral Therapy for Insomnia: A Systematic Review and Application of Tolin's Criteria for Empirically Supported Treatments

The American Psychological Association's Society of Clinical Psychology recently adopted the "Tolin Criteria" to evaluate empirically supported treatments. These criteria better account for strength and quality of rapidly accumulating evidence bases for various treatments. Here we apply this framework to cognitive behavioral therapy for insomnia (CBT-I). Following procedures outlined by Tolin, McKay, et al. (2015), Step 1 included an examination of quantitative systematic reviews; nine met inclusion criteria. Step 2 evaluated review quality and effect size data. We found high-quality evidence that CBT-I produces clinically and statistically significant effects on insomnia and other sleep-related outcomes. Based on the Tolin Criteria, the literature merits a "strong" recommendation for CBT-I. This report is a working model for subsequent applications of the Tolin Criteria.