Depression prevention in digital cognitive behavioral therapy for insomnia: Is rumination a mediator?

Relationships between rumination and different types of rapid eye movement sleep in patients with chronic insomnia disorder

BACKGROUND AND OBJECTIVE

Rumination, a common factor of chronic insomnia disorder (CID) caused by cognitive-emotional arousal, is associated with an increased amount of rapid eye movement (REM) sleep. However, the specific subtypes, such as phasic REM and tonic REM, that contribute to the increased REM sleep have not been reported. This study aimed to determine the association between rumination and different REM sleep subtypes in patients with CID.

METHODS

This study enrolled 35 patients with CID and 27 age- and sex-matched healthy controls. The Immersion-Rumination Questionnaire evaluated participants' rumination, and the Insomnia Severity Index was used to assess insomnia severity. Finally, polysomnography was used to monitor objective sleep quality and quantification of different types of REM.

RESULTS

The CID patients had higher rumination scores than the healthy controls. They had a shorter REM sleep duration, less phasic REM, a lower percentage of phasic REM time, and a higher percentage of tonic REM time. Spectral analysis revealed that the patients affected by insomnia had higher β power during REM sleep, higher β and σ power during phasic REM sleep, and higher β, and γ power during tonic REM sleep. Partial correlation analysis showed that rumination in the CID patients correlated negatively with the duration of phasic REM sleep. Additionally, rumination correlated negatively with δ power in REM sleep and positively with β power in REM sleep, tonic REM sleep, phasic REM sleep, N3and N2 sleep in the patients with CID.

CONCLUSION

The CID patients had stronger rumination, reduced total and phasic REM sleep, and the stronger rumination was, the shorter phasic REM was and the higher fast (β) wave power in REM sleep.

Who benefits from indirect prevention and treatment of depression using an online intervention for insomnia? Results from an individual-participant data meta-analysis

BACKGROUND

Major depressive disorder (MDD) is highly prevalent and burdensome for individuals and society. While there are psychological interventions able to prevent and treat MDD, uptake remains low. To overcome structural and attitudinal barriers, an indirect approach of using online insomnia interventions seems promising because insomnia is less stigmatized, predicts MDD onset, is often comorbid and can outlast MDD treatment. This individual-participant-data meta-analysis evaluated the potential of the online insomnia intervention GET.ON Recovery as an indirect treatment to reduce depressive symptom severity (DSS) and potential MDD onset across a range of participant characteristics.

METHODS

Efficacy on depressive symptom outcomes was evaluated using multilevel regression models controlling for baseline severity. To identify potential effect moderators, clinical, sociodemographic, and work-related variables were investigated using univariable moderation and random-forest methodology before developing a multivariable decision tree.

RESULTS

IPD were obtained from four of seven eligible studies (N = 561); concentrating on workers with high work-stress. DSS was significantly lower in the intervention group both at post-assessment (d = -0.71 [95% CI-0.92 to -0.51]) and at follow-up (d = -0.84 [95% CI -1.11 to -0.57]). In the subsample (n = 121) without potential MDD at baseline, there were no significant group differences in onset of potential MDD. Moderation analyses revealed that effects on DSS differed significantly across baseline severity groups with effect sizes between d = -0.48 and -0.87 (post) and d = - 0.66 to -0.99 (follow-up), while no other sociodemographic, clinical, or work-related characteristics were significant moderators.

CONCLUSIONS

An online insomnia intervention is a promising approach to effectively reduce DSS in a preventive and treatment setting.

Identifying the insomnia-related psychological issues associated with hyperarousal: A network perspective

Hyperarousal, recognized as a fundamental characteristic of insomnia for decades, has yielded limited evidence concerning its direct psychological associations. This study aimed to explore the psychological factors linked to hyperarousal within the framework of interrelated variables. Two independent samples, comprising n = 917 and n = 652 young adults, were included in the study. Employing the first dataset as a discovery sample and the second dataset as a replication sample, network analyses were conducted using 26 variables derived from 17 scales. The objective was to estimate the direct and indirect associations between psychological issues, including hyperarousal and insomnia. Additionally, linear regression analysis was employed to assess the convergence of findings obtained from the network analysis. Network analyses in both samples converged to reveal direct associations between insomnia severity and several psychological factors, including negative sleep beliefs, physical fatigue, insomnia response to stress, hyperarousal, self-reported depression, and mental fatigue. Notably, the nodes with relative importance within the network include trait anxiety, depressive rumination, hyperarousal, perfectionism sub-dimension of concern over mistakes, and private self-consciousness. Hyperarousal is one of the key factors linking insomnia with a variety of psychological issues, including emotion-related factors (rumination, perveived stress), sleep-related factors (dysfunctional sleep beliefs and attitudes, insomnia response to stress, fatigue, chronotype), and self-related factors (self-consciousness, perfectionism). The results suggest that forthcoming strategies for enhancing the treatment efficacy of insomnia could consider supplementary interventions that specifically address hyperarousal, other factors directly linked to insomnia, or the hub nodes within the network.

How Can Digital Mental Health Enhance Psychiatry?

The use of digital technologies is constantly growing around the world. The wider-spread adoption of digital technologies and solutions in the daily clinical practice in psychiatry seems to be a question of when, not if. We propose a synthesis of the scientific literature on digital technologies in psychiatry and discuss the main aspects of its possible uses and interests in psychiatry according to three domains of influence that appeared to us: 1) assist and improve current care: digital psychiatry allows for more people to have access to care by simply being more accessible but also by being less stigmatized and more convenient; 2) develop new treatments: digital psychiatry allows for new treatments to be distributed via apps, and practical guidelines can reduce ethical challenges and increase the efficacy of digital tools; and 3) produce scientific and medical knowledge: digital technologies offer larger and more objective data collection, allowing for more detection and prevention of symptoms. Finally, ethical and efficacy issues remain, and some guidelines have been put forth on how to safely use these solutions and prepare for the future.

Mechanisms of cognitive behavioural therapy for insomnia

Although much is known now about behavioural, cognitive and physiological consequences of insomnia, little is known about changes after cognitive behavioural therapy for insomnia on these particular factors. We here report baseline findings on each of these factors in insomnia, after which we address findings on their changes after cognitive behavioural therapy. Sleep restriction remains the strongest determinant of insomnia treatment success. Cognitive interventions addressing dysfunctional beliefs and attitudes about sleep, sleep-related selective attention, worry and rumination further drive effectiveness of cognitive behavioural therapy for insomnia. Future studies should focus on physiological changes after cognitive behavioural therapy for insomnia, such as changes in hyperarousal and brain activity, as literature on these changes is sparse. We introduce a detailed clinical research agenda on how to address this topic.

"Life will never be the same": a qualitative analysis of the impact of COVID-19 on adults with a history of insomnia

Study Objectives

To utilize qualitative data analysis to enrich our understanding of the impact of coronavirus (COVID-19) on those with a pre-pandemic history of insomnia.

Methods

The sample included 208 participants who completed the Coronavirus Impact Scale in April and May 2020. A content analysis was used to analyze responses to a free-response item "Please tell us about any other ways the coronavirus has impacted your life" (n = 175), using a combination of inductive and deductive coding.

Results

Both negative and positive themes emerged, including altered access to health care, negative financial impacts, and various emotions surrounding COVID-19. Some shared "silver linings" such as having more time for physical activity and deepening familial connections.

Conclusions

This analysis provides novel insight into the shared concerns and lived experiences of those with a history of insomnia. Understanding these unique stressors can enable healthcare professionals to better anticipate the needs of this population, as well as learn to navigate future stressful events.

[Insomnia]

Patients with insomnia suffer from problems falling asleep and/or maintaining sleep. This has a negative effect on their daytime wellbeing and performance. Insomnia is primarily diagnosed by a detailed clinical history, supplemented by questionnaires and sleep diaries. Polysomnography may be necessary for the differential diagnosis of organic sleep disorders. Insomnia is a frequent comorbidity of most mental disorders and many physical diseases. It is treated according to guidelines with cognitive behavioural therapy for insomnia (CBT-I). CBT-I is offered in individual or group format as well as online-supported treatment. If behavioural therapy is not effective or not available, pharmacotherapy can be discussed.

Dysfunctional beliefs and attitudes about sleep (DBAS) mediate outcomes in dCBT-I on psychological distress, fatigue, and insomnia severity

OBJECTIVE/BACKGROUND

Digital cognitive behavioral therapy for insomnia (dCBT-I) improves several sleep and health outcomes in individuals with insomnia. This study investigates whether changes in Dysfunctional Beliefs and Attitudes about Sleep (DBAS) during dCBT-I mediate changes in psychological distress, fatigue, and insomnia severity.

PATIENTS/METHODS

The study presents a secondary planned analysis of data from 1073 participants in a randomized control trial (Total sample = 1721) of dCBT-I compared with patient education (PE). Self-ratings with the Dysfunctional Beliefs and Attitudes about Sleep (DBAS), the Hospital Anxiety Depression Scale (HADS), the Chalder Fatigue Scale (CFQ), and the Insomnia Severity Index (ISI) were obtained at baseline and 9-week follow-up. Hayes PROCESS mediation analyses were conducted to test for mediation.

RESULTS AND CONCLUSION

sDBAS scores were significantly reduced at 9-week follow-up for those randomized to dCBT-I (n = 566) compared with PE (n = 507). The estimated mean difference was -1.49 (95% CI -1.66 to -1.31, p < .001, Cohen's d. = 0.93). DBAS mediated all the effect of dCBT-I on the HADS and the CFQ, and 64% of the change on the ISI (Estimated indirect effect -3.14, 95% CI -3.60 to -2.68) at 9-week follow-up compared with PE. Changes in the DBAS fully mediated the effects of dCBT-I on psychological distress and fatigue, and the DBAS partially mediated the effects on insomnia severity. These findings may have implications for understanding how dCBT-I works and highlights the role of changing cognitions in dCBT-I.

Reducing cognitive arousal and sleep effort alleviates insomnia and depression in pregnant women with DSM-5 insomnia disorder treated with a mindfulness sleep program

Objectives

Combining mindfulness with behavioral sleep strategies has been found to alleviate symptoms of insomnia and depression during pregnancy, but mechanisms for this treatment approach remain unclear. The present study examined nocturnal cognitive arousal and sleep effort as potential treatment mechanisms for alleviating insomnia and depression via a mindfulness sleep program for pregnant women.

Methods

Secondary analysis from a proof-of-concept trial of 12 pregnant women with DSM-5 insomnia disorder who were treated with Perinatal Understanding of Mindful Awareness for Sleep (PUMAS), which places behavioral sleep strategies within a mindfulness framework. Data were collected across eight weekly assessments: pretreatment, six sessions, and posttreatment. Measures included the insomnia severity index (ISI), Edinburgh postnatal depression scale (EPDS), pre-sleep arousal scale's cognitive factor (PSASC), and the Glasgow sleep effort scale (GSES). We used linear mixed modeling to test cognitive arousal and sleep effort as concurrent and prospective predictors of insomnia and depression.

Results

Most patients reported high cognitive arousal before PUMAS (75.0%), which decreased to 8.3% after treatment. All insomnia remitters reported low cognitive arousal after treatment, whereas half of nonremitters continued reporting high cognitive arousal. Both nocturnal cognitive arousal and sleep effort were associated with same-week changes in insomnia throughout treatment, and sleep effort yielded a prospective effect on insomnia. Lower levels of nocturnal cognitive arousal and sleep effort prospectively predicted reductions in depression.

Conclusions

The present study offers preliminary evidence that reducing sleep effort and nocturnal cognitive arousal may serve as key mechanisms for alleviating insomnia and depression via mindfulness-based insomnia therapy. ClinicalTrials.gov ID: NCT04443959.

Perinatal Understanding of Mindful Awareness for Sleep (PUMAS): A single-arm proof-of-concept clinical trial of a mindfulness-based intervention for DSM-5 insomnia disorder during pregnancy

OBJECTIVES

Cognitive-behavioral therapy is effective for prenatal insomnia, but unresolved cognitive arousal limits patient outcomes. Therapies aimed at reducing cognitive arousal may benefit pregnant women with insomnia. This proof-of-concept trial evaluated Perinatal Understanding of Mindful Awareness for Sleep (PUMAS, which combines mindfulness with behavioral sleep strategies) on insomnia, depression, and cognitive arousal.

METHODS

A single-arm trial of 12 pregnant women with DSM-5 insomnia disorder (n = 5/12 with comorbid depression) who received six sessions of PUMAS delivered individually via telemedicine. Pretreatment and posttreatment outcomes included the insomnia severity index (ISI), Edinburgh postnatal depression scale (EPDS), pre-sleep arousal scale's cognitive factor (PSASC; nocturnal cognitive arousal), perinatal-focused rumination (appended to PSASC), and Glasgow sleep effort scale.

RESULTS

Eleven of 12 patients completed all sessions. Intent-to-treat analyses revealed a 10.83-point reduction in ISI (Cohen's dz = 3.05), resulting in 83.3% insomnia remission. PUMAS produced large reductions in EPDS (Cohen's dz = 2.76 in depressed group), resulting in all five baseline depressed patients remitting from depression. PUMAS produced large reductions in nocturnal cognitive arousal, perinatal-focused rumination, and sleep effort (all Cohen's dzs>2.00). Patients were highly satisfied with PUMAS and identified the telemedicine format and meditation app as positive features of its delivery. Patients rated sleep restriction and guided meditations as the most helpful treatment components.

CONCLUSION

Prenatal insomnia patients were highly engaged in PUMAS, which produced large acute reductions in insomnia, depression, and cognitive arousal. These findings support the concept and feasibility of PUMAS for pregnant women with insomnia who present with or without comorbid depression.

CLINICALTRIALS

GOV ID

NCT04443959.

Improved resilience following digital cognitive behavioral therapy for insomnia protects against insomnia and depression one year later

BACKGROUND

While the negative consequences of insomnia are well-documented, a strengths-based understanding of how sleep can increase health promotion is still emerging and much-needed. Correlational evidence has connected sleep and insomnia to resilience; however, this relationship has not yet been experimentally tested. This study examined resilience as a mediator of treatment outcomes in a randomized clinical trial with insomnia patients.

METHODS

Participants were randomized to either digital cognitive behavioral therapy for insomnia (dCBT-I; n = 358) or sleep education control (n = 300), and assessed at pre-treatment, post-treatment, and 1-year follow-up. A structural equation modeling framework was utilized to test resilience as a mediator of insomnia and depression. Risk for insomnia and depression was also tested in the model, operationalized as a latent factor with sleep reactivity, stress, and rumination as indicators (aligned with the 3-P model). Sensitivity analyses tested the impact of change in resilience on the insomnia relapse and incident depression at 1-year follow-up.

RESULTS

dCBT-I resulted in greater improvements in resilience compared to the sleep education control. Furthermore, improved resilience following dCBT-I lowered latent risk, which was further associated with reduced insomnia and depression at 1-year follow-up. Sensitivity analyses indicated that each point improvement in resilience following treatment reduced the odds of insomnia relapse and incident depression 1 year later by 76% and 65%, respectively.

CONCLUSIONS

Improved resilience is likely a contributing mechanism to treatment gains following insomnia therapy, which may then reduce longer-term risk for insomnia relapse and depression.

Does insomnia treatment prevent depression?

Rates of major depressive disorder (MDD) are increasing globally, in part due to the coronavirus disease 2019 pandemic, contributing to disease burden. It has long been known that insomnia is intricately connected with depression as indicated by greater depression severity and lower treatment response. Furthermore, insomnia is a significant risk factor for new-onset depression. Treatment of insomnia is thus a logical target for prevention of incidents and recurrent MDD. This systematic review sought to evaluate the current evidence for the preventive effects of insomnia treatment on depression onset. A database search yielded 186 studies, six of which met criteria for inclusion in this review. All of the studies utilized cognitive behavioral treatment for insomnia (CBT-I) as the target intervention and most delivered treatment via a digital platform. Four of the studies found significantly lower rates of MDD onset in those who received CBT-I compared to a control condition. The two remaining studies failed to confirm these effects in primary analyses but secondary analyses suggested evidence of a preventive effect. There was significant methodologic heterogeneity across studies in terms of sample selection, outcomes, and follow-up periods, limiting the ability to draw firm conclusions. The evidence overall is in the direction of insomnia treatment reducing the risk for onset of MDD, but further research is warranted.

Baseline symptoms of depression and anxiety negatively impact the effectiveness of CBTi in treating acute insomnia among young adults

Background

Cognitive-behavioural therapy for insomnia (CBTi) is the first-line treatment for those with this sleep disorder. However, depressive and anxiety symptoms often co-occur with acute insomnia, which may affect the effectiveness of CBTi treatment.

Aims

This study aimed to determine the impact of depressive and anxiety symptoms on the efficacy of CBTi in treating acute insomnia.

Methods

A single-arm clinical trial was conducted among individuals who have acute insomnia. Participants underwent self-guided CBTi for 1-week. Their insomnia, depressive symptoms and anxiety symptoms were evaluated using the Insomnia Severity Index and the Hospital Anxiety and Depression Scale at baseline, post-treatment and 3-month follow-up. Repeated measures analysis of variance was used to assess the effectiveness of CBTi in treating insomnia, depressive symptoms and anxiety symptoms. A multivariate Cox regression model was used to determine the impact of depressive and anxiety symptoms on insomnia.

Results

The study found significant reductions in insomnia, depressive symptoms and anxiety symptoms at both post-treatment and 3-month follow-up (F=17.45, p<0.001; F=36.37, p=0.001; and F=81.51, p<0.001, respectively). The duration of CBTi treatment had a positive impact on insomnia recovery (hazard ratio (HR)=0.94, p=0.018). However, baseline depressive symptoms (HR=1.83, p=0.004) and baseline anxiety symptoms (HR=1.99, p=0.001) had significant negative effects on insomnia recovery.

Conclusions

The study showed that a 1-week self-guided CBTi treatment is effective in treating acute insomnia and comorbid depressive and anxiety symptoms. However, baseline depressive and anxiety symptoms negatively impact treatment effectiveness. Therefore, clinicians should assess for depressive and anxiety symptoms before treating acute insomnia with monotherapy CBTi.

Mindfulness as an Adjunct or Alternative to CBT-I

Mindfulness-based interventions (MBIs) are programs that teach mindfulness concepts through guided meditation and self-regulation practices. MBIs have been found to improve sleep and reduce cognitive arousal, which are central to the development and perpetuation of insomnia. In this article, we review theoretic frameworks and clinical trial effectiveness data supporting MBIs for insomnia. Based on this review, we provide suggestions for using MBIs as an adjunct or alternative treatment option to CBT-I with regard to how, when, and for whom. We conclude with an agenda for future directions that can clarify the use of mindfulness as a treatment option for insomnia.

Hope Buffers the Effect of Fear of COVID-19 on Depression among College Students: Insomnia as a Mediator

BACKGROUND

In the period of the global pandemic, psychophysical problems induced by the fear of COVID-19 among college students deserve attention since the dormitory environment in college greatly increases the possibility of COVID-19 infection.

METHODS

A hypothesized mediated moderation model was to be verified using a cross-sectional study among 2453 college students. Fear of COVID-19, insomnia, hope, and depression were assessed by using the relevant scales.

RESULTS

(1) The fear of COVID-19 was positively correlated to depression (β = 0.365, t = 5.553, 95% CI = [0.236, 0.494]); (2) hope moderated the influence of the fear of COVID-19 on depression (β = -0.093, t = -4.066, 95% CI = [-0.137, -0.048]), as well as on insomnia (β = -0.095, t = -4.841, 95% CI = [-0.133, -0.056]); and (3) the mediated moderation model with hope as the moderator and insomnia as the full mediating variable between fear of COVID-19 and depression was verified (β = -0.060, 95% CI = [-0.093, -0.028]).

CONCLUSIONS

The findings suggest that hope is a vital mechanism to explain the relationship between the fear of COVID-19 and depression in early adulthood. In practical application, mental health practitioners should focus on boosting hope and alleviating insomnia when addressing COVID-19-related depression issues among college students.

Racial disparities in treatment engagement and outcomes in digital cognitive behavioral therapy for insomnia among pregnant women

OBJECTIVES

In the United States, Black women are disproportionately afflicted with prenatal insomnia. Although cognitive-behavioral therapy for insomnia (CBTI) may represent a strategy to reduce disparities in insomnia, racial minorities attend fewer healthcare appointments and have poorer outcomes from prenatal care and mental health treatment relative to white patients. The present study examined differences in treatment engagement and patient-reported outcomes in non-Hispanic Black and white pregnant women receiving digital CBTI.

METHODS

Secondary analysis of 39 pregnant women with clinical insomnia who received digital CBTI. Treatment engagement was operationalized as the number of sessions completed (≥4 considered an adequate dose). Treatment outcomes were assessed using the Insomnia Severity Index (ISI; insomnia) and Pittsburgh Sleep Quality Index (PSQI; global sleep disturbance).

RESULTS

Black women were 4 times more likely than white women to discontinue CBTI before receiving an adequate dose (8.3% vs. 33.3%). Regarding treatment outcomes, white women reported a mean reduction of 5.75 points on the ISI and a reduction of 3.33 points on the PSQI (Cohen's dz = 1.10-1.19). By comparison, Black women reported reductions of 2.13 points on the ISI and 1.53 points on the PSQI, which were statistically non-significant. Differences in treatment engagement did not account for the disparities in patient-reported outcomes.

CONCLUSIONS

During pregnancy, Black women completed fewer CBTI sessions and experienced poorer treatment outcomes in response to digital CBTI relative to white women. Enhancements to insomnia therapy and its digital delivery may improve adherence and outcomes in Black pregnant women.

Cognitive-behavioral therapy for insomnia prevents and alleviates suicidal ideation: insomnia remission is a suicidolytic mechanism

STUDY OBJECTIVES

Insomnia is associated with elevated levels of suicidal thoughts and behaviors. Emerging evidence suggests that cognitive-behavioral therapy for insomnia (CBTI) may reduce suicidal ideation (SI). However, the role of digital therapeutics in both the alleviation and prevention of SI remains unclear, and treatment mechanisms facilitating SI reductions have not been clearly identified.

METHODS

A total of 658 adults with Diagnostic and Statistical Manual of Mental Disorders, 5th Edition insomnia disorder enrolled in a single-site randomized controlled trial evaluating the efficacy of digital CBTI relative to attention control. Outcomes were measured at pretreatment, posttreatment, and 1-year follow-up.

RESULTS

Before treatment, 126 patients endorsed SI (19.1% prevalence). Among those with baseline SI, CBTI patients reported lower SI rates at posttreatment (30.0% vs 54.5%, p = .005) and 1-year follow-up (29.6% vs 46.8%, p = .042) relative to control. PRODCLIN analysis estimated that half of suicidolytic effects of CBTI were mediated through insomnia remission. Among those without baseline SI, CBTI did not directly prevent new onset SI. However, insomnia remitters reported lower rates of new-onset SI at posttreatment relative to non-remitters (1.5% vs 6.5%, p = .009). Mediation analysis supported a significant indirect effect wherein CBTI increased the likelihood of insomnia remission, which was associated with SI prevention (αβ = -3.20, 95% CI = -5.74 to -0.87).

CONCLUSION

Digital CBTI reduces insomnia symptoms, which promotes SI alleviation and prevention. For nonsuicidal patients, digital CBTI may serve as a highly accessible monotherapy for improving sleep, thereby reducing the risk for SI. For suicidal patients, digital CBTI may be appropriately administered as an adjunct treatment to support mainline intervention more directly targeting suicidogenic thoughts.

Sleep to Reduce Incident Depression Effectively (STRIDE): study protocol for a randomized controlled trial comparing stepped-care cognitive-behavioral therapy for insomnia versus sleep education control to prevent major depression

BACKGROUND

Prevention of major depressive disorder (MDD) is a public health priority. Strategies targeting individuals at elevated risk for MDD may guide effective preventive care. Insomnia is a reliable precursor to depression, preceding half of all incident and relapse cases. Thus, insomnia may serve as a useful entry point for preventing MDD. Cognitive-behavioral therapy for insomnia (CBT-I) is recommended as the first-line treatment for insomnia, but widespread implementation is limited by a shortage of trained specialists. Innovative stepped-care approaches rooted in primary care can increase access to CBT-I and reduce rates of MDD.

METHODS/DESIGN

We propose a large-scale stepped-care clinical trial in the primary care setting that utilizes a sequential, multiple assignment, randomized trial (SMART) design to determine the effectiveness of dCBT-I alone and in combination with clinician-led CBT-I for insomnia and the prevention of MDD incidence and relapse. Specifically, our care model uses digital CBT-I (dCBT-I) as a first-line intervention to increase care access and reduce the need for specialist resources. Our proposal also adds clinician-led CBT-I for patients who do not remit with first-line intervention and need a more personalized approach from specialty care. We will evaluate negative repetitive thinking as a potential treatment mechanism by which dCBT-I and CBT-I benefit insomnia and depression outcomes.

DISCUSSION

This project will test a highly scalable model of sleep care in a large primary care system to determine the potential for wide dissemination and implementation to address the high volume of population need for safe and effective insomnia treatment and associated prevention of depression.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03322774. Registered on October 26, 2017.

Self-efficacy in Insomnia Symptom Management after Digital CBT-I Mediates Insomnia Severity during the COVID-19 Pandemic

STUDY OBJECTIVES

Digital cognitive behavioral therapy for insomnia (dCBT-I) can reduce acute insomnia and depressive symptoms and prevent symptom recurrence. The current study evaluated self-efficacy in managing insomnia symptoms as a potential mediator of the relationship between prior dCBT-I and subsequent insomnia and depressive symptoms assessed during the coronavirus 2019 (COVID-19) pandemic.

METHOD

Participants were 208 adults who completed a randomized controlled trial of dCBT-I versus sleep education in 2016-2017 and also completed self-report assessments of insomnia, depression, and self-efficacy in managing insomnia symptoms. Data were collected in May 2020, five weeks into state-wide COVID-19 stay-at-home orders. Regression and mediation analyses were used to evaluate the extent to which self-efficacy accounted for the relationship between treatment condition and improvement in insomnia and depressive symptoms from pre-treatment to COVID-19 follow-up.

RESULTS

Prior dCBT-I predicted greater self-efficacy in managing insomnia symptoms. Self-efficacy accounted for 49% and 67% of the protective effect of dCBT-I against COVID-era insomnia and depressive symptoms, respectively.

CONCLUSIONS

This study affirms the importance of self-efficacy as a key intervention outcome and potential mechanism by which dCBT-I predicts future sleep and mental health. Future studies that evaluate the role of self-efficacy in treatment effectiveness and resilience can provide additional clues about how to optimize dCBT-I for maximum benefit to public health.

Early indicators of vulnerability to depression: The role of rumination and heart rate variability

BACKGROUND

Despite the evidence of increased levels of rumination and reduced heart rate variability (HRV) in depression, whether these measures can be considered early indicators of vulnerability to depression has yet to be investigated. Therefore, the present study aimed to investigate both levels of rumination and resting HRV in individuals with familial risk for depression that is the most reliable risk factor for the disorder.

METHODS

Rumination and vagally-mediated HRV were assessed using the Ruminative Response Scale and a smartphone-based photoelectric volumetric pulse wave assay, respectively, in 25 individuals who had family history of depression (but did not report current depressive symptoms), 15 individuals who reported depressive symptoms (but had no family history of depression), and 25 controls (without depressive symptoms and family history of depression).

RESULTS

Individuals with depressive symptoms and those with a family history of depression were characterized by higher levels of rumination and lower cardiac vagal control than controls.

LIMITATIONS

Given the small sample size, this study should be used to design larger confirmatory studies; the cross-sectional nature of the study does not allow discussing the results in terms of cause-effect relationships.

CONCLUSIONS

Our findings suggested that individuals at risk of developing depression, also in absence of depressive symptoms, are defined by defective self-regulation capacity that may lead to future depression episodes. Increased ruminative thoughts and reduced HRV may represent early indicators of vulnerability to depression. Effective prevention programs designed to reduce rumination and/or increase HRV may reduce the risk of developing a full-blown depressive episode.

Prevalence of anxiety and depression among pregnant women during the COVID-19 pandemic: a meta-analysis

PURPOSE

Coronavirus disease (COVID-19) is a newly emerged respiratory illness, which has spread around the world. Pregnant women are exposed to additional pressure due to the indirect adverse effects of this pandemic on their physical and mental health. Since the psychological wellness framework is weak in developing countries, it is likely that geographical factors affect the prevalence. Therefore, the goal of this meta-analysis is to investigate the prevalence of anxiety and depression among pregnant women during the COVID-19 pandemic.

METHODS

We searched databases including PubMed/MEDLINE, Web of Science, Cochrane Library for articles. The quality of studies was determined based on the STROBE checklist. I2 and Cochrane Q-test were used to determine heterogeneity. Fixed effects and/or random effects models were also employed to estimate pooled prevalence.

RESULTS

Since heterogeneity was fairly high in all analyses, the random effect model was used. According to the results of random effects in the meta-analysis, the pooled prevalence was 18.7% (95% CI: 0.06-0.36%; I2=99%,P<0.001) for anxiety and 25.1% (95% CI: 0.18-0.33%; I2=97%, P<0.001) for depression. The results of continent subgroup analysis showed that the prevalence of anxiety was higher in western country (38%) than in Asia country (7.8%). The prevalence of anxiety in Italy (38%), Canada (56%), Pakistan (14%), Greece (53%), Sri Lanka (17.5%), and China (0.3-29%) and Iran 3.8% as well as the prevalence of depression in Canada (37%), Belgium (25%), Turkey (35.4%), Sri Lanka (19.5%), and China (11-29%) has been reported.

CONCLUSION

Covid-19 may impose extra pressure on the emotional wellbeing of pregnant women. Therefore, there is an urgent need for resources to help mitigate anxiety and depression in pregnant women.

The Potential for Outdoor Nature-Based Interventions in the Treatment and Prevention of Depression

There is growing interest in nature-based interventions (NBI) to improve human health and wellbeing. An important nascent area is exploring the potential of outdoor therapies to treat and prevent common mental health problems like depression. In this conceptual analysis on the nature-depression nexus, we distil some of the main issues for consideration when NBIs for depression are being developed. We argue that understanding the mechanisms, or 'active ingredients' in NBIs is crucial to understand what works and for whom. Successfully identifying modifiable mediating intervention targets will pave the way for interventions with increased efficacy. We highlight a non-exhaustive list of five clinically relevant putative, candidate mechanisms which may underly the beneficial effects of NBIs on depression: stress, rumination, mindfulness, sleep and exercise. We also make the case that when developing NBIs it is important to not neglect young people, explore personalised approaches and focus on both treatment and prevention approaches. To achieve these aims methodologically rigorous programmes of clinical research are needed that include well-powered and controlled experimental designs including randomised controlled trials, qualitative research, longitudinal studies and large prospective cohorts.

Examining Patient Feedback and the Role of Cognitive Arousal in Treatment Non-response to Digital Cognitive-behavioral Therapy for Insomnia during Pregnancy

OBJECTIVE

Insomnia affects over half of pregnant and postpartum women. Early evidence indicates that cognitive-behavioral therapy for insomnia (CBTI) improves maternal sleep and mood. However, standard CBTI may be less efficacious in perinatal women than the broader insomnia population. This study sought to identify patient characteristics in a perinatal sample associated with poor response to CBTI, and characterize patient feedback to identify areas of insomnia therapy to tailor for the perinatal experience.

PARTICIPANTS

Secondary analysis of 46 pregnant women with insomnia symptoms who were treated with digital CBTI in a randomized controlled trial.

METHODS

We assessed insomnia, cognitive arousal, and depression before and after prenatal treatment, then 6 weeks postpartum. Patients provided feedback on digital CBTI.

RESULTS

Residual cognitive arousal after treatment was the most robust factor associated with treatment non-response. Critically, CBTI responders and non-responders differed on no other sociodemographic or pretreatment metrics. After childbirth, short sleep (<6 hrs/night) was associated with maternal reports of poor infant sleep quality. Patient feedback indicated that most patients preferred online treatment to in-person treatment. Although women described digital CBTI as convenient and helpful, many patients indicated that insomnia therapy would be improved if it addressed sleep challenges unique to pregnancy and postpartum. Patients requested education on maternal and infant sleep, flexibility in behavioral sleep strategies, and guidance to manage infant sleep.

CONCLUSIONS

Modifying insomnia therapy to better alleviate refractory cognitive arousal and address the changing needs of women as they progress through pregnancy and early parenting may increase efficacy for perinatal insomnia.Name: Insomnia and Rumination in Late Pregnancy and the Risk for Postpartum DepressionURL: clinicaltrials.govRegistration: NCT03596879.

Moderators of Cognitive Behavioral Treatment for Insomnia on Depression and Anxiety Outcomes

PURPOSE OF REVIEW

With a focus on reviewing adequately powered randomized controlled trials, we present recent research on the potential of cognitive behavioral therapy for insomnia (CBT-I) to improve depression and anxiety outcomes among patients with insomnia and one of the following comorbid psychiatric disorders: major depressive disorder (MDD), generalized anxiety disorder (GAD), or posttraumatic stress disorder (PTSD). We also examine potential moderators of CBT-I on depression and anxiety outcomes in this population.

RECENT FINDINGS

Despite high comorbidity rates, current behavioral and pharmacological treatments for MDD, GAD, and PTSD do not substantially target or improve insomnia symptoms; residual insomnia is exceedingly common even among patients who experience remission. Insomnia plays a critical role in the onset and maintenance of depression and anxiety, and treating insomnia with CBT-I may improve global outcomes for patients with MDD, GAD, and PTSD. CBT-I is superior to traditional depression/anxiety treatment in improving insomnia symptoms among patients with comorbid psychiatric disorders. Results are mixed on whether CBT-I (either alone or augmented with depression/anxiety treatment) is effective in improving overall MDD, GAD, and PTSD outcomes. Evening circadian preference and depression/anxiety symptom severity may moderate the effect of CBT-I on depression and anxiety outcomes.

Childhood Maltreatment, Sleep Disturbances, and Anxiety and Depression: A Prospective Longitudinal Investigation

This research sought to determine whether inadequate sleep conditions in childhood and sleep problems in young adulthood in part explain the relationship between childhood abuse and neglect and anxiety and depression later in life. Children with documented histories of abuse and neglect and matched controls were followed up and assessed in young and middle adulthood. Abused and neglected children were more likely to report experiencing inadequate sleep conditions in childhood, sleep problems in young adulthood, and higher levels of depression and anxiety later in middle adulthood. Results revealed significant indirect paths from childhood maltreatment to anxiety and depression in middle adulthood through inadequate sleep conditions in childhood and sleep problems in young adulthood. This longitudinal follow-up of children with documented cases of maltreatment reveals the important role of sleep disturbances in the lives of maltreated children and adults and sleep disturbances in the development of subsequent anxiety and depression.

Does adjunctive digital CBT for insomnia improve clinical outcomes in an improving access to psychological therapies service?

BACKGROUND

Insomnia has a bidirectional relationship with broader mental health functioning, including anxiety and depression. Yet, poor sleep has historically been neglected as a specific treatment target in mental health programmes (Freeman, Sheaves, Waite, Harvey, & Harrison, 2020).

METHOD

All patients over a 12-month period entering the Improving Access to Psychological Therapies (IAPT) service endorsing a 'poor sleep' questionnaire item at assessment, were offered a self-guided digital sleep intervention, Sleepio, in addition to routine care. Sleepio is based on the principles of Cognitive Behavioural Therapy for Insomnia (CBT-I). Propensity score matching established a non-Sleepio control group matched on demographic and baseline clinical measures.

RESULTS

Patients who signed up to Sleepio (n = 510) achieved significantly better outcomes on core clinical metrics (PHQ-9, GAD-7, WSAS) than controls. IAPT recovery rates¹ (on PHQ-9 and GAD-7) were 64.7%, versus 58% in the control group. Duration of clinical contact time was marginally elevated overall in the Sleepio group but by less than 1 h CONCLUSIONS: Significant clinical benefit was associated with the introduction of an evidence-based digital sleep intervention alongside other mental health interventions for depression and anxiety. Widespread deployment was achieved with immediate availability, minimal additional clinical time or staff training. This approach provides a feasible and highly scalable model for improving mental health outcomes in clinical services.

Digital cognitive behavioral therapy for insomnia promotes later health resilience during the coronavirus disease 19 (COVID-19) pandemic

STUDY OBJECTIVES

Stressful life events contribute to insomnia, psychosocial functioning, and illness. Though individuals with a history of insomnia may be especially vulnerable during stressful life events, risk may be mitigated by prior intervention. This study evaluated the effect of prior digital cognitive-behavioral therapy for insomnia (dCBT-I) versus sleep education on health resilience during the COVID-19 pandemic.

METHODS

COVID impact, insomnia, general- and COVID-related stress, depression, and global health were assessed in April 2020 in adults with a history of insomnia who completed a randomized controlled trial of dCBT-I (n = 102) versus sleep education control (n = 106) in 2016-2017. Regression analyses were used to evaluate the effect of intervention conditions on subsequent stress and health during the pandemic.

RESULTS

Insomnia symptoms were significantly associated with COVID-19 related disruptions, and those who previously received dCBT-I reported less insomnia symptoms, less general stress and COVID-related cognitive intrusions, less depression, and better global health than those who received sleep education. Moreover, the odds for resurgent insomnia was 51% lower in the dCBT-I versus control condition. Similarly, odds of moderate to severe depression during COVID-19 was 57% lower in the dCBT-I condition.

CONCLUSIONS

Those who received dCBT-I had increased health resilience during the COVID-19 pandemic in adults with a history of insomnia and ongoing mild to moderate mental health symptoms. These data provide evidence that dCBT-I is a powerful tool to promote mental and physical health during stressors, including the COVID-19 pandemic.

CLINICAL TRIAL REGISTRATION

NCT02988375.

How does cognitive behavioural therapy for insomnia work? A systematic review and meta-analysis of mediators of change

Insomnia is prevalent and debilitating, comprising sustained difficulties initiating or maintaining sleep. Cognitive-behavioural therapy for insomnia (CBT-I) is a multicomponent intervention recommended as the first-line treatment, but the mediators of change remain unclear. This systematic review and meta-analysis aimed to synthesise and evaluate the evidence for potential mediators of CBT-I. Searches were performed for studies published until February 2021, reporting on mediation analyses with CBT-I. Seventeen unique samples of adults with insomnia (20 studies, N = 3125) were included. Two-stage structural equation modelling was applied to the available data, where 7 studies examined the cognitive mediator, 'dysfunctional beliefs about sleep', 5 studies examined a hyperarousal mediator, and 3 studies examined the behavioural mediator, 'time in bed'. There was evidence in support of changes in dysfunctional beliefs as a cognitive mediator of insomnia symptom improvement following CBT-I. There was more limited evidence in support of changes in hyperarousal-related mediators, and no significant effect of time in bed as a mediator. Numerous studies recorded diary-based measures of potential behavioural mediators, but analyses of these variables were not typically conducted. The most serious limitation of the evidence base is that the temporal precedence of mediator changes cannot be established. Future studies should consider: i) using mid-treatment measurements of mediator changes; ii) reporting on mediator psychometric properties; and iii) explicitly stating analyses as pre-specified or exploratory.

Objective sleep disturbance is associated with poor response to cognitive and behavioral treatments for insomnia in postmenopausal women

STUDY OBJECTIVES

To determine whether insomnia patients with objective sleep disturbance are less responsive to cognitive and behavioral treatments than those without objective sleep disturbance, characterize effects of insomnia therapy on objective sleep, and determine whether reductions in nocturnal cognitive arousal correspond to changes in objective sleep.

METHODS

Secondary analysis of a single-site, randomized controlled trial. 113 postmenopausal women (56.40 ± 5.34 years) with menopause-related insomnia disorder were randomized to three treatment conditions: cognitive-behavioral therapy for insomnia (CBTI), sleep restriction therapy (SRT), or sleep education control. Primary outcomes were the Insomnia Severity Index (ISI) and polysomnography (PSG) sleep parameters and were collected at pretreatment, posttreatment, and six-month follow-up.

RESULTS

Patients with lower pretreatment PSG sleep efficiency had lower rates of insomnia remission after active treatment relative to those with higher sleep efficiency (37.8% vs 61.8%). Neither CBTI and SRT produced clinically meaningful effects on PSG sleep. Exploratory analyses revealed that reductions in nocturnal cognitive arousal were associated with decreases in PSG sleep latency, but not wake after sleep onset.

CONCLUSIONS

Our findings support an emerging literature suggesting that insomnia patients with objective sleep disturbance may have blunted response to insomnia therapy. Research is needed to enhance treatments to better improve insomnia in patients with objective sleep disturbance. A lack of observed CBTI and SRT effects on PSG sleep suggests that these therapies may be presently ill-designed to improve objective sleep. Nocturnal cognitive arousal may represent an entry point to improve objective sleep latency in insomnia. NAME: Behavioral Treatment of Menopausal Insomnia: Sleep and Daytime Outcomes. URL: clinicaltrials.gov. Registration: NCT01933295.