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

Insomnia is more likely to persist than remit after a time of stress and uncertainty: a longitudinal cohort study examining trajectories and predictors of insomnia symptoms

STUDY OBJECTIVES

The study aimed to characterize insomnia symptom trajectories over 12 months during a time of stress and uncertainty, the coronavirus disease 2019 (COVID-19) pandemic. It also aimed to investigate sleep and psychological predictors of persistent insomnia symptoms.

METHODS

This longitudinal cohort study comprised 2069 participants with and without insomnia symptoms during the first year of the pandemic. Participants completed online surveys investigating sleep, insomnia, and mental health at four timepoints over 12 months (April 2020-May 2021). Additional trait-level cognitive/psychological questionnaires were administered at 3 months only.

RESULTS

Six distinct classes of insomnia symptoms emerged: (1) severe persistent insomnia symptoms (21.65%), (2) moderate persistent insomnia symptoms (32.62%), (3) persistent good sleep (32.82%), (4) severe insomnia symptoms at baseline but remitting over time (2.27%), (5) moderate insomnia symptoms at baseline but remitting over time (7.78%), and (6) good sleep at baseline but deteriorating into insomnia symptoms over time (2.85%). Persistent insomnia trajectories were predicted by high levels of sleep reactivity, sleep effort, pre-sleep cognitive arousal, and depressive symptoms at baseline. A combination of high sleep reactivity and sleep effort reduced the odds of insomnia remitting. Higher sleep reactivity also predicted the deterioration of good sleep into insomnia symptoms over 12 months. Lastly, intolerance of uncertainty emerged as the only trait-level cognitive/psychological predictor of insomnia trajectory classes.

CONCLUSIONS

Insomnia was more likely to persist than remit over the first year of the COVID-19 pandemic. Addressing sleep reactivity and sleep effort appears critical for reducing insomnia persistence rates after times of stress and uncertainty.

The sleep response to stress: how sleep reactivity can help us prevent insomnia and promote resilience to trauma

Sleep reactivity is a predisposition to sleep disturbance during environmental perturbations, pharmacological challenges, or stressful life events. Consequently, individuals with highly reactive sleep systems are prone to insomnia disorder after a stressor, engendering risk of psychopathology and potentially impeding recovery from traumatic stress. Thus, there is tremendous value in ameliorating sleep reactivity to foster a sleep system that is robust to stress exposure, ultimately preventing insomnia and its downstream consequences. We reviewed prospective evidence for sleep reactivity as a predisposition to insomnia since our last review on the topic in 2017. We also reviewed studies investigating pre-trauma sleep reactivity as a predictor of adverse post-traumatic sequelae, and clinical trials that reported the effect of behavioural treatments for insomnia on mitigating sleep reactivity. Most studies measured sleep reactivity via self-report using the Ford Insomnia Response to Stress Test (FIRST), demonstrating high scores on this scale reliably indicate a sleep system with a lower capacity to tolerate stress. Nascent evidence suggests elevated sleep reactivity prior to trauma increases the risk of negative posttraumatic outcomes, namely acute stress disorder, depression, and post-traumatic stress disorder. Lastly, sleep reactivity appears most responsive to behavioural insomnia interventions when delivered early during the acute phase of insomnia. Overall, the literature strongly supports sleep reactivity as a premorbid vulnerability to incident acute insomnia disorder when faced with an array of biopsychosocial stressors. The FIRST identifies individuals at risk of insomnia a priori, thereby guiding early interventions toward this vulnerable population to prevent insomnia and promote resilience to adversity.

Insomnia symptoms among older adults during the first year of the COVID-19 pandemic: A longitudinal study

OBJECTIVE

To identify sociodemographic, psychological, and health factors related to trajectories of insomnia symptoms in older adults during the COVID-19 pandemic.

METHODS

From May 2020 to May 2021, 644 older adults (mean age = 78.73, SD = 5.60) completed telephone-administered self-reported measures (ie, Insomnia Severity Index, consensus sleep diaries, UCLA Loneliness Scale, Kessler Psychological Distress Scale, Post-Traumatic Checklist, perceived health threat, and International Physical Activity Questionnaire) and provided sociodemographic data at 4 timepoints. Using the Insomnia Severity Index score at each timepoint, group-based trajectory modeling was conducted to identify groups with distinct insomnia trajectories.

RESULTS

On average, there was no significant change in insomnia symptoms over time. Three groups with distinct sleep trajectories were identified: clinical (11.8%), subthreshold (25.3%), and good sleepers (62.9%). Older adults who were younger, male, had elevated psychological distress and posttraumatic stress disorder symptoms, perceived more SARS-CoV-2 health threat, spent more time in bed, and had shorter sleep duration during the first wave of the pandemic were more likely to belong to the clinical than to the good sleepers group. Those who were younger, female, had elevated psychological distress and PTSD symptoms, greater loneliness, spent more time in bed, and had reduced sleep duration during the first wave were more likely to belong to the subthreshold than to the good sleepers group.

CONCLUSIONS

Over 1 in 3 older adults experienced persistent subthreshold or clinically significant insomnia symptoms. Both sleep-related behaviors as well as general and COVID-19-related psychological factors were associated with insomnia trajectories.

People with passive sleep delay have more severe depression and sleep problems than those with active sleep delays-a cross-sectional study after the COVID-19 pandemic

Objective

This study was designed to investigate the effect of different types of sleep delay in depression and sleep characteristics after the pandemic. Meanwhile, risk factors for depression were also explored.

Methods

The survey was conducted in Wuhan from March 1 to May 30, 2021, and participants were recruited through a snowball process. A total of 1,583 people with sleep delays responded to the invitation, of which 1,296 were enrolled. Participants filled out a questionnaire including social demographics, sleep characteristics, Social Support Rating Scale (SSRS), Pittsburgh Sleep Quality Index (PSQI) and Patient Health Questionnaire-9 (PHQ-9).

Results

There were no significant differences in sex, social support and level of education between the two types of sleep delay (p = 0.961, p = 0.110, p = 0.090), but the average age of the passive sleep delay group was higher (p = 0.015). And most people with active sleep delay were caused by the use of electronic devices (73.6%), while most people with passive sleep delay were caused by work or study tasks (73.2%), with a significant difference between the two groups (p < 0.001). People who actively delayed sleep had more regular sleep (p < 0.001), better sleep quality and longer sleep duration (p < 0.001, p < 0.001). In addition, although they delayed sleep more frequently (p < 0.001), they had significantly lower depression degree than people who passively delayed sleep (p < 0.001).

Conclusions

Passive sleep delays, usually caused by work or study, has higher levels of depression and more adverse sleep behaviors than active sleep delay. The findings help further understand the effects of delayed sleep and provide insight for people with delayed sleep to evaluate their own condition. Future studies are required to standardize and accurately classify sleep delay and further explore it.

Pre-pandemic sleep reactivity prospectively predicts distress during the COVID-19 pandemic: The protective effect of insomnia treatment

The COVID-19 pandemic is a rare stressor that has precipitated an accompanying mental health crisis. Prospective studies traversing the pandemic's onset can elucidate how pre-existing disease vulnerabilities augured risk for later stress-related morbidity. We examined how pre-pandemic sleep reactivity predicted maladaptive stress reactions and depressive symptoms in response to, and during, the pandemic. This study is a secondary analysis of a randomised controlled trial from 2016 to 2017 comparing digital cognitive behavioural therapy for insomnia (dCBT-I) against sleep education (N = 208). Thus, we also assessed whether dCBT-I moderated the association between pre-pandemic sleep reactivity and pandemic-related distress. Pre-pandemic sleep reactivity was measured at baseline using the Ford Insomnia Response to Stress Test. In April 2020, participants were recontacted to report pandemic-related distress (stress reactions and depression). Controlling for the treatment condition and the degree of COVID-19 impact, higher pre-pandemic sleep reactivity predicted more stress reactions (β = 0.13, ± 0.07 SE, p = 0.045) and depression (β = 0.22, ± 0.07 SE, p = 0.001) during the pandemic. Further, the odds of reporting clinically significant stress reactions and depression during the pandemic were over twice as high in those with high pre-pandemic sleep reactivity. Notably, receiving dCBT-I in 2016-2017 mitigated the relationship between pre-pandemic sleep reactivity and later stress reactions (but not depression). Pre-pandemic sleep reactivity predicted psychological distress 3-4 years later during the COVID-19 pandemic, and dCBT-I attenuated its association with stress reactions, specifically. Sleep reactivity may inform prevention and treatment efforts by identifying individuals at risk of impairment following stressful events.