Psychological status and levels of sleepiness-alertness among patients with insomnia

Sleep parameters improvement in PTSD soldiers after symptoms remission

Eye movement desensitization and reprocessing (EMDR) is a psychotherapy for the treatment of posttraumatic stress disorder (PTSD). It is still unclear whether symptoms remission through EMDR therapy is associated with a beneficial effect on one of the PTSD symptoms, sleep disturbance. Our objective was therefore to study sleep parameters before and after symptom remission in soldiers with PTSD. The control group consisted of 20 healthy active duty military men who slept in a sleep lab with standard polysomnography (PSG) on two sessions separated by one month. The patient group consisted of 17 active duty military with PTSD who underwent EMDR therapy. PSG-recorded sleep was assessed 1 week before the EMDR therapy began and 1 week after PTSD remission. We found that the increased REMs density after remission was positively correlated with a greater decrease of symptoms. Also, the number of EMDR sessions required to reach remission was correlated with intra-sleep awakenings before treatment. These results confirm the improvement of some sleep parameters in PTSD after symptoms remission in a soldier's population and provide a possible predictor of treatment success. Further experiments will be required to establish whether this effect is specific to the EMDR therapy.

Examining Insomnia and PTSD Over Time in Veterans in Residential Treatment for Substance Use Disorders and PTSD

Objective/Background: Insomnia occurs in 66-90% of individuals with posttraumatic stress disorder (PTSD) and 36-72% of individuals with substance use disorder (SUD). Individuals with both PTSD and SUD are more likely to have insomnia than individuals with only one disorder. Insomnia is associated with poorer treatment outcomes for both PTSD and SUD, increased daytime symptomology for PTSD, and increased relapse for SUDs. As such, it is important to understand how sleep affects PTSD treatment among patients dually diagnosed with SUD and how sleep changes over time in a residential unit for SUDs. Participants: Participants were 40 veterans with comorbid PTSD and SUD in a 28-day Substance Abuse Residential Rehabilitation Treatment Program (SARRTP) PTSD track. Methods: Analyses used mixed models with Time (baseline, posttreatment, 3-month follow-up) to examine PTSD and insomnia severity over time. Results: Results of the longitudinal mixed model showed that PTSD symptoms improved over time but that insomnia symptoms did not. Although baseline insomnia did not affect follow-up PTSD symptoms, individuals with greater insomnia severity at the start of treatment had more severe baseline PTSD symptomatology. However, there was not an interaction of insomnia and PTSD severity over time such that baseline insomnia did not affect PTSD trajectories. Conclusions: These findings are consistent with the PTSD outpatient treatment findings and further adds evidence that insomnia is unremitting without direct intervention. Given the relationship insomnia has with PTSD severity, SUD, and relapse, directly targeting insomnia may further help improve both PTSD and SUD treatment outcomes.

Cognitive behavioral therapy for insomnia in posttraumatic stress disorder: a randomized controlled trial

STUDY OBJECTIVES

Examine whether cognitive behavioral therapy for insomnia (CBT-I) improves sleep in posttraumatic stress disorder (PTSD) as well as nightmares, nonsleep PTSD symptoms, depression symptoms, and psychosocial functioning.

DESIGN

RANDOMIZED CONTROLLED TRIAL WITH TWO ARMS: CBT-I and monitor-only waitlist control.

SETTING

Department of Veterans Affairs (VA) Medical Center.

PARTICIPANTS

Forty-five adults (31 females: [mean age 37 y (22-59 y)] with PTSD meeting research diagnostic criteria for insomnia, randomly assigned to CBT-I (n = 29; 22 females) or monitor-only waitlist control (n = 16; nine females).

INTERVENTIONS

Eight-session weekly individual CBT-I delivered by a licensed clinical psychologist or a board-certified psychiatrist.

MEASUREMENTS AND RESULTS

Measures included continuous monitoring of sleep with diary and actigraphy; prepolysomnography and postpolysomnography and Clinician-Administered PTSD Scale (CAPS); and pre, mid, and post self-report questionnaires, with follow-up of CBT-I participants 6 mo later. CBT-I was superior to the waitlist control condition in all sleep diary outcomes and in polysomnography-measured total sleep time. Compared to waitlist participants, CBT-I participants reported improved subjective sleep (41% full remission versus 0%), disruptive nocturnal behaviors (based on the Pittsburgh Sleep Quality Index-Addendum), and overall work and interpersonal functioning. These effects were maintained at 6-mo follow-up. Both CBT-I and waitlist control participants reported reductions in PTSD symptoms and CAPS-measured nightmares.

CONCLUSIONS

Cognitive behavioral therapy for insomnia (CBT-I) improved sleep in individuals with posttraumatic stress disorder, with durable gains at 6 mo. Overall psychosocial functioning improved following CBT-I. The initial evidence regarding CBT-I and nightmares is promising but further research is needed. Results suggest that a comprehensive approach to treatment of posttraumatic stress disorder should include behavioral sleep medicine.

CLINICAL TRIAL INFORMATION

TRIAL NAME: Cognitive Behavioral Treatment Of Insomnia In Posttraumatic Stress Disorder. URL: http://clinicaltrials.gov/ct2/show/NCT00881647.

REGISTRATION NUMBER

NCT00881647.

Excessive sleepiness: under-recognized and essential marker for sleep/wake disorder management

BACKGROUND

Research during the past few decades has provided substantial evidence indicating that excessive sleepiness (ES) and associated sleep/wake disorders can result in significant morbidity and mortality. However, symptomatology (e.g., ES) and the relationships among common morbidities (e.g., cardiovascular disease, metabolic disorders, mood impairment) and sleep/wake disorders remain under-recognized in clinical practice, particularly in primary care. Yet assessment of sleep/wakefulness and associated symptoms can often be easily conducted in the primary care setting, providing valuable information to facilitate the diagnosis and management of sleep/wake disorders.

OBJECTIVE

To provide a conceptual and educational framework that helps primary care physicians comprehensively assess, differentially diagnosis, and appropriately manage patients presenting with ES or ES-related sleep/wake disorders.

METHODS

Comprised of six sleep specialists and six primary care physicians, the Sleep/Wake Disorders Working Group (SWG) used a modified, two-round Delphi approach to create and harmonize consensus recommendations for the assessment, diagnosis, treatment, and ongoing management of patients with common sleep/wake disorders related to ES.

RESULTS

After a review of the relevant literature, the SWG arrived at consensus on a number of clinical recommendations for the assessment and management ES and some of the most commonly associated sleep/wake disorders. Ten consensus statements – five each for assessment/diagnosis and treatment/ongoing care – were created for ES, insomnia, obstructive sleep apnea, circadian rhythm disorders, restless legs syndrome, and narcolepsy.

CONCLUSION

ES and ES-related sleep/wake disorders are commonly encountered in the primary care setting. By providing an educational framework for primary care physicians, the SWG hopes to improve patient outcomes by emphasizing recognition, prompt diagnosis, and appropriate ongoing management of ES and associated sleep/wake disorders.

Treatment options for insomnia--pharmacodynamics of zolpidem extended-release to benefit next-day performance

BACKGROUND

Insomnia can manifest as difficulty in falling asleep, in maintaining sleep throughout the night, or waking up too early, with symptoms often unpredictably changing over time. Pharmacologic options for insomnia treatment include prescription hypnotics, such as gamma-amino butyric acid-receptor agonists, sedating antidepressants, over-the-counter antihistamines, melatonin-receptor agonists, and alternative therapies. A concern with insomnia medications is the risk of next-day residual effects, which can impair memory and ability to perform certain tasks, such as driving, and may increase the risk of accidents and falls, especially in the elderly.

OBJECTIVES

To describe the impact of current insomnia treatments on next-day performance.

RESULTS

The longer-acting benzodiazepines are associated with next-day "hangover" effects and, as a result, have been largely replaced by agents in the nonbenzodiazepine class, which typically have shorter half-lives. The hypnotic, sedative activities of these classes of drugs depend on variations in binding characteristics to the alpha1 subunit of the gamma-amino butyric acidA-receptor, which inhibits neuronal activity in broad areas of the brain and is found in areas of the brain responsible for sleep/wakefulness and sedation. However, nonbenzodiazepines with a rapid onset of action and short half-life have shown limited efficacy for maintaining sleep throughout the night. These properties have contributed to the development of modified-release formulations. Zolpidem extended-release is a bilayer tablet that retains the fast onset of action of its parent compound zolpidem while extending the duration of hypnotic activity, owing to a slower-release portion of the tablet.

CONCLUSIONS

Based on clinical evidence, the risk of residual next-day effects of zolpidem extended-release is limited, mainly due to the similarly short half-life in its extended-release formulation.

Sleep disturbances in an arctic population: the Tromsø Study

Background

Prevalence estimates for insomnia range from 10 to 50% in the adult general population. Sleep disturbances cause great impairment in quality of life, which might even rival or exceed the impairment in other chronic medical disorders. The economic implications and use of health-care services related to chronic insomnia represent a clinical concern as well as a pronounced public health problem. Hypnotics are frequently prescribed for insomnia, but alcohol and over-the-counter sleep aids seem to be more widely used by insomniacs than prescription medications. Despite the complex relationship between insomnia and physical and mental health factors, the condition appears to be underrecognized and undertreated by health care providers, probably due to the generally limited knowledge of the causes and natural development of insomnia.

Methods/Design

The Tromsø Study is an ongoing population-based cohort study with five previous health studies undertaken between 1974 and 2001. This protocol outlines a planned study within the sixth Tromsø Study (Tromsø VI), aiming at; 1) describing sleep patterns in a community-based sample representative of the general population of northern Norway, and 2) examining outcome variables of sleep disturbances against possible explanatory and confounding variables, both within a cross-sectional approach, as well as retrospectively in a longitudinal study – exploring sleep patterns in subjects who have attended two or more of the previous Tromsø studies between 1974 and 2009. First, we plan to perform a simple screening in order to identify those participants with probable sleep disturbances, and secondly to investigate these sleep disturbances further, using an extensive sleep-questionnaire. We will also collect biological explanatory variables, i.e. blood samples, weight, height and blood pressure. We plan to merge data on an individual level from the Tromsø VI Study with data from the Norwegian Prescription Database (NorPD), which is a national registry including data for all prescription drugs issued at Norwegian pharmacies. Participants with sleep disturbances will be compared with pair-matched controls without sleep disturbances.

Discussion

Despite ongoing research, many challenges remain in the characterization of sleep disturbances and its correlates. Future mapping of the biological dimensions, natural history, as well as the behavioral and drug-related aspects of sleep disturbances in a representative population samples is clearly needed.

Objective and subjective measures for sleep disorders

Subjective and objective measures of sleep structure or quality could help to characterize the chronic sleep disturbances, with relation to patients' risk factor profiles and co-morbidities. Studies have shown that discrepancies can occur between subjective data regarding sleep disturbances and the impact of insomnia and objective assays, and surrogate markers of sleep and sleep disturbances. Both objective and subjective measures should be incorporated into clinic studies. It seems likely that sleep quality is represented by a combination of more than one subjective sleep parameter. Objective and subjective assessments of sleep quality may relate to different parameters. Future studies incorporated both subjective and objective measures could help to address the sleep disorders.

The influence of age, gender, ethnicity, and insomnia on Epworth sleepiness scores: A normative US population

BACKGROUND AND PURPOSE

This study explored the distribution of Epworth Sleepiness Scale (ESS) scores in a randomly sampled, community population and provided percentile scores that will assist in decision-making in both research and clinical settings.

PATIENTS AND METHODS

Participants included 703 individuals between the ages of 20 and 98, with 116 people with insomnia (PWI) and 587 people not having insomnia (PNI). Analyses produced main effects for sleep status and ethnicity.

RESULTS

PWI had higher ESS scores than PNI and African-Americans had higher ESS scores than Caucasians, although effect sizes were small. Gender, age group, and season did not impact ESS scores. Receiver operating characteristic (ROC) curve analysis proved the ESS to discriminate poorly between PWI and PNI.

CONCLUSIONS

This study found higher percentages of 'sleepy' individuals than previous studies. PWI did have slightly elevated scores on the ESS, but this elevation was not necessarily predictive of an insomnia diagnosis. Results support a continuum of sleepiness/alertness among PWI.

Psychometric Evaluation of the Chinese Version of the Pittsburgh Sleep Quality Index (CPSQI) in Primary Insomnia and Control Subjects

In order to effectively study the population experiencing insomnia, it is important to identify reliable and valid tools to measure sleep that can be administered in the home setting. The purpose of this study was to assess psychometric properties for the Chinese version of the Pittsburgh Sleep Quality Index (CPSQI) in community-dwelling adults with primary insomnia. The CPSQI had an overall reliability coefficient of 0.82 -0.83 for all subjects. "Subjective sleep quality" was the component most highly correlated with the global score. Overall, the CPSQI showed acceptable test-retest reliability over a 14- to 21-day interval with a coefficient of 0.85 for all subjects and 0.77 for primary insomniacs. The two contrasting groups had significantly different global and component scores. A CPSQI of greater than 5 yielded a sensitivity and specificity of 98 and 55% in primary insomniacs vs. controls. A CPSQI of greater than 6 resulted in a sensitivity and specificity of 90 and 67%. Results suggest that the CPSQI is a psychometrically sound measure of sleep quality and disturbance for patients with primary insomnia. It may not be an effective screening tool because of its low specificity, but it can be a sensitive, reliable, and valid outcome assessment tool for use in community-based studies of primary insomnia.

A pilot study of subjective daytime alertness and mood in primary insomnia participants using ecological momentary assessment

This pilot study compared daytime symptom ratings in primary insomniacs (n = 7) and age-matched controls (n = 8). Participants completed sleep diaries and rated their daytime symptoms using a Daytime Symptom Diary (DSD) 4 times per day for 1 week. DSD responses were collapsed into 4 domains: mood, subjective alertness, energy, and concentration. The level and variability of DSD domains, and correlations between the domains and sleep diary characteristics, were examined. Significant Group x Time of Day interactions were observed in values for each DSD domain, with the most consistent group differences occurring in the morning. Coefficients of variation for DSD domains were greater in the insomnia group. Frequent measures of daytime symptoms may be useful outcomes in insomnia studies.

Increased utilization of health services by insomniacs--an epidemiological perspective

OBJECTIVES

Epidemiological data describing the prevalence of sleep complaints in Hungary and its region are lacking; furthermore, limited information is available on health care use by individuals with sleep complaints. We assessed the prevalence of sleep complaints, insomnia in particular, in a nationally representative sample of the Hungarian population and assessed health care utilization by insomniacs.

METHODS

Cross-sectional study, enrolling a nationally representative sample (N=12,643) of the adult Hungarian population. A battery of questionnaires was administered during a home interview. The Athens Insomnia Scale (AIS), additional questions on sleep behavior, as well as questions on current medical therapy for somatic and mental disorders were included in the battery of questionnaires administered. Psychosocial and demographic characteristics were also tabulated.

RESULTS

Forty-seven percent of the sample reported at least one complaint related to sleep. Based on the AIS we report a 9% prevalence of insomnia in the total sample. Sleep deprivation was highly prevalent in the younger and middle-aged groups. The frequency of sleep problems increased with age. Individuals diagnosed with insomnia reported more frequent utilization of health services, including sick leave, emergency visits and hospitalization, than those without insomnia.

CONCLUSION

Sleep complaints and sleep deprivation are frequent problems in the Hungarian population and are associated with increased health care utilization. The prevalence of insomnia in our sample was similar to what has been previously reported from other countries. The high prevalence of sleep-deprived individuals warrants further attention. Interventions that effectively improve insomnia may also reduce health care utilization by the affected individuals.