Change in Dysfunctional Sleep-Related Beliefs is Associated with Changes in Sleep and Other Health Outcomes Among Older Veterans With Insomnia: Findings From a Randomized Controlled Trial

Race as a Potential Moderator of the Association between Dysfunctional Beliefs about Sleep and Global Sleep Health

OBJECTIVES

Dysfunctional beliefs about sleep are associated with components of sleep health, but their association with global sleep health is understudied. Beliefs about sleep may systematically vary by race, which may influence the association between dysfunctional beliefs about sleep and global sleep health. This study aimed to investigate whether race influences the association between dysfunctional beliefs about sleep and global sleep health.

METHODS

Data were collected as part of an online survey. Participants were Black (n = 181) and White (n = 179) adults who were matched on age, self-reported sex, and level of education. Global sleep health was measured using the RU-SATED and dysfunctional beliefs about sleep were measured using the DBAS-16. Moderation analyses were conducted to investigate whether race moderated the association between DBAS-16 total and subscale scores and RU-SATED total scores.

RESULTS

Race moderated the associations between DBAS-16 total score and subscale scores and RU-SATED total score (b = 0.54, p < .001). Higher DBAS-16 scores were significantly associated with lower RU-SATED scores in the white sample, while this association was not significant in the Black sample, except for the Sleep Expectations subscale, where the association was not significant in the White sample, and it was significant in the Black sample.

CONCLUSIONS

These findings highlight that the association between dysfunctional beliefs about sleep and global sleep health may systematically vary by race which may have implications for promoting sleep health equity in racial minority populations through clinical and advocacy work. Future studies are needed to investigate what specific factors may be impacting these unique associations.

Sleep quality and its association with anxiety, stress, sleep-related beliefs and attitudes and postural control in young adults: a cross-sectional study

OBJECTIVES

Adequate sleep is essential for young adults, as this age group primarily consists of students, job seekers, and working people constantly managing a hectic lifestyle. Poor quality of sleep, which is essential for physical and mental well-being in the short and long term, can result in impaired overall health. However, there exists a gap in the literature regarding the factors affecting sleep among young adults. Hence, the objective of this study was to find the prevalence of sleep-related parameters (sleep health, hygiene, and sleep-related beliefs and attitudes) and potential risk factors for sleep quality and to investigate the association between sleep and postural control in young adults.

METHODS

This prospective, cross-sectional, analytical study included 181 young adults, 113 (62.43 %) females, and 68 (37.57 %) males, with a mean age of 23.82 ± 2.88 years. Sleep quality, health, beliefs, hygiene, stress, anxiety, and depression were assessed using questionnaires. Postural control was assessed using center of pressure (COP) indices.

RESULTS

The overall prevalence of poor sleep quality was 79.01 % among young adults. Multiple linear regression showed that predictors explained 44 % of sleep quality variance (adjusted R square=0.44, f (12,168) = 20.91, p<0.05). Poor sleep-related beliefs and attitudes (95 % CI [0.037, 0.679], p=0.029), higher perceived stress (95 % CI [0.005, 0.219], p=0.039), higher anxiety severity (95 % CI [0.108, 0.526], p=0.003), and poor COP stability index A/P (95 % CI [4.986, 11.248], p=0.00) were found to be significant predictors of poor sleep quality.

CONCLUSIONS

High anxiety and stress, and poor dysfunctional beliefs and attitudes about sleep are predictors of poor sleep quality in young adults. These factors may significantly affect sleep quality and the experience of restful sleep among young adults. Also, poor sleep quality is associated with reduced postural control (decreased stability in the A/P direction). These findings are crucial for improving young adults' overall health and well-being, as poor sleep is highly prevalent among this age group.

Challenging beliefs for quality sleep: A systematic review of maladaptive sleep beliefs and treatment outcomes following cognitive behavioral therapy for insomnia

Cognitive behavioral therapy for insomnia (CBT-I) is an empirically supported intervention for insomnia. Given the strong, consistent support of its efficacy, scholars have become increasingly interested in the behavioral and cognitive mechanisms targeted during CBT-I. The purpose of the systematic review was to synthesize findings from the literature regarding the associations among maladaptive sleep beliefs, a cognitive mechanism implicated in maintaining insomnia, and treatment outcomes following CBT-I. The systematic review was completed using Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Seventeen studies were included in the final sample of reviewed articles and a study quality assessment was performed for all studies included in the review. The results suggested that reductions in maladaptive sleep beliefs were associated with improved insomnia severity; however, reductions in maladaptive beliefs were not associated with changes in sleep efficiency or other sleep parameters. Moreover, in some cases, improved sleep parameters preceded reductions in maladaptive beliefs. Maladaptive sleep beliefs may be an important target for improving insomnia. Targeting maladaptive sleep beliefs may initiate a trickle-down process that limits the influence of other cognitive and behavioral processes maintaining insomnia. Additional investigation is needed to evaluate the directional relationship between improved insomnia symptoms and reduced maladaptive beliefs.

Posttraumatic sleep disturbances in veterans: A pilot randomized controlled trial of cognitive behavioral therapy for insomnia and imagery rehearsal therapy

OBJECTIVES

Posttraumatic stress disorder (PTSD) is associated with sleep disturbances including insomnia and nightmares. This study compared cognitive behavioral therapy for insomnia (CBT-I) with CBT-I combined with imagery rehearsal therapy (IRT) for nightmares to evaluate if the combined treatment led to greater reductions in trauma-related sleep disturbances in Australian veterans.

METHODS

Veterans with diagnosed PTSD, high insomnia symptom severity, and nightmares (N = 31) were randomized to eight group CBT-I sessions or eight group CBT-I + IRT sessions. Self-reported sleep, nightmare, and psychological measures (primary outcome: Pittsburgh Sleep Quality Index), and objective actigraphy data were collected; the effect of obstructive sleep apnea (OSA) risk on treatment outcomes was also examined.

RESULTS

No treatment condition effects were detected for the combined treatment compared to CBT-I alone, and no moderating effect of OSA risk was detected. On average, participants from both groups improved on various self-report measures over time (baseline to 3 months posttreatment). Despite the improvements, mean scores for sleep-specific measures remained indicative of poor sleep quality. There were also no significant differences between the groups on the actigraphy indices.

CONCLUSIONS

The findings indicate that there is potential to optimize both treatments for veterans with trauma-related sleep disturbances.

Marital status and living apart affect sleep quality in male military personnel: a study of the China's Navy during COVID-19

Background

Marital status is a robust sociodemographic predictor of sleep. Having to live apart from spouse may have different implications than those of cohabitants or singles, especially in military personnel. Further research on this group will help provide knowledge in advance and facilitate early targeted interventions.

Methods

An online questionnaire study was conducted from July to November 2021. A total of 1,832 male military personnel completed the questionnaire. The marital status was measured by a self-reported single choice question. Pittsburgh sleep quality index (PSQI), Epworth Sleepiness Scale (ESS) and The Dysfunctional Beliefs and Attitudes about sleep scale (DBAS-16) were used to measure sleep-related outcomes. Inverse probability weighting (IPW) was applied to reduce the effects of confounding. Logistic regression was used to analyze the relationship between marital status and sleep and explore the impact of living together or not.

Results

After inverse probability weighting, the prevalence of poor sleep quality, sleepiness and dysfunctional beliefs were 16.1, 20.1 and 7.1%, respectively. One-way ANOVA results for the means of both groups were statistically significantly different, except for the sleep latency and sleep disturbance dimensions of PSQI. Participants who were married were more likely to have poor sleep quality (OR: 1.408, 95% CI: [1.10, 1.80]), to have daytime sleepiness (OR: 1.560, 95% CI: [1.27, 1.92]) and to develop dysfunctional beliefs and attitudes (OR: 2.497, 95% CI: [1.65, 3.80]) than those who were unmarried. Further analysis showed that the odds of developing poor sleep quality and DBAS in participants who married but living apart were significantly bigger than those unmarried (OR: 1.548 and 3.991, respectively.), while there were no significant differences in the odds of daytime sleepiness (OR: 0.738, p = 0.050). Age was a protective factor for the development of bad sleep outcomes, while family economic was an independent risk factor.

Conclusion

Marital status appear important for sleep quality, daytime sleepiness and sleep beliefs. The effect of living apart or not should be considered separately as an important predictor of sleep.

The relationships between physical function, nutrition, cognitive function, depression, and sleep quality for facility-dwelling older adults with dynapenia

BACKGROUND

The growing population of older adults worldwide is associated with an extended life expectancy and an increasing proportion of older adults with dynapenia. Most research on dynapenia has involved only populations of older adults living in the community; little research has examined the effects of risk factors on sleep quality among older adults with dynapenia residing in assisted living facilities.

AIM

This study examined the relationships among physical function, nutrition, cognitive function, depression, and sleep quality among older adults with dynapenia residing in assisted living facilities.

METHODS

In this cross-sectional study, data on physical function, nutrition, cognitive function, depression, and sleep quality was collected from 178 older adults with dynapenia residing in assisted living facilities, who were selected using purposive sampling. Descriptive statistical analysis, independent-sample t tests, chi-squared tests, and logistic regression analysis were performed using SPSS 25.0.

RESULTS

The statistical analyses revealed correlations between sleep quality and age (t = 2.37, p < 0.05), level of education (χ2 = 3.85, p < 0.05), grip strength (t = 3.40, p < 0.01), activities of daily living (t = 4.29, p < 0.001), instrumental activities of daily living (t = 2.23, p < 0.001), calf circumference (t = 2.89, p < 0.01), Mini Nutritional Assessment scores (t = 2.29, p < 0.05), Mini Mental State Exam (MMSE) scores (t = 4.50, p < 0.001), and Geriatric Depression Scale (GDS) scores (t = - 4.20, p < 0.001). Calf circumference (OR = 0.8, 95% CI = 0.650.97, p < 0.05), GDS score (OR = 1.42, 95% CI = 1.05-1.92, p < 0.05), and MMSE score (OR = 0.85, 95% CI = 0.73-0.97, p < 0.05) were related to sleep quality among the sample population.

CONCLUSION

Physical function, nutrition, cognitive function, and depression affect the sleep quality of older adults with dynapenia residing in assisted living facilities. Facility nurses must regularly assess these aspects of their patients to ensure that facility-dwelling older adults can maintain their physical function and improve their health to improve the quality of their sleep.

[Does a short telemedicine-based CBT programme for insomnia lead to changes in dysfunctional beliefs about sleep?]

INTRODUCTION

The Morphee Sleep network runs a short group CBT programme. During the pandemic, the programme was administered by videoconference. The programme focuses on behavioral modification. The objective of our study was to evaluate whether the videoconference programme produced changes in dysfunctional beliefs about sleep and whether these changes were linked to improvements in insomnia.

METHODS

Observational study of 3×90minute sessions of group CBT by videoconference over one month delivered by experienced psychologists. The outcome measures : insomnia severity scale (ISI), dysfunctional beliefs and attitudes about sleep short version (DBAS 16), hospital anxiety and depression scale (subscales depression HADD and anxiety HADA), and epworth sleepiness scale (ESS) completed before session 1 and at the end of session 3. The effectiveness of the programme on insomnia was evaluated by the decrease in the ISI score : full response R+ (>7 points), partial response, R- (4 - 6 points) non response, NR (<3 points). The effect on dysfunctional beliefs and attitudes about sleep were measured by the decrease in the DBAS 16 with response CR (>9 points) and no response CNR (<9 points).

RESULTS

There were fifty-five participants, 64 % women with a mean age of 49.1±16.1 years. The DBAS 16 was reduced by 6.12±1.29 to 5.09±1.57 (P< 0.0001) with 67 % of participants showing a response CR. The ISI score reduced from 17.7±3.6 to 14.0±4.9 (P< 0.0001) with 49 % showing at least a partial response (R+ and R-). A significant correlation (0.327, P=0.015) between the CBT response and dysfunctional beliefs about sleep was observed with a significant reduction in the DBAS 16 between responders R+ and non-responders (R+ vs. NR 1.67±1.3 vs. 0.57±1.28 P=0.012). Seventy-nine of R+ showed improvements in the DBAS 16 vs. 69 % of R- and 61 % of non-responders NR.

CONCLUSION

A short group CBT programme by videoconference focused on behavioral modification can reduce dysfunctional beliefs about sleep.

Group-delivered cognitive behavioural therapy versus waiting list in the treatment of insomnia in primary care: study protocol for a pragmatic, multicentre randomized controlled trial

BACKGROUND

Insomnia is common in the general population and is a risk factor for ill-health, which highlights the importance of treating insomnia effectively and cost-efficiently. Cognitive-behavioural therapy for insomnia (CBT-I) is recommended as first-line treatment due to its long-term effectiveness and few side-effects, but its availability is limited. The aim of this pragmatic, multicentre randomized controlled trial is to investigate the effectiveness of group-delivered CBT-I in primary care compared to a waiting-list control group.

METHODS

A pragmatic multicentre randomized controlled trial will be conducted with about 300 participants recruited across 26 Healthy Life Centres in Norway. Participants will complete online screening and provide consent before enrolment. Those who meet the eligibility criteria will be randomized to a group-delivered CBT-I or to a waiting list according to a 2:1 ratio. The intervention consists of four two-hour sessions. Assessments will be performed at baseline, 4 weeks, 3- and 6 months post-intervention, respectively. The primary outcome is self-reported insomnia severity at 3 months post-intervention. Secondary outcomes include health-related quality of life, fatigue, mental distress, dysfunctional beliefs and attitudes about sleep, sleep reactivity, 7-day sleep diaries, and data obtained from national health registries (sick leave, use of relevant prescribed medications, healthcare utilization). Exploratory analyses will identify factors influencing treatment effectiveness, and we will conduct a mixed-method process evaluation to identify facilitators and barriers of participants' treatment adherence. The study protocol was approved by the Regional Committee for Medical and Health Research ethics in Mid-Norway (ID 465241).

DISCUSSION

This large-scale pragmatic trial will investigate the effectiveness of group-delivered cognitive behavioural therapy versus waiting list in the treatment of insomnia, generating findings that are generalizable to day-to-day treatment of insomnia in interdisciplinary primary care services. The trial will identify those who would benefit from the group-delivered therapy, and will investigate the rates of sick leave, medication use, and healthcare utilization among adults who undergo the group-delivered therapy.

TRIAL REGISTRATION

The trial was retrospectively registered in the ISRCTN registry (ISRCTN16185698).

Subjective versus objective sleep outcomes in older adults with and without uncoupled sleep following online cognitive behavioural therapy for insomnia

BACKGROUND

Uncoupled sleep is a phenomenon characterised by a disconnect between sleep pattern and sleep complaint. This study examined the impact of uncoupled sleep on dysfunctional sleep beliefs and objective and subjective sleep outcomes in community-dwelling older adults following digitally delivered Cognitive Behavioural Therapy for Insomnia (CBT-I) to assess how these groups respond to CBT-I.

METHODS

Objective sleep was measured using wrist actigraphy, subjective sleep quality via sleep diaries and the Pittsburgh Sleep Quality Index (PSQI). Dysfunctional sleep beliefs were assessed by the Dysfunctional Beliefs and Attitudes about Sleep scale (DBAS-16). All measurements were taken prior to and following a 4-week online CBT-I program. Linear mixed model and generalised linear mixed model analyses were conducted to examine objective and subjective sleep onset latency, total sleep time, wake after sleep onset and number of awakenings as well as PSQI and DBAS-16 scores, respectively.

RESULTS

Out of 80 enrolled participants, 62 participants (55 females, 89%; 16 complaining good sleepers, 26 complaining poor sleepers, 11 non-complaining good sleepers, and nine non-complaining poor sleepers) completed the study. CBT-I reduced dysfunctional sleep beliefs across all sleeper classifications. Objective and self-reported changes in sleep parameters were demonstrated in complaining poor sleepers without uncoupled sleep. Complaining good sleepers with uncoupled sleep only reported a decrease in the number of subjective sleep awakenings. There were no changes in sleep outcomes in non-complaining good and non-complaining poor sleepers.

CONCLUSIONS

Online CBT-I was effective in improving the sleep outcomes of individuals who had both subjective and objective poor sleep. However, as the online CBT-I reduced dysfunctional sleep beliefs in all sleep groups, further examination of dysfunctional sleep beliefs and whether they mediate the outcomes of digital CBT-I in older adults will need to be conducted.

The dysfunctional beliefs and attitudes about sleep scale: Dimensions of the European Portuguese DBAS-30 and development of a new short version (DBAS–SF–16)

OBJECTIVES

The Dysfunctional Beliefs and Attitudes about Sleep Scale (DBAS) is the most widely validated instrument for assessing sleep-related cognitions. This study aimed to examine the reliability of the DBAS-30 European Portuguese version, explore its dimensionality, and develop a new short version suitable for differentiating the presence/absence of insomnia.

METHODS

From 824 participants aged 18-85 years, the Insomnia Group (IG, n = 355, 261 females and 94 males) and Normal Sleepers Group (NSG, n = 292, 237 females, 54 males and 1 with no response) were constituted. Thirty-one patients with Obstructive Sleep Apnea Syndrome were also recruited. For the DBAS 16-items version, the ability to differentiate dysfunctional beliefs between people with and without insomnia was used as the main criterion for item retention.

RESULTS

DBAS-30 PT demonstrated good internal consistency and significantly discriminated IG from NSG. Based on a robust EFA (RDWLS), a three-dimensional structure was determined for IG (Ageing and Hopelessness, Sleep Expectations, and Consequences and Helplessness). DBAS-SF-16 presented as an internally-consistent measure with a reliable two-factor structure (Consequences and Helplessness, Medication and Hopelessness) and showed construct and known groups validity. ROC analysis demonstrated DBAS-SF-16's relevant clinical accuracy, and 4.3 provides the best cut-off score in detecting the level of dysfunctional beliefs associated with clinical insomnia.

CONCLUSIONS

A new and meaningful dimensionality of the DBAS-30 was found. DBAS-SF-16 showed to be a reliable, valid, and robust tool for evaluating dysfunctional beliefs about insomnia in clinical and non-clinical populations.

Relationship Between Attitudes and Beliefs About Sleep, Sleep Disturbance, and Pain Interference in Patients With Spinal Pain

OBJECTIVES

Sleep impairments are a strong predictor of pain, making sleep a potential interest when treating patients with spine pain. Typical beliefs about the importance of sleep in patients seeking care for spinal pain are unknown. The purpose of this study was to describe the beliefs and attitudes about sleep in patients seeking care for spinal pain and to examine the relationships between dysfunctional beliefs and attitudes about sleep (DBAS), disordered sleep, and pain interference.

MATERIALS AND METHODS

This cross-sectional study included patients presenting to physical therapy with spine pain. Participants completed questionnaires including demographics, medical history, pain interference (pain, enjoyment, and general activity), DBAS-16, and sleep-related impairment (Patient-Reported Outcome Measurement Information System). Correlations were calculated between DBAS-16 scores and measures of sleep quality/quantity, and a generalized linear model was used to investigate the predictive ability of DBAS-16 scores on pain interference.

RESULTS

The mean DBAS-16 score was 4.22 (SD=2.03), with 52.5% of participants having DBAS. There was a strong relationship between DBAS-16 and Patient-Reported Outcome Measurement Information System ( rs =0.7; P <0.001). For every point higher score on the DBAS-16, pain interference scores increased by approximately half a point (B=0.46; 95% CI 0.33, 0.59, 1.80; P <0.001).

DISCUSSION

These results highlight a strong relationship between beliefs and attitudes about sleep and measures of sleep quality/quantity and a linear association with pain interference scores. These findings provide a rationale for targeting beliefs and attitudes about sleep when managing pain-related symptoms in patients seeking care for spine pain.

Multi-Scale Permutation Entropy: A Potential Measure for the Impact of Sleep Medication on Brain Dynamics of Patients with Insomnia

Insomnia is a common sleep disorder that is closely associated with the occurrence and deterioration of cardiovascular disease, depression and other diseases. The evaluation of pharmacological treatments for insomnia brings significant clinical implications. In this study, a total of 20 patients with mild insomnia and 75 healthy subjects as controls (HC) were included to explore alterations of electroencephalogram (EEG) complexity associated with insomnia and its pharmacological treatment by using multi-scale permutation entropy (MPE). All participants were recorded for two nights of polysomnography (PSG). The patients with mild insomnia received a placebo on the first night (Placebo) and temazepam on the second night (Temazepam), while the HCs had no sleep-related medication intake for either night. EEG recordings from each night were extracted and analyzed using MPE. The results showed that MPE decreased significantly from pre-lights-off to the period during sleep transition and then to the period after sleep onset, and also during the deepening of sleep stage in the HC group. Furthermore, results from the insomnia subjects showed that MPE values were significantly lower for the Temazepam night compared to MPE values for the Placebo night. Moreover, MPE values for the Temazepam night showed no correlation with age or gender. Our results indicated that EEG complexity, measured by MPE, may be utilized as an alternative approach to measure the impact of sleep medication on brain dynamics.