Randomized controlled trial of digital cognitive behavior therapy for prenatal insomnia symptoms: Effects on postpartum insomnia and mental health

Efficacy and safety of lemborexant in subjects with insomnia disorder receiving medications for depression or anxiety symptoms

AIM

Individuals with insomnia frequently have comorbid depression or anxiety. This study sought to provide a preliminary indication of the effects of lemborexant (LEM) in subjects treated for mild depression/anxiety symptoms.

METHODS

E2006-G000-303 (NCT02952820; EudraCT 2015-001463-39; SUNRISE-2) was a 12-month, phase 3, randomized, placebo-controlled, double-blind study where subjects with insomnia disorder were randomized (1:1:1) to placebo, LEM 5 mg (LEM5), or LEM 10 mg (LEM10) for 6 months. During the second 6 months (not reported), placebo-treated subjects were re-randomized to LEM5 or LEM10. In this post hoc analysis, changes from baseline (CFB) in subject-reported (subjective) sleep onset latency (sSOL), sleep efficiency (sSE), wake after sleep onset (sWASO), total sleep time (sTST), Fatigue Severity Scale, and Insomnia Severity Index were evaluated in subjects treated with medications for symptoms of depression/anxiety (subpopulation).

RESULTS

Of 949 randomized subjects, 61 treated with medications for symptoms of depression/anxiety were included. In the subpopulation, CFB comparing LEM with placebo were generally smaller than the overall population due to a larger placebo response in the subpopulation. However, the magnitudes of CFB within the active treatment groups for sSOL, sWASO, sTST, and sSE were similar between the subpopulation and the overall population. No new safety signals were observed in the subpopulation.

CONCLUSION

LEM treatment benefited subjects with insomnia treated with medications for depression/anxiety symptoms, with no new safety signals. A greater placebo response in the subpopulation than in the overall population decreased the drug versus placebo effect size for LEM, as has been reported for other insomnia medications.

Comparative effectiveness of interventions for the prevention and treatment of perinatal depression: A systematic review and network meta-analysis

BACKGROUND

Several interventions have been investigated addressing perinatal depression; however, interventions have not been compared using both direct and indirect evidence. This study compared the relative effectiveness of all interventions that prevent depression (objective 1) or treat depression symptoms (objective 2) in perinatal women.

METHODS

Eight databases searched from their inception to March 2024. Inclusion criteria were randomised controlled trials in perinatal women participants evaluating any interventions that addressed prevention or treatment of depression. Two random-effects Bayesian network meta-analyses were conducted using studies with perinatal women participants reporting frequency of depression or reporting depression severity. For objective 1 odds ratios (OR) and objective 2 standardised mean differences (SMD) were used.

RESULTS

A total of 177 articles were included (n = 76 objective 1, n = 101 objective 2). For objective 1; mindfulness was the highest-ranking intervention (SCURA=88), with significant OR compared to treatment as usual (TAU) (OR=0.21; 0.06, 0.71 95 %CrI). Other interventions with significant OR, compared to TAU included: pharmacological treatments, CBT, physical activities, education, and collaborative care. For objective 2; interpersonal therapy plus massage was the highest-ranking intervention (SCURA=89) with significant SMD compared to TAU (SMD=-1.38; -2.54, -0.21). Other interventions with significant SMD compared to TAU: IPT, alternative therapies, physical activities, mindfulness, CBT, collaborative care, education, and enhanced TAU. Pharmacological treatments were effective compared to sham/placebo.

CONCLUSION

CBT, mindfulness, physical activity, collaborative care, education, and pharmacological interventions were effective in addressing prevention and treatment of perinatal depression symptoms compared to control arms. Healthcare providers may consider offering these interventions to perinatal women.

Sleeping for two: A randomized controlled trial of cognitive behavioural therapy for insomnia (CBTI) delivered in pregnancy and secondary impacts on symptoms of postpartum depression

BACKGROUND

Insomnia in pregnancy is common and highly comorbid with depression.

OBJECTIVE

To investigate if: 1) depressive symptoms decrease after cognitive behavioural therapy for insomnia (CBTI) delivered in pregnancy, and 2) changes in insomnia symptoms represent a mechanism linking CBT-I treatment and reduced symptoms of postpartum depression.

METHODS

A two-arm, single-blind, parallel groups randomized controlled trial (RCT) design was used to evaluate the impact of a 5-week CBT-I intervention adapted for pregnant people with insomnia (N = 62). Participants were eligible if they were pregnant, between 12 and 28 weeks gestation, and met diagnostic criteria for insomnia. Participants completed questionnaires assessing symptoms of insomnia and depression pre-intervention (T1), post-intervention (T2), and six months postpartum (T3). A path analysis model was used to test direct and indirect effects simultaneously.

RESULTS

There was a significant direct effect of CBT-I on postpartum depressive symptoms at T3. Additionally, significant indirect treatment effects on depressive symptoms at T3 emerged, through depressive symptoms at T2 and through improvements in insomnia that persisted from T2 to T3.

LIMITATIONS

Limitations to the current study include limited generalizability, the non-depressed sample, and variability in treatment and assessment delivery (in-person vs. online).

CONCLUSIONS

CBT-I treatment in pregnancy may indirectly reduce postpartum depressive symptoms, through sustained improvements in insomnia symptoms.

Causal associations of Insomnia and postpartum depression: a two-sample mendelian randomization study

BACKGROUND

Postpartum depression (PPD), a prevalent social-mental condition, impacts the mother and the newborn and several facets of their lives. It has been suggested that insomnia is related to both the occurrence and progression of PPD. However, because of lingering confounding and bias, it is impossible to determine the cause of this connection using observational analysis. In this study, we evaluate the causal importance of insomnia on postpartum depression using Mendelian randomization (MR).

METHODS

Utilizing summary data from genome-wide association studies (GWAS), a two-sample MR study was conducted. A GWAS dataset of IEU study of the United Kingdom Biobank phenotypes comprising 462,341 people of European heritage yielded 38 single-nucleotide polymorphisms (SNPs) for insomnia. The PPD data were provided by the FinnGen project and comprised 7604 cases and 59,601 controls. Inverse variance weighting (IVW) was utilized for the primary MR analysis, with weighted median and MR-Egger as sensitivity analyses.

RESULTS

As a result, we found that genetically predicted insomnia was positively associated with postpartum depression. The odds ratios (OR) of PPD were 1.849 (95% (confidence interval) CI 1.011-3.381; p = 0.046).

CONCLUSION

For the first time, the causative role of sleeplessness for postpartum depression has been extensively evaluated in the current two-sample MR investigation. Our findings show that insomnia and PPD are related causally.

Preventing postpartum insomnia: findings from a three-arm randomized-controlled trial of cognitive behavioral therapy for insomnia, a responsive bassinet, and sleep hygiene

STUDY OBJECTIVES

Insomnia symptoms are common during the perinatal period and are linked to adverse outcomes. This single-blind three-arm randomized-controlled trial examined whether two interventions targeting different mechanisms prevent postpartum insomnia.

METHODS

Participants were nulliparous females 26-32 weeks gestation with Insomnia Severity Index (ISI) scores ≥ 8, recruited in Australia and randomized 1:1:1 to: (1) a responsive bassinet (RB) designed to support infant sleep and reduce maternal sleep disruption until 6 months postpartum, (2) therapist-assisted cognitive behavioral therapy for insomnia (CBT-I) delivered during pregnancy and postpartum, or (3) a sleep hygiene booklet (control; CTRL). Outcomes were assessed at baseline (T1), 35-36 weeks gestation (T2), and 2, 6, and 12 months postpartum (T3-T5). The primary outcome was ISI scores averaged T3-T5. Primary analyses were regressions controlling for baseline outcomes.

RESULTS

One hundred and twenty-seven participants (age M ± SD = 32.62 ± 3.49) were randomized (RB = 44, CBT-I = 42, CTRL = 41). Both interventions were feasible and well-accepted, with few related adverse events reported. Compared to CTRL, the average ISI across T3-T5 was lower for CBT-I (p = .014, effect size [ES] = 0.56, medium) but not RB (p = .270, ES = 0.25, small). Exploratory findings on maternal insomnia diagnosis, sleep disturbance, sleep-related impairment, beliefs and attitudes about sleep, depression, anxiety, as well as infant sleep outcomes were also presented.

CONCLUSIONS

CBT-I but not RB reduced prenatal insomnia (very large effect) and prevented postpartum insomnia (medium effect). Further research is needed to examine the effects of both CBT-I and RB on other outcomes such as sleep-related well-being, postpartum depression, and maternal postpartum sleep duration.

CLINICAL TRIAL REGISTRATION

The Study for Mother-Infant Sleep (The SMILE Project): reducing postpartum insomnia using an infant sleep intervention and a maternal sleep intervention in first-time mothers. https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=377927, Australian New Zealand Clinical Trials Registry: ACTRN12619001166167.

Improvements in Maternal Cardiovascular Health Over the Perinatal Period Longitudinally Predict Lower Postpartum Psychological Distress Among Individuals Who Began Their Pregnancies With Overweight or Obesity

BACKGROUND

Adverse cardiovascular events during pregnancy (eg, preeclampsia) occur at higher rates among individuals with overweight or obesity (body mass index ≥25 kg/m2) and have been associated with postpartum depression. The present study examined whether changes in cardiovascular health (CVH) during the perinatal period, as defined by the American Heart Association's Life's Essential 8 framework, predicted postpartum psychological functioning among individuals with prepregnancy body mass index ≥25 kg/m2.

METHODS AND RESULTS

Pregnant individuals (N = 226; mean ± SD age = 28.43 ± 5.4 years; mean body mass index = 34.17 ± 7.15 kg/m2) were recruited at 12 to 20 weeks of gestation (mean, 15.64 ± 2.45 weeks) for a longitudinal study of health and well-being. Participants completed ratings of depression and perceived stress and reported on CVH behaviors (dietary intake, physical activity, nicotine exposure, and sleep) at baseline and at 6 months postpartum. Body mass index and CVH behaviors were used to calculate a composite CVH score at both time points. Linear regression analyses were performed to examine whether change in CVH related to postpartum symptom scores. Because sleep was measured in only a subset of participants (n = 114), analyses were conducted with and without sleep. Improved CVH was associated with lower postpartum depression (β = -0.18, P<0.01) and perceived stress (β = -0.13, P=0.02) scores. However, when including sleep, these relationships were no longer significant (all P>0.4).

CONCLUSIONS

Improvements in CVH from early pregnancy to 6 months postpartum were associated with lower postpartum depressive symptoms and perceived stress but not when including sleep in the CVH metric, potentially due to the large reduction in sample size. These data suggest that intervening during pregnancy to promote CVH may improve postpartum psychological functioning among high-risk individuals.

Promoting sleep health during pregnancy for enhancing women's health: a longitudinal randomized controlled trial combining biological, physiological and psychological measures, Maternal Outcome after THERapy for Sleep (MOTHERS)

BACKGROUND

Sleep is vital for maintaining individuals' physical and mental health and is particularly challenged during pregnancy. More than 70% of women during the gestational period report insomnia symptoms. Sleep dysfunction in the peripartum increases the risk for a cascade of negative health outcomes during late pregnancy, birth, and postpartum. While psychological interventions are considered the first line treatment for sleep difficulties, they are still scarcely offered during pregnancy and there is a lack of longitudinal research combining psychological and physiological indices.

METHODS

The present protocol outlines a randomized controlled trial aimed at testing the long-term effectiveness of an automatized digitalized psychoeducational intervention for insomnia for expectant mothers complaining insomnia symptoms without comorbidity. Outcomes include physiological, hormonal, and subjective indices of maternal psychopathology, stress, and emotional processes, and sleep and wellbeing of the family system. The trial is part of a longitudinal study evaluating expectant mothers from early pregnancy (within the 15th gestational week) to 6-months postpartum through 6 observational phases: baseline (BSL), 6- and 12-weeks from BSL (FU1-FU2), 2-to-4 weeks after delivery (FU3), and 3- and 6-months after delivery (FU4-5). We plan to recruit 38 women without sleep difficulties (Group A) and 76 women with sleep difficulties (Group B). Group B will be randomly assigned to digital psychological control intervention (B1) or experimental psychoeducational intervention targeting insomnia (B2). At 3 time points, an ecological-momentary-assessment (EMA) design will be used to collect data on sleep and emotions (diaries), sleep-wake parameters (actigraphy) and stress reactivity (salivary cortisol). We will also test the DNA methylation of genes involved in the stress response as biomarkers of prenatal poor sleep. Information on partner's insomnia symptoms and new-borns' sleep will be collected at each stage.

DISCUSSION

The proposed protocol aims at testing an easily accessible evidence-based psychoeducational intervention for expectant mothers to help them improving sleep, health, and wellbeing in the peripartum. The results could improve the understanding and management of sleep difficulties and peripartum depression.

TRIAL REGISTRATION

The study protocol has been registered on 22 April 2024 with ClinicalTrials.gov Protocol Registration and Results System (PRS), ID: NCT06379074.

PROTOCOL VERSION

April 23, 2024.

Maternal Sleeping Problems Before and After Childbirth - A Systematic Review

The perinatal and postpartum period is of great significance for women due to physiological changes, shifts in circadian rhythms, social setting, and psychological well-being, all of which affect the quality and quantity of their sleep. A mixed-studies systematic review was undertaken to enhance our understanding of sleep disturbances and mood disorders in women in late pregnancy and the postpartum period, their connection with breastfeeding, and the assessment of interventions for sleep disturbance. Three electronic databases (PUBMED, EMBASE and Google Scholar) were searched for qualitative, observational, and mixed-method studies from the year 2016 to June 2023. Twenty-nine articles were included in the analysis. The results were synthesized into four overarching themes: (і) the sleep quality of women in the perinatal period; (ii) the relationship between sleep and breastfeeding; (iii) the relationship between sleep quality and emotional disturbance in the perinatal period; (iv) sleep interventions in the researched group. The subjective nature of the perception of sleep disturbances, along with the absence of an objective measurement tool is clearly an inconvenience. It is advisable to include the assessment of maternal sleep hygiene and family sleep patterns during postpartum healthcare provider appointments to develop strategies not only for women's sleep quality but also for their mental well-being.

The Impact of Intervention Design on User Engagement in Digital Therapeutics Research: Factorial Experiment With a Mixed Methods Study

BACKGROUND

User engagement is crucial for digital therapeutics (DTx) effectiveness; due to variations in the conceptualization of engagement and intervention design, assessment and retention of engagement remain challenging.

OBJECTIVE

We investigated the influence of the perceived acceptability of experimental intervention components and satisfaction with core intervention components in DTx on user engagement, while also identifying potential barriers and facilitators to user engagement.

METHODS

We conducted a mixed methods study with a 2 × 2 factorial design, involving 12 outpatients with atopic dermatitis. Participants were randomized into 4 experimental groups based on push notification ("basic" or "advanced") and human coach ("on" or "off") experimental intervention components. All participants engaged in self-monitoring and learning courses as core intervention components within an app-based intervention over 8 weeks. Data were collected through in-app behavioral data, physician- and self-reported questionnaires, and semistructured interviews assessed at baseline, 4 weeks, and 8 weeks. Descriptive statistics and thematic analysis were used to evaluate user engagement, perceived acceptability of experimental intervention components (ie, push notification and human coach), satisfaction with core intervention components (ie, self-monitoring and learning courses), and intervention effectiveness through clinical outcomes.

RESULTS

The primary outcome indicated that group 4, provided with "advanced-level push notifications" and a "human coach," showed higher completion rates for self-monitoring forms and learning courses compared to the predetermined threshold of clinical significance. Qualitative data analysis revealed three key themes: (1) perceived acceptability of the experimental intervention components, (2) satisfaction with the core intervention components, and (3) suggestions for improvement in the overall intervention program. Regarding clinical outcomes, the Perceived Stress Scale and Dermatology Life Quality Index scores presented the highest improvement in group 4.

CONCLUSIONS

These findings will help refine the intervention and inform the design of a subsequent randomized trial to test its effectiveness. Furthermore, this design may serve as a model for broadly examining and optimizing overall engagement in DTx and for future investigation into the complex relationship between engagement and clinical outcomes.

TRIAL REGISTRATION

Clinical Research Information Service KCT0007675; http://tinyurl.com/2m8rjrmv.

Modulators of GABAA receptor-mediated inhibition in the treatment of neuropsychiatric disorders: past, present, and future

The predominant inhibitory neurotransmitter in the brain, γ-aminobutyric acid (GABA), acts at ionotropic GABAA receptors to counterbalance excitation and regulate neuronal firing. GABAA receptors are heteropentameric channels comprised from subunits derived from 19 different genes. GABAA receptors have one of the richest and well-developed pharmacologies of any therapeutic drug target, including agonists, antagonists, and positive and negative allosteric modulators (PAMs, NAMs). Currently used PAMs include benzodiazepine sedatives and anxiolytics, barbiturates, endogenous and synthetic neurosteroids, and general anesthetics. In this article, I will review evidence that these drugs act at several distinct binding sites and how they can be used to alter the balance between excitation and inhibition. I will also summarize existing literature regarding (1) evidence that changes in GABAergic inhibition play a causative role in major depression, anxiety, postpartum depression, premenstrual dysphoric disorder, and schizophrenia and (2) whether and how GABAergic drugs exert beneficial effects in these conditions, focusing on human studies where possible. Where these classical therapeutics have failed to exert benefits, I will describe recent advances in clinical and preclinical drug development. I will also highlight opportunities to advance a generation of GABAergic therapeutics, such as development of subunit-selective PAMs and NAMs, that are engendering hope for novel tools to treat these devastating conditions.

Improvements in cardiovascular health over the perinatal period predicts lower postpartum psychological distress

Background

Adverse cardiovascular events during pregnancy (e.g., pre-eclampsia) occur at higher rates among individuals with pre-pregnancy overweight or obesity (body mass index [BMI]≥25kg/m2) and have been associated with postpartum depression. However, it is unclear whether cardiovascular health (CVH), defined more holistically than the absence of cardiovascular conditions in pregnancy, relates to postpartum psychological functioning. The present study examined whether changes in CVH during the perinatal period predicted postpartum psychological functioning among individuals with pre-pregnancy BMI≥25kg/m2.

Methods

Individuals (N=226; Mage=28.43±5.4 years; MBMI=34.17±7.15kg/m2) were recruited when their pregnancies were 12-20 weeks gestation (M=15.64±2.45 weeks) for a longitudinal study of health and well-being. Participants completed the Center for Epidemiological Studies Depression Scale (CES-D) and Perceived Stress Scale (PSS) and reported on CVH behaviors (dietary intake, physical activity, nicotine exposure, and sleep) at baseline and at 6-months postpartum. BMI and CVH behaviors were coded according to the American Heart Association's Life's Essential 8 to create a CVH score at both timepoints. Linear regression analyses were performed to examine whether change in CVH related to postpartum CES-D and PSS scores. Because sleep was only measured in a subset of participants (n=114), analyses were conducted with and without sleep included. Baseline CVH, CES-D and PSS scores, and demographic factors were included as covariates in all models.

Results

Improved CVH was associated with lower postpartum CES-D (β=-0.18, p<0.01) and PSS (β=-0.13, p=0.02) scores when excluding sleep. Compared to those whose CVH improved by >1SD from pregnancy to 6-months postpartum, individuals whose CVH worsened by >1SD scored 6.42 points higher on the CESD (MCESD=15.25±10.92 vs. 8.52±6.90) and 6.12 points higher on the PSS (MPSS=24.45±8.29 vs. 17.83±8.70). However, when including sleep, these relationships were no longer significant (ps>0.4).

Conclusions

Improvements in CVH from early pregnancy to 6-months postpartum were associated with lower postpartum depressive symptoms and perceived stress. However, these relationships were no longer significant when including sleep in the CVH metric, potentially due to the large reduction in sample size. These data suggest that intervening during pregnancy to promote CVH may improve postpartum psychological functioning among high-risk individuals.

A comprehensive insight on cognitive behavioral therapy for insomnia in pregnant women: A systematic review and meta-analysis

BACKGROUND

Cognitive behavioral therapy for insomnia (CBT-I) as a first-line treatment may improve insomnia in pregnant women. The efficacy of the components, modalities, doses, and effectiveness of CBT-I in pregnant women at follow-up remains unclear.

OBJECTIVES

To assess the effectiveness of CBT-I in pregnant women and identify effective intervention components, modalities, and doses.

DESIGN

Systematic review and meta-analysis.

METHODS

Six English databases (PubMed, Embase, Cochrane Library, Web of Science, PsycINFO, CINAHL) and four Chinese databases (CNKI, WanFang Data, SinoMed, and CQVIP) were searched from inception to 10 January 2023. Randomized controlled trials (RCTs) on CBT-I in pregnant women with outcomes of insomnia severity measured by Insomnia Severity Index (ISI) or sleep quality measured by Pittsburgh Sleep Quality Index (PSQI). Two reviewers independently completed records selection, data extraction, and study quality assessment. The fixed-effect or random-effect model was used for pooled analyses. Subgroup analyses were conducted based on different delivery types and intervention duration. The GRADE approach was used to evaluate the certainty of the evidence. Narrative analyses were used when meta-analysis was not appropriate. Mean differences with 95% CIs of insomnia severity and sleep quality scores were the main outcomes (greater scores indicating greater severity).

RESULTS

Nine RCTs (N = 978) meeting the inclusion criteria were included. These trials included individual- (n = 6) or group-based (n = 3) interventions, which were conducted via face-to-face (n = 5), digital (n = 3) or telephone and e-mail (n = 1) formats. Six studies stated intervention components specific to pregnant women. CBT-I improved insomnia severity (MD = -2.69, 95% CI: -3.41 to -1.96, P ＜ 0.001, high quality evidence; MD = -3.69, 95% CI: -5.91 to -1.47, P = 0.001, moderate quality evidence) and sleep quality (MD = -2.85, 95% CI: -4.73 to -0.97, P = 0.003, moderate quality evidence; MD = -1.88, 95% CI: -2.89 to -0.88, P ＜ 0.001, moderate quality evidence) immediately after intervention (＜1-month) and at short-term (≥1 month to ＜6 months) follow-up, respectively. Two RCTs reported no effectiveness on insomnia severity at medium-term (≥6 months to＜12 months) follow-up. Only 1 RCT showed reduced insomnia severity at long-term (≥12 months) follow-up. One RCT reported no effectiveness in sleep quality at medium-term follow-up and effectiveness at long-term follow-up was not reported.

CONCLUSIONS

Pregnant women may benefit from CBT-I to improve short-term insomnia, but long-term effectiveness is unclear. Rigorous RCTs with long-term follow-ups are warranted.

Insomnia During the Perinatal Period and its Association with Maternal and Infant Psychopathology: A Systematic Review and Meta-Analysis

PURPOSE OF REVIEW

While sleep serves important regulatory functions for mental health, sleep disturbances, in particular insomnia, may contribute to mental disorders. Since insomnia symptoms are frequent during the perinatal period, the aim of this work is to systematically review the potential association between perinatal insomnia and maternal and infant psychopathology.

RECENT FINDINGS

A systematic search was conducted according with PRISMA guidelines, and meta-analytic calculations were conducted. Totally, 34 studies were included and involved 835,021 perinatal women. Four meta-analysis yielded four statistically significant random-effect models. All models show that women with perinatal symptoms of insomnia possess increased odds of developing clinically relevant symptoms of depression OR = 3.69, p = 0.001 and anxiety OR = 2.81; p < 0.001, as well as increased suicidal risk OR = 3.28; p < 0.001, and distress in the newborn OR = 2.80 (P = 0.007). These findings emphasize the role of assessing and addressing insomnia during the perinatal period to mitigate its negative effect on maternal and infant mental health via sleep regulation.

Effects of digital psychotherapy for depression and anxiety: A systematic review and bayesian network meta-analysis

OBJECTIVE

To evaluate the effectiveness of digital psychotherapies for depression and anxiety. We conducted a systematic review and network meta-analyses (NMA) to make comparisons of digital psychotherapies.

METHODS

A bayesian NMA was conducted in this study. The databases including PubMed, Embase, Web of Science, the Cochrane Central Register of Controlled Trials and CINAL were searched for all eligible randomized controlled trials (RCTs) published from Jan 1, 2012 to Oct 1, 2022. We used the Cochrane Collaboration's Risk of bias tool for quality assessment. The primary outcomes were set as a standardized mean difference model in efficacy to describe continuous outcomes. We used STATA and WinBUGS to conduct a bayesian network meta-analysis of all interventions based on a random-effects model. This study was registered with PROSPERO, number CRD42022374558.

RESULTS

From the retrieved 16,750 publications, we included 72 RCTs (13,096 participants) with the overall medium quality and above. In terms of depression scale, cognitive behavioral therapy (CBT) was more effective than TAU (SMDs 0.53) and NT (SMDs 0.98). In terms of anxiety scale, CBT (SMDs 0.68; SMDs 0.72) and exercise therapy (ERT) (SMDs 1.01; SMDs 1.05) were more effective than TAU and NT.

LIMITATIONS

Uneven quality of literature, simple network, and subjective judgment.

CONCLUSION

Based on NMA results, we suggest that CBT, which is the most commonly used digital technology, should be preferred among digital psychotherapy for relieving depression and anxiety symptoms. Digital exercise therapy is an effective strategy to relieve some anxiety problems in the context of COVID-19.

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.

Randomized controlled trial of cognitive behavioral therapy for perinatal insomnia: postpartum outcomes

STUDY OBJECTIVES

This study aimed to assess the effectiveness of cognitive behavioral therapy for insomnia (CBTI) during the postpartum period as part of a larger randomized controlled trial of CBTI on perinatal insomnia.

METHODS

A total of 179 women of 18-30 gestational weeks with insomnia disorder were randomly assigned to CBTI or an active control (CTRL) therapy. Participants were assessed between 18 and 32 weeks of pregnancy at baseline, after the intervention during pregnancy, and at 8, 18, and 30 weeks postpartum. The primary outcomes were Insomnia Severity Index (ISI) scores and total awake time, defined as minutes awake during the sleep opportunity period, assessed with actigraphy and sleep diaries. Included in the analyses were women who provided data for at least 1 of 3 postpartum assessments (68 in CBTI; 61 in CTRL).

RESULTS

Piecewise mixed-effects models revealed a main effect reflecting reduction in ISI scores from 8-18 weeks postpartum (P = .036) and a nonsignificant increase from 18-30 weeks; significant effects for group allocation were present only in week 30 (P = .042). CTRL participants reported significantly longer time awake, excluding time spent caring for the infant, at each postpartum assessment; time awake at night caring for the infant did not differ between groups. There was no significant group difference in the postpartum trajectory of actigraphy-measured total awake time, the two diary measures of time awake (P values > .05). CBTI participants with at least 50% reduction in ISI during pregnancy had consistently stable ISI scores (mean < 6) during the postpartum period; those in the CTRL group had variable ISI scores over time with large individual differences.

CONCLUSIONS

For women with insomnia disorder during pregnancy, CBTI initiated during pregnancy conferred postpartum benefits in terms of wakefulness after sleep onset (excluding time spent caring for the infant) and insomnia severity, though the latter emerged only later in the postpartum period. These findings underscore the importance of treating insomnia during pregnancy, a conclusion that is further supported by our finding that pregnant women who responded to insomnia treatment during pregnancy experienced better sleep in the postpartum period.

CLINICAL TRIAL REGISTRATION

Registry: Clinicaltrials.gov; Name: Treatment for Insomnia During Pregnancy; URL: https://www.clinicaltrials.gov/ct2/show/NCT01846585; Identifier: NCT01846585.

CITATION

Manber R, Bei B, Suh S, et al. Randomized controlled trial of cognitive behavioral therapy for perinatal insomnia: postpartum outcomes. J Clin Sleep Med. 2023;19(8):1411-1419.

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.

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.

Contemporary Concise Review 2022: Sleep

COVID-19 AND SLEEP: The COVID-19 pandemic is associated with an increase in insomnia and impaired sleep quality Health care workers are particularly susceptible and improved with cognitive behavioural therapy for insomnia (CBT-I) Long COVID has significant effects on sleep OSA impacts on the severity of acute COVID-19 illness OBSTRUCTIVE SLEEP APNOEA: Large trials of clinically representative patients confirm the cardiovascular benefits of CPAP treatment in OSA CPAP may improve long-term cognitive outcomes in OSA, but further research is needed Racial disparities in OSA prevalence and mortality risk are becoming evident Periodic evaluation of OSA risk in pregnancy is important as timing may be key for intervention to prevent or treat cardiovascular risk factors INSOMNIA: Comorbid insomnia and obstructive sleep apnoea (COMISA) can frequently co-exist and the combined negative effects of both may be deleterious, particularly to cardiovascular health There is evidence for effectiveness with novel orexin receptor antagonists.

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.

Endorsement of a single-item measure of sleep disturbance during pregnancy and risk for postpartum depression: a retrospective cohort study

Poor prenatal sleep quality is associated with increased risk for depressive symptoms but may go undetected in brief, busy prenatal care visits. Among non-depressed pregnant participants, we evaluated whether 1) the endorsement of sleep disturbance on a depression questionnaire predicted postpartum depressive symptoms, 2) the strength of these associations was higher than other somatic symptoms of pregnancy and depression (i.e., fatigue, appetite disturbance), and 3) the endorsement of prenatal sleep disturbance varied by participant characteristics. In this retrospective cohort study, participants had a live birth and completed Patient Health Questionnaire (PHQ-9) during pregnancy and within 8 weeks postpartum between 2012 and 2017. Participants who were non-depressed during pregnancy (PHQ-9 < 10) were included (n = 3619). We operationalized sleep disturbance, fatigue, and appetite disturbance as endorsement of item 3, 4, and 5 on the PHQ-9, respectively, and postpartum depressive symptoms as PHQ-9 total score ≥ 10. Participant characteristic variables included age, race, ethnicity, parity, gestational age at delivery, and preterm birth. Prenatal sleep disturbance was associated with higher odds of postpartum depressive symptoms (aORs 1.9, 95% CI 1.2-3.1 for first trimester; 3.7, 95% CI 1.5-11.5 for second trimester; 3.4, 95% CI 1.9-6.8 for third trimester). Fatigue and appetite disturbance in the first and third trimesters were associated with higher odds of postpartum depressive symptoms. Sleep disturbance varied by race during the first and second trimesters (p < 0.05) and was highest among Black or African American participants (61.8-65.1%). A routinely administered single-item measure of sleep disturbance could identify otherwise lower-risk pregnant individuals who may benefit from depression prevention efforts.

Effect of brexanolone on depressive symptoms, anxiety, and insomnia in women with postpartum depression: Pooled analyses from 3 double-blind, randomized, placebo-controlled clinical trials in the HUMMINGBIRD clinical program

BACKGROUND

Brexanolone is currently the only treatment specifically approved for postpartum depression (PPD) in the United States, based on the results from one Phase 2 and two Phase 3 double-blind, randomized, controlled trials in the HUMMINGBIRD program.

METHODS

Adults with PPD randomized to a 60-h infusion of brexanolone 90 μg/kg/h (BRX90) or placebo from the 3 trials were included in these post hoc analyses. Data on change from baseline (CFB) in the 17-item Hamilton Rating Scale for Depression (HAMD-17) total score, HAMD-17 Anxiety/Somatization and Insomnia subscales, and Clinical Global Impression of Improvement (CGI-I) scale were pooled. Response rates for HAMD-17 (≥50 % reduction from baseline) and CGI-I (score of 1 or 2) scales and time to response were analyzed.

RESULTS

Patients receiving BRX90 (n = 102) versus placebo (n = 107) achieved a more rapid HAMD-17 response (median, 24 vs 36 h; p = 0.0265), with an Hour-60 cumulative response rate of 81.4 % versus 67.3 %; results were similar for time to CGI-I response (median, 24 vs 36 h; p = 0.0058), with an Hour-60 cumulative response rate of 81.4 % versus 61.7 %. CFB in HAMD-17 Anxiety/Somatization and Insomnia subscales also favored BRX90 versus placebo, starting at Hour 24 through Day 30 (all p < 0.05), and response rates for both subscales were higher with BRX90.

LIMITATIONS

The study was not powered to assess exploratory outcomes.

CONCLUSIONS

Brexanolone was associated with rapid improvement in depressive symptoms and symptoms of anxiety and insomnia compared with placebo in women with PPD. These data continue to support the use of brexanolone to treat adults with PPD.

Recent advances in sleep and depression

PURPOSE OF REVIEW

There is increasing interest in the connection between sleep disturbances and mood disorders. The purpose of this review is to summarize and evaluate current research on the role of sleep disturbance in the development of depression, as well as to describe recent advances in treatments that improve both sleep and depression symptoms.

RECENT FINDINGS

Relevant publications included in this review cover a wide range of topics related to sleep and depression. Data from large longitudinal studies suggest that insomnia and evening circadian preference are unique risk factors for depression. Depression treatment studies indicate poorer outcomes for those with comorbid sleep disturbances. A few recent trials of cognitive behavioral therapy for insomnia and triple chronotherapy in unipolar depression have shown promising results.

SUMMARY

Sleep disturbance is a modifiable risk factor in the development and maintenance of depression. In the context of current depression, although the data is mixed, some evidence suggests treating sleep disturbance can improve overall outcomes. Recent evidence also suggests that treating sleep disturbance may prevent the future depressive episodes.

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.

Postpartum Psychosis: The Role of Women's Health Care Providers and the Health Care System

Importance

The postpartum period is a time of high risk for serious psychiatric symptoms and hospitalization. Postpartum psychosis (PPP) is the most severe disorder that emerges during this time, with significant and wide-ranging consequences that can include suicide and infanticide.

Evidence Acquisition

A PubMed, MEDLINE, and PsycINFO search was completed for English-language publications about PPP, including subtopics (eg, infanticide, maternal suicide). Citations in these articles were also reviewed for relevant references.

Results

Although it is clear that the triggering event for PPP is childbirth, the processes by which this occurs are not fully understood, which is a critical need for being able to predict, prevent, and manage PPP. There are risk factors that contribute to PPP, and specific groups of women may be at increased risk (eg, women with bipolar disorder). Many questions and challenges remain related to the phenomenology, nosology, prevention, and treatment of PPP. However, there are changes that women's health care providers and systems can take to improve the care of women at risk of and experiencing PPP.

Results

Of the 1382 articles reviewed, 8 met eligibility criteria, representing 6 distinct cohorts and 726 subjects. Synthetic slings available for review were either tension-free vaginal tape (TVT) or minisling. The vast majority of studies demonstrated similar short- and long-term success rates of AFS and SS procedures utilizing a range of outcome measures. Both AFS and TVT sling had low recurrence rates in short- and long-term follow-up. However, AFS had significantly longer operative time, and longer hospital stay. Bladder perforation, on the other hand, occurred more commonly in TVT sling. Health-related quality-of-life scores, including sexual function, were similar between groups.

Conclusions and Relevance

Postpartum psychosis is a rare but serious condition. However, recovery is possible. Women's health care providers and systems can improve the care by better understanding the needs of women and families, offering patient-centered discussions and options for care, particularly those that promote recovery, minimize risk, and limit the interruption of the maternal-infant bond. Improving the prevention and treatment of PPP can have a broad impact for women, children, and families.

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.