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Malarkey ME, Fu AJ, Mannan N, Shaw OM, Haight TJ, Cota MR, Jahed NC, Werner JK, Brody DL. Internet-Guided Cognitive Behavioral Therapy for Insomnia Among Patients With Traumatic Brain Injury: A Randomized Clinical Trial. JAMA Netw Open 2024; 7:e2420090. [PMID: 38980675 PMCID: PMC11234237 DOI: 10.1001/jamanetworkopen.2024.20090] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/10/2024] Open
Abstract
Importance Many military service members and veterans report insomnia after sustaining traumatic brain injury (TBI). Limitations of first-line treatment, cognitive-behavioral therapy for insomnia (CBT-I), include availability of qualified clinicians, low completion rates, and cost. Objective To investigate the feasibility and efficacy of internet-guided CBT-I (eCBT-I) in military service members and veterans with insomnia and a history of TBI. Design, Setting, and Participants This randomized clinical trial of fully remote internet-based interventions and evaluations was conducted from September 1, 2020, to June 30, 2021, with 3 months of follow-up. Participants included a volunteer sample of military service members and veterans aged 18 to 64 years with a history of mild TBI/concussion and at least moderately severe insomnia defined as an insomnia severity index (ISI) score of greater than 14 and Pittsburgh Sleep Quality Index of greater than 4. Self-reported race, ethnicity, and educational level were generally representative of the US military. Data were analyzed from October 21, 2021, to April 29, 2024. Intervention Internet-based CBT-I delivered over 6 weekly lesson modules with assigned homework activities. Main Outcomes and Measures The prespecified primary outcome measure was change in ISI score over time. Prespecified secondary outcome measures included self-reported measures of depression symptoms, posttraumatic stress disorder (PTSD) symptoms, sleep quality, migraine impact, and fatigue. Results Of 204 people screened, 125 were randomized 3:1 to eCBT-I vs online sleep education, and 106 completed baseline evaluations (83 men [78.3%]; mean [SD] age, 42 [12] years). Of these, 22 participants (20.8%) were Hispanic or Latino and 78 (73.6%) were White. Fifty participants completed postintervention evaluations, and 41 completed the 3-month follow-up. Baseline mean (SD) ISI scores were 19.7 (4.0) in those randomized to eCBT-I and 18.9 (5.0) in those randomized to sleep education. After intervention, mean (SD) ISI scores were 13.7 (5.6) in those randomized to eCBT-I and 16.6 (5.7) in those randomized to sleep education. The difference in the extent of reduction in ISI scores between groups was 3.5 (95% CI,-6.5 to -0.4 [P = .03]; Cohen d, -0.32 [95% CI, -0.70 to -0.04]). In the eCBT-I group, the extent of insomnia improvement correlated with the extent of depressive symptom improvement (Spearman ρ = 0.68 [P < .001]), PTSD symptoms (ρ = 0.36 [P = .04]), sleep quality (ρ = 0.54 [P = .001]), and fatigue impact (ρ = -0.58 [P < .001]) but not migraine-related disability. Conclusions and Relevance The findings of this randomized clinical trial suggest that fully remote eCBT-I was moderately feasible and effective for self-reported insomnia and depression symptoms in military service members and veterans with a history of TBI. There is great potential benefit for eCBT-I due to low availability and cost of qualified CBT-I clinicians, although optimization of completion rates remains a challenge. Future studies may use home-based objective sleep assessments and should increase study retention. Trial Registration ClinicalTrials.gov Identifier: NCT04377009.
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Affiliation(s)
- Molly E Malarkey
- The Henry M. Jackson Foundation for the Advancement of Military Medicine Inc, Bethesda, Maryland
- Military Traumatic Brain Injury Initiative (formerly the Center for Neuroscience and Regenerative Medicine), Bethesda, Maryland
| | - Adele J Fu
- The Henry M. Jackson Foundation for the Advancement of Military Medicine Inc, Bethesda, Maryland
- Military Traumatic Brain Injury Initiative (formerly the Center for Neuroscience and Regenerative Medicine), Bethesda, Maryland
| | - Noushin Mannan
- The Henry M. Jackson Foundation for the Advancement of Military Medicine Inc, Bethesda, Maryland
- Military Traumatic Brain Injury Initiative (formerly the Center for Neuroscience and Regenerative Medicine), Bethesda, Maryland
| | - Olivia M Shaw
- The Henry M. Jackson Foundation for the Advancement of Military Medicine Inc, Bethesda, Maryland
- Military Traumatic Brain Injury Initiative (formerly the Center for Neuroscience and Regenerative Medicine), Bethesda, Maryland
| | - Thaddeus J Haight
- The Henry M. Jackson Foundation for the Advancement of Military Medicine Inc, Bethesda, Maryland
- Military Traumatic Brain Injury Initiative (formerly the Center for Neuroscience and Regenerative Medicine), Bethesda, Maryland
| | - Martin R Cota
- The Henry M. Jackson Foundation for the Advancement of Military Medicine Inc, Bethesda, Maryland
- Military Traumatic Brain Injury Initiative (formerly the Center for Neuroscience and Regenerative Medicine), Bethesda, Maryland
| | - Nasreen C Jahed
- The Henry M. Jackson Foundation for the Advancement of Military Medicine Inc, Bethesda, Maryland
- Military Traumatic Brain Injury Initiative (formerly the Center for Neuroscience and Regenerative Medicine), Bethesda, Maryland
| | - J Kent Werner
- Military Traumatic Brain Injury Initiative (formerly the Center for Neuroscience and Regenerative Medicine), Bethesda, Maryland
- Department of Neurology, Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - David L Brody
- Military Traumatic Brain Injury Initiative (formerly the Center for Neuroscience and Regenerative Medicine), Bethesda, Maryland
- Department of Neurology, Uniformed Services University of the Health Sciences, Bethesda, Maryland
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Lotzin A, Laskowsky I. Feasibility of a breath robot intervention to reduce sleep problems in posttraumatic stress disorder: protocol for a randomized controlled study. Pilot Feasibility Stud 2024; 10:24. [PMID: 38317264 PMCID: PMC10840171 DOI: 10.1186/s40814-023-01426-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2023] [Accepted: 12/19/2023] [Indexed: 02/07/2024] Open
Abstract
BACKGROUND Many patients with posttraumatic stress disorder (PTSD) suffer from sleep problems. Robot-based interventions might be an innovative approach to reduce sleep problems and hyperarousal in PTSD. However, the feasibility and effectiveness of a breath robot in patients with PTSD have never been empirically tested. The aim of this study is to investigate the feasibility of a breath robot to reduce sleep problems and hyperarousal in patients with PTSD. METHODS This randomized controlled feasibility study will include N = 30 adult patients with at least subsyndromal PTSD (PTSD Symptom Scale - Interview-5 (PSSI-5)) according to the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5) and impaired sleep quality (Pittsburgh Sleep Quality Index (PSQI) > 5). Patients with organic sleep disorders or currently in psychotherapeutic treatment are excluded. Study participants are randomized to receive either a 4-week Somnox 2 robot intervention including simulation of human breath or a 4-week Somnox 2 robot intervention without human breath simulation. The primary outcome will be the proportion of randomized participants providing outcome data at post-treatment. We consider a proportion of > 50% to indicate feasibility. Additional feasibility outcomes include eligibility rate, recruitment speed, uptake, retention, treatment adherence, and dropout. Potential outcomes of effectiveness (sleep quality, PSQI; severity of PTSD symptoms, PSSI-5) will be assessed at two time points, before (T0) and after (T1) the intervention. Sleep characteristics (Consensus Sleep Diary (CSD)) are measured daily. DISCUSSION This study is the first to investigate the feasibility of a novel breath robot intervention for reducing sleep problems and hyperarousal in PTSD patients, with effectiveness considered as a secondary outcome. If feasible and effective, the use of a breath robot could be a nonintrusive and flexible intervention to supplement psychotherapy or to bridge treatment gaps. TRIAL REGISTRATION DRKS, DRKS00031063. Registered on 10/012023.
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Affiliation(s)
- Annett Lotzin
- Department of Psychology, Institute of Clinical Psychology and Psychotherapy Research, MSH Medical School Hamburg, Hamburg, Germany.
- Department for Psychiatry and Psychotherapy, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.
| | - Isabelle Laskowsky
- Department of Psychology, Institute of Clinical Psychology and Psychotherapy Research, MSH Medical School Hamburg, Hamburg, Germany
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Hildebrand L, Huskey A, Dailey N, Jankowski S, Henderson-Arredondo K, Trapani C, Patel SI, Chen AYC, Chou YH, Killgore WDS. Transcranial Magnetic Stimulation of the Default Mode Network to Improve Sleep in Individuals With Insomnia Symptoms: Protocol for a Double-Blind Randomized Controlled Trial. JMIR Res Protoc 2024; 13:e51212. [PMID: 38277210 PMCID: PMC10858423 DOI: 10.2196/51212] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Revised: 12/24/2023] [Accepted: 12/26/2023] [Indexed: 01/27/2024] Open
Abstract
BACKGROUND Cortical hyperarousal and ruminative thinking are common aspects of insomnia that have been linked with greater connectivity in the default mode network (DMN). Therefore, disrupting network activity within the DMN may reduce cortical and cognitive hyperarousal and facilitate better sleep. OBJECTIVE This trial aims to establish a novel, noninvasive method for treating insomnia through disruption of the DMN with repetitive transcranial magnetic stimulation, specifically with continuous theta burst stimulation (cTBS). This double-blind, pilot randomized controlled trial will assess the efficacy of repetitive transcranial magnetic stimulation as a novel, nonpharmacological approach to improve sleep through disruption of the DMN prior to sleep onset for individuals with insomnia. Primary outcome measures will include assessing changes in DMN functional connectivity before and after stimulation. METHODS A total of 20 participants between the ages of 18 to 50 years with reported sleep disturbances will be recruited as a part of the study. Participants will then conduct an in-person screening and follow-on enrollment visit. Eligible participants then conduct at-home actigraphic collection until their first in-residence overnight study visit. In a double-blind, counterbalanced, crossover study design, participants will receive a 40-second stimulation to the left inferior parietal lobule of the DMN during 2 separate overnight in-residence visits. Participants are randomized to the order in which they receive the active stimulation and sham stimulation. Study participants will undergo a prestimulation functional magnetic resonance imaging scan and a poststimulation functional magnetic resonance imaging scan prior to sleep for each overnight study visit. Sleep outcomes will be measured using clinical polysomnography. After their first in-residence study visit, participants conduct another at-home actigraphic collection before returning for their second in-residence overnight study visit. RESULTS Our study was funded in September 2020 by the Department of Defense (W81XWH2010173). We completed the enrollment of our target study population in the October 2022 and are currently working on neuroimaging processing and analysis. We aim to publish the results of our study by 2024. Primary neuroimaging outcome measures will be tested using independent components analysis, seed-to-voxel analyses, and region of interest to region of interest analyses. A repeated measures analysis of covariance (ANCOVA) will be used to assess the effects of active and sham stimulation on sleep variables. Additionally, we will correlate changes in functional connectivity to polysomnography-graded sleep. CONCLUSIONS The presently proposed cTBS protocol is aimed at establishing the initial research outcomes of the effects of a single burst of cTBS on disrupting the network connectivity of the DMN to improve sleep. If effective, future work could determine the most effective stimulation sites and administration schedules to optimize this potential intervention for sleep problems. TRIAL REGISTRATION ClinicalTrials.gov NCT04953559; https://clinicaltrials.gov/ct2/show/NCT04953559. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) DERR1-10.2196/51212.
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Affiliation(s)
- Lindsey Hildebrand
- Department of Psychiatry, University of Arizona, Tucson, AZ, United States
| | - Alisa Huskey
- Department of Psychiatry, University of Arizona, Tucson, AZ, United States
| | - Natalie Dailey
- Department of Psychiatry, University of Arizona, Tucson, AZ, United States
| | - Samantha Jankowski
- Department of Psychiatry, University of Arizona, Tucson, AZ, United States
| | | | | | - Salma Imran Patel
- Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, University of Arizona, Tucson, AZ, United States
| | | | - Ying-Hui Chou
- Department of Psychology, University of Arizona, Tucson, AZ, United States
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Nazem S, Barnes SM, Forster JE, Hostetter TA, Monteith LL, Kramer EB, Gaeddert LA, Brenner LA. Efficacy of an Internet-Delivered Intervention for Improving Insomnia Severity and Functioning in Veterans: Randomized Controlled Trial. JMIR Ment Health 2023; 10:e50516. [PMID: 37999953 DOI: 10.2196/50516] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2023] [Revised: 09/26/2023] [Accepted: 10/06/2023] [Indexed: 11/25/2023] Open
Abstract
BACKGROUND Despite a growing evidence base that internet-delivered cognitive behavioral therapy for insomnia (iCBT-I) is associated with decreased insomnia severity, its efficacy has been minimally examined in veterans. OBJECTIVE The objective of this study was to evaluate the efficacy of an unguided iCBT-I (Sleep Healthy Using the Internet [SHUTi]) among veterans. METHODS We conducted a single-blind, randomized controlled trial in Operation Enduring Freedom, Operation Iraqi Freedom, and Operation New Dawn veterans eligible for Veterans Health Administration care. Participants were randomly assigned (1:1) to receive SHUTi (a self-guided and interactive program) or an Insomnia Education Website (IEW) that provided nontailored and fixed insomnia information. Web-based assessments were administered at baseline, postintervention, 6 months postintervention, and 1 year postintervention. The primary outcome was self-reported insomnia severity (Insomnia Severity Index [ISI]). Secondary outcomes were self-reported mental and physical health functioning (Veterans RAND 36-item Health Survey). Exploratory outcomes comprised sleep diary parameters. RESULTS Of the 231 randomized participants (mean age 39.3, SD 7.8 years; 170/231, 73.5% male sex; 26/231, 11.3% Black; 172/231, 74.5% White; 10/231, 4.3% multiracial; and 17/231, 7.4% other; 36/231, 15.6% Hispanic) randomized between April 2018 and January 2019, a total of 116 (50.2%) were randomly assigned to SHUTi and 115 (49.8%) to the IEW. In intent-to-treat analyses, SHUTi participants experienced significantly larger ISI decreases compared with IEW participants at all time points (generalized η2 values of 0.13, 0.12, and 0.10, respectively; all P<.0001). These corresponded to estimated larger differences in changes of -3.47 (95% CI -4.78 to -2.16), -3.80 (95% CI -5.34 to -2.27), and -3.42 (95% CI -4.97 to 1.88) points on the ISI for the SHUTi group. SHUTi participants experienced significant improvements in physical (6-month generalized η2=0.04; P=.004) and mental health functioning (6-month and 1-year generalized η2=0.04; P=.009 and P=.005, respectively). Significant sleep parameter improvements were noted for SHUTi (all P<.05), though the pattern and magnitude of these reductions varied by parameter. No adverse events were reported. CONCLUSIONS Self-administered iCBT-I was associated with immediate and long-term improvements in insomnia severity. Findings suggest that leveraging technology to meet insomnia treatment demands among veterans may be a promising approach. TRIAL REGISTRATION ClinicalTrials.gov NCT03366870; https://clinicaltrials.gov/ct2/show/NCT03366870.
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Affiliation(s)
- Sarra Nazem
- Dissemination & Training Division, National Center for Posttraumatic Stress Disorder, Menlo Park, CA, United States
- Veterans Affairs Rocky Mountain Mental Illness Research, Education and Clinical Center, Aurora, CO, United States
| | - Sean M Barnes
- Veterans Affairs Rocky Mountain Mental Illness Research, Education and Clinical Center, Aurora, CO, United States
- Department of Psychiatry, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
| | - Jeri E Forster
- Veterans Affairs Rocky Mountain Mental Illness Research, Education and Clinical Center, Aurora, CO, United States
- Department of Physical Medicine and Rehabilitation, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
| | - Trisha A Hostetter
- Veterans Affairs Rocky Mountain Mental Illness Research, Education and Clinical Center, Aurora, CO, United States
| | - Lindsey L Monteith
- Veterans Affairs Rocky Mountain Mental Illness Research, Education and Clinical Center, Aurora, CO, United States
- Department of Psychiatry, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
- Department of Physical Medicine and Rehabilitation, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
| | - Emily B Kramer
- Veterans Affairs Rocky Mountain Mental Illness Research, Education and Clinical Center, Aurora, CO, United States
| | - Laurel A Gaeddert
- Veterans Affairs Rocky Mountain Mental Illness Research, Education and Clinical Center, Aurora, CO, United States
| | - Lisa A Brenner
- Veterans Affairs Rocky Mountain Mental Illness Research, Education and Clinical Center, Aurora, CO, United States
- Department of Psychiatry, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
- Department of Physical Medicine and Rehabilitation, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
- Department of Neurology, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
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Song J, Fisher AJ, Woodward SH. Bedtime regularity predicts positive affect among veterans with posttraumatic stress disorder: an ecological momentary assessment study. BMC Psychiatry 2023; 23:869. [PMID: 37993848 PMCID: PMC10666399 DOI: 10.1186/s12888-023-05373-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Accepted: 11/11/2023] [Indexed: 11/24/2023] Open
Abstract
BACKGROUND Regularizing bedtime and out-of-bed times is a core component of behavioral treatments for sleep disturbances common among patients with posttraumatic stress disorder (PTSD). Although improvements in subjective sleep complaints often accompany improvements in PTSD symptoms, the underlying mechanism for this relationship remains unclear. Given that night-to-night sleep variability is a predictor of physical and mental well-being, the present study sought to evaluate the effects of bedtime and out-of-bed time variability on daytime affect and explore the optimal window lengths of over which variability is calculated. METHODS For about 30 days, male U.S. military veterans with PTSD (N = 64) in a residential treatment program provided ecological momentary assessment data on their affect and slept on beds equipped with mattress actigraphy. We computed bedtime and out-of-bed time variability indices with varying windows of days. We then constructed multilevel models to account for the nested structure of our data and evaluate the impact of bedtime and out-of-bed time variability on daytime affect. RESULTS More regular bedtime across 6-9 days was associated with greater subsequent positive affect. No similar effects were observed between out-of-bed time variability and affect. CONCLUSIONS Multiple facets of sleep have been shown to differently predict daily affect, and bedtime regularity might represent one of such indices associated with positive, but not negative, affect. A better understanding of such differential effects of facets of sleep on affect will help further elucidate the complex and intertwined relationship between sleep and psychopathology. TRIAL REGISTRATION The trial retrospectively was registered on the Defense Technical Information Center website: Award # W81XWH-15-2-0005.
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Affiliation(s)
- Jiyoung Song
- Department of Psychology, University of California, 2121 Berkeley Way, Berkeley, CA, 94720, USA.
| | - Aaron J Fisher
- Department of Psychology, University of California, 2121 Berkeley Way, Berkeley, CA, 94720, USA
| | - Steven H Woodward
- Dissemination and Training Division, National Center for PTSD, 795 Willow Road, Menlo Park, CA, 94025, USA
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Hoyt T, Lee MRG, Stolee JD, Breitstein JA, Kwon HP, Mysliwiec V. Cognitive Behavioral Therapy for Insomnia Among Active Duty Military Personnel Diagnosed With Obstructive Sleep Apnea. Mil Med 2023; 188:2856-2861. [PMID: 36050797 DOI: 10.1093/milmed/usac264] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Revised: 06/10/2022] [Accepted: 08/18/2022] [Indexed: 11/12/2022] Open
Abstract
INTRODUCTION Insomnia and obstructive sleep apnea are common conditions among military service members, with high rates of comorbidity. Although cognitive behavioral therapy for insomnia (CBT-I) has been established as an effective treatment for insomnia, it is unclear whether or not CBT-I is effective among service members with comorbid insomnia and obstructive sleep apnea. MATERIALS AND METHODS This retrospective, observational study examined insomnia outcomes among a group of service member patients (N = 73) with comorbid insomnia and obstructive sleep apnea. All patients received individual CBT-I in a specialty sleep clinic at a military treatment facility. Seven outcomes associated with insomnia were evaluated before and after treatment. RESULTS On average, patients showed significant improvement in sleep onset latency, wake after sleep onset, sleep efficiency, number of awakenings, and symptoms reported on the Insomnia Severity Index. Twenty-six percent of patients showed clinically significant improvement in reported insomnia symptoms. CONCLUSIONS These results suggest that CBT-I may be effective in treating military service members with comorbid insomnia and obstructive sleep apnea. Despite the limitations of data collected in a clinical setting, consistent findings across five of the seven outcome measures provide good evidence that this treatment can be implemented in military settings.
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Affiliation(s)
- Tim Hoyt
- Madigan Army Medical Center, Tacoma, WA 98431, USA
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Taylor DJ, Pruiksma KE, Mintz J, Slavish DC, Wardle-Pinkston S, Dietch JR, Dondanville KA, Young-McCaughan S, Nicholson KL, Litz BT, Keane TM, Peterson AL, Resick PA. Treatment of comorbid sleep disorders and posttraumatic stress disorder in U.S. active duty military personnel: A pilot randomized clinical trial. J Trauma Stress 2023; 36:712-726. [PMID: 37322836 PMCID: PMC11057368 DOI: 10.1002/jts.22939] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2022] [Revised: 03/28/2023] [Accepted: 03/29/2023] [Indexed: 06/17/2023]
Abstract
Insomnia and nightmares are common in patients with posttraumatic stress disorder (PTSD). They are associated with worse psychological and physical health and worse PTSD treatment outcomes. In addition, they are resistant to PTSD treatments, which do not typically address sleep disorders. Cognitive behavioral therapy for insomnia and nightmares (CBT-I&N) and cognitive processing therapy (CPT) for PTSD are first-line treatments, but limited evidence exists guiding the treatment of individuals with all three disorders. The current study randomized U.S. military personnel (N = 93) to one of three conditions: CBT-I&N delivered before CPT, CBT-I&N delivered after CPT, or CPT alone; all groups received 18 sessions. Across groups, participants demonstrated significantly improved PTSD symptoms. Because the study was terminated prematurely due to challenges with recruitment and retention, it was underpowered to answer the initially intended research questions. Nonetheless, statistical findings and relevant clinically meaningful changes were observed. Compared to participants who received CPT alone, those who received CBT-I&N and CPT, regardless of sequencing, demonstrated larger improvements in PTSD symptoms, d = -0.36; insomnia, d = -0.77; sleep efficiency, d = 0.62; and nightmares, d = -.53. Compared to participants who received CBT-I&N delivered before CPT, those who received CBT-I&N delivered after CPT demonstrated larger improvements in PTSD symptoms, d = 0.48, and sleep efficiency, d = -0.44. This pilot study suggests that treating comorbid insomnia, nightmares, and PTSD symptoms results in clinically meaningful advantages in improvement for all three concerns compared to treating PTSD alone.
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Affiliation(s)
- Daniel J. Taylor
- Department of Psychology, University of Arizona, Tucson, Arizona, USA
| | - Kristi E. Pruiksma
- Department of Psychiatry and Behavioral Sciences, University of Texas Health Science Center at San Antonio, San Antonio, Texas, USA
- Research and Development Service, South Texas Veterans Health Care System, San Antonio, Texas, USA
| | - Jim Mintz
- Department of Psychiatry and Behavioral Sciences, University of Texas Health Science Center at San Antonio, San Antonio, Texas, USA
- Research and Development Service, South Texas Veterans Health Care System, San Antonio, Texas, USA
| | - Danica C. Slavish
- Department of Psychology, University of North Texas, Denton, Texas, USA
| | | | - Jessica R. Dietch
- School of Psychological Science, Oregon State University, Corvallis, Oregon, USA
| | - Katherine A. Dondanville
- Department of Psychiatry and Behavioral Sciences, University of Texas Health Science Center at San Antonio, San Antonio, Texas, USA
| | - Stacey Young-McCaughan
- Department of Psychiatry and Behavioral Sciences, University of Texas Health Science Center at San Antonio, San Antonio, Texas, USA
- Research and Development Service, South Texas Veterans Health Care System, San Antonio, Texas, USA
| | - Karin L. Nicholson
- Department of Medicine, Carl R. Darnall Army Medical Center, Fort Hood, Texas, USA
| | - Brett T. Litz
- Massachusetts Veterans Epidemiological Research and Information Center, VA Boston Healthcare System, Boston, Massachusetts, USA
- Department of Psychiatry, Boston University Chobanian & Avedisian School of Medicine, Boston, Massachusetts, USA
- Department of Psychological and Brain Sciences, Boston University, Boston, Massachusetts, USA
| | - Terence M. Keane
- Department of Psychiatry, Boston University Chobanian & Avedisian School of Medicine, Boston, Massachusetts, USA
- Behavioral Sciences Division, National Center for PTSD at VA Boston Healthcare System, Boston, Massachusetts, USA
| | - Alan L. Peterson
- Department of Psychiatry and Behavioral Sciences, University of Texas Health Science Center at San Antonio, San Antonio, Texas, USA
- Research and Development Service, South Texas Veterans Health Care System, San Antonio, Texas, USA
- Department of Psychology, University of Texas at San Antonio, San Antonio, Texas, USA
| | - Patricia A. Resick
- Department of Psychiatry and Behavioral Sciences, Duke Health, Durham, North Carolina, USA
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Lape EC, LaRowe LR, Zale EL, Gellis LA, Park A, Ditre JW. Tobacco cigarette smokers who endorse greater intolerance for nicotine withdrawal also report more severe insomnia symptoms. Exp Clin Psychopharmacol 2022; 30:269-278. [PMID: 33630648 PMCID: PMC8396043 DOI: 10.1037/pha0000440] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
It has been suggested that nighttime nicotine withdrawal may help to explain why tobacco cigarette smokers are more likely than nonsmokers to experience clinically significant insomnia. There is also reason to believe that intolerance for withdrawal symptoms could play a role in withdrawal-related sleep disturbance. However, we are not aware of any previous research that examined whether smokers who endorse greater intolerance for smoking abstinence also report greater difficulty initiating and/or maintaining sleep. To address this question, 224 adult cigarette smokers (42.9% female, Mcigarettes per day = 21.3) completed the baseline portion of an experimental study that included assessment of current/historical smoking behavior, perceived intolerance for smoking abstinence, and insomnia severity and impact on functioning. The results indicated that, after accounting for general distress intolerance and sociodemographic factors, smokers who endorsed greater intolerance for nicotine withdrawal also reported greater insomnia severity and impact. Logistic regression further revealed that, for every 1-point increase in nicotine withdrawal intolerance scores, smokers were nearly twice as likely to score above threshold for clinically significant insomnia (p = .001). Collectively, these initial findings suggest that intolerance for nicotine withdrawal may warrant consideration as a potentially modifiable mechanistic factor in comorbid insomnia and nicotine/tobacco dependence. (PsycInfo Database Record (c) 2022 APA, all rights reserved).
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Affiliation(s)
| | | | | | | | - Aesoon Park
- Department of Psychology, Syracuse University
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Staines AC, Broomfield N, Pass L, Orchard F, Bridges J. Do non-pharmacological sleep interventions affect anxiety symptoms? A meta-analysis. J Sleep Res 2021; 31:e13451. [PMID: 34331373 DOI: 10.1111/jsr.13451] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2021] [Revised: 07/09/2021] [Accepted: 07/16/2021] [Indexed: 12/13/2022]
Abstract
Research indicates a bidirectional relationship between sleep and anxiety, with findings suggesting anxiety can precede poor sleep and vice versa. Evidence suggests sleep-related thought processes associated with anxiety are involved in the maintenance of insomnia. Previous meta-analyses provide some evidence to suggest cognitive behavioural therapy for insomnia moderately improves anxiety, yet little research has investigated the effect of other sleep interventions on anxiety symptoms. The aim of this meta-analysis was to review whether non-pharmacological sleep interventions have an impact on anxiety symptoms immediately post-intervention. A systematic search of electronic databases was conducted to identify all randomized control trials (RCTs) investigating non-pharmacological sleep interventions that included anxiety symptoms as an outcome. Forty-three RCTs (n = 5945) met full inclusion criteria and were included in a random-effects meta-analysis model. The combined effect size of non-pharmacological sleep interventions on anxiety symptoms was moderate (Hedges' g = -0.38), indicating a reduction in symptoms. Subgroup analyses found a moderate effect for those with additional physical health difficulties (g = -0.46), a moderate effect for those with additional mental health difficulties (g = -0.47) and a moderate effect for those with elevated levels of anxiety at baseline (g = -0.43). A secondary meta-analysis found a large effect of non-pharmacological sleep interventions on sleep-related thought processes (g = -0.92). These findings indicate non-pharmacological sleep interventions are effective in reducing anxiety and sleep-related thought processes, and these effects may be larger in patients with anxiety. This has clinical implications for considering sleep interventions in the treatment of anxiety.
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Affiliation(s)
- Alex Catherine Staines
- Department of Clinical Psychology, Norwich Medical School, University of East Anglia, Norwich, UK
| | - Niall Broomfield
- Department of Clinical Psychology, Norwich Medical School, University of East Anglia, Norwich, UK
| | - Laura Pass
- Department of Clinical Psychology, Norwich Medical School, University of East Anglia, Norwich, UK
| | - Faith Orchard
- School of Psychology, University of Sussex, Brighton, UK
| | - Jessica Bridges
- Department of Clinical Psychology, Norwich Medical School, University of East Anglia, Norwich, UK
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Cooper AD, Kolaja CA, Markwald RR, Jacobson IG, Chinoy ED. Longitudinal associations of military-related factors on self-reported sleep among U.S. service members. Sleep 2021; 44:6314292. [PMID: 34216467 DOI: 10.1093/sleep/zsab168] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2020] [Revised: 06/24/2021] [Indexed: 11/15/2022] Open
Abstract
STUDY OBJECTIVES Sleep loss is common in the military, which can negatively affect health and readiness; however, it is largely unknown how sleep varies over a military career. This study sought to examine the relationships between military-related factors and the new onset and reoccurrence of short sleep duration and insomnia symptoms. METHODS Millennium Cohort Study data were used to track U.S. military service members over time to examine longitudinal changes in sleep. Outcomes were self-reported average sleep duration (categorized as ≤5 hours, 6 hours, or 7-9 hours [recommended]) and/or insomnia symptoms (having trouble falling or staying asleep). Associations between military-related factors and the new onset and reoccurrence of these sleep characteristics were determined, after controlling for multiple health and behavioral factors. RESULTS Military-related factors consistently associated with an increased risk for new onset and/or reoccurrence of short sleep duration and insomnia symptoms included active duty component, Army or Marine Corps service, combat deployment, and longer than average deployment lengths. Military officers and noncombat deployers had decreased risk for either sleep characteristic. Time-in-service and separation from the military were complex factors; they lowered risk for ≤5 hours sleep but increased risk for insomnia symptoms. CONCLUSIONS Various military-related factors contribute to risk of short sleep duration and/or insomnia symptoms over time, although some factors affect these sleep characteristics differently. Also, even when these sleep characteristics remit, some military personnel have an increased risk of reoccurrence. Efforts to improve sleep prioritization and implement interventions targeting at-risk military populations, behaviors, and other significant factors are warranted.
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Affiliation(s)
- Adam D Cooper
- Deployment Health Research Department, Naval Health Research Center, San Diego, CA, USA.,Sleep, Tactical Efficiency, and Endurance Laboratory, Warfighter Performance Department, Naval Health Research Center, San Diego, CA, USA.,Innovative Employee Solutions, San Diego, CA, USA
| | - Claire A Kolaja
- Deployment Health Research Department, Naval Health Research Center, San Diego, CA, USA.,Leidos, Inc., San Diego, CA, USA
| | - Rachel R Markwald
- Sleep, Tactical Efficiency, and Endurance Laboratory, Warfighter Performance Department, Naval Health Research Center, San Diego, CA, USA
| | - Isabel G Jacobson
- Deployment Health Research Department, Naval Health Research Center, San Diego, CA, USA.,Leidos, Inc., San Diego, CA, USA
| | - Evan D Chinoy
- Sleep, Tactical Efficiency, and Endurance Laboratory, Warfighter Performance Department, Naval Health Research Center, San Diego, CA, USA.,Leidos, Inc., San Diego, CA, USA
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11
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Brownlow JA, Miller KE, Gehrman PR. Treatment of Sleep Comorbidities in Posttraumatic Stress Disorder. ACTA ACUST UNITED AC 2021; 7:301-316. [PMID: 33552844 DOI: 10.1007/s40501-020-00222-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Purpose of the review Sleep disturbances, insomnia and recurrent nightmares in particular, are among the most frequently endorsed symptoms of posttraumatic stress disorder (PTSD). The present review provides a summary of the prevalence estimates and methodological challenges presented by sleep disturbances in PTSD, highlights the recent evidence for empirically supported psychotherapeutic and pharmacological interventions for comorbid sleep disturbances implicated in PTSD, and provides a summary of recent findings on integrated and sequential treatment approaches to ameliorate comorbid sleep disturbances in PTSD. Recent Findings Insomnia, recurrent nightmares, and other sleep disorders are commonly endorsed among individuals with PTSD; however, several methodological challenges contribute to the varying prevalence estimates. Targeted sleep-focused therapeutic interventions can improve sleep symptoms and mitigate daytime PTSD symptoms. Recently, attention has focused on the role of integrated and sequential approaches, suggesting that comprehensively treating sleep disturbances in PTSD is likely to require novel treatment modalities. Summary Evidence is growing on the development, course, and treatment of comorbid sleep disturbances in PTSD. Further, interventions targeting sleep disturbances in PTSD show promise in reducing symptoms. However, longitudinal investigations and additional rigorous controlled trials with diverse populations are needed to identify key features associated with treatment response in order to alleviate symptoms.
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Affiliation(s)
- Janeese A Brownlow
- Department of Psychology, College of Health & Behavioral Sciences, Delaware State University, Dover, Delaware, USA.,Department of Psychiatry, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Katherine E Miller
- Mental Illness Research, Education, and Clinical Center, Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, Pennsylvania, USA
| | - Philip R Gehrman
- Department of Psychiatry, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Mental Illness Research, Education, and Clinical Center, Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, Pennsylvania, USA
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12
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Zhang C, Yang L, Liu S, Xu Y, Zheng H, Zhang B. One-Week Self-Guided Internet Cognitive Behavioral Treatments for Insomnia in Adults With Situational Insomnia During the COVID-19 Outbreak. Front Neurosci 2021; 14:622749. [PMID: 33551732 PMCID: PMC7859353 DOI: 10.3389/fnins.2020.622749] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2020] [Accepted: 12/14/2020] [Indexed: 11/13/2022] Open
Abstract
Objective: In the current global home confinement due to COVID-19, most individuals are facing unprecedented stress which can induce situational insomnia. We explored the efficacy of self-guided online cognitive behavioral treatment for insomnia (CBTI) on situational insomnia during the COVID-19 outbreak. Methods: Participants were recruited from March to April in 2020 in Guangzhou, China. A 1-week Internet CBTI intervention was performed for all individuals with situational insomnia. The Pre-sleep Arousal Scale (PSAS), Insomnia Severity Index (ISI), and Hospital Anxiety and Depression Scale (HADS) were measured before and after the intervention and compared between individuals who completed the intervention and those who did not. Results: One hundred and ninety-four individuals with situational insomnia were included. For PSAS score, significant group effects were found on total score (p = 0.003), somatic score (p = 0.014), and cognitive score (p = 0.009). Time effect was significant on total score (p = 0.004) and cognitive score (p < 0.001). There was a significant group × time effect of the somatic score (p = 0.025). For ISI total score, there were significant time effect (p < 0.001) and group × time effect (p = 0.024). For the HADS score, a significant group effect was found on the anxiety score (p = 0.045). The HADS had significant time effects for anxiety and depressive symptoms (all p < 0.001). Conclusion: Our study suggests good efficacy of CBTI on situational insomnia during COVID-19 for adults in the community, as well as on pre-sleep somatic hyperarousal symptom. The CBTI intervention is not applied to improve pre-sleep cognitive hyperarousal, depression, and anxiety symptoms.
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Affiliation(s)
- Chenxi Zhang
- Department of Psychiatry, Nanfang Hospital, Southern Medical University, Guangzhou, China.,Guangdong-Hong Kong-Macao Greater Bay Area Center for Brain Science and Brain-Inspired Intelligence, Guangzhou, China
| | - Lulu Yang
- Department of Psychiatry, Nanfang Hospital, Southern Medical University, Guangzhou, China.,Guangdong-Hong Kong-Macao Greater Bay Area Center for Brain Science and Brain-Inspired Intelligence, Guangzhou, China
| | - Shuai Liu
- Department of Psychiatry, Nanfang Hospital, Southern Medical University, Guangzhou, China.,Guangdong-Hong Kong-Macao Greater Bay Area Center for Brain Science and Brain-Inspired Intelligence, Guangzhou, China
| | - Yan Xu
- Department of Psychiatry, Nanfang Hospital, Southern Medical University, Guangzhou, China.,Guangdong-Hong Kong-Macao Greater Bay Area Center for Brain Science and Brain-Inspired Intelligence, Guangzhou, China
| | - Huirong Zheng
- Guangdong Mental Health Center, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Affliated School of Medicine of South China University of Technology, Guangzhou, China
| | - Bin Zhang
- Department of Psychiatry, Nanfang Hospital, Southern Medical University, Guangzhou, China.,Guangdong-Hong Kong-Macao Greater Bay Area Center for Brain Science and Brain-Inspired Intelligence, Guangzhou, China
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13
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Germain A, Markwald RR, King E, Bramoweth AD, Wolfson M, Seda G, Han T, Miggantz E, O’Reilly B, Hungerford L, Sitzer T, Mysliwiec V, Hout JJ, Wallace ML. Enhancing behavioral sleep care with digital technology: study protocol for a hybrid type 3 implementation-effectiveness randomized trial. Trials 2021; 22:46. [PMID: 33430955 PMCID: PMC7798254 DOI: 10.1186/s13063-020-04974-z] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2020] [Accepted: 12/14/2020] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Insomnia affects almost one in four military service members and veterans. The first-line recommended treatment for insomnia is cognitive-behavioral therapy for insomnia (CBTI). CBTI is typically delivered in-person or online over one-to-four sessions (brief versions) or five-to-eight sessions (standard versions) by a licensed doctoral or masters-level clinician with extensive training in behavioral sleep medicine. Despite its effectiveness, CBTI has limited scalability. Three main factors inhibit access to and delivery of CBTI including restricted availability of clinical expertise; rigid, resource-intensive treatment formats; and limited capacities for just-in-time monitoring and treatment personalization. Digital technologies offer a unique opportunity to overcome these challenges by providing scalable, personalized, resource-sensitive, adaptive, and cost-effective approaches for evidence-based insomnia treatment. METHODS This is a hybrid type 3 implementation-effectiveness randomized trial using a scalable evidence-based digital health software platform, NOCTEM™'s Clinician-Operated Assistive Sleep Technology (COAST™). COAST includes a clinician portal and a patient app, and it utilizes algorithms that facilitate detection of sleep disordered patterns, support clinical decision-making, and personalize sleep interventions. The first aim is to compare three clinician- and system-centered implementation strategies on the reach, adoption, and sustainability of the COAST digital platform by offering (1) COAST only, (2) COAST plus external facilitation (EF: assistance and consultation to providers by NOCTEM's sleep experts), or (3) COAST plus EF and internal facilitation (EF/IF: assistance/consultation to providers by NOCTEM's sleep experts and local champions). The second aim is to quantify improvements in insomnia among patients who receive behavioral sleep care via the COAST platform. We hypothesize that reach, adoption, and sustainability and the magnitude of improvements in insomnia will be superior in the EF and EF/IF groups relative to the COAST-only group. DISCUSSION Digital health technologies and machine learning-assisted clinical decision support tools have substantial potential for scaling access to insomnia treatment. This can augment the scalability and cost-effectiveness of CBTI without compromising patient outcomes. Engaging providers, stakeholders, patients, and decision-makers is key in identifying strategies to support the deployment of digital health technologies that can promote quality care and result in clinically meaningful sleep improvements, positive systemic change, and enhanced readiness and health among service members. TRIAL REGISTRATION ClinicalTrials.gov NCT04366284 . Registered on 28 April 2020.
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Affiliation(s)
- Anne Germain
- NOCTEM, LLC, 218 Oakland Avenue, Pittsburgh, PA 15213 USA
| | - Rachel R. Markwald
- Warfighter Performance Department, Naval Health Research Center, 140 Sylvester Rd, San Diego, CA 92106 USA
| | - Erika King
- Mental Health Division, Air Force Medical Readiness Agency, 2261 Hughes Ave, Suite 153, JBSA Lackland AFB, TX 78236-9853 USA
| | - Adam D. Bramoweth
- VA Pittsburgh Healthcare System, Research Office Building (151RU), University Drive C, Pittsburgh, PA 15240 USA
| | - Megan Wolfson
- NOCTEM, LLC, 218 Oakland Avenue, Pittsburgh, PA 15213 USA
| | - Gilbert Seda
- Naval Medical Center San Diego, 34800 Bob Wilson Dr, San Diego, CA 92134 USA
| | - Tony Han
- Naval Medical Center San Diego, 34800 Bob Wilson Dr, San Diego, CA 92134 USA
| | - Erin Miggantz
- Warfighter Performance Department, Naval Health Research Center, 140 Sylvester Rd, San Diego, CA 92106 USA
- Leidos, Inc., 4161 Campus Point Ct., San Diego, 92121 USA
| | - Brian O’Reilly
- Madigan Army Medical Center, 9040A Jackson Ave, Joint Base Lewis-McChord, WA 98431 USA
| | - Lars Hungerford
- Naval Medical Center San Diego, 34800 Bob Wilson Dr, San Diego, CA 92134 USA
- Defense and Veterans Brain Injury Center, Naval Medical Center San Diego, 34800 Bob Wilson Drive, San Diego, CA 92134 USA
| | - Traci Sitzer
- Naval Medical Center San Diego, 34800 Bob Wilson Dr, San Diego, CA 92134 USA
| | - Vincent Mysliwiec
- Division of Behavioral Medicine, Department of Psychiatry, UT Health San Antonio, 7703 Floyd Curl Drive, MC 7747, San Antonio, TX 78229-3900 USA
| | - Joseph J. Hout
- Knowesis, Inc., 816 Camaron St. Suite 231, San Antonio, TX 78212 USA
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14
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Xu D, Cardell E, Broadley SA, Sun J. Efficacy of Face-to-Face Delivered Cognitive Behavioral Therapy in Improving Health Status of Patients With Insomnia: A Meta-Analysis. Front Psychiatry 2021; 12:798453. [PMID: 35002813 PMCID: PMC8733003 DOI: 10.3389/fpsyt.2021.798453] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2021] [Accepted: 11/17/2021] [Indexed: 01/07/2023] Open
Abstract
Background: Face-to-face cognitive behavioral therapy (CBT) is one of the most widely used non-pharmacological treatment approaches for insomnia. The aim of this study is to assess the efficacy of face-to-face delivered CBT on health outcomes and to evaluate the effect of CBT components as subgroup variables to explain the efficacy of face-to-face delivered CBT on health outcomes in adults over 18 years old with insomnia. Methods: Relevant randomized controlled trial studies published in the past 22 years were searched through the electronic databases. The Physiotherapy Evidence Database (PEDro) scale was used to assess the quality of the 31 included studies. The mean difference and standard deviation of outcome variables and subgroup variables were analyzed using random effect model, and the heterogeneity among the articles was assessed with the Q-test and I 2. Egger regression analysis was used to assess publication bias. Results: The meta-analysis showed a significant reduction in Insomnia Severity Index [standardized mean difference (SMD) = -2.56, 95% CI -3.81 to -1.30, p < 0.001], Pittsburgh Sleep Quality Index (SMD = -0.96, 95% CI -1.25 to -0.68, p < 0.001), sleep onset latency (SMD = -1.31, 95% CI -2.00 to -0.63, p < 0.001), wakening after sleep onset (SMD = -1.44, 95% CI -2.14 to -0.74, p < 0.001), number of awakenings (SMD = -1.18, 95% CI -2.10 to -0.26, p < 0.05), depression (SMD = -1.14, 95% CI -1.85 to -0.42, p < 0.01), and fatigue (SMD = -2.23, 95% CI -3.87 to -0.58, p < 0.01), and a significant increase in total sleep time (SMD = 0.63, 95% CI 0.28 to 0.98, p < 0.001), sleep efficiency (SMD = 1.61, 95% CI 0.92 to 2.29, p < 0.001), and physical health (SMD = 0.42, 95% CI 0.08 to 0.76, p < 0.05), in the CBT intervention group compared with the control group. There was no significant change in anxiety (SMD = -0.62, 95% CI -1.55 to 0.32, p > 0.05) and mental health (SMD = 1.09, 95% CI -0.59 to 2.77, p > 0.05) in CBT intervention group compared with control group. Group-delivered studies with larger number of intervention sessions and longer duration of single session provided a larger improvement in sleep quality. Conclusion: Face-to-face delivered CBT is effective in increasing total sleep time, sleep efficiency, and physical health, and reducing Insomnia Severity Index scores, Pittsburgh Sleep Quality Index scores, sleep onset latency, wakening after sleep onset, number of awakenings, depression, anxiety, and fatigue in patients with insomnia. Face-to-face delivered CBT is more effective when delivered through a larger number of sessions with longer duration of each session, and when delivered in groups. Face-to-face CBT is recommended to provide treatment to patients with insomnia in clinical settings. Systematic Review Registration: www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42020200091, identifier: CRD4202020009.
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Affiliation(s)
- Dawei Xu
- School of Medicine and Dentistry, Griffith University, Gold Coast, QLD, Australia
| | - Elizabeth Cardell
- School of Medicine and Dentistry, Griffith University, Gold Coast, QLD, Australia.,Menzies Health Institute Queensland, Griffith University, Gold Coast, QLD, Australia
| | - Simon A Broadley
- School of Medicine and Dentistry, Griffith University, Gold Coast, QLD, Australia.,Menzies Health Institute Queensland, Griffith University, Gold Coast, QLD, Australia
| | - Jing Sun
- School of Medicine and Dentistry, Griffith University, Gold Coast, QLD, Australia.,Menzies Health Institute Queensland, Griffith University, Gold Coast, QLD, Australia
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15
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Skarpsno ES, Gismervik SØ, Fimland MS, Aasdahl L. Insomnia is Associated with the Effect of Inpatient Multimodal Occupational Rehabilitation on Work Participation in Workers with Musculoskeletal or Mental Health Disorders: Secondary Analyses of a Randomized Clinical Trial. Nat Sci Sleep 2021; 13:1431-1439. [PMID: 34456595 PMCID: PMC8387244 DOI: 10.2147/nss.s318052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2021] [Accepted: 07/10/2021] [Indexed: 11/30/2022] Open
Abstract
STUDY OBJECTIVES Insomnia is common among people with musculoskeletal and/or mental health disorders. This study aimed to assess whether insomnia is associated with the favorable effect from inpatient multimodal occupational rehabilitation on future work participation among individuals with these conditions. METHODS Insomnia was measured at baseline through a randomized clinical trial that compared the effect of inpatient multimodal occupational rehabilitation with a less-comprehensive program of outpatient acceptance and commitment therapy on future work participation. The inpatient multimodal program lasted 3.5 weeks at the rehabilitation center, comprising psychoeducational sessions (including sleep education), fixed schedules, acceptance and commitment therapy, physical exercise and work-related problem-solving, whereas the outpatient program comprised mainly six weekly acceptance and commitment therapy sessions. Both programs were group-based. The study tracked cumulative sick leave during the 12 months of follow-up using national registry data. RESULTS Among the 163 adults included in this subgroup analysis, 56% (n=91) reported insomnia. Overall, we found statistical evidence of interaction between the occupational program and insomnia concerning cumulative sick leave (p=0.03). Compared with people without insomnia in the comprehensive inpatient multimodal program, people with insomnia had 12 (95% CI: -48 to 24) fewer days with sick leave if they participated in the inpatient program and 46 (95% CI: 8 to 83) more days if they participated in the outpatient program. CONCLUSION These findings suggest that insomnia should be addressed specifically before individuals on sick leave are considered for participation in occupational rehabilitation and that individuals with insomnia may benefit in particular from inpatient rehabilitation.
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Affiliation(s)
- Eivind Schjelderup Skarpsno
- Department of Public Health and Nursing, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology (NTNU), Trondheim, Norway.,Department of Neurology and Clinical Neurophysiology, St. Olavs Hospital, Trondheim, Norway
| | - Sigmund Østgård Gismervik
- Department of Public Health and Nursing, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology (NTNU), Trondheim, Norway.,Department of Physical Medicine and Rehabilitation, St. Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
| | - Marius Steiro Fimland
- Department of Neuromedicine and Movement Science, Faculty of Medicine and Health Sciences, NTNU, Norwegian University of Science and Technology, Trondheim, Norway.,Unicare Helsefort Rehabilitation Centre, Rissa, Norway
| | - Lene Aasdahl
- Department of Public Health and Nursing, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology (NTNU), Trondheim, Norway.,Unicare Helsefort Rehabilitation Centre, Rissa, Norway
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Sweetman A, Putland S, Lack L, McEvoy RD, Adams R, Grunstein R, Stocks N, Kaambwa B, Van Ryswyk E, Gordon C, Vakulin A, Lovato N. The effect of cognitive behavioural therapy for insomnia on sedative-hypnotic use: A narrative review. Sleep Med Rev 2020; 56:101404. [PMID: 33370637 DOI: 10.1016/j.smrv.2020.101404] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Revised: 07/12/2020] [Accepted: 07/26/2020] [Indexed: 01/09/2023]
Abstract
Although cognitive behavioural therapy for insomnia (CBTi) is the recommended 'first-line' treatment for insomnia, most patients are initially treated with sedative-hypnotic medications. Given the risk of impaired cognitive and psychomotor performance, serious adverse events, and long-term dependence associated with sedative-hypnotics, guidelines recommend that prescriptions should be limited to short-term use and that patients are provided with support for withdrawal where possible. CBTi is an effective insomnia treatment in the presence of sedative-hypnotic use. Furthermore, guidelines recommended that CBTi techniques are utilised to facilitate withdrawal from sedative-hypnotics. However, there is very little research evaluating the effect of CBTi on reduced medication use. The current narrative review integrates 95 studies including over 10,000 participants, investigating the effect of CBTi on reduced sedative-hypnotic use in different populations (e.g., hypnotic-dependent patients, older adults, military personnel), settings (e.g., primary care settings, psychiatric inpatients), CBTi modalities (e.g., self-administered reading/audio materials, digital, and therapist-administered), and in combination with gradual dose reduction programs. Based on this research, we discuss the theoretical mechanistic effects of CBTi in facilitating reduced sedative-hypnotic use, provide clear recommendations for future research, and offer pragmatic clinical suggestions to increase access to CBTi to reduce dependence on sedative-hypnotics as the 'default' treatment for insomnia.
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Affiliation(s)
- Alexander Sweetman
- The Adelaide Institute for Sleep Health: A Centre of Research Excellence, College of Medicine and Public Health, Flinders University, Adelaide, South Australia, Australia; National Centre for Sleep Health Services Research: A NHMRC Centre of Research Excellence, Flinders University, Adelaide, South Australia, Australia.
| | | | - Leon Lack
- College of Education, Psychology and Social Work, Flinders University, Adelaide, South Australia, Australia; National Centre for Sleep Health Services Research: A NHMRC Centre of Research Excellence, Flinders University, Adelaide, South Australia, Australia
| | - R Doug McEvoy
- The Adelaide Institute for Sleep Health: A Centre of Research Excellence, College of Medicine and Public Health, Flinders University, Adelaide, South Australia, Australia; National Centre for Sleep Health Services Research: A NHMRC Centre of Research Excellence, Flinders University, Adelaide, South Australia, Australia
| | - Robert Adams
- The Adelaide Institute for Sleep Health: A Centre of Research Excellence, College of Medicine and Public Health, Flinders University, Adelaide, South Australia, Australia; The Health Observatory, Discipline of Medicine, The Queen Elizabeth Hospital Campus, University of Adelaide, Woodville, South Australia, Australia; Respiratory and Sleep Service, Southern Adelaide Local Health Network, Bedford Park, Adelaide, South Australia, Australia; National Centre for Sleep Health Services Research: A NHMRC Centre of Research Excellence, Flinders University, Adelaide, South Australia, Australia
| | - Ron Grunstein
- Sleep and Chronobiology Research Group, Woolcock Institute of Medical Research, University of Sydney, New South Wales, Australia; National Centre for Sleep Health Services Research: A NHMRC Centre of Research Excellence, Flinders University, Adelaide, South Australia, Australia
| | - Nigel Stocks
- Discipline of General Practice, Adelaide Medical School, University of Adelaide, South Australia, Australia; National Centre for Sleep Health Services Research: A NHMRC Centre of Research Excellence, Flinders University, Adelaide, South Australia, Australia
| | - Billingsley Kaambwa
- Health Economics, College of Medicine and Public Health, Bedford Park, Adelaide, South Australia, Australia; National Centre for Sleep Health Services Research: A NHMRC Centre of Research Excellence, Flinders University, Adelaide, South Australia, Australia
| | - Emer Van Ryswyk
- The Adelaide Institute for Sleep Health: A Centre of Research Excellence, College of Medicine and Public Health, Flinders University, Adelaide, South Australia, Australia; National Centre for Sleep Health Services Research: A NHMRC Centre of Research Excellence, Flinders University, Adelaide, South Australia, Australia
| | - Christopher Gordon
- Susan Wakil School of Nursing and Midwifery, Faculty of Medicine and Health, University of Sydney, NSW, Australia; Sleep and Chronobiology Research Group, Woolcock Institute of Medical Research, University of Sydney, New South Wales, Australia; National Centre for Sleep Health Services Research: A NHMRC Centre of Research Excellence, Flinders University, Adelaide, South Australia, Australia
| | - Andrew Vakulin
- The Adelaide Institute for Sleep Health: A Centre of Research Excellence, College of Medicine and Public Health, Flinders University, Adelaide, South Australia, Australia; National Centre for Sleep Health Services Research: A NHMRC Centre of Research Excellence, Flinders University, Adelaide, South Australia, Australia
| | - Nicole Lovato
- The Adelaide Institute for Sleep Health: A Centre of Research Excellence, College of Medicine and Public Health, Flinders University, Adelaide, South Australia, Australia; National Centre for Sleep Health Services Research: A NHMRC Centre of Research Excellence, Flinders University, Adelaide, South Australia, Australia
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17
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Treatment of comorbid sleep disorders and posttraumatic stress disorder in active duty military: Design and methodology of a randomized clinical trial. Contemp Clin Trials 2020; 99:106186. [PMID: 33091589 DOI: 10.1016/j.cct.2020.106186] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Revised: 10/07/2020] [Accepted: 10/15/2020] [Indexed: 11/23/2022]
Abstract
Many individuals with posttraumatic stress disorder (PTSD) also suffer from insomnia and nightmares, which may be symptoms of PTSD or constitute partially independent comorbid disorders. Sleep disturbances are resistant to current treatments for PTSD, and those suffering from PTSD, insomnia, and nightmares have worse PTSD treatment outcomes. In addition, insomnia and nightmares are risk factors for depression, substance abuse, anxiety, and suicide. Cognitive-Behavioral Therapy for Insomnia and Nightmares (CBT-I&N) and Cognitive Processing Therapy (CPT) for PTSD are first line treatments of these conditions. CPT does not typically address insomnia or nightmares, and CBT-I&N does not typically address other symptoms of PTSD. There are limited scientific data on how best to provide these therapies to individuals suffering with all three disorders. This project aims to inform the most effective way to treat individuals suffering from PTSD, insomnia, and nightmares, potentially changing the standard of care. U.S. military personnel and recently discharged Veterans who served in support of combat operations following 9/11 aged 18-65 with PTSD, insomnia, and nightmares (N = 222) will be randomly assigned to one of the following 18-session individual treatment conditions delivered over 12-weeks: (1) 6 sessions of CBT-I&N followed by 12 sessions of CPT; (2) 12 sessions of CPT followed by 6 sessions of CBT-I&N; or (3) 12 sessions of CPT followed by an additional 6 sessions of CPT. All participants will be assessed at baseline, during treatment, and at 1-week, 1-month, 3-months, and 6-months posttreatment. The primary outcome will be PTSD symptom severity.
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18
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The Clinical Effectiveness of Cognitive Behavioral Therapy for Patients with Insomnia and Depression: A Systematic Review and Meta-Analysis. EVIDENCE-BASED COMPLEMENTARY AND ALTERNATIVE MEDICINE 2020; 2020:8071821. [PMID: 32733587 PMCID: PMC7378630 DOI: 10.1155/2020/8071821] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/07/2019] [Revised: 02/27/2020] [Accepted: 06/19/2020] [Indexed: 12/24/2022]
Abstract
BACKGROUND Insomnia and depression often co-occurr. However, there is lack of effective treatment for such comorbidity. CBT-I has been recommended as the first-line treatment for insomnia; whether it is also effective for comorbidity of insomnia and depression is still unknown. Therefore, we conducted this meta-analysis of randomized controlled trials to assess the clinical effectiveness and safety of CBT-I for insomnia comorbid with depression. Data Sources. Seven electronic databases, including China National Knowledge Infrastructure (CNKI), Wanfang Database, China Science Technology Journal Database, SinoMed Database, PubMed, the Cochrane Library, and EMBASE, as well as grey literature, were searched from the beginning of each database to July 1, 2019. Study Eligibility Criteria. Randomized controlled trials that compared CBT-I to no treatment or hypnotics (zopiclone, estazolam, and benzodiazepine agonist) for insomnia comorbid with depression and reported both insomnia scales and depression scales. Study Assessment and Synthesis Methods. Cochrane Reviewer's Handbook was used for evaluating the risk of bias of included studies. Review Manager 5.3 software was used for meta-analysis. Online GRADEpro was used to assess the quality of evidence. RESULTS The pooled data showed that CBT-I was superior to no treatment for insomnia, while it was unsure whether CBT-I was better than no treatment for depression. And the effectiveness of CBT-I was comparable to hypnotics for both insomnia and depression. CBT-I was likely to be safe due to its noninvasive nature. The methodological quality varied across these trials. The evidence quality varied from moderate to very low, and the recommendation level was low. CONCLUSIONS Currently, findings support that CBT-I seems to be effective and safe for insomnia comorbid with depression to improve the insomnia condition, while it is unsure whether CBT-I could improve depression condition. More rigorous trials are needed to confirm our findings.
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Pruiksma KE, Hale WJ, Mintz J, Peterson AL, Young-McCaughan S, Wilkerson A, Nicholson K, Dondanville KA, Fina BA, Borah EV, Roache JD, Litz BT, Bryan CJ, Taylor DJ. Predictors of Cognitive Behavioral Therapy for Insomnia (CBTi) Outcomes in Active-Duty U.S. Army Personnel. Behav Ther 2020; 51:522-534. [PMID: 32586427 DOI: 10.1016/j.beth.2020.02.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2019] [Revised: 02/10/2020] [Accepted: 02/10/2020] [Indexed: 10/25/2022]
Abstract
Cognitive behavioral therapy for insomnia (CBTi) is well established as the first-line treatment for the management of chronic insomnia. Identifying predictors of response to CBTi should enable the field to efficiently utilize resources to treat those who are likely to respond and to personalize treatment approaches to optimize outcomes for those who are less likely to respond to traditional CBTi. Although a range of studies have been conducted, no clear pattern of predictors of response to CBTi has emerged. The purpose of this study was to examine the impact and relative importance of a comprehensive group of pretreatment predictors of insomnia outcomes in 99 active-duty service members who received in-person CBTi in a randomized clinical trial. Results indicated that higher levels of baseline insomnia severity and total sleep time predicted greater improvements on the Insomnia Severity Index (ISI) following treatment. Higher depression symptoms and a history of head injury predicted a worse response to treatment (i.e., smaller improvements on the ISI). Clinically meaningful improvements, as measured by the reliable change index (RCI), were found in 59% of the sample. Over and above baseline insomnia severity, only depressive symptoms predicted this outcome. Future studies should examine if modifications to CBTi based on these predictors of response can improve outcomes.
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Affiliation(s)
| | - Willie J Hale
- University of Texas Health Science Center at San Antonio; University of Texas at San Antonio
| | - Jim Mintz
- University of Texas Health Science Center at San Antonio
| | - Alan L Peterson
- University of Texas Health Science Center at San Antonio; South Texas Veterans Health Care System, San Antonio; University of Texas at San Antonio
| | | | | | | | | | - Brooke A Fina
- University of Texas Health Science Center at San Antonio
| | - Elisa V Borah
- University of Texas Health Science Center at San Antonio
| | - John D Roache
- University of Texas Health Science Center at San Antonio
| | | | - Craig J Bryan
- National Center for Veterans Studies, Salt Lake City, UT; University of Utah
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Mental health, physical health, and health-related behaviors of U.S. Army Special Forces. PLoS One 2020; 15:e0233560. [PMID: 32492027 PMCID: PMC7269253 DOI: 10.1371/journal.pone.0233560] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2019] [Accepted: 05/07/2020] [Indexed: 11/30/2022] Open
Abstract
Objectives To prospectively examine the health and health-related behaviors of Army Special Forces personnel in comparison with two distinct, but functionally similar Army groups. Methods Special Forces, Ranger Qualified, and General Purposes Forces enrolled in the Millennium Cohort Study were identified using data from the Defense Manpower Data Center. Using prospective survey data (2001–2014), we estimated the association of Army specialization with mental health, social support, physical health, and health-related behaviors with multivariable regression models. Results Among the 5,392 eligible participants (84.4% General Purposes Forces, 10.0% Special Forces, 5.6% Ranger Qualified), Special Forces personnel reported the lowest prevalence of mental disorders, physical health problems, and unhealthy behaviors. In the multivariable models, Special Forces personnel were less likely to report mental health problems, multiple somatic symptoms, and unhealthy behaviors compared with General Purpose Forces infantrymen (odds ratios [OR]: 0.20–0.54, p-values < .01). Overall, Special Forces personnel were similar in terms of mental and physical health compared with Ranger Qualified infantrymen, but were less likely to sleep < 5 hours/night (OR: 0.60, 95% confidence intervals: 0.40, 0.92) and have 5 or more multiple somatic symptoms (OR: 0.69, 95% CI: 0.49, 0.98). Both Special Forces personnel and Ranger Qualified infantrymen engaged in more healthy behaviors compared with General Purpose Forces infantrymen (OR: 2.57–6.22, p-values<0.05). Engagement in more healthy behaviors reduced the odds of subsequent adverse health outcomes, regardless of specialization. Conclusions Army Special Forces personnel were found to be mentally and physically healthier than General Purpose Forces infantrymen, which may in part be due to their tendency to engage in healthy behaviors. Findings indicate that engagement in a greater number of healthy behaviors may reduce odds for subsequent adverse outcomes.
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Taylor DJ, Straud C, Hale W, Grieser E, Garb L, Garb H. Sleep difficulties as a predictor of attrition in United States Air Force recruits. Sleep Health 2020; 6:338-343. [PMID: 32273194 DOI: 10.1016/j.sleh.2020.01.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2019] [Revised: 01/06/2020] [Accepted: 01/10/2020] [Indexed: 11/17/2022]
Abstract
STUDY OBJECTIVES The objective of the study was to estimate the rates of "difficulty sleeping at night" in newly enlisted United States Air Force (USAF) recruits and determine if these sleep difficulties predicted 1-year attrition (discharge for any reason) independently and after controlling for all other Lackland Behavioral Questionnaire (LBQ) predictors. METHODS The LBQ was administered to 202,339 active duty, enlisted USAF trainees completing basic military training at Joint Base San Antonio-Lackland, Texas, from January 2006 to December 2012. Attrition data were obtained through the Defense Manpower Data Center. RESULTS Fifty percent of the sample reported at least occasional sleep difficulties in the past year, with 9% reporting frequent (6% = often and 3% = most of the time) sleep difficulties. Twelve percent of trainees had been discharged within one year, and sleep difficulties were the second strongest significant predictor of this attrition after accounting for all other predictor variables in the LBQ, Wald χ2 = 254.19, p < .0001. Trainees with frequent sleep difficulties were 2.7 times more likely to be discharged than those without sleep difficulties based on the odds ratio statistic. CONCLUSIONS Rates of self-reported frequent "difficulty sleeping…," before basic training started, were similar to civilian populations and were the second strongest predictor of one-year attrition. "Difficulty sleeping…" encompasses many sleep problems (e.g., insomnia, sleep deprivation, circadian misalignment). Future studies should determine what specific sleep difficulties pose the greatest risk for attrition and then determine if they can be remediated, thus decreasing attrition risk, or if they should be a focus of screening.
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Affiliation(s)
- Daniel J Taylor
- University of Arizona, 1503 East University Blvd., Tucson, AZ 85721.
| | - Casey Straud
- University of Texas Health Science Center at San Antonio, 7550 Interstate Highway 10 West, Suite 1325, San Antonio, TX 78229; University of Texas at San Antonio, One UTSA Circle, San Antonio, TX 78249
| | - Willie Hale
- University of Texas Health Science Center at San Antonio, 7550 Interstate Highway 10 West, Suite 1325, San Antonio, TX 78229; University of Texas at San Antonio, One UTSA Circle, San Antonio, TX 78249
| | - Emily Grieser
- United States Air Force, Cannon Air Force Base, Clovis, NM
| | - Leanna Garb
- The University of Texas at Austin, 1925 San Jacinto Blvd, Austin, TX 78712
| | - Howard Garb
- Joint Base San Antonio-Lackland, 1940 Carswell Avenue, San Antonio, TX 78236-1500
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22
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Good CH, Brager AJ, Capaldi VF, Mysliwiec V. Sleep in the United States Military. Neuropsychopharmacology 2020; 45:176-191. [PMID: 31185484 PMCID: PMC6879759 DOI: 10.1038/s41386-019-0431-7] [Citation(s) in RCA: 76] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2019] [Revised: 05/23/2019] [Accepted: 05/31/2019] [Indexed: 02/07/2023]
Abstract
The military lifestyle often includes continuous operations whether in training or deployed environments. These stressful environments present unique challenges for service members attempting to achieve consolidated, restorative sleep. The significant mental and physical derangements caused by degraded metabolic, cardiovascular, skeletomuscular, and cognitive health often result from insufficient sleep and/or circadian misalignment. Insufficient sleep and resulting fatigue compromises personal safety, mission success, and even national security. In the long-term, chronic insufficient sleep and circadian rhythm disorders have been associated with other sleep disorders (e.g., insomnia, obstructive sleep apnea, and parasomnias). Other physiologic and psychologic diagnoses such as post-traumatic stress disorder, cardiovascular disease, and dementia have also been associated with chronic, insufficient sleep. Increased co-morbidity and mortality are compounded by traumatic brain injury resulting from blunt trauma, blast exposure, and highly physically demanding tasks under load. We present the current state of science in human and animal models specific to service members during- and post-military career. We focus on mission requirements of night shift work, sustained operations, and rapid re-entrainment to time zones. We then propose targeted pharmacological and non-pharmacological countermeasures to optimize performance that are mission- and symptom-specific. We recognize a critical gap in research involving service members, but provide tailored interventions for military health care providers based on the large body of research in health care and public service workers.
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Affiliation(s)
- Cameron H. Good
- 0000 0001 2151 958Xgrid.420282.ePhysical Scientist, US Army Research Laboratory, Aberdeen Proving Ground, MD, 21005 USA
| | - Allison J. Brager
- 0000 0001 0036 4726grid.420210.5Sleep Research Center, Center for Military Psychiatry and Neuroscience, Walter Reed Army Institute of Research, Silver Spring, MD 20910 USA
| | - Vincent F. Capaldi
- 0000 0001 0036 4726grid.420210.5Department of Behavioral Biology Branch, Center for Military Psychiatry and Neuroscience, Walter Reed Army Institute of Research, Silver Spring, Silver Spring, MD 20910 USA
| | - Vincent Mysliwiec
- 0000 0004 0467 8038grid.461685.8San Antonio Military Health System, Department of Sleep Medicine, JBSA, Lackland, TX 78234 USA
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Maguire DG, Ruddock MW, Milanak ME, Moore T, Cobice D, Armour C. Sleep, a Governor of Morbidity in PTSD: A Systematic Review of Biological Markers in PTSD-Related Sleep Disturbances. Nat Sci Sleep 2020; 12:545-562. [PMID: 32801980 PMCID: PMC7402856 DOI: 10.2147/nss.s260734] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Accepted: 07/06/2020] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Sleep disturbances (SD) are the most impactful and commonly reported symptoms in post-traumatic stress disorder (PTSD). Yet, they are often resistant to primary PTSD therapies. Research has identified two distinct SDs highly prevalent in PTSD; insomnia and nightmares. Those who report SDs prior to a traumatic event are at greater risk for developing PTSD; highlighting that sleep potentially plays a role in PTSD's pathology. To further understand the pathobiological mechanisms that lead to the development of PTSD, it is first imperative to understand the interplay which exists between sleep and PTSD on a biological level. The aim of this systematic review is to determine if biological or physiological markers are related to SD in PTSD. METHODS A systematic literature search was conducted on the electronic databases; Medline, Embase, AMED and PsycINFO, using Medical Subject Headings and associated keywords. RESULTS Sixteen studies were included in the final analyses. Physiological makers of autonomic function, and biochemical markers of HPA-axis activity; inflammatory processes; and trophic factor regulation were related to the severity of SDs in PTSD. CONCLUSION These findings add to the growing literature base supporting a central focus on sleep in research aiming to define the pathophysiological processes which result in PTSD, as well as emphasising the importance of specifically targeting sleep as part of a successful PTSD intervention strategy. Resolving SDs will not only reduce PTSD symptom severity and improve quality of life but will also reduce all-cause mortality, hospital admissions and lifetime healthcare costs for those with PTSD. Limitations of the current literature are discussed, and key recommendations future research must adhere to are made within.
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Affiliation(s)
- Daniel G Maguire
- Biomedical Sciences Research Institute, Ulster University, Coleraine BT52 1SA, Northern Ireland
| | - Mark W Ruddock
- Randox Laboratories Ltd, Clinical Studies, Crumlin, County Antrim BT29 4QY, Northern Ireland
| | - Melissa E Milanak
- Department of Psychiatry & Behavioral Sciences, Medical University of South Carolina, Charleston, SC 29425, USA
| | - Tara Moore
- Biomedical Sciences Research Institute, Ulster University, Coleraine BT52 1SA, Northern Ireland
| | - Diego Cobice
- Biomedical Sciences Research Institute, Ulster University, Coleraine BT52 1SA, Northern Ireland
| | - Cherie Armour
- School of Psychology, David Keir Building, Queen's University Belfast, Belfast BT9 5BN, Northern Ireland
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Miller KE, Brownlow JA, Gehrman PR. Sleep in PTSD: treatment approaches and outcomes. Curr Opin Psychol 2019; 34:12-17. [PMID: 31541965 DOI: 10.1016/j.copsyc.2019.08.017] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2019] [Revised: 08/12/2019] [Accepted: 08/16/2019] [Indexed: 12/17/2022]
Abstract
The high incidence of sleep disturbance associated with trauma exposure and posttraumatic stress disorder (PTSD) points to the need for effective sleep interventions for trauma survivors. The present review focuses on recent psychotherapeutic, pharmacological, and sleep medicine treatment approaches for sleep disturbances in PTSD. Findings highlight that targeted sleep interventions can ameliorate sleep symptoms and mitigate daytime PTSD symptoms. Attention has turned to the role of multidisciplinary and integrative approaches, as comprehensive treatment for sleep disturbances in PTSD is likely to require innovative assessment modalities and multiple interventions. A method for compressing these components into a treatment plan acceptable to most PTSD-diagnosed patients remains to be developed.
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Affiliation(s)
- Katherine E Miller
- Mental Illness Research, Education, and Clinical Center, Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, PA, USA
| | - Janeese A Brownlow
- Department of Psychology, College of Health and Behavioral Sciences at Delaware State University, Dover, DE, USA
| | - Philip R Gehrman
- Mental Illness Research, Education, and Clinical Center, Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, PA, USA; Department of Psychiatry, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA.
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Pulantara IW, Parmanto B, Germain A. Clinical Feasibility of a Just-in-Time Adaptive Intervention App (iREST) as a Behavioral Sleep Treatment in a Military Population: Feasibility Comparative Effectiveness Study. J Med Internet Res 2018; 20:e10124. [PMID: 30530452 PMCID: PMC6303679 DOI: 10.2196/10124] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2018] [Revised: 08/22/2018] [Accepted: 09/10/2018] [Indexed: 01/23/2023] Open
Abstract
Background Although evidence-based cognitive behavioral sleep treatments have been shown to be safe and effective, these treatments have limited scalability. Mobile health tools can address this scalability challenge. iREST, or interactive Resilience Enhancing Sleep Tactics, is a mobile health platform designed to provide a just-in-time adaptive intervention (JITAI) in the assessment, monitoring, and delivery of evidence-based sleep recommendations in a scalable and personalized manner. The platform includes a mobile phone–based patient app linked to a clinician portal. Objective The first aim of the pilot study was to evaluate the effectiveness of JITAI using the iREST platform for delivering evidence-based sleep interventions in a sample of military service members and veterans. The second aim was to explore the potential effectiveness of this treatment delivery form relative to habitual in-person delivery. Methods In this pilot study, military service members and veterans between the ages of 18 and 60 years who reported clinically significant service-related sleep disturbances were enrolled as participants. Participants were asked to use iREST for a period of 4 to 6 weeks during which time they completed a daily sleep/wake diary. Through the clinician portal, trained clinicians offered recommendations consistent with evidence-based behavioral sleep treatments on weeks 2 through 4. To explore potential effectiveness, self-report measures were used, including the Insomnia Severity Index (ISI), the Pittsburgh Sleep Quality Index (PSQI), and the PSQI Addendum for Posttraumatic Stress Disorder. Results A total of 27 participants completed the posttreatment assessments. Between pre- and postintervention, clinically and statistically significant improvements in primary and secondary outcomes were detected (eg, a mean reduction on the ISI of 9.96, t26=9.99, P<.001). At posttreatment, 70% (19/27) of participants met the criteria for treatment response and 59% (16/27) achieved remission. Comparing these response and remission rates with previously published results for in-person trials showed no significant differences. Conclusion Participants who received evidence-based recommendations from their assigned clinicians through the iREST platform showed clinically significant improvements in insomnia severity, overall sleep quality, and disruptive nocturnal disturbances. These findings are promising, and a larger noninferiority clinical trial is warranted.
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Affiliation(s)
- I Wayan Pulantara
- Health and Rehabilitation Informatics Laboratory, Department of Health Information Management, University of Pittsburgh, Pittsburgh, PA, United States
| | - Bambang Parmanto
- Health and Rehabilitation Informatics Laboratory, Department of Health Information Management, University of Pittsburgh, Pittsburgh, PA, United States
| | - Anne Germain
- Sleep and Behavioral Neuroscience Center, Department of Psychiatry, University of Pittsburgh, Pittsburgh, PA, United States
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Abstract
BACKGROUND Insomnia is a public sleep disorder defined as a deficiency of sleep quantity or quality. Acupressure is a low-cost treatment that has potential as an insomnia therapy. METHODS Four databases will be searched from inception to date. The researchers will screen clinical randomized trials of acupressure and auricular acupuncture for insomnia. The screening of the study, data extraction will be carried out independently by 2 researchers. The specific process will refer to the Cochrane Handbook for Systematic Review. RESULTS The results of the study will be published in a scientific journal after peer-review. We integrate the latest study about acupressure for insomnia. CONCLUSION This systematic review will provide evidence for assessing the improvement of acupressure for insomnia. ETHICS AND DISSEMINATION The systematic review will be published in a peer-reviewed journal. The review will also be disseminated electronically and in print.PROSPERO registration: CRD42018104155.
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Affiliation(s)
- Dong-Jie Wu
- Graduate School, Zhejiang Chinese Medical University, Hangzhou, Zhejiang
- School of Chinese Medicine, Hong Kong Baptist University, Hong Kong
| | - Hai-Cheng Dong
- Department of Tradition Chinese Medicine, Children's Hospital, Zhejiang University School of Medicine, Hangzhou
| | - Tsz-Nga Tang
- Graduate School, Zhejiang Chinese Medical University, Hangzhou, Zhejiang
| | - Shi-Feng Zhu
- Tongde Hospital of Zhejiang Province, Hangzhou, Zhejiang, China
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