Sleep disturbance, personality and the onset of depression and anxiety: prospective cohort study

Association between non-restorative sleep and psychotic-like experiences among Chinese college students: A latent profile and moderated mediation analysis

BACKGROUND

Non-restorative sleep (NRS) is a core symptom of insomnia that has considerable consequences for daily life. However, the association between NRS and psychotic-like experiences (PLEs) remains unclear. The current study was designed to explore the relationship between NRS and PLEs as well as the mediation/moderation role of rumination and resilience among college students in China.

METHODS

3060 college students were recruited from two universities in South China from September 21st to October 26th, 2022. Non-restorative Sleep Scale, 8-item Positive Subscale of the Community Assessment of Psychic Experiences, Ruminative Response Scale, and 10-item Connor-Davidson Resilience Scale were administered. Latent profile analysis and moderated mediation analysis were performed.

RESULTS

11.3 % participants reported frequent PLEs in the past one month. Three profiles of rumination were identified and named as "low rumination" group (27.7 %), "medium rumination" group (55.3 %), and "high rumination" group (16.9 %). NRS directly predicted PLEs, and rumination played a significant mediation role between NRS and PLEs. Resilience significantly moderated the association between NRS and rumination as well as the association between NRS and PLEs.

CONCLUSIONS

NRS, rumination and resilience are important predictors to PLEs. Strategies on increasing restorative sleep, decreasing rumination, and enhancing resilience are of great significance in the prevention of PLEs.

Mapping of the network connection between sleep quality symptoms, depression, generalized anxiety, and burnout in the general population of Peru and El Salvador

BACKGROUND

A meta-analysis of randomized controlled trials has suggested a bidirectional relationship between sleep problems and mental health issues. Despite these findings, there is limited conclusive evidence on the relationship between sleep quality, depression, anxiety, and burnout.

OBJECTIVE

The current study aimed to evaluate the relationships between sleep quality symptoms, anxiety, depression, and burnout in samples of adult individuals from two Latin American countries, Peru and El Salvador, through network analysis and to identify key symptoms that reinforce the correlation and intensify the syndromes.

METHODS

A total of 1012 individuals from El Salvador and Peru participated, with an average age of 26.5 years (SD = 9.1). Symptom networks were constructed for both countries based on data from the Jenkins Sleep Scale, Patient Health Questionnaire-2, General Anxiety Disorder-2, and a single burnout item.

RESULTS

The results indicated that Depressed Mood, Difficulty Falling Asleep, and Nervousness were the most central symptoms in a network in the participating countries. The strongest conditional associations were found between symptoms belonging to the same construct, which were similar in both countries. Thus, there is a relationship between Nervousness and Uncontrollable Worry, Anhedonia and Depressed Mood, and Nighttime Awakenings and Difficulty in Staying Asleep. It was observed that burnout is a bridge symptom between both countries and presents stronger conditional associations with Tiredness on Awakening, Depressed Mood, and Uncontrollable Worry. Other bridge symptoms include a Depressed Mood and Nervousness. The network structure did not differ between the participants from Peru and El Salvador.

CONCLUSION

The networks formed by sleep quality, anxiety, depression, and burnout symptoms play a prominent role in the comorbidity of mental health problems among the general populations of Peru and El Salvador. The symptom-based analytical approach highlights the different diagnostic weights of these symptoms. Treatments or interventions should focus on identifying central and bridge symptoms.

Psychological inflexibility as a predictor associated with insomnia

Psychological flexibility has recently attracted the attention of researchers in the field of sleep disorders; therefore, in the study, psychological flexibility was evaluated as a predictor or factor related to the presence/severity of insomnia. We included 2218 individuals selected from the randomized-control trial for behavioural therapy for insomnia and cross-sectional studies, including 1797 individuals with insomnia and 421 controls without insomnia. All participants completed the DSM-5-based insomnia diagnosis interview, Insomnia Severity Index, Hospital Anxiety and Depression Scale, and Acceptance Action Questionnaire-II. Linear regression and multinomial logistic regression models were used. Sex, education, occupation, marital status, anxiety, depression and psychological inflexibility were possible predictors or factors associated with the severity of insomnia. Multivariate linear regression analysis demonstrated that sex (𝛽 = 0.88; t = 2.80; p = 0.005), depression (𝛽  = 0.41; t = 10.7; p < 0.001), anxiety (𝛽  = 0.58; t = 14.1; p < 0.001) and psychological inflexibility (𝛽  = 0.09; t = 5.07; p < 0.001) were predictors of insomnia. The results of the multinomial logistic regression demonstrate that, in comparison to the absence of insomnia, insomnia at all levels (mild, moderate and severe) was associated with sex, anxiety and depression. Psychological inflexibility was only associated with severe insomnia (odds ratio = 1.04). These findings are important from a public health perspective because behavioural strategies designed to treat insomnia with a focus on psychological flexibility are low-cost and may help improve sleep quality in adults with insomnia, which also influences mental health.

The IMPACT survey: a mixed methods study to understand the experience of children, adolescents and adults with osteogenesis imperfecta and their caregivers

BACKGROUND

Osteogenesis imperfecta (OI) is a rare, heritable connective tissue disorder associated with a variety of symptoms, that affect individuals' quality of life (QoL) and can be associated with increased healthcare resource use. While some aspects of OI are well studied, others remain poorly understood. Therefore, the IMPACT survey aimed to elucidate the humanistic, clinical and economic burden of OI on individuals with OI, their families, caregivers and wider society.

METHODS

We developed an international mixed methods online survey in eight languages (fielded July-September 2021), aimed at adults (aged ≥ 18 years) or adolescents (aged ≥ 12-17 years) with OI, caregivers (with or without OI) of individuals with OI and other close relatives. All respondents provided data on themselves; caregivers additionally provided data on individuals in their care by proxy. Data were cleaned, coded, and analysed using the pandas Python software package and Excel.

RESULTS

IMPACT collected 2208 eligible questionnaires (covering 2988 individuals of whom 2312 had OI) including 1290 non-caregiver adults with OI, 92 adolescents with OI, 150 caregiver adults with OI, 560 caregivers for individuals with OI, 116 close relatives and 780 proxy care-recipients with OI. Most individuals with OI (direct or proxy) described their OI as moderate (41-52% across populations) and reported OI type 1 (33-38%). Pain (72-82%) was the most reported clinical condition experienced in the past 12 months and was also most frequently rated as severely or moderately impactful. Further, among adults, 67% reported fatigue, 47% scoliosis, and 46% sleep disturbance; in adolescents, fatigue affected 65%, scoliosis and other bone problems 60%, and mental health problems 46%; in children, fractures were common in 67%, fatigue in 47%, and dental problems in 46%.

CONCLUSION

IMPACT has generated an extensive dataset on the experience of individuals with OI, their caregivers and relatives. We found that, irrespective of age, individuals with OI experience numerous and evolving symptoms that affect their QoL; however, pain and fatigue are consistently present. Upcoming analyses will provide further insights into the economic impact, healthcare journey and caregiver wellbeing, aiming to contribute to improved treatment and care for the OI community.

Psychosocial factors of insomnia in depression: a network approach

BACKGROUND

Insomnia symptoms in patients with major depressive disorder (MDD) are common and deleterious. Childhood trauma, personality traits, interpersonal distress, and social support contribute to insomnia, but how they interact to affect insomnia remains uncertain.

METHODS

A total of 791 patients with MDD completed the Insomnia Severity Index, Eysenck Personality Questionnaire, Interpersonal Relationship Comprehensive Diagnostic Scale, Childhood Trauma Questionnaire, Social Support Rating Scale and Hamilton Depression Scale-17. This study utilized network analyses to identify the central symptoms of insomnia and their associations with psychosocial factors.

RESULTS

Worrying about sleep was identified as the central symptom in the insomnia network, insomnia and associated personality network, insomnia and associated interpersonal disturbance network, insomnia and associated childhood trauma network, insomnia and associated social support network, and the integrated network of insomnia symptoms and associated psychosocial factors. In the networks of insomnia symptoms and individual psychosocial factors, most psychosocial factors (other than childhood trauma) were directly or indirectly related to insomnia symptoms; however, neuroticism was the only factor directly associated with insomnia symptoms before and after controlling for covariates. In the final integrated network of insomnia symptoms and psychosocial factors, neuroticism was a bridge node and mediated the relationships of social support and interpersonal disturbances with insomnia symptoms, which is clearly presented in the shortest pathways.

CONCLUSIONS

Worrying about sleep and neuroticism were prominent in the integrated network of insomnia symptoms and associated psychosocial factors, and the edge between them connected psychosocial factors and insomnia symptoms in MDD patients.

No difference in extra-axial cerebrospinal fluid volumes across neurodevelopmental and psychiatric conditions in later childhood and adolescence

BACKGROUND

While autism spectrum disorder has been associated with various organizational and developmental aberrations in the brain, an increase in extra-axial cerebrospinal fluid volume has recently garnered attention. A series of studies indicate that an increased volume between the ages of 6 months and 4 years was both predictive of the autism diagnosis and symptom severity regardless of genetic risk for the condition. However, there remains a minimal understanding regarding the specificity of an increased volume of extra-axial cerebrospinal fluid to autism.

METHODS

In the present study, we explored extra-axial cerebrospinal fluid volumes in children and adolescents ages 5-21 years with various neurodevelopmental and psychiatric conditions. We hypothesized that an elevated extra-axial cerebrospinal fluid volume would be found in autism compared with typical development and the other diagnostic group. We tested this hypothesis by employing a cross-sectional dataset of 446 individuals (85 autistic, 60 typically developing, and 301 other diagnosis). An analysis of covariance was used to examine differences in extra-axial cerebrospinal fluid volumes between these groups as well as a group by age interaction in extra-axial cerebrospinal fluid volumes.

RESULTS

Inconsistent with our hypothesis, we found no group differences in extra-axial cerebrospinal fluid volume in this cohort. However, in replication of previous work, a doubling of extra-axial cerebrospinal fluid volume across adolescence was found. Further investigation into the relationship between extra-axial cerebrospinal fluid volume and cortical thickness suggested that this increase in extra-axial cerebrospinal fluid volume may be driven by a decrease in cortical thickness. Furthermore, an exploratory analysis found no relationship between extra-axial cerebrospinal fluid volume and sleep disturbances.

CONCLUSIONS

These results indicate that an increased volume of extra-axial cerebrospinal fluid may be limited to autistic individuals younger than 5 years. Additionally, extra-axial cerebrospinal fluid volume does not differ between autistic, neurotypical, and other psychiatric conditions after age 4.

Effectiveness of one-week internet-delivered cognitive behavioral therapy for insomnia to prevent progression from acute to chronic insomnia: A two-arm, multi-center, randomized controlled trial

Acute insomnia is common and a substantial proportion of people with acute insomnia (i.e. 3 days to 3 months) transit into chronic insomnia (i.e. 3 months or longer). Therefore, early intervention for acute insomnia is vital to prevent chronicity. Previous trials with small sample sizes have shown that brief versions of both individual and group-based face-to-face cognitive behavioral therapy for insomnia (CBT-I) can improve insomnia symptoms among those with acute insomnia. However, it is unknown whether one-week internet-delivered cognitive behavioral therapy for insomnia (CBT-I) is effective in treating acute insomnia. This was a randomized controlled trial and 192 participants were randomly assigned to the CBT-I group (n = 95) or control group (n = 97). The primary outcome was the incidence of chronic insomnia, determined via a structured diagnostic questionnaire for insomnia disorders according to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Secondary outcomes were Insomnia Severity Index (ISI), Dysfunctional Beliefs and Attitudes about Sleep (DBAS), Epworth Sleepiness Scale (ESS), Pre-sleep Arousal Scale (PSAS), Ford Insomnia Response to Stress Test (FIRST), Sleep Hygiene and Practices Scale (SHPS), Hospital Anxiety and Depression Scale (HADS), and Short-Form 12-Item Health Survey version 2 (SF-12v2). At week 12, the incidence of chronic insomnia was significantly lower in the CBT-I group compared with control group (33.3% [27/81] vs. 65.8% [52/79]). Participants in the CBT-I group achieved significantly more improvements in ISI, ESS, PSAS, FIRST, SHPS, HADS-Depression, and the mental component summary and physical component summary of SF-12v2 than control group, but not DBAS and HADS-Anxiety. This one-week internet-delivered CBT-I program is an effective tool to prevent the chronicity of acute insomnia.

The Role of Sleep Effort as a Mediator Between Anxiety and Depression

Depression, anxiety, and insomnia are all conditions that share a complex bidirectional relationship. Sleep effort is a construct with cognitive and behavioral components that perpetuates insomnia. Although many studies have examined the associations between these three variables, no studies have yet examined sleep effort as a mediating variable between anxiety and depression and vice versa. Online versions of the Hospital Anxiety and Depression Scale and the Glasgow Sleep Effort Scale were administered to a sample of 1927 higher education students aged 18-40 years (75.9% women and 76% from 18 to 23 years old). As part of the survey, participants also completed a sociodemographic questionnaire. Mediation analysis indicated that sleep effort mediates the relationship between depression and anxiety, when the former was the predictor and the latter was the criterion. Moreover, sleep effort also mediated the relationship between anxiety and depression when the former was the predictor and the latter was the criterion, albeit in a lesser extent. Sleep effort appears to play a bidirectional mediational role between depression and anxiety, being a potential target for intervention.

Daily Associations of Sleep Quality and Sleep Duration with Anxiety in Young Adults: The Moderating Effect of Alexithymia

OBJECTIVES

The present study examined the daily, within-individual associations of anxiety with sleep quality and sleep duration and the moderating effects of alexithymia on these associations in community-dwelling young adults. It was hypothesized that daily anxiety and sleep parameters would be bidirectionally related and alexithymia would moderate these relationships.

METHOD

Participants completed morning and evening diaries assessing daily anxiety and sleep parameters for 30 consecutive days. They also completed questionnaires assessing baseline sleep parameters, anxiety, and alexithymia. Multilevel modeling was used to evaluate the within-individual associations between daily anxiety and sleep parameters and whether between-individual differences in alexithymia moderated these associations.

RESULTS

Higher anxiety relative to personal averages across the study period was associated with shorter sleep duration at night. Poorer sleep quality and shorter sleep duration relative to personal averages were associated with higher next-day anxiety. A significantly stronger association between poorer sleep quality and higher next-day anxiety was observed in individuals with higher levels of alexithymia.

CONCLUSION

Daily anxiety and sleep quantity are bidirectionally associated within individuals in community-dwelling young adults. Poorer sleep quality was associated with higher next-day anxiety but not vice versa. Individuals with higher levels of alexithymia might be more vulnerable to the effects of poor sleep on next-day anxiety.

Serial Mediation Roles of Perceived Stress and Depressive Symptoms in the Association Between Sleep Quality and Life Satisfaction Among Middle-Aged American Adults

In this study, we used data from the second wave of Midlife in the United States (MIDUS) Study, MIDUS Biomarkers and MIDUS 3. We applied the serial mediation model to explore the serial mediating effects of perceived stress and depressive symptoms on the relationship between sleep quality and life satisfaction. A total of 945 participants were included in our study. The total indirect effect of sleep quality on life satisfaction through perceived stress, depressive symptoms and the combination of perceived stress and depressive symptoms accounted for within the overall model was 45.5%. At the intervention level, programs designed to improve the level of life satisfaction among adults should focus on perceived stress and depressive symptoms. The prevention of perceived stress and depression contributes to improving life satisfaction and wellbeing. The serial mediation results should be confirmed by further longitudinal study.

A pathogenic cycle between insomnia and cognitive arousal fuels perinatal depression: exploring the roles of nocturnal cognitive arousal and perinatal-focused rumination

STUDY OBJECTIVES

Depression is among the most prevalent perinatal complications, yet modifiable risk factors remain elusive. Over half of perinatal women endorse clinical insomnia symptoms, which are etiologically implicated in depression in nonperinatal samples. Yet, prospective data on perinatal insomnia and depression are mixed. We sought to clarify temporal associations of insomnia and depression during peripartum, and to investigate cognitive arousal as a potential mechanism facilitating this relationship.

METHODS

Seventy pregnant women completed sociodemographic information and baseline sleep and mood symptoms between gestational weeks 25 and 30. Beginning at gestational week 30, participants completed 17 weekly online surveys assessing insomnia, depression, and three cognitive arousal indices (nocturnal cognitive arousal, perseverative thinking, and perinatal-focused rumination). Mixed effects models were conducted to test hypotheses.

RESULTS

Women were at risk for depression when experiencing insomnia (odds ratio [OR] = 2.36, 95% confidence interval [CI] = 1.28 to 4.35), nocturnal cognitive arousal (OR = 3.05, 95% CI = 1.60 to 5.79), perinatal-focused rumination (OR = 2.05, 95% CI = 1.11 to 3.79), and perseverative thinking (OR = 7.48, 95% CI = 3.90 to 14.32). Prospective analyses revealed bidirectional effects between insomnia and cognitive arousal, and both predicted future depression. Nocturnal cognitive arousal mediated 23-43% of the effect of insomnia on depression. Insomnia mediated 12%-18% of the effect of nocturnal cognitive arousal on depression. A similar pattern was observed with perinatal-focused rumination. Depression did not predict insomnia.

CONCLUSION

Nocturnal cognitive arousal, including ruminating on perinatal concerns while trying to fall asleep, fuels insomnia. In turn, lying awake at night provides an opportunity for nocturnal cognitive arousal. This cycle feeds perinatal depression. Daytime cognitive arousal may indirectly disrupt sleep as perseverating during the day persists into the night.

Altered sleep behavior in a genetic mouse model of impaired fear extinction

Sleep disturbances are a common complaint of anxiety patients and constitute a hallmark feature of post-traumatic stress disorder (PTSD). Emerging evidence suggests that poor sleep is not only a secondary symptom of anxiety- and trauma-related disorders but represents a risk factor in their development, for example by interfering with emotional memory processing. Fear extinction is a critical mechanism for the attenuation of fearful and traumatic memories and multiple studies suggest that healthy sleep is crucial for the formation of extinction memories. However, fear extinction is often impaired in anxiety- and trauma-related disorders-an endophenotype that is perfectly modelled in the 129S1/SvImJ inbred mouse strain. To investigate whether these mice exhibit altered sleep at baseline that could predispose them towards maladaptive fear processing, we compared their circadian sleep/wake patterns to those of typically extinction-competent C57BL/6 mice. We found significant differences regarding diurnal distribution of sleep and wakefulness, but also sleep architecture, spectral features and sleep spindle events. With regard to sleep disturbances reported by anxiety- and PTSD patients, our findings strengthen the 129S1/SvImJ mouse models' face validity and highlight it as a platform to investigate novel, sleep-focused diagnostic and therapeutic strategies. Whether the identified alterations causally contribute to its pathological anxiety/PTSD-like phenotype will, however, have to be addressed in future studies.

Abnormal Sleep Signals Vulnerability to Chronic Social Defeat Stress

There is a tight association between mood and sleep as disrupted sleep is a core feature of many mood disorders. The paucity in available animal models for investigating the role of sleep in the etiopathogenesis of depression-like behaviors led us to investigate whether prior sleep disturbances can predict susceptibility to future stress. Hence, we assessed sleep before and after chronic social defeat (CSD) stress. The social behavior of the mice post stress was classified in two main phenotypes: mice susceptible to stress that displayed social avoidance and mice resilient to stress. Pre-CSD, mice susceptible to stress displayed increased fragmentation of Non-Rapid Eye Movement (NREM) sleep, due to increased switching between NREM and wake and shorter average duration of NREM bouts, relative to mice resilient to stress. Logistic regression analysis showed that the pre-CSD sleep features from both phenotypes were separable enough to allow prediction of susceptibility to stress with >80% accuracy. Post-CSD, susceptible mice maintained high NREM fragmentation while resilient mice exhibited high NREM fragmentation, only in the dark. Our findings emphasize the putative role of fragmented NREM sleep in signaling vulnerability to stress.

Differences in the Association of Anxiety, Insomnia and Somatic Symptoms between Medical Staff and the General Population During the Outbreak of COVID-19

BACKGROUND

During the outbreak of coronavirus disease 2019 (COVID-19), occupational differences were recognized with respect to psychological issues, but there are no reports regarding the insomnia and anxiety comorbidities and their related factors among the general public and medical staff. Our study aimed to compare the prevalence of anxiety and anxiety with insomnia, as well as the relationship between different psychological symptoms between the two groups.

METHODS

A total of 605 medical staff and 1091 public respondents were assessed through an online questionnaire survey, including the 7-item Insomnia Severity Index (ISI), the somatization subscale of Symptom Checklist 90-Revised (SCL-90-R), and the 7-item Generalized Anxiety Disorder scale (GAD-7).

RESULTS

Compared with the general public, medical staff had a higher incidence of anxiety (45.5% vs 32.4%). The incidence of insomnia in anxious participants was 52.7% in medical staff and 44.6% in the general public, and the difference was significant (p < 0.05). The GAD-7 score and somatization subscore of the SCI-90 were independently associated with insomnia among anxiety participants in both groups (all p < 0.001).

CONCLUSION

Our findings suggest that during the epidemic period of COVID-19, medical staff experienced more anxiety and anxiety with insomnia. Somatization, anxiety and insomnia are highly correlated among medical staff and the general public.

Using 24-h Heart Rate Variability to Investigate the Sleep Quality and Depression Symptoms of Medical Students

There have been numerous studies on the relationship between sleep and depression, as well as the relationship between sleep and depression, and heart rate variability (HRV), respectively. Even so, few studies have combined 24-h HRV analysis to study sleep quality and depressive symptoms. The purpose of this cross-sectional study was to investigate the relationship between depressed symptoms, sleep quality, and 24-h HRV in medical students. The particiants were all students at a medical university in Guangdong province, China. A total of 74 college students participated. They were asked to complete a questionnaire that included the Pittsburgh Sleep Quality Index (PSQI), the Beck Depression Inventory-II (BDI-II), the Positive and Negative Affect Scale (PANAS), and 24-h ECG monitoring. The results showed that 41.7% of the medical students had poor sleep quality, with higher levels of depressive symptoms and more negative emotions, and there was no difference in 24-h HRV indices between the low PSQI group and the high one. Correlation analysis showed that there was a significant relationship between sleep quality and depressive symptoms (r = 0.617), but the relationship between 24-h HRV indices and PSQI global scores, BDI scores were not significant. However, the correlation analysis of PSQI components and 24-h HRV showed that sleep disturbance was significantly negatively correlated with SDNN and LF in waking period (r = -0.285, -0.235), and with SDNN in sleeping period (r = -0.317). In general, the sleep disturbance in PSQI components can sensitively reflect the relationship between sleep quality and 24-h HRV of medical students. Individuals with higher sleep disturance may have lower SDNN during awake period and bedtime period, and lower LF in awake period. Twenty-four hour HRV has certain application value in clinical sleep quality monitoring, and its sensitivity and specificity in clinical application and daily life are still worth further investigation.

The Association Between Depressive Symptoms and Insomnia in College Students in Qinghai Province: The Mediating Effect of Rumination

Background: This study investigates the mediating effect of rumination on the associations between depressive symptoms and insomnia. Methods: This is a cross-sectional study. Insomnia Severity Index (ISI), Ruminant Response Scale (RRS) and Beck Depression Inventory (BDI) were determined in 12,178 college students in Qinghai province by a questionnaire network platform. Results: The prevalence of insomnia was 38.6% in the participants. Insomnia symptoms [interquartile range: 6 (3, 9)], depressive symptoms [interquartile range: 5 (1, 9)], and rumination [interquartile range: 22 (20, 26)] were positively correlated (r = 0.25-0.46, p < 0.01). Mediation effect analysis showed that the depressive symptoms affected insomnia directly and indirectly. The direct effect and the indirect effect through rumination account for 92.4 and 7.6% of the total effect, respectively. Conclusion: The study shows that insomnia, depressive symptoms, and rumination are related constructs in college students in Qinghai province. It demonstrates the direct effects and the rumination-mediated indirect effects between depressive symptoms and insomnia; the direct effects seem to be dominant.

The Association between Insomnia and Anxiety Symptoms in a Naturalistic Anxiety Treatment Setting

Objective/Background: Few studies have examined the relationship between insomnia and anxiety treatment outcomes in naturalistic settings. Furthermore, prior studies typically examine insomnia within a single anxiety diagnosis without accounting for the high overlap between disorders. Here we investigate the association between insomnia and multiple anxiety disorders over a course of cognitive behavioral treatment (CBT) in a naturalistic treatment setting. Participants: Insomnia was assessed in 326 patients seeking treatment at a clinic specializing in CBT for anxiety. Methods: Multilevel modeling was used to investigate whether insomnia moderated reductions in anxiety symptoms. A cross-lagged analysis tested for bidirectional effects between insomnia and anxiety. Multiple regression was used to investigate the relationship between insomnia and anxiety while controlling for the other anxiety disorders and depression. Results: While there was a significant reduction in insomnia during treatment in all anxiety disorders, the majority of the most severe patients remained in the clinical range at post-treatment. Baseline insomnia did not significantly moderate anxiety outcomes, suggesting that patients with high or low levels of insomnia will do equally well in CBT for anxiety. The bidirectional effect between insomnia and anxiety did not reach significance. Additionally, posttraumatic stress disorder, generalized anxiety disorder, and panic disorder were associated with the greatest endorsement of insomnia, after controlling for the overlap between disorders. Conclusions: Sleep problems may persist after anxiety treatment, suggesting that CBT for insomnia may be warranted during or after a course of CBT for anxiety. Importantly, baseline insomnia does not impede anxiety reduction during CBT.

Insight into the relationship between sleep characteristics and anxiety: A cross-sectional study in indigenous and minority populations in northeastern Greece

A cross-sectional population-based study was conducted in order to evaluate the association of sleep characteristics with anxiety disorders using self-reported questionnaires and taking into account several socio-demographic, lifestyle and health related characteristics. 957 participants between 19 and 86 years old were enrolled in our study. Anxiety symptoms were assessed using the Zung Self-rating Anxiety Scale. Participants self-reported their daily sleep habits and filled in the following scales: Epworth Sleepiness Scale, Athens Insomnia Scale, Pittsburgh Sleep Quality Index and Berlin Questionnaire. Overall prevalence of anxiety was 33.6%. Anxiety symptoms were more prominent among minority groups. Subjects with anxiety reported shorter sleep duration and reduced sleep efficiency. After adjusting for all possible confounders, they were five times more likely to exhibit short sleep duration (≤6h) and 0.60 times less likely long sleep duration (>8h). These relations remained significant in both genders, but were more pronounced among men. Moreover, anxiety was associated with excessive daytime sleepiness, insomnia, poor sleep quality and higher risk of obstructive sleep apnea (OSA). Results highlight the association of sleep disturbances with anxiety disorders and call for conduction of larger scale prospective studies in order to assess causality on the clinically important relationship between sleep characteristics and anxiety disorders.

Depression prevention in digital cognitive behavioral therapy for insomnia: Is rumination a mediator?

Background There has been growing support for digital Cognitive Behavioral Therapy (dCBT-I) as a scalable intervention that both reduces insomnia and prevents depression. However, the mechanisms by which dCBT-I reduces and prevents depression is less clear. Methods This was a randomized controlled trial with two parallel arms: dCBT-I (N=358), or online sleep education as the control condition (N=300). Outcome variables were measured at pre-treatment, post-treatment, and one-year follow-up, and included the Insomnia Severity Index (ISI), the Quick Inventory of Depressive Symptomatology (QIDS-SR₁₆), and the Perseverative Thinking Questionnaire (PTQ). The analyses tested change in PTQ scores as a mediator for post-treatment insomnia, post-treatment depression, and incident depression at one-year follow-up. Results Reductions in rumination (PTQ) were significantly larger in the dCBT-I condition compared to control. Results also showed that reductions in rumination significantly mediated the improvement in post-treatment insomnia severity (proportional effect = 11%) and post-treatment depression severity (proportional effect = 19%) associated with the dCBT-I condition. Finally, reductions in rumination also significantly mediated the prevention of clinically significant depression via dCBT-I (proportional effect = 42%). Limitations Depression was measured with a validated self-report instrument instead of clinical interviews. Durability of results beyond one-year follow-up should also be tested in future research. Conclusions Results provide evidence that rumination is an important mechanism in how dCBT-I reduces and prevents depression.

Nocturnal cognitive arousal is associated with objective sleep disturbance and indicators of physiologic hyperarousal in good sleepers and individuals with insomnia disorder

BACKGROUND

Cognitive arousal is central to models of sleep disturbance and insomnia, but findings remain mixed regarding whether cognitive arousal is associated with objective sleep disturbance and physiologic hyperarousal. This study explored associations of objective nocturnal wakefulness and indicators of physiologic hyperarousal with cognitive arousal in healthy sleepers and individuals with insomnia.

METHODS

In sum, 52 adults (51.9% women; 18 with insomnia disorder, 34 healthy sleepers) underwent two overnight polysomnography (PSG) studies (adaptation + baseline nights) and a multiple sleep latency test (MSLT). Baseline depression was assessed and presleep cognitive arousal and somatic arousal were recorded for each night. Multivariate regression was used to evaluate associations of PSG sleep parameters with insomnia, cognitive arousal, and somatic arousal.

RESULTS

Analyses showed that high levels of nocturnal cognitive arousal were associated with prolonged sleep latency, lower sleep efficiency, and shorter total sleep time by PSG on both nights. An association between nocturnal cognitive arousal and wake after sleep onset was observed on night one only. Moreover, greater nocturnal cognitive arousal was associated with greater likelihood of obtaining short sleep and with longer MSLT sleep latencies. Insomnia diagnosis, depression, and somatic arousal were not associated with PSG sleep parameters or MSLT latency.

CONCLUSIONS

Heightened cognitive arousal at night is linked to objective sleep disturbances and indicators of physiologic hyperarousal at night and during the day. For patients with insomnia, cognitive arousal may contribute to the 24-hr physiologic hyperarousal. Cognitive arousal may be a critical therapeutic target for severe or treatment-resistant sleep disturbance.

Cognitive Behavioral Therapy for Insomnia: A Promising Treatment for Insomnia, Pain, and Depression in Patients With IBD

Over 75% of people with active inflammatory bowel diseases (IBDs) report sleep disturbances, which heighten risk for IBD relapse and flares. Despite mounting evidence for sleep disturbances in IBD, discussion of treatment is severely limited. The most common sleep disturbance, insomnia, occurs in over 50% of adults with chronic health conditions. Herein we describe the gold standard treatment for insomnia, Cognitive Behavioral Therapy for Insomnia (CBT-I). Although yet to be studied in IBD, CBT-I reduces a number of IBD-related comorbidities, including chronic pain, depression, and systemic inflammation. We describe treatment with CBT-I, the impact of CBT-I on these comorbidities, and recommendations for providers.

Mindfulness and nocturnal rumination are independently associated with symptoms of insomnia and depression during pregnancy

BACKGROUND

Insomnia and depression are highly prevalent perinatal complications. Ruminating on stress is etiologically implicated in both disorders, and ruminating while trying to fall asleep has been linked to insomnia and depression during pregnancy. Incompatible with rumination is everyday mindfulness, i.e., living with intentional and nonjudgmental awareness of internal and external experiences in the present moment. Responding to stress mindfully may protect against stress-related perinatal complications such as insomnia and depression. The present study described the association between everyday mindfulness and nocturnal rumination, and examined whether these trait characteristics were independently related to perinatal insomnia and depression.

METHODS

Cross-sectional and secondary analysis of existing data from 65 pregnant women recruited from a multisite hospital in Metro Detroit, MI, USA. Subjects completed online surveys including the Insomnia Severity Index, Edinburgh Postnatal Depression Scale, Presleep Arousal Scale, and the revised Cognitive and Affective Mindfulness Scale.

RESULTS

Over half (53.8%) of women screened positive for clinical insomnia and 12.3% screened positive for major depression. Women high in mindfulness, relative to those low in mindfulness, reported less nocturnal rumination (Cohen's d=1.16), insomnia symptoms (Cohen's d=1.24), and depressive symptoms (Cohen's d=1.35). Multivariate linear regression revealed that both mindfulness (β=-.24, p=.03) and rumination (β=.38, p<.01) were independently associated with insomnia. Similarly, a multivariate model showed that mindfulness (β=-.41, p<.001) and rumination (β=.35, p<.01) were independently associated with depression.

CONCLUSIONS

Ruminating in bed at night is strongly associated with insomnia and depression during pregnancy, whereas mindfulness may potentially protect against these stress-related perinatal complications.

Sleep in the anxiety-related disorders: A meta-analysis of subjective and objective research

Although sleep disturbance is implicated in psychopathology, its role in anxiety-related disorders remains unclear. The present meta-analysis characterizes sleep disturbance in anxiety-related disorders collectively and individually. Subjective measures of total sleep time and sleep continuity were included with objective measures. Results indicate a large effect for increased subjective sleep disturbance (g = 2.16), medium effects for decreased total sleep time (g = -.40) and sleep continuity (g = -.49), and a small effect for decreased sleep depth (g = -.20) in anxiety-related disorders compared to healthy controls. Each anxiety-related disorder exhibited a distinct sleep disturbance pattern, suggesting that sleep may facilitate identification of unique biopsychological underpinnings. Effects were not moderated by comorbid depression and were similar in magnitude to those found for depression. Sleep disturbances, particularly decreased sleep continuity, may be a key pathology in the anxiety-related disorders that could highlight novel etiological mechanisms and intervention targets.

Can sleep disturbance be a cue of mood spectrum comorbidity? A preliminary study in panic disorder

OBJECTIVE

To investigate if sleep disturbances may affect treatment outcomes of patients with panic disorder (PD).

METHODS

Eighty-five PD outpatients with no Axis I comorbidity for mood disorders completed a baseline assessment (T1) and were evaluated after 3 (T2), 6 (T3) and 12 months (T4), with the Panic Disorder Severity Scale (PDSS) total score as outcome measure during a 12-month naturalistic follow-up. Patients were assessed with the Mood Spectrum Self-Report (MOODS-SR, Lifetime Version), and the PDSS.

RESULTS

Forty-three patients (50.5%) met criteria for remission (PDSS<5) and 42 (49.5%) for no remission. In a logistic regression model with remission as the dependent variable, MOODS-SR sleep disturbances was the only determinant for a lower likelihood of PD remission. The items accounting for this result were the following: Repeated difficulty falling asleep (chi-square = 4.4; df = 1; p = 0.036), and Repeatedly waking up in the middle of the night (chi-square = 5.2; df = 1; p = 0.022).

CONCLUSION

Lifetime sleep disturbances would represent a cue of mood spectrum (in absence of overt affective comorbidity) that may impair remission in PD.

Emotional exhaustion and sleep-related worry as serial mediators between sleep disturbance and depressive symptoms in student nurses: A longitudinal analysis

OBJECTIVE

The multi-wave longitudinal study was to explore the underlying mechanisms between sleep disturbance and depressive symptoms for up to 9.5 months among student nurses and to examine whether emotional exhaustion and sleep-related worry could be the mediators.

METHODS

856 student nurses aged 15-24 years (mean age = 17.8 years; all female) were recruited from a nursing school. Participants reported demographic variables (age, sibling, location, health condition, family monthly income and parents' marital quality) at baseline (Time1), Body Mass Index, weekly exercise, sleep disturbance and depressive symptoms at 3-month into internship (Time2), emotional exhaustion and sleep-related worry at 6-month into internship (Time3), and depressive symptoms at 9.5-month follow-up (Time4). Mediation analyses with bootstrapping were conducted to investigate the mediating role of emotional exhaustion and sleep-related worry in the relationship between sleep disturbance and depressive symptoms.

RESULTS

Adjusted analyses suggested that the direct effect of sleep disturbance on depressive symptoms was not significant (β = 0.026, SE = 0.069, p = .71). Mediation analyses revealed two significant indirect effects between Time2 sleep disturbance and Time4 depressive symptoms with the mediating effect of emotional exhaustion (β = 0.019, SE = 0.009, BC95%CI [0.0036,0.0405]) and sleep-related worry (β = 0.016, SE = 0.008, BC95%CI [0.0026,0.0337]) respectively. When testing serial multiple mediation, the specific indirect effect of sleep disturbance on depressive symptoms through both emotional exhaustion and sleep-related worry was significant (β = 0.005, SE = 0.003, BC95%CI [0.0004,0.0123]).

CONCLUSIONS

Emotional exhaustion and sleep-related worry were positively associated with sleep disturbance and depressive symptoms.

The role of maladaptive personality domains across multiple levels of the HiTOP structure

This study aimed to examine associations between maladaptive personality traits and psychopathology from the perspective of the hierarchical taxonomy of psychopathology (HiTOP). We tested hierarchical structural models to further validate a portion of the structural components of HiTOP. We also tested a priori personality and psychopathology associations with three levels of the HiTOP hierarchy: general psychopathology, spectra and syndromes/disorders. We used a large sample from the general Australian population who completed a large set of personality and psychopathology inventories online. Confirmatory factor analyses indicated that internalizing, externalizing and thought dysfunction spectra emerged structurally, as expected per HiTOP, but also revealed that obsessive-compulsive disorder loaded on both internalizing and thought dysfunction and attention deficit hyperactivity disorder on both externalizing and internalizing. Furthermore, results indicated that almost all personality and psychopathology hypotheses were supported, although trait antagonism did not predict externalizing to the degree initially expected. Implications for personality and psychopathology are discussed. © 2019 John Wiley & Sons, Ltd.

Abnormalities of thalamus volume and resting state functional connectivity in primary insomnia patients

Primary insomnia (PI) is associated with deteriorating attention, memory, physical and mood complaints. Based on the extensive literature demonstrating the critical roles of the thalamus in sleep regulation, we hypothesized that insomnia would be associated with functional and structural changes of the thalamus. This information is needed to better understand the neural mechanisms of insomnia, and would be useful for informing future attempts to alleviate or treat insomnia symptoms. Twenty-seven PI patients and 39 matched healthy controls were included in the present study. Subcortical volume and resting state functional connectivity (RSFC) of thalamus were compared between groups, and the relationships between neuroimaging differences and clinical features, including the Pittsburgh Sleep Quality Index (PSQI), the Insomnia Severity Index Scale (ISI), the Self-Rating Anxiety Scale (SAS) and the Self-Rating Depression Scale (SDS), also be explored. Compared with the control group, the PI group showed significantly reduced volume of thalamus. In addition, several brain regions showed reduced RSFC with thalamus in PI patients, such as anterior cingulate cortex (ACC), orbitofrontal cortex, hippocampus, caudate and putamen. Correlation analyses revealed that, several of these RSFC patterns were negatively correlated with PSQI score among PI patients, including thalamic connections with the putamen, caudate, hippocampus. Negative correlation was also observed between the RSFC strength of right thalamus-right ACC and SDS score in PI patients. This work demonstrates the structural and functional abnormalities of the thalamus in PI patients that were associated with key clinical features of insomnia. These data further highlight the important role of the thalamus in sleep and PI.

Sleep disturbance in PTSD and other anxiety-related disorders: an updated review of clinical features, physiological characteristics, and psychological and neurobiological mechanisms

The current report provides an updated review of sleep disturbance in posttraumatic stress disorder and anxiety-related disorders. First, this review provides a summary description of the unique and overlapping clinical characteristics and physiological features of sleep disturbance in specific DSM anxiety-related disorders. Second, this review presents evidence of a bidirectional relationship between sleep disturbance and anxiety-related disorders, and provides a model to explain this relationship by integrating research on psychological and neurocognitive processes with a current understanding of neurobiological pathways. A heuristic neurobiological framework for understanding the bidirectional relationship between abnormalities in sleep and anxiety-related brain pathways is presented. Directions for future research are suggested.

Depression prevention via digital cognitive behavioral therapy for insomnia: a randomized controlled trial

STUDY OBJECTIVES

Insomnia is a common precursor to depression; yet, the potential for insomnia treatment to prevent depression has not been demonstrated. Cognitive behavioral therapy for insomnia (CBT-I) effectively reduces concurrent symptoms of insomnia and depression and can be delivered digitally (dCBT-I); however, it remains unclear whether treating insomnia leads to sustained reduction and prevention of depression. This randomized controlled trial examined the efficacy of dCBT-I in reducing and preventing depression over a 1-year follow-up period.

METHODS

Patients with Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) insomnia disorder were randomly assigned to receive dCBT-I or an attentional control. The follow-up sample included 358 patients in the dCBT-I condition and 300 patients in the online sleep education condition. The primary outcome measure was relative rate ratios for depression at 1-year follow-up. Insomnia responses to treatment were also tested as predictors of incident depression at the 1-year follow-up.

RESULTS

At 1-year follow-up, depression severity continued to be significantly lower in the dCBT-I condition relative to control. In addition, the number of individuals who reported no depression at 1-year follow-up was 51% higher in the dCBT-I condition relative to control. In those with minimal to no depression at baseline, the incident rate of moderate-to-severe depression at 1-year follow-up was reduced by half in the dCBT-I condition relative to the control condition.

CONCLUSION

dCBT-I showed robust effects as an intervention that prevents depression. Future research should examine dose-response requirements and further characterize mechanisms of action of dCBT-I for depression prevention.

CLINICAL TRIAL

Sleep to Prevent Evolving Affective Disorders; NCT02988375.

Associations of fatigue and sleep disturbance with nine common mental disorders

OBJECTIVE

To investigate the contribution of nine mental/substance use disorders to fatigue and sleep disturbance.

METHODS

3620 Australians aged 18 years or older recruited from the general community via Facebook during January-February 2016 completed an online survey assessing demographic characteristics, diagnosed medical conditions and nine mental disorders. Outcome measures were Patient Reported Outcomes Measurement Information System (PROMIS®) fatigue and PROMIS sleep disturbance.

RESULTS

Overall, 56% of the sample met criteria for at least one mental disorder. Linear regression models of sleep disturbance revealed all mental disorders except obsessive compulsive disorder (β = 0.038) had independent associations with sleep disturbance, with generalised anxiety disorder (GAD) (β = 0.173), major depressive disorder (MDD) (β = 0.117) and post-traumatic stress disorder (PTSD) (β = 0.111) making the greatest contribution. Inclusion of fatigue in the model attenuated the effects of panic disorder, MDD and attention-deficit hyperactive disorder (ADHD) to non-significance. For the outcome of fatigue, GAD (β = 0.223), MDD (β = 0.176) and PTSD (β = 0.147) made the greatest contributions, although all disorders had significant independent relationships. After adjusting for sleep disturbance, all mental disorders continued to make a significant contribution except for alcohol use disorder and substance use disorder.

CONCLUSION

Sleep disturbance and fatigue have independent associations with many mental disorders after correcting for comorbidity and known confounds. The disorders providing the greatest contribution to sleep disturbance and fatigue were GAD and MDD. Sleep disturbance and fatigue may be appropriate transdiagnostic targets for improving symptoms and global functioning for people with mental disorders.

Depression and suicidal ideation in pregnancy: exploring relationships with insomnia, short sleep, and nocturnal rumination

BACKGROUND

Sleep problems and depression are highly prevalent in pregnancy. Nocturnal rumination has been linked to insomnia and depression in non-pregnant samples, but remains poorly characterized in pregnancy. This study explored relationships of depression and suicidal ideation with insomnia, short sleep, and nocturnal rumination in mid-to-late pregnancy.

METHODS

In this study, 267 pregnant women were recruited from obstetric clinics and completed online surveys on sleep, depression, and nocturnal rumination.

RESULTS

Over half (58.4%) of the sample reported clinical insomnia on the Insomnia Severity Index, 16.1% screened positive for major depression on the Edinburgh Postnatal Depression Scale (EPDS), and 10.1% endorsed suicidal ideation. Nocturnal rumination was more robustly associated with sleep onset difficulties than with sleep maintenance issues. Depressed women were at greater odds of sleep onset insomnia (OR = 2.80), sleep maintenance insomnia (OR = 6.50), high nocturnal rumination (OR = 6.50), and negative perinatal-focused rumination (OR = 2.70). Suicidal ideation was associated with depression (OR = 3.64) and negative perinatal-focused rumination (OR = 3.50). A four-group comparison based on insomnia status and high/low rumination revealed that pregnant women with insomnia and high rumination endorsed higher rates of depression (35.6%) and suicidal ideation (17.3%) than good-sleeping women with low rumination (1.2% depressed, 4.9% suicidal). Women with insomnia alone (depression: 3.9%, suicidal: 5.9%) or high rumination alone (depression: 10.7%, suicidal: 7.1%) did not differ from good-sleeping women with low rumination.

CONCLUSIONS

High rumination and insomnia are highly common in mid-to-late pregnancy and both are associated with depression and suicidal ideation. Depression and suicidal ideation are most prevalent in pregnant women with both insomnia and high rumination. CLINICALTRIALS.

GOV IDENTIFIER

NCT03596879.

Short-term sleep fragmentation enhances anxiety-related behavior: The role of hormonal alterations

Introduction

The neuroendocrine background of acute sleep fragmentation in obstructive sleep apnea and sleep fragmentation involvement in psychiatric comorbidities, common in these patients, are still largely unknown. The aim of this study was to determine the effects of short-term experimental sleep fragmentation on anxiety -like behavior and hormonal status in rats.

Methods

Male rats were adapted to treadmill (ON and OFF mode with belt speed set on 0.02m/s and 0.00m/s) and randomized to: 1) treadmill control (TC, only OFF mode); 2) motion, activity control (AC, 10min ON and 30min OFF mode) and 3) sleep fragmentation (SF, 30s ON and 90s OFF mode) group. Six hours later, the animals were tested in the open field, elevated plus maze and light/dark test (n = 8/group). Testosterone, estradiol, progesterone and corticosterone were determined in separate animal cohort immediately upon sleep fragmentation (n = 6/group).

Results

SF rats showed decreased rearings number, decreased time spent in the central area and increased thigmotaxic index compared to TC and AC rats in the open field test. Similarly, increased anxiety upon sleep fragmentation was observed in the elevated plus maze and the light/dark test. Significantly lower testosterone, estradiol and progesterone levels were determined in SF in comparison to AC and TC groups, while there was no significant difference in the levels of corticosterone.

Conclusion

Short term sleep fragmentation enhances anxiety-related behavior in rats, which could be partly mediated by the observed hormonal changes presented in the current study in form of testosterone, estradiol and progesterone depletion.

Anxiety and depression mediate the relationship between insomnia symptoms and the personality traits of conscientiousness and emotional stability

This study examined the relationship between the Big Five personality traits and insomnia symptoms in the general population. Additionally, the mediating role of anxiety and depression was examined. Participants (N = 625) completed online measures of the big five personality traits and insomnia severity. Insomnia symptoms were independently related to extroversion, agreeableness, conscientiousness, emotional stability, anxiety and depression in univariate analysis. Linear regression determined conscientiousness and emotional stability to be the only traits predicting insomnia symptoms. However, these relationships were at least partially mediated by anxiety and depression. Whilst reduced levels of conscientiousness and emotional stability has previously associated with poor sleep and insomnia, the current outcomes shed light on the mechanisms which serve to mediate this relationship.

Pathways among sleep onset latency, relationship functioning, and negative affect differentiate patients with suicide attempt history from patients with suicidal ideation

Depression, anxiety, sleep disturbances and poor relationship functioning often co-occur with the confluence of these factors contributing to greater suicide risk. This study investigated whether the pathways between depression, anxiety, sleep disturbances, and relationship functioning differentiated patients with suicide attempt history from those with suicidal ideation history. Patients seeking partial hospital treatment for severe psychiatric symptoms (N = 180) completed interviews assessing psychiatric and suicidal symptom histories, and self-report measures of sleep behaviors, anxiety, depression, and relationship functioning. Multiple sleep behaviors were examined: duration, sleep onset latency, and bedtime. Bias-corrected bootstrap mediation and moderated mediation analyses with suicide attempt as the moderator were used to evaluate pathways between variables. Among patients with ideation and attempt history, (1) sleep onset latency significantly mediated the association between depression and relationship functioning and that between anxiety and relationship functioning; (2) relationship functioning significantly mediated the association between depression and sleep onset latency and that between anxiety and sleep onset latency. These pathways were not significant among patients with suicidal ideation only. No other sleep behaviors were related to study variables. The reciprocal relationship between disrupted sleep onset latency and poor relationship functioning was specifically linked to more severe psychiatric symptoms among acute patients with suicide attempt histories.

Online insomnia treatment and the reduction of anxiety symptoms as a secondary outcome in a randomised controlled trial: The role of cognitive-behavioural factors

OBJECTIVE

Insomnia and anxiety commonly co-occur, yet the mechanisms underlying this remain unclear. The current paper describes the impact of an Internet-based intervention for insomnia on anxiety, and explores the influence of two cognitive-behavioural constructs - dysfunctional beliefs about sleep and sleep-threat monitoring.

METHODS

A large-scale, 9-week, two-arm randomised controlled trial ( N = 1149) of community-dwelling Australian adults with insomnia and elevated yet subclinical depression symptoms was conducted, comparing a cognitive behavioural therapy-based online intervention for insomnia (Sleep Healthy Using The Internet) with an attention-matched online control intervention (HealthWatch). Symptoms of anxiety were assessed at pretest, posttest, and 6-month follow-up. Dysfunctional beliefs about sleep and sleep threat monitoring were assessed only at pretest.

RESULTS

Sleep Healthy Using The Internet led to a greater reduction in anxiety symptoms at both posttest ( t_724.27 = -6.77, p < 0.001) and at 6-month follow-up ( t_700.67 = -4.27, p < 0.001) than HealthWatch. At posttest and follow-up, this effect was found to moderated by sleep-threat monitoring ( t_713.69 = -2.39, p < 0.05 and t_694.77 = -2.98, p < 0.01 respectively) but not by dysfunctional beliefs about sleep at either posttest or follow-up ( t_717.53 = -0.61, p = 0.55 and t_683.79 = 0.22, p = 0.83 respectively). Participants in the Sleep Healthy Using The Internet condition with higher levels of sleep-threat monitoring showed a greater reduction in anxiety than those with lower levels from pretest to posttest, ( t_724.27 = -6.77, p < 0.001) and through to 6-month follow-up ( t_700.67 = -4.27, p < 0.001). This result remained after controlling for baseline anxiety levels.

CONCLUSION

The findings suggest that online cognitive behavioral therapy interventions for insomnia are beneficial for reducing anxiety regardless of people's beliefs about their sleep and insomnia, and this is particularly the case for those with high sleep-threat monitoring. This study also provides further evidence for cognitive models of insomnia.

Time of day effects on the relationship between daily sleep and anxiety: An ecological momentary assessment approach

Previous research has linked sleep disturbance to anxiety. However, evidence for this relation has been inconsistent, largely limited to retrospective reports that do not account for daily variability, and silent on when the association is most pronounced. Thus, the present study utilized ecological momentary assessment (EMA) to examine the effects of daily deviations in total sleep time (TST) and person-average TST on anxiety and whether these effects varied as a function of time of day in a sample of unselected adults (N = 138). Results indicate that the amount of TST on a given night, relative to personal average TST, negatively predicted anxiety, and this relation was significant in the morning and afternoon, but not evening. In contrast, person-average TST was unrelated to average anxiety. Relations between TST and anxiety did not differ across objective (e.g., actigraphy) and subjective (e.g., sleep diary) measures. Furthermore, the pattern of results remained the same when controlling for previous day's anxiety and were not bidirectional. These findings suggest that getting less sleep than is typical for the individual predicts subsequent anxiety, and this effect is particularly strong in the morning. Average sleep duration may be less important to the experience of anxiety than deviations from that average. These findings highlight the importance of EMA to examine how and when variability in sleep confers vulnerability for anxiety symptoms.

The effect of stabilization exercise on pain-related disability, sleep disturbance, and psychological status of patients with non-specific chronic low back pain

Background

Sleep disturbance and depression are becoming more recognized as important symptoms among individuals with chronic low back pain. This study evaluated the effect of stabilization exercise on pain-related disability, sleep disturbance and the psychological status of patients with non-specific chronic low back pain (NSCLBP).

Methods

A total of 26 patients (M/F = 17/9) with NSCLBP with a mean age of 50.0 ± 15.5 took part in this study. Participants were recruited from selected hospitals in Lagos state. Ethical approval was sought and obtained from the health research and ethics committee of Lagos University Teaching Hospital Idi-araba, Lagos, Nigeria. Participants performed stabilization exercise for eight weeks consecutively and were assessed for pain-related disability, anxiety, depression, and sleep disturbance using the pain-disability index, hospital anxiety and depression scale, and the insomnia severity index at baseline, the 4th week, and the 8th week, post-intervention.

Results

The participants studied recorded significant reduction in pain-related disability (P = 0.001). There was also improvement in the sleep quality (P = 0.001), depression level (P = 0.001), and anxiety level (P = 0.001), post intervention.

Conclusions

This study revealed that stabilization exercise is very useful in the management of sleep disturbance, pain-related disability, depression, and anxiety in NSCLBP patients.

A Multimethod Examination of the Effect of Insomnia Symptoms on Anxious Responding to a Social Stressor

A growing number of studies identify insomnia symptoms as a potential risk factor for the development of anxiety disorders. However, little research has examined potential mechanisms through which insomnia could confer increased risk for anxiety. A separate line of literature suggests sleep is necessary for adaptive emotional and behavioral responding to stressors, a potential mechanism linking insomnia symptoms to anxiety risk. To test whether insomnia symptoms affect emotional and behavioral responding to an anxiety-relevant stressor, the current study recruited a sample of 99 undergraduates with varying levels of insomnia symptoms. Participants completed self-report and psychophysiological measures before, during, and after an impromptu speech task. Results indicated that, after covarying for negative affectivity, increased insomnia symptoms were significantly associated with elevated anticipatory anxiety and skin conductance response prior to the speech, and increased skin conductance response, emotion regulation difficulties, and safety aid use during the speech. Taken together, results provide evidence for the notion that insomnia symptoms are associated with maladaptive emotional and behavioral responding to an anxiety-relevant stressor.

Nocturnal insomnia symptoms and stress-induced cognitive intrusions in risk for depression: A 2-year prospective study

Nearly half of US adults endorse insomnia symptoms. Sleep problems increase risk for depression during stress, but the mechanisms are unclear. During high stress, individuals having difficulty falling or staying asleep may be vulnerable to cognitive intrusions after stressful events, given that the inability to sleep creates a period of unstructured and socially isolated time in bed. We investigated the unique and combined effects of insomnia symptoms and stress-induced cognitive intrusions on risk for incident depression. 1126 non-depressed US adults with no history of DSM-5 insomnia disorder completed 3 annual web-based surveys on sleep, stress, and depression. We examined whether nocturnal insomnia symptoms and stress-induced cognitive intrusions predicted depression 1y and 2y later. Finally, we compared depression-risk across four groups: non-perseverators with good sleep, non-perseverators with insomnia symptoms, perseverators with good sleep, and perseverators with insomnia symptoms. Insomnia symptoms (β = .10-.13, p < .001) and cognitive intrusions (β = .19-.20, p < .001) predicted depression severity 1y and 2y later. Depression incidence across 2 years was 6.2%. Perseverators with insomnia had the highest rates of depression (13.0%), whereas good sleeping non-perseverators had the lowest rates (3.3%, Relative Risk = 3.94). Perseverators with sleep latency >30 m reported greater depression than good sleeping perseverators (t = 2.09, p < .04). Cognitive intrusions following stress creates a depressogenic mindset, and nocturnal wakefulness may augment the effects of cognitive arousal on depression development. Poor sleepers may be especially vulnerable to cognitive intrusions when having difficulty initiating sleep. As treatable behaviors, nighttime wakefulness and cognitive arousal may be targeted to reduce risk for depression in poor sleepers.

Anxiety sensitivity and sleep disturbance: Investigating associations among patients with co-occurring anxiety and substance use disorders

Sleep disturbance is a common problem among individuals with anxiety and substance use disorders (SUD). Anxiety sensitivity (AS) is elevated in patients with anxiety disorders and SUD and has been linked to sleep-related problems, including insomnia and somnolence (i.e., daytime sleepiness). We examined the unique roles of AS cognitive, physical, and social concerns in sleep disturbance among a sample of 99 residential SUD patients with anxiety disorders. Clinical levels of insomnia or somnolence were evidenced by 53.5% of the sample. Consistent with predictions, AS physical concerns was significantly associated with insomnia, and AS cognitive concerns was significantly related to insomnia and somnolence. Hierarchical linear regression models were conducted to test the association of AS cognitive and physical concerns with insomnia and somnolence symptoms while controlling for relevant factors. AS cognitive concerns accounted for unique variance, above and beyond withdrawal symptoms, anxiety, and depressive symptoms, in the model examining insomnia symptoms (B=0.30, SE=0.13, p=0.023). Results suggest that AS cognitive concerns may represent an important transdiagnostic mechanism underlying sleep disturbance among individuals with dual diagnosis.

Insomnia in hospitalized psychiatric patients: prevalence and associated factors

OBJECTIVES

To quantify and describe the prevalence of insomnia in hospitalized psychiatric patients and to investigate the associations between insomnia and demographic and clinical factors in hospitalized psychiatric patients.

METHODS

The participants included 203 individuals hospitalized for psychiatric treatment at an academic medical center. Demographic information, psychiatric diagnoses, current psychotropic medication use, and history of substance use were collected. Insomnia screening was performed using the Insomnia Severity Index. Depressive and anxiety symptoms were also evaluated using the Generalized Anxiety Disorder questionnaire and the Patient Health Questionnaire. Restless legs syndrome (RLS) symptoms were evaluated using the Restless Legs Syndrome Rating Scale (RLSRS). Statistical analysis was conducted to detect the prevalence of insomnia among the participants and to examine possible associations among psychiatric disorders, psychotropic medications, and RLS.

RESULTS

Out of the 203 participants that completed the survey, 67.4% were found to have insomnia and 14.3% were found to have RLS. The severity of insomnia was found to be associated with the presence of RLS, depressive and anxious symptomatology, suicidal ideation, use of selective serotonin reuptake inhibitors, and use of benzodiazepines.

Sleep disturbances in young and middle-aged adults - Empirical patterns and related factors from an epidemiological survey

BACKGROUND

Previous research suggests that sleep disorders are highly associated with other mental health problems. However, sleep problems even below the diagnostic threshold of sleep disorders are very common in the general population, which highly affects wellbeing and functioning. In order to broaden the focus beyond those severe cases we explored empirical patterns across the whole spectrum of sleep problems as well as associated clinical and other factors.

METHOD

A representative community sample of N=1274 residents from the canton of Zurich was interviewed for sleep problems and diagnostic criteria for mental disorders as well as was given a number of mental health-related psychometrical checklists. Based on a broader spectrum of sleep problems we conducted a latent class analysis (LCA) to derive distinct classes of such disturbances. Classes were compared regarding their associations to mental health-relevant and other risk factors.

RESULTS

The LCA revealed four classes - no sleep disturbances (72.6%), difficulties initiating and maintaining sleep (15.8%), delayed sleep (5.3%), and severe sleep problems (6.4%). Severe sleep problems were related to female gender and generalized anxiety disorder, while depression was linked to all sleep problem classes. Persons with difficulties initiating and maintaining sleep and severe sleep problems reported higher levels of psychopathology, burnout and neuroticism, while all sleep problem types were tied to stress-related variables, but not alcohol use disorder.

DISCUSSION

Sleep problems are highly prevalent among the young and middle-aged adults in our representative sample of young and middle-aged adults and as such represent a serious public mental health problem. Our findings indicate sleep problems to have a multi-dimensional structure with some differential associations. While all subtypes were associated with poorer mental health and particularly more depression, severe sleep problems appeared to be the sleep subtype seen in agoraphobia and GAD, while delayed sleep had no specific associations. The variety of associations assessed leads one to assume that likewise a variety of sleep interventions is required.

Trajectories of change and long-term outcomes in a randomised controlled trial of internet-based insomnia treatment to prevent depression

BACKGROUND

Insomnia treatment using an internet-based cognitive-behavioural therapy for insomnia (CBT-I) program reduces depression symptoms, anxiety symptoms and suicidal ideation. However, the speed, longevity and consistency of these effects are unknown.

AIMS

To test the following: whether the efficacy of online CBT-I was sustained over 18 months; how rapidly the effects of CBT-I emerged; evidence for distinct trajectories of change in depressive symptoms; and predictors of these trajectories.

METHOD

A randomised controlled trial compared the 6-week Sleep Healthy Using the Internet (SHUTi) CBT-I program to an attention control program. Adults (N=1149) with clinical insomnia and subclinical depression symptoms were recruited online from the Australian community.

RESULTS

Depression, anxiety and insomnia decreased significantly by week 4 of the intervention period and remained significantly lower relative to control for >18 months (between-group Cohen's d=0.63, 0.47, 0.55, respectively, at 18 months). Effects on suicidal ideation were only short term. Two depression trajectories were identified using growth mixture models: improving (95%) and stable/deteriorating (5%) symptoms. More severe baseline depression, younger age and limited comfort with the internet were associated with reduced odds of improvement.

CONCLUSIONS

Online CBT-I produced rapid and long-term symptom reduction in people with subclinical depressive symptoms, although the initial effect on suicidal ideation was not sustained.

DECLARATION OF INTEREST

P.J.B. has received grants from the National Health and Medical Research Council (NHMRC) during the conduct of the study. H.C. has received grants from the NHMRC and the Australian Research Council during the conduct of the study. L.M.R. receives research funding from the National Institutes of Health (NIH) that, in part, focuses on insomnia. F.P.T. and L.M.R. have equity ownership in BeHealth Solutions (Charlottesville, VA, USA), a company that develops and makes available products related to the research reported in this manuscript. BeHealth Solutions has licensed the SHUTi program and the software platform on which it was built from the University of Virginia. The terms of this arrangement have been reviewed and approved by the University of Virginia in accordance with its conflict of interest policy. N.G. has received grants from the NHMRC during the conduct of the study and personal fees from Lundbeck, Servier and Janssen outside the submitted work.

COPYRIGHT AND USAGE

© The Royal College of Psychiatrists 2017. This is an open access article distributed under the terms of the Creative Commons Non-Commercial, No Derivatives (CC BY-NC-ND) license.

Interplay among pain intensity, sleep disturbance and emotion in patients with non-specific low back pain

Background

Low back pain (LBP) is the most common problem worldwide. There are several negative consequences of LBP, such as sleep disorders, work leave, disability, depression, anxiety, and poor quality of life. In this study, we designed to evaluate the prevalence of sleep disturbance in patients with non-specific LBP(NSLBP), and cross-correlation among sleep disorder, anxiety, depression and pain intensity in patients with NSLBP.

Aim

In this study, we designed to evaluate the prevalence of sleep disturbance in patients with NSLBP, and cross-correlation among sleep disorder, anxiety, depression and pain intensity in patients with NSLBP.

Methods

A cross-sectional self-assessment questionnaire survey was carried out in an outpatient clinic. Anonymous assessments were used to characterize the presence of NSLBP, PSQI, VAS, SF-36 form, ODI, BAI and BDI. Cross-correlation among the severity of NSLBP and sleep disturbance, anxiety, depression and life quality were evaluated.

Results

Patients with NSLBP have a higher incidence of sleep disorder, anxiety and depression, and higher ODI scores than healthy people without LPB (P < 0.01). NSLBP patients with sleep disorders have more severe anxiety, depression, an increased VAS score and poor daily living (P < 0.05). NSLBP patients with anxiety have declined sleep quality, poor daily living, decreased work and social skills, and increased LBP severity (P < 0.05). NSLBP patients with depression have declined sleep quality, poor daily living, decreased work and social skills (P < 0.05). Significant associations were found between the severity of NSLBP and sleep disorders, anxiety and ODI scores.

Conclusion

Psychological and social factors play an important role in the development of NSLBP. NSLBP leads to sleep disorders, which decrease the sleep quality and increase the unpleasant emotions and memories in return; these can exacerbate the severity of LBP, with the cycle repeating to form a vicious circle.

The Course and Impact of Poststroke Insomnia in Stroke Survivors Aged 18 to 65 Years: Results from the Psychosocial Outcomes In StrokE (POISE) Study

Background

Insomnia symptoms are common in the population and have negative psychosocial and functional sequelae. There are no prospective studies of the course of such symptoms and their impact, if any, in stroke survivors. This prospective cohort study investigated insomnia after stroke in working-age adults and evaluated its impact on psychological and functional outcomes over the subsequent year.

Methods

We prospectively recruited 441 young (<65 years) consecutive stroke survivors from 20 public hospitals in the New South Wales Stroke Service network. Participants were assessed by self-report and interview at 28 days, 6 months, and 12 months after stroke. Insomnia was defined using a common epidemiological measure of sleep disturbance and daytime consequences. Depression, anxiety, disability, and return to work were assessed through standardized measures.

Results

The point prevalence of insomnia at each time point in the year after stroke was stable at 30–37% and more common in females. Fifty-eight (16%) of all participants reported “chronic” insomnia, with symptoms at both baseline and 6 months later. At 12 months, this group was more likely to be depressed (OR 6.75, 95% CI 2.78–16.4), anxious (OR 3.31, 95% CI 1.54–7.09), disabled (OR 3.60, 95% CI 2.07–6.25), and not have returned to work, compared to those without insomnia over the same period.

Conclusions

Chronic insomnia has a negative effect on disability and return to work 1 year after stroke even after adjusting for demographic, psychiatric, and disability factors. Identifying and appropriately targeting insomnia through known effective treatments may improve functional outcomes after stroke.