Regensburg Insomnia Scale (RIS): a new short rating scale for the assessment of psychological symptoms and sleep in insomnia; study design: development and validation of a new short self-rating scale in a sample of 218 patients suffering from insomnia and 94 healthy controls

Multi-night acoustic stimulation is associated with better sleep, amyloid dynamics, and memory in older adults with cognitive impairment

Sleep is a potential early, modifiable risk factor for cognitive decline and dementia. Impaired slow wave sleep (SWS) is pronounced in individuals with cognitive impairment (CI). Cognitive decline and impairments of SWS are bi-directionally linked in a vicious cycle. SWS can be enhanced non-invasively using phase-locked acoustic stimulation (PLAS), potentially breaking this vicious cycle. Eighteen healthy older adults (HC, agemean±sd, 68.3 ± 5.1) and 16 older adults (agemean±sd, 71.9 ± 3.9) with CI (Montreal Cognitive Assessment ≤ 25) underwent one baseline (sham-PLAS) night and three consecutive stimulation nights (real-PLAS). EEG responses and blood-plasma amyloid beta Aβ42/Aβ40 ratio were measured pre- and post-intervention, as was episodic memory. The latter was again evaluated 1 week and 3 months after the intervention. In both groups, PLAS induced a significant electrophysiological response in both voltage- and time-frequency analyses, and memory performance improved in association with the magnitude of this response. In the CI group, both electrophysiological and associated memory effects were delayed compared to the healthy group. After 3 intervention nights, electrophysiological response to PLAS was no longer different between CI and HC groups. Only in the CI sample, stronger electrophysiological responses were significantly associated with improving post-intervention Aβ42/Aβ40 ratios. PLAS seems to improve SWS electrophysiology, memory, and amyloid dynamics in older adults with CI. However, effects on memory require more time to unfold compared to healthy older adults. This indicates that PLAS may become a potential tool to ameliorate cognitive decline, but longer interventions are necessary to compensate for declining brain integrity. This study was pre-registered (clinicaltrials.gov: NCT04277104).

Depressive symptoms in patients with hypersomnia measured with Beck Depression Inventory

BACKGROUND

Patients with central hypersomnia (HCO) often show symptoms of depression. Despite of many studies conducted in this field, the link between these two disorders remains unclear. In order to contribute data to this research, we examined the question of which depressive symptoms characterize these patients. Furthermore, we investigated the differences between HCO who were more or less depressed regarding insomnia, sleep quality and daytime tiredness.

METHODS AND MATERIAL

The retrospective analysis assesses the presence and kind of depressive symptoms as measured by the Beck Depression Inventory (BDI) in 168 HCO including narcolepsy type I (NAR1), narcolepsy type II (NAR2) and idiopathic hypersomnia (HYP). Sleep parameters from one night of polysomnography, scores of questionnaires for insomnia and for daytime sleepiness, and data from sustained attention tests were compared between HCO with and without depression, as determined by BDI scores (cut off >12).

RESULTS

According to BDI scores 52% exhibited no depression. The BDI items pertaining to tiredness and work inhibition exhibited elevated scores, whereas those pertaining to suicidality showed low scores. No difference was found between depressed and non-depressed HCO with regard to daytime vigilance performance or daytime sleepiness. However, depression was associated with older age, higher insomnia scores, and a shorter sleep time on polysomnography.

CONCLUSION

A potential interpretation of our findings is that depressive symptoms in HCO may be a consequence of restricted life quality due to hypersomnia. Thus, therapeutical effort should focus more intensely on coping strategies.

Evaluation of a Brief Three-Item Insomnia Severity Index (ISI-3) Among Healthcare Workers

OBJECTIVES

Sleep disorder is a growing public health concern that requires attentive assessment and treatment. However, the length of assessment tools for sleep disorders, including insomnia, hinders their use in both research and clinical settings. Brief assessment measures expedite assessment time, reducing respondent burden, and save resources, especially in resource-limited settings.

METHODS

This study investigated the validity and reliability of a short three-item insomnia scale, the Insomnia Severity Index-3 (ISI-3) and established two cutoff scores in a sample of 238 healthcare providers in Oman (45.8% physicians and 54.2% nurses).

RESULTS

The ISI-3 demonstrated good convergent and divergent validity. The receiver operator characteristic recommended two cutoff scores of > 4 (a sensitivity of 0.87.3 and a specificity of 0.96.4) and > 6 (a sensitivity of 0.96.9 and a specificity of 0.97.1).

CONCLUSIONS

The ISI-3 is a good assessment index of insomnia, especially when the utilization of the full insomnia index is unfeasible.

Single-Item Assessment of Quality of Life: Associations with Well-Being, Mood, Health Correlates, and Lifestyle

Background: Quality of life (QoL) is traditionally assessed using multiple-item questionnaires. These can be either general, global assessments of QoL or disease-specific questionnaires. However, the use of single-item QoL scales is becoming increasingly popular, as these are more time- and cost-effective, with a readily available and easy-to-interpret outcome. In particular, these are often preferred for quick assessments (e.g., 'at home' testing and mobile phone assessments), and other cases when time constraints are common (e.g., clinical trials and clinical practice). Previous research revealed that multiple-item questionnaires and single-item assessments of QoL have the same validity and reliability. Here we further evaluate the relationship of QoL, assessed with a single-item QoL scale, with well-being, mood, health correlates (e.g., immune fitness, and having underlying diseases), and lifestyle (e.g., sleep, nutrition). Methods: Data from two online surveys are presented. In Study 1, 100 students participated. The single-item QoL score was compared with the World Health Organization Well-Being Index (WHO-5), a single-item score of sleep quality, the Regensburg Insomnia Scale (RIS) score, and the Healthy Diet Scale (HDS). Study 2 comprised a survey among 1415 Dutch adults. Single-item QoL was evaluated and compared with assessments of mood, health correlates (immune fitness and disease status), and lifestyle factors (e.g., sleep, nutrition, stress). Results: The first study revealed significant correlations between QoL and well-being, sleep quality, insomnia ratings, and attaining a healthy diet. The second study revealed significant correlations between QoL and mood, health status, and lifestyle factors (e.g., the ability to cope with stress). Conclusions: The results presented here demonstrate that the single-item QoL scale is an effective and easy-to-implement assessment tool that can be used in both clinical practice and research.

The Association Between Tinnitus Sensation-Level Loudness and Sleep Quality in Patients With Subjective Consecutive Tinnitus: A Mediation Analysis

PURPOSE

So far, there have been no in-depth analyses of the connection between tinnitus sensation-level loudness and sleep quality. Accordingly, the present study was formulated as a mediation analysis focused on exploring this relationship.

METHOD

Overall, 1,255 adults with consecutive subjective tinnitus who had sought outpatient treatment were enrolled in the present study.

RESULTS

Direct effects of tinnitus sensation-level loudness on sleep quality were not statistically significant (95% confidence intervals [CI] include zero), as measured by the point estimate, -0.016. However, the 95% CI for indirect effects did not include zero when assessing the Self-Rating Anxiety Scale (SAS) scores, the Self-Rating Depression Scale (SDS) scores, the visual analogue scale (VAS) scores, and self-reported tinnitus annoyance.

CONCLUSIONS

These results suggest that tinnitus sensation-level loudness does not directly have an effect on sleep quality. However, it indirectly impacts sleep quality, mediated by SAS scores, SDS scores, the impact of tinnitus on life measured using the VAS, and self-reported tinnitus annoyance. As such, alleviating anxiety and depression in patients with tinnitus may result in reductions in their insomnia even if there is no reduction in tinnitus loudness. Importantly, otolaryngologists and other clinicians treating tinnitus should refer patients with tinnitus suffering from insomnia with comorbid depression or anxiety for appropriate psychological and/or psychiatric treatment.

EEG Microstate Dynamics Associated with Dream-Like Experiences During the Transition to Sleep

Consciousness always requires some representational content; that is, one can only be conscious about something. However, the presence of conscious experience (awareness) alone does not determine whether its content is in line with the external and physical world. Dreams, apart from certain forms of hallucinations, typically consist of non-veridical percepts, which are not recognized as false, but rather considered real. This type of experiences have been described as a state of dissociation between phenomenal and reflective awareness. Interestingly, during the transition to sleep, reflective awareness seems to break down before phenomenal awareness as conscious experience does not immediately fade with reduced wakefulness but is rather characterized by the occurrence of uncontrolled thinking and perceptual images, together with a reduced ability to recognize the internal origin of the experience. Relative deactivation of the frontoparietal and preserved activity in parieto-occipital networks has been suggested to account for dream-like experiences during the transition to sleep. We tested this hypothesis by investigating subjective reports of conscious experience and large-scale brain networks using EEG microstates in 45 healthy young subjects during the transition to sleep. We observed an inverse relationship between cognitive effects and physiological activation; dream-like experiences were associated with an increased presence of a microstate with sources in the superior and middle frontal gyrus and precuneus. Additionally, the presence of a microstate associated with higher-order visual areas was decreased. The observed inverse relationship might therefore indicate a disengagement of cognitive control systems that is mediated by specific, inhibitory EEG microstates.

Sudarshan Kriya Yoga Breathing and a Meditation Program for Burnout Among Physicians: A Randomized Clinical Trial

Importance

Physicians are exposed to high stress and strain that results in burnout, which affects them, their families, their patients, and the entire health care system; thus, there is an urgent need to develop methods to increase the resiliency of physicians. Sudarshan Kriya Yoga (SKY) is a comprehensive yoga breathing and meditation-based program that is a potential approach to mitigate physician burnout.

Objective

To determine whether SKY can reduce psychological distress and improve wellness in physicians.

Design, Setting, and Participants

This randomized clinical trial assessed the potential efficacy of SKY compared with a stress management education (SME) training as control. This study was conducted online from November 11, 2021, to March 14, 2022, and included physicians from Turkey, Germany, and Dubai. Both the SKY and the SME control groups received 1.5 hours of training for 3 consecutive days via a group video conference call. Participants were physicians willing to do some form of relaxation exercise everyday for 2 months. Exclusion criteria included presence of major illness and maintaining a regular mind-body program practice. Statistical analysis took place from March to November 2023.

Interventions

Participants were randomly assigned 1:1 into 2 groups-the SKY group or the SME (control) group-using a computer algorithm. After the 3-day instruction period, the participants in the SKY group practiced for approximately 30 minutes per day on their own and participated in a weekly 1-hour, group-based online follow-up practice. After the 3-day instruction period, participants in the SME group reviewed and applied the notes from stress management education training at their initiative and had a weekly 1-hour group-based online follow-up session.

Main Outcomes and Measures

The primary outcomes were stress and depression (measured by the 42-item Depression, Anxiety, and Stress Scale [DASS-42]) and insomnia measured by the Regensburg Insomnia Scale (RIS) with primary end point at 8 weeks. Secondary outcomes included anxiety (DASS-42); optimism (Life Orientation Test-Revised [LOT-R]); professional fulfillment, work exhaustion, interpersonal disengagement, and overall burnout (Professional Fulfillment Index [PFI]); and self-reported professional errors (Self-Reported Professional Error Questionnaire).

Results

This study included 129 participants (SME, 63 participants [48.9%]; SKY, 66 participants [51.1%]; 115 females [89.2%]; 14 males [10.8%]; mean [SD] age, 46.2 [9.0] years). Compared with the SME control group, participants in the SKY group had significantly decreased stress on the DASS-42 at posttraining (difference, -6.8 points; 95% CI, -9.6 to -4.1 points; P = .006) and at postintervention (difference, -6.0 points; 95% CI, -8.8 to -3.3 points; P = .03), significantly decreased depression at posttraining (difference, -5.7 points; 95% CI, -8.6 to -2.8 points; P < .001) and postintervention (difference, -5.4 points; 95% CI, -8.3 to -2.5 points; P < .001), and significantly decreased anxiety at postintervention. In addition, there was a significant decrease in insomnia from baseline to postintervention in the SKY group (difference, -0.3 points; 95% CI, -2.3 to 1.7 points; P = .01). The SKY group also showed significantly increased professional fulfillment as well as significant decreases in work exhaustion, interpersonal disengagement, and burnout. There was no effect on self-reported medical errors.

Conclusions and Relevance

In this randomized clinical trial, physicians who regularly practiced SKY throughout a 2-month period experienced improvements in wellness and decreased burnout. These data suggest that SKY may be an effective, practical, and safe strategy to increase wellness and mitigate burnout in physicians.

Trial Registration

ClinicalTrials.gov Identifier: NCT05956470.

Content analysis of insomnia questionnaires: A step to better evaluate the complex and multifaceted construct of insomnia disorder

Insomnia disorder is a mental disorder that includes various types of symptoms (e.g., insomnia initiating, worries, mood disturbances) and impairments (e.g., distress related to sleep alterations). Self-report questionnaires are the most common method for assessing insomnia but no systematic quantified analysis of their content and overlap has been carried out. We used content analysis and a visualization method to better identify the different types of clinical manifestations that are investigated by nine commonly used insomnia questionnaires for adults and the Jaccard index to quantify the degree to which they overlap. Content analysis found and visualized 16 different clinical manifestations classified into five dimensions ("Insomnia symptoms", "Insomnia-related symptoms", "Daytime symptoms", "Insomnia-related impairments", "Sleep behaviors"). The average Jaccard Index was 0.409 (moderate overlap in content). There is a lack of distinction between symptoms and impairments, and the assessment of sleep duration and hyperarousal symptoms remains overlooked. This preliminary analysis makes it possible to visualize the content of each of the nine questionnaires and to select the most appropriate questionnaire based on the issue to be addressed. Suggestions are made regarding the development of future questionnaires to better distinguish symptoms and impairments, and the different phenotypes of insomnia disorder.

Effects of a Self-Guided Transdiagnostic Smartphone App on Patient Empowerment and Mental Health: Randomized Controlled Trial

BACKGROUND

Mental disorders impact both individuals and health systems. Symptoms and syndromes often remain undetected and untreated, resulting in chronification. Besides limited health care resources, within-person barriers such as the lack of trust in professionals, the fear of stigmatization, or the desire to cope with problems without professional help contribute to the treatment gap. Self-guided mental health apps may support treatment seeking by reducing within-person barriers and facilitating mental health literacy. Digital mental health interventions may also improve mental health related self-management skills and contribute to symptom reduction and the improvement of quality of life.

OBJECTIVE

This study aims to investigate the effects of a self-guided transdiagnostic app for mental health on help seeking, reduced stigma, mental health literacy, self-management skills, mental health symptoms, and quality of life using a randomized controlled design.

METHODS

Overall, 1045 participants (recruited via open, blinded, and web-based recruitment) with mild to moderate depression or anxiety-, sleep-, eating-, or somatization-related psychopathology were randomized to receive either access to a self-guided transdiagnostic mental health app (MindDoc) in addition to care as usual or care as usual only. The core features of the app were regular self-monitoring, automated feedback, and psychological courses and exercises. The coprimary outcomes were mental health literacy, mental health-related patient empowerment and self-management skills (MHPSS), attitudes toward help seeking, and actual mental health service use. The secondary outcomes were psychopathological symptom burden and quality of life. Data were collected at baseline and 8 weeks and 6 months after randomization. Treatment effects were investigated using analyses of covariance, including baseline variables as predictors and applying multiple imputation.

RESULTS

We found small but robust between-group effects for MHPSS (Cohen d=0.29), symptoms burden (Cohen d=0.28), and quality of life (Cohen d=0.19) 8 weeks after randomization. The effects on MHPSS were maintained at follow-up. Follow-up assessments also showed robust effects on mental health literacy and preliminary evidence for the improvement of help seeking. Predictors of attrition were lower age and higher personality dysfunction. Among the non-attritors, predictors for deterioration were less outpatient treatment and higher initial symptom severity.

CONCLUSIONS

A self-guided transdiagnostic mental health app can contribute to lasting improvements in patient empowerment. Symptoms of common mental disorders and quality of life improved faster in the intervention group than in the control group. Therefore, such interventions may support individuals with symptoms of 1 or more internalizing disorders, develop health-centered coping skills, prevent chronification, and accelerate symptom improvement. Although the effects for individual users are small and predictors of attrition and deterioration need to be investigated further, the potential public health impact of a self-guided intervention can be large, given its high scalability.

TRIAL REGISTRATION

German Clinical Trials Register DRKS00022531; https://drks.de/search/de/trial/DRKS00022531.

Effect of Work-Related Behavior and Experience Patterns on Sleep Quality in Emergency Medical Service Personnel

OBJECTIVE

The aim of this study was to examine the influence of work-related behavior and experience patterns on sleep quality in emergency medical service personnel.

METHODS

From the total sample of 508 emergency medical service workers who took part in the Germany-wide online survey, 368 respondents completed the questionnaires on sleep characteristics (Pittsburgh Sleep Quality Index [PSQI]) and work-related behavior and experience pattern. Three hundred sixty-seven of the 368 participants also finished the Regensburg Insomnia Scale.

RESULTS

Based on their work-related behavior and experience pattern results, individuals were categorized into one of the four following patterns: two risk patterns (A, B) and two healthy behavior and experience patterns (G, S). Participants that were classified into risk-pattern A and B (33.85%) scored significantly higher in both PSQI and Regensburg Insomnia Scale overall score and all PSQI components implicating a poorer sleep quality. A total of 78.5% of the individuals with pattern A and B were considered bad sleepers whereas only 43.4% of individuals with pattern G and S were scored as bad sleepers.

CONCLUSIONS

Work-related behavior and experience patterns showed a strong association to sleep characteristics and may therefore be used to identify appropriate preventative measures.

Pilot Study to Gain First Indications for the Impact of a 3-Month's Oral Intake of a Sucrosomial Iron Supplement on Hemoglobin in Iron-Deficient Blood Donors

Introduction

Regular whole blood donors often suffer from iron deficiency (ID) or iron deficiency anemia due to the loss of 200-300 mg of iron with each donation. Hemoglobin (Hb) as donor eligibility criterion reflects iron stores only poorly. ID in blood donors is typically prevented or treated with orally administered ferrous salts, which frequently cause gastrointestinal side effects. A high daily oral iron dose is counterproductive due to hepcidin upregulation. Oral sucrosomial iron (sucriron) is encapsulated ferric pyrophosphate that may be an option for blood donors due to its supposed high bioavailability and good tolerability.

Methods

This monocentric single-cohort pilot study included fifty whole blood donors (divided into premenopausal women, postmenopausal women, and men) who did not meet Hb donation criteria. Participants aged 18-65 years with ferritin <30 ng/mL and venous Hb <12.5 g/dL in women and Hb <13.5 g/dL in men received oral sucriron (30 mg iron) for 90-120 days. Primary endpoints were the increase of Hb and ferritin.

Results

Forty-seven participants completed the study. With the limitation that no control group was included, there was a substantial overall median increase of 0.94 g/dL Hb and 4.97 ng/mL ferritin (standardized on 90 days of iron intake). These value improvements were likewise observed in each of the subgroups. sucriron was very well tolerated, with almost no gastrointestinal side effects identified.

Conclusion

A clear increase of Hb and ferritin was observed after the intake of sucriron, so it may be a reasonable and useful alternative to traditional oral iron therapy. The ease of administration, pleasant taste, dietary supplement status, and, most importantly, good tolerability highlight the value of sucriron supplementation.

Sleep behaviour differs in women and men with psoriatic arthritis and axial spondyloarthritis with impact on quality of life and depressive symptoms

OBJECTIVES

Axial spondyloarthritis (axSpA) and psoriatic arthritis (PsA) may have a profound impact on sleep and health-related quality of life. The aim of this study was to assess sleep quality and quality of life and determine associated factors in patients treated with spondyloarthritides (SpA).

METHODS

Cross-sectional questionnaire-based assessment of sleep behaviour, quality of life, functional impairment and depression (Regensburg Insomnia Scale, WHO Quality of Life questionnaire, Funktionsfragebogen Hannover questionnaire, Beck Depression Inventory II, Patient health questionnaire 9) and retrospective medical chart analysis of a monocentric cohort of 330 patients with SpA (n=168 PsA and n=162 axSpA).

RESULTS

46.6% of patients with SpA demonstrated abnormal sleep behaviour. Linear regression models showed HLA-B27 positivity, Bath Ankylosing Spondylitis Disease Activity Index, depressive symptoms, functional capacity and disease duration to be predictive of insomnia symptoms in axSpA, respectively, depressive symptoms, female sex and Disease Activity Score 28 in patients with PsA. Patients with unrestful sleep had a significantly reduced health-related quality of life (p<0.001) as well as significantly more depressive symptoms (p<0.001). Satisfaction with health was rated significantly lower (p<0.001), indicating poor sleep as a burden on general well-being.In particular, female patients had a significantly worse sleep quality with a prolonged sleep latency (p=0.009), increased sleep disturbances (p=0.014) and unrestful sleep (p<0.001) as well as a reduced physical and mental health-related quality of life (p=0.015, p<0.001) and more depressive symptoms (p=0.015).

CONCLUSION

Despite treatment, many patients with SpA demonstrate abnormal sleep behaviour with symptoms of insomnia and a reduced quality of life with significant differences between male and female patients. An interdisciplinary and holistic approach may be needed to address unmet needs.

The role of biofield energy treatment on psychological symptoms, mental health disorders, and stress-related quality of life in adult subjects: A randomized controlled clinical trial

Background

Western and Eastern cultures have practiced biofield energy therapy for thousands of years, but empirical research on effectiveness of this therapy is relatively nascent. Study was aimed to assess the safety and efficacy of biofield therapy on psychological symptoms and mental health disorders in adult subjects.

Methods

Seventy-seven participants (39 male and 38 female) underwent clinical trial. This trial was simple randomized, placebo-controlled, parallel-group, open-label, and single-center with subjects, who have one or more psychological symptoms. Two sessions of biofield energy attunement were given in-person at day 0 and 90 for 3 min (treatment group, n = 35) and others allocated to naive attunement (placebo group, n = 42). Subjects were assessed psychological questionnaire scoring using standard scale of assessment and levels of physiological biomarkers in serum were determined by parameter-specific ELISA.

Results

Perceived psychological symptoms/scores (asthenia, sleep disturbances, anxiety, depression, stress, confusion, future fearness, sexual desireness, motivation, confidence, emotional trauma, etc.) were significantly (p ≤ 0.0001) improved in the treatment group than placebo control group. Furthermore, physiological biomarkers: vitamins (B12, C, and D3 metabolites), immune biomarker (CD8+CD28-), neurotransmitters (acetylcholine, noradrenaline, and dopamine), hormones (oxytocin, 17-β-estradiol, and insulin), and antiaging protein (klotho) levels were significantly (p ≤ 0.001) increased in treatment group than placebo. Proinflammatory cytokines (TNF-α, IL-1β, IL-6, and IL-8) and oxidative stress biomarkers (isoprostane and oxidized LDL) were reduced in treatment group compared with placebo.

Conclusions

Results suggest that experimenter's biofield energy plays a significant role in information transfer processes that contribute to individual's state of physical, mental, emotional, and spiritual well-being as well as improved overall health and quality of life.

Evaluation of a Structured Screening Assessment to Detect Isolated Rapid Eye Movement Sleep Behavior Disorder

BACKGROUND

Isolated rapid eye movement (REM) sleep behavior disorder (iRBD) cohorts have provided insights into the earliest neurodegenerative processes in α-synucleinopathies. Even though polysomnography (PSG) remains the gold standard for diagnosis, an accurate questionnaire-based algorithm to identify eligible subjects could facilitate efficient recruitment in research.

OBJECTIVE

This study aimed to optimize the identification of subjects with iRBD from the general population.

METHODS

Between June 2020 and July 2021, we placed newspaper advertisements, including the single-question screen for RBD (RBD1Q). Participants' evaluations included a structured telephone screening consisting of the RBD screening questionnaire (RBDSQ) and additional sleep-related questionnaires. We examined anamnestic information predicting PSG-proven iRBD using logistic regressions and receiver operating characteristic curves.

RESULTS

Five hundred forty-three participants answered the advertisements, and 185 subjects fulfilling inclusion and exclusion criteria were screened. Of these, 124 received PSG after expert selection, and 78 (62.9%) were diagnosed with iRBD. Selected items of the RBDSQ, the Pittsburgh Sleep Quality Index, the STOP-Bang questionnaire, and age predicted iRBD with high accuracy in a multiple logistic regression model (area under the curve >80%). When comparing the algorithm to the sleep expert decision, 77 instead of 124 polysomnographies (62.1%) would have been carried out, and 63 (80.8%) iRBD patients would have been identified; 32 of 46 (69.6%) unnecessary PSG examinations could have been avoided.

CONCLUSIONS

Our proposed algorithm displayed high diagnostic accuracy for PSG-proven iRBD cost-effectively and may be a convenient tool for research and clinical settings. External validation sets are warranted to prove reliability. © 2023 The Authors. Movement Disorders published by Wiley Periodicals LLC on behalf of International Parkinson and Movement Disorder Society.

Digitally supported shared decision-making and treat-to-target in rheumatology: a qualitative study embedded in a multicenter randomized controlled trial

Patient-reported outcomes (PRO) represent a cornerstone in the management of patients with rheumatoid arthritis (RA). However, PRO are currently recorded mainly on paper and only during on-site appointments. Electronic PRO (ePRO) enable continuous remote monitoring and could improve shared decision-making (SDM) and implementation of a treat-to-target (T2T) approach. This study aims to investigate patient and physician experiences, perceived drawbacks and benefits of using an ePRO web-app (ABATON RA) to digitally support SDM and T2T. A qualitative study embedded in a multicenter randomized controlled trial (RCT) consisting of interviews with RA patients and physicians that were subsequently analyzed using deductive-inductive qualitative content analysis. Between August 2021 and May 2022, interviews with ten RA patients and five physicians were completed. Three key themes emerged in the analysis: (i) App user experiences; (ii) perceived drawbacks of app-supported rheumatology care; and (iii) perceived benefits of app-supported rheumatology care. Continuous ePRO collection and a high level of standardization strained some RA patients. Certain ePRO seemed outdated and were hard to understand. Patients and physicians appreciated having an improved overview of disease activity, capturing disease flares and continuous remote monitoring. Paper- and time-saving were associated with using ePRO. Physicians feared to become too focused on ePRO data, stressed the lack of ePRO monitoring reimbursement and app interoperability. For RA patients and physicians, benefits seemed to outweigh observed drawbacks of the digitally supported SDM using ePRO. The software was easy to use and could lead to a better understanding of the individual disease course, resource allocation and treatment of rheumatoid arthritis.

Effectiveness of an App-Based Short Intervention to Improve Sleep: Randomized Controlled Trial

BACKGROUND

A growing body of evidence for digital interventions to improve sleep shows promising effects. The interventions investigated so far have been primarily web-based; however, app-based interventions may reach a wider audience and be more suitable for daily use.

OBJECTIVE

This study aims to evaluate the intervention effects, adherence, and acceptance of an unguided app-based intervention for individuals who wish to improve their sleep.

METHODS

In a randomized controlled trial, we evaluated the effects of an app-based short intervention (Refresh) to improve sleep compared with a waitlist condition. Refresh is an 8-week unguided intervention covering the principles of cognitive behavioral therapy for insomnia (CBT-I) and including a sleep diary. The primary outcome was sleep quality (insomnia symptoms) as self-assessed by the Regensburg Insomnia Scale (RIS). The secondary outcomes were depression (9-item Patient Health Questionnaire [PHQ-9] score) and perceived insomnia-related impairment.

RESULTS

We included 371 participants, of which 245 reported poor sleep at baseline. About 1 in 3 participants who were allocated to the intervention group never accessed the intervention. Active participants completed on average 4 out of 8 chapters. Retention rates were 67.4% (n=250) at postassessment and 57.7% (n=214) at the 6-month follow-up. At postintervention, insomnia symptoms in the intervention group had improved more than those in the waitlist group, with a small effect (d=0.26) in the whole sample and a medium effect (d=0.45) in the subgroup with poor sleep. Effects in the intervention group were maintained at follow-up. Perceived insomnia-related impairment also improved from pre- to postassessment. No significant intervention effect on depression was detected. Working alliance and acceptance were moderate to good.

CONCLUSIONS

An app-based, unguided intervention is a feasible and effective option to scale-up CBT-I-based treatment, but intervention uptake and adherence need to be carefully addressed.

TRIAL REGISTRATION

ISRCTN Registry ISRCTN53553517; https://www.isrctn.com/ISRCTN53553517.

Unlocking infodemics and mysteries in COVID-19 vaccine hesitancy: Nexus of conspiracy beliefs, digital informational support, psychological Well-being, and religious fatalism

Guarding against an anti-science camouflage within infodemics is paramount for sustaining the global vaccination drive. Vaccine hesitancy remains a growing concern and a significant threat to public health, especially in developing countries. Infodemics, conspiracy beliefs and religious fatalism primarily fuel vaccine hesitancy. In addition, anti-vaccine disinformation, lack of understanding, and erroneous religious beliefs also trigger vaccine hesitancy. Global behavioral strategies such as wearing face masks and long-term preventive measures (i.e., COVID-19 vaccination) have effectively limited the virus's spread. Despite the alarming rate of global deaths (i.e., over 99% being unvaccinated), a large proportion of the global population remains reluctant to vaccinate. New evidence validates the usefulness of technology-driven communication strategies (i.e., digital interventions) to address the complex socio-psychological influence of the pandemic. Hence, the present research explored the digital information processing model to assess the interface between informational support (through digital interventions) and antecedents of vaccine hesitancy. This research involved two separate studies: a focus group to operationalize the construct of infodemics, which remained ambiguous in previous literature (Study 1), followed by a cross-sectional survey (Study 2) to examine the conceptual model. Data were collected from 1906 respondents through a standard questionnaire administered online. The focus group's findings revealed a multi-dimensional nature of infodemics that was also validated in Study 2. The cross-sectional survey results substantiated infodemics, religious fatalism and conspiracy beliefs as significant predictors of vaccine hesitancy. Similarly, conspiracy beliefs negatively influence an individual's psychological well-being. Furthermore, information support (through digital intervention) affected infodemics and religious fatalism, whereas it inversely influenced the strength of their relationships with vaccine hesitancy. Information support (through digital intervention) also moderated the relationship between conspiracy beliefs and psychological well-being.

Respiratory tract infections and risk factors for infection in a cohort of 330 patients with axial spondyloarthritis or psoriatic arthritis

Respiratory tract infections (RTIs) are the most common infections in patients with rheumatic diseases under immunosuppressive treatment and may contribute to morbidity and mortality as well as increased healthcare costs. However, to date only limited data on infection risk in spondyloarthritis (SpA) patients are available. In this study we assessed the occurrence of respiratory tract infections in a monocentric real-world cohort consisting of 330 patients (168 psoriatic arthritis and 162 axial spondyloarthritis patients) and determined factors associated with increased infection risk. Out of 330 SpA patients, 89.3% had suffered from ≥ 1 upper respiratory tract infection (URTI) and 31.1% from ≥ 1 lower respiratory tract infection (LRTI) within the last two years. The most common URTIs were rhinitis and laryngitis/pharyngitis with 87.3% and 36.1%, respectively. Bronchitis constituted the most common LRTI, reported in 29.7% of patients. In a multivariate binomial logistic regression model occurrence of LRTI was associated with chronic lung disease (OR 17.44, p=0.006), glucocorticoid therapy (OR 9.24, p=0.012), previous history of severe airway infections (OR 6.82, p=0.013), and number of previous biological therapies (OR 1.72, p=0.017), whereas HLA B27 positivity was negatively associated (OR 0.29, p=0.025). Female patients reported significantly more LRTIs than male patients (p=0.006) and had a higher rate of antibiotic therapy (p=0.009). There were no significant differences between axSpA and PsA patients regarding infection frequency or antibiotic use. 45.4% of patients had required antibiotics for respiratory tract infections. Antibiotic therapy was associated with smoking (OR 3.40, p=0.008), biological therapy (OR 3.38, p=0.004), sleep quality (OR 1.13, p<0.001) and age (OR 0.96, p=0.030). Hypogammaglobulinemia (IgG<7g/l) was rare (3.4%) in this SpA cohort despite continuous immunomodulatory treatment. Awareness of these risk factors will assist physicians to identify patients with an increased infection risk, who will benefit from additional preventive measures, such as vaccination and smoking cessation or adjustment of DMARD therapy.

Daily life stress and the cortisol awakening response over a 13-months stress period - Findings from the LawSTRESS project

The LawSTRESS project is a controlled prospective-longitudinal study on psychological, endocrine, central nervous and genetic predictors of responses to long-lasting academic stress in a homogenous cohort. In this first project report, we focused on the association between daily life stress and the cortisol awakening response (CAR). The CAR, a distinct cortisol rise in the first 30-45 min after morning awakening, is a well-established marker of cortisol regulation in psychoneuroendocrinology. Law students from Bavarian universities (total n = 452) have been studied over a 13-months period at six sampling points starting 12 months prior exam. The stress group (SG) consisted of students experiencing a long-lasting and significant stress period, namely the preparation for the first state examination for law students. Law students assigned to the control group (CG) were studied over an equally long period without particular and sustained stress exposure. To investigate stress related alterations in the CAR, we examined a subsample of the LawSTRESS project consisting of 204 students with 97 participants from the SG (69.1% female, mean age = 22.84 ± 1.82) and 107 from the CG (78.5% female, mean age = 20.95 ± 1.93). At each sampling point, saliva samples for cortisol assessment were collected immediately upon awakening and 30 as well as 45 min later. Perceived stress in daily life was measured by repeated ambulatory assessments (about 100 queries over six sampling points). The time course of perceived stress levels in the two groups differed significantly, with the SG showing an increase in perceived stress until the exam and a decrease thereafter. Stress levels in the CG were relatively stable. The CAR was not significantly different between groups at baseline. However, a blunted CAR in the SG compared to the baseline measure and to the CG developed over the measurement timepoints and reached significance during the exam. Remarkably, this effect was neither associated with the increase in perceived stress nor with anxiety and depression symptoms, test anxiety and chronic stress at baseline. The present study successfully assessed multidimensional stress trajectories over 13 months and it documented the significant burden, law students preparing for the first state examination are exposed to. This period was related to a blunted CAR with presumed physiological consequences (e.g., on energy metabolism and immune function). Mean psychological stress levels as well as the CAR returned to baseline levels after the exam, suggesting a fast recovery in the majority of the participants.

The relationship between the HDRS insomnia items and polysomnographic (PSG) measures in individuals with treatment-resistant depression

The Hamilton Depression Rating Scale (HDRS), which includes several insomnia-related items, is potentially valuable in evaluating both depressive and sleep symptoms. However, the HDRS insomnia items have not been fully assessed by objective measures. This study compared the three HDRS insomnia items (Early, Middle, and Late) with the corresponding objective polysomnography (PSG) measures of Sleep Latency (SL), middle wakefulness, and late wakefulness. The study used HDRS and PSG data from 130 baseline nights, drawn from 80 participants enrolled in clinical trials for treatment-resistant depression (TRD). Mixed models evaluated the relationship between the HDRS and PSG, and primary analyses examined the Early, Middle, and Late Insomnia HDRS items and the PSG variables SL and Waking After Sleep Onset (WASO). To approximate the Middle and Late HDRS Insomnia items more closely, WASO was divided into WASO before 4:00 a.m. (waking between Sleep Onset and 0400 h) and WASO after 4:00 a.m. (waking between 0400 h and 0700 h). Secondary analyses included summed HDRS Global Insomnia score. HDRS Early and Late Insomnia items predicted objective PSG measures of early and late wakefulness. For Early Insomnia, each additional point in severity was associated with 61% [95%CI: 35%, 93%] longer SL. For Late Insomnia, each additional point was associated with a 35% [95% CI: 13%, 63%] increase in WASO after 4:00 a.m. Middle Insomnia was marginally related to WASO before 4:00 a.m. HDRS Early and Late Insomnia items may thus provide an index of wakefulness in TRD and help monitor treatment response when objective measures such as PSG are not feasible. CLINICAL TRIALS IDENTIFIER: www.clinicaltrials.gov (NCT01204918, NCT00054704, NCT00088699).

Die primäre und die psychiatrisch-„komorbide“, nichtorganische Insomnie in einem neurologisch geführten Schlaflabor

Patientinnen und Patienten, die in einem neurologischen Schlaflabor die Abschlussdiagnose nichtorganische Insomnie erhalten, leiden zu einem großen Teil (34 von 43 Personen) unter einer psychiatrischen Erkrankung: Persönlichkeitsstörungen, mit und ohne zusätzliche affektive Störung, Depression, Dysthymie, Zyklothymie, bipolare Störung, Angststörungen (generalisierte Angststörung, soziale Phobie), somatoforme (autonome) Funktionsstörung, hypochondrische Störung, Zwangsstörung, Anpassungsstörungen nach dramatischen Lebensereignissen sowie posttraumatische Belastungsstörungen. Sie befinden sich in laufender psychiatrischer und psychotherapeutischer Behandlung, leiden aber anhaltend unter den Symptomen der Insomnie. Allen Patientinnen und Patienten mit nichtorganischer Insomnie wird die kognitive Verhaltenstherapie der Insomnie angeboten.

Sleep disturbances in the context of neurohormonal dysregulation in patients with bipolar disorder

Background

Sleep dysfunction is a core symptom in bipolar disorder (BD), especially during major mood episodes. This study investigated the possible link between subjective and objective sleep disturbances in inter-episode BD, changes in melatonin and cortisol levels, and circadian melatonin alignment. The study included 21 euthymic BD patients and 24 healthy controls. Participants had to wear an actigraphy device, keep a weekly sleep diary and take salivary samples: five samples on the last evening to determine the dim light melatonin onset (DLMO) and one the following morning to measure rising cortisol. Sleep quality was assessed by the Pittsburgh Sleep Quality Index (PSQI) and Regensburg Insomnia Scale (RIS), and circadian alignment by the phase angle difference (PAD).

Results

In comparison to healthy controls, BD patients had: (1) higher PSQI (5.52 ± 3.14 vs. 3.63 ± 2.18; p = 0.022) (significant after controlling for age and gender), and higher RIS scores (8.91 ± 5.43 vs. 5.83 ± 3.76; p = 0.031); (2) subjective a longer mean TST (p = 0.024) and TIB (p = 0.002) (both significant after controlling for age and gender), longer WASO (p = 0.019), and worse SE (p = 0.036) (significant after controlling for gender); (3) actigraphically validated earlier sleep onset (p = 0.002), less variation in sleep onset time (p = 0.005) and no longer TST (p = 0.176); (4) no differing melatonin levels (4.06 ± 2.77 vs. 3.35 ± 2.23 p = 0.352), an 1.65 h earlier DLMO (20.17 ± 1.63 vs. 21.82 ± 1.50; p = 0. 001) (significant after controlling for gender), and a phase advance of melatonin (6.35 ± 1.40 vs. 7.48 ± 1.53; p = 0.017) (significant after controlling for gender); and (5) no differing cortisol awakening response (16.97 ± 10.22 vs 17.06 ± 5.37 p = 0.969).

Conclusions

Patients with BD, even in euthymic phase, have a significantly worse perception of their sleep. Advanced sleep phases in BD might be worth further investigation and could help to explain the therapeutic effects of mood stabilizers such as lithium and valproate.

[Sleep medicine in psychiatry and psychotherapy]

Sleep medicine is a cross-disciplinary subject with high relevance for psychiatry and psychotherapy. The three most common sleep disorders (insomnia, sleep apnea syndrome and restless legs syndrome) are presented here with practical relevance. Cognitive behavioral therapy is the treatment of choice for insomnia, whereas symptomatic drug treatment (especially with GABA receptor agonists) should be used with caution. Sleep-related breathing disorders have a high prevalence of around 24% among psychiatric inpatients in Germany. Typical symptoms of obstructive sleep apnea syndrome should lead to a staged diagnostic process and, if necessary, cardiorespiratory polysomnography. It is not unusual for restless legs syndrome to be caused by psychopharmacological treatment. The primary form was usually treated with dopamine or dopamine agonists but due to the risk of augmentation, alternatives should be considered more often.

Insomnia and other sleep disorders in dermatology patients: A questionnaire-based study with 634 patients

Insufficient sleep duration and quality are associated with various adverse health outcomes. Whereas sleep disorders have been studied in a few skin conditions, data in a more comprehensive dermatology population are lacking. We sought to describe the prevalence, causes, and consequences of sleep disorders in dermatology patients. In this cross-sectional, single-center study, dermatology patients completed a questionnaire addressing skin-related and non-skin-related health, sleep behavior, causes, and consequences of sleep disorders. According to the Regensburg Insomnia Scale, 27.92% of the 634 participants had insomnia (177 of 634 patients). Of these 177 patients, 115 (64.97%) were subjectively sleep disturbed, with skin-related causes accounting for 55.65% (64 of 115 patients), non-skin-related accounting for 33.04% (38 of 115 patients), and combined accounting for 11.30% (13 of 115 patients). Itch was the leading cause of skin-related sleep disorders (64.49%, 50 of 77 patients), followed by skin-related pain (55.84%, 43 of 77 patients) and skin-related fearful thoughts (54.55%, 42 of 77 patients). Sleep disorders reduced daytime performance in 68.70% (79 of 115 patients) and sleep quality of relatives in 20.87% (24 of 115 patients). The prevalence of insomnia among different diagnostic categories ranged from 20.31% to 50.00%. The most common strategy to improve sleep was taking sleep medication (57.39%, 66 of 115 patients). We conclude that sleep disorders are highly prevalent in dermatology patients, often leading to reduced daytime performance, impaired sleep among the patients' relatives, and increased use of substances.

Assessing sleep problems and daytime functioning: a translation, adaption, and validation of the Athens Insomnia Scale for non-clinical application (AIS-NCA)

OBJECTIVE & DESIGN

Sleep problems are common and have been linked to health problems, diminished well-being, and impaired performance. Many scales to diagnose clinically relevant sleep problems are time-consuming, complex, and difficult to administer in non-clinical and multi-thematic studies. Through a multi-stage translation (from English to German) and scale testing process, we developed a parsimonious measure of sleep problems and daytime functioning for non-clinical applications based on the Athens Insomnia Scale. Results: Exploratory (N_{Study 1} = 25,140) and confirmatory (N_{Study 2} = 14,797) factor analyses suggest a two-dimensional structure with the subscales "sleep problems" and "daytime functioning". Internal scale consistency was acceptable. Measurement invariance was found across time, gender, age, and diagnosed sleep disorders. The scale discriminates between people with and without sleep disorders and predicts emerging sleep disorders. Short-term retest reliability was acceptable (N_{Study 3} = 78). Convergent validity with other sleep measures and discriminant validity with indicators of well-being were observed (N_{Study 4} = 341). After a multi-stage translation to English, we confirmed the factor structure and found measurement invariance across languages (N_{Study 5} = 623). Conclusion: Our short 7-item scale has good psychometric properties and is suitable for self-administration, making it useful in measuring sleep problems and daytime functioning efficiently and reliably, especially for large population studies.

Investigating Binge-Watching Adverse Mental Health Outcomes During Covid-19 Pandemic: Moderating Role of Screen Time for Web Series Using Online Streaming

Background and Purpose

Watching multiple episodes using streaming services, such as Netflix, Hulu, and Youku, has become widespread in recent years. While much attention has been paid to binge-watching, there is, however, a dearth of research on binge-watching and its adverse psychological effects during the COVID-19 pandemic. To the best of our knowledge, less attention has been paid to understanding the multiple influences of binge-watching on binge-watchers during the COVID-19 pandemic. Most of the past studies on this topic mainly underscored the individual's motivations for binge-watching. Also, past studies were limited and inconclusive as they mostly espoused only the underpinning adverse effects of binge-watching without looking into the association between binge-watching and screen time for web series through online streaming services during the COVID-19 pandemic. Therefore, this study sought to fill this gap by probing the association between binge-watching and psychological aftereffects.

Participants and Methods

The study employed a cross-sectional research design vis-à-vis the survey method. A sample of 1089 adult respondents was collected through an online administrated questionnaire.

Results

The findings of this study demonstrated that extensive binge-watching is an antecedent of stress, loneliness, insomnia, depression and anxiety. Furthermore, it was found that screen time on binge-watching could intensify these adverse effects of binge-watching. Interestingly, the moderating effect of screen time on binge-watching was found to be insignificant for stress and loneliness.

Conclusion

The findings of this study suggest that binge-watching correlates with psychological and mental health symptoms including stress, loneliness, insomnia, depression and anxiety. Hence, this study suggests that consumption of web series through online streaming services related literacy interventions are imperative to help the audience become critical about online streaming content and its comparison to the real social world.

Nocturnal pruritus and sleep disturbance associated with dermatologic disorders in adult patients

Nocturnal pruritus (NP) is a relatively common reason for dermatologic consultation. Its pathophysiology is partially understood. Skin conditions such as atopic dermatitis, psoriasis, urticaria, and prurigo nodularis are well-described causes of NP. The most distressing sequela of NP is sleep deficit, which can lead to physical and mental disturbances (e.g., daytime somnolence and fatigue) and negative emotional states that profoundly affect quality of life. However, this aspect of NP is often overlooked by dermatologists. It is essential to assess sleep quality in such patients and adopt appropriate measures to arrest the problem at an early stage. We conducted an evidence-based literature review to highlight the pathogenetic mechanisms of NP, identify dermatologic etiologies, and explore methods that have been used to assess the quality of sleep. Furthermore, we performed a systematic review of studies on sleep disturbance relevant to NP in patients with dermatologic conditions. Finally, we discuss the evidence on treatment options for NP and indicate therapies that may target both NP and sleep disturbance.

Assessment of effects of total sleep deprivation and subsequent recovery sleep: a methodological strategy feasible without sleep laboratory

Background

Sleep is critical for maintaining homeostasis in bodily and neurobehavioral functions. This homeostasis can be disturbed by sleep interruption and restored to normal by subsequent recovery sleep. Most research regarding recovery sleep (RS) effects has been conducted in specialized sleep laboratories, whereas small, less-well equipped research units may lack the possibilities to run studies in this area. Hence, the aims of the present study were to develop and validate an experimental protocol, which allows a thorough assessment of at-home recovery sleep after sleep deprivation.

Methods

The experimental protocol, comprising one night of baseline sleep (BL) at home, one night of monitored total sleep deprivation and a subsequent recovery night at home, was tested in a sample of 30 healthy participants. Subjects’ fatigue and alertness were assessed prior to and after each night. Sleep at home (BL, RS) was objectively assessed using portable polysomnography. To check whether our at-home sleep assessments yielded results that are comparable to those conducted in sleep laboratories, we compared the sleep data assessed in our study with sleep data assessed in laboratory studies.

Results

Sleep parameters assessed during RS exhibited changes as expected (prolonged total sleep time, better sleep efficiency, slow wave sleep rebound). Sleep parameters of BL and RS were in line with parameters assessed in previous studies examining sleep in a laboratory setting. Fatigue normalized after one night of RS; alertness partly recovered.

Conclusions

Our results suggest a successful implementation of our new experimental protocol, emphasizing it as a useful tool for future studies on RS outside of well-equipped sleep laboratories.

Anonymous online cognitive behavioral therapy for sleep disorders in shift workers-a study protocol for a randomized controlled trial

Background

Many shift workers suffer from sleep issues, which negatively affect quality of life and performance. Scientifically evaluated, structured programs for prevention and treatment are scarce. We developed an anonymous online cognitive behavioral therapy for insomnia (CBT-I) program. After successful completion of a feasibility study, we now start this prospective, randomized, controlled superiority trial to compare outcomes of two parallel groups, namely an intervention group and a waiting-list control-group. Additionally, we will compare these outcomes to those of a face-to-face CBT-I outpatient sample.

Methods

Collaborating companies will offer our anonymous online intervention to their shift-working employees. Company physicians and counseling services will screen those interested for inclusion and exclusion criteria. Participants will receive access to our online service, where they will complete psychometric assessment and receive random assignment to either the intervention group or the waiting-list control group. Participants and providers will be aware of the group assignment. We aim to allocate at least N = 60 participants to the trial. The intervention consists of psychoeducation, sleep restriction, stimulus control, relaxation techniques, and individual feedback delivered via four e-mail contacts. During the intervention, as well as during the waiting period, participants will fill out weekly sleep diaries. Immediately after completion of the program, the post-intervention assessment takes place. Participants in the control group will be able to participate in the program after all study assessments. To recruit an additional sample, collaborating outpatient sleep clinics will provide six sessions of standard face-to-face CBT-I to an ad hoc sample of shift working patients. We expect both the online and the face-to-face CBT-I interventions to have beneficial effects compared to the control group on the following primary outcomes: self-reported symptoms of depression and insomnia, sleep quality, and daytime sleepiness.

Conclusions

The online intervention allows shift workers to follow a CBT-I program independently of their working schedule and location. Forthcoming results might contribute to further improvement of prevention and therapy of sleep issues in shift workers.

Trial registration

German Clinical Trials Register DRKS DRKS00017777. Registered on 14 January 2020—retrospectively registered.

Sleep Habits during COVID-19 Confinement: An Exploratory Analysis from Portugal

COVID-19 pandemic consequences are tragic, and many problems will persist after the health problem ends. Some studies have focused on mental health issues, reporting worrying percentages. It is known that there is a bidirectional relationship between mental health and sleep quality, and it would be expected that sleep would be affected by the pandemic. In order to know the Portuguese people’s habits before and during the confinement, we carried out a survey of 188 people aged 13 to 84 (38 ± 15) to find out the most frequent sleep patterns, habits and disorders before and during confinement. With this survey it was also intended to measure the most frequent changes in sleep patterns, habits, and disturbances on the general population and according to demographic data (gender, age group and professional status), sleep disorders arise, perceptions about sleep during confinement and if Portuguese think that in the future the sleep patterns will be the pre or during outbreak. Results indicate that, comparing before and during confinement, there is a slight correlation between gender and sleep disorders (before vs. during), a correlation between age group and professional status time to wake up, and between professional status and sleep disorders, and a strong correlation between the professional situation and changes in the invigorated feeling level (p < 0.001). Support for mental health and interventions to improve sleep quality should be offered to the population in general, and, according to our study, the Portuguese population.

A review of sleep disturbance in adults prescribed medications for opioid use disorder: potential treatment targets for a highly prevalent, chronic problem

BACKGROUND

Sleep disturbance in individuals prescribed medications for opioid use disorder (MOUD) is common, though the nature and progression of such concerns are difficult to discern due to differing terminology and assessment type between studies. Accurately identifying and treating sleep problems in this growing population has the potential to improve comorbidity and other MOUD outcomes.

OBJECTIVE

The aim of the present review is to provide an overview of sleep in individuals stabilized on MOUD. Specifically, the following aspects of sleep were reviewed: 1) prevalence of clinically significant sleep disturbance; 2) sleep disturbance compared to findings in those not prescribed MOUD; 3) correlates of sleep disturbance; 4) self-reported sleep compared to objective measures.

METHOD

Studies were identified using 6 large databases and included if they contained at least one measure of sleep during MOUD treatment as usual. Studies were excluded if they were case studies, not available in English, or participants were in withdrawal or detoxification.

RESULTS

Forty-two studies were included and categorized by type of sleep assessment: validated self-report questionnaire; provider-assessed; polysomnography; multi-method. Correlates were included if they were statistically significant (generally p < 0.05).

CONCLUSIONS

This review indicates there is a high prevalence of chronic self-reported sleep disturbance (eg, insomnia symptoms) in this population and suggests quantitative sleep parameters (eg, total sleep time) and respiratory problems during sleep are worse than in the general population. These sleep problems are correlated with psychiatric comorbidity and other substance use. Other correlates (eg, sociodemographic factors) require further study to draw definitive conclusions.

Does app-based unguided self-management improve mental health literacy, patient empowerment and access to care for people with mental health impairments? Study protocol for a randomised controlled trial

INTRODUCTION

Mental disorders pose a huge burden to both individuals and health systems. Symptoms and syndromes often remain undetected and untreated, resulting in comorbidity and chronification. Besides limited resources in healthcare systems, the treatment-gap is-to a large extent-caused by within-person barriers impeding early treatment seeking. These barriers include a lack of trust in professionals, fear of stigmatisation, or the desire to cope with problems without professional help. While unguided self-management interventions are not designed to replace psychotherapy, they may support early symptom assessment and recognition by reducing within-person barriers. Digital self-management solutions may also reduce inequalities in access to care due to external factors such as regional unavailability of services.

METHODS AND ANALYSIS

Approximately 1100 patients suffering from mild to moderate depressive, anxiety, sleep, eating or somatisation-related mental disorders will be randomised to receive either a low-threshold unguided digital self-management tool in the form of a transdiagnostic mental health app or care as usual. The primary outcomes will be mental health literacy, patient empowerment and access to care while secondary outcomes will be symptom distress and quality of life. Additional moderator and predictor variables are negative life events, personality functioning, client satisfaction, mental healthcare service use and application of self-management strategies. Data will be collected at baseline as well as 8 weeks and 6 months after randomisation. Data will be analysed using multiple imputation and analysis of covariance employing the intention-to-treat principle, while sensitivity analyses will be based on different multiple imputation parameters and a per-protocol analysis.

ETHICS AND DISSEMINATION

Approval was obtained from the Ethics Committee of the Faculty of Educational Science and Psychology at the Freie Universität Berlin. The results will be submitted to peer-reviewed specialised journals and presented at national and international conferences.

TRIAL REGISTERATION

The trial has been registered in the DRKS trial register (DRKS00022531);Pre-results.

The global prevalence of depression, anxiety, stress, and, insomnia and its changes among health professionals during COVID-19 pandemic: A rapid systematic review and meta-analysis

BACKGROUND

During the COVID-19 pandemic, the health professionals who are at the frontline of this crisis have been facing extreme psychological disorders. This research aims to provide an overall scenario of the prevalence of depression, anxiety, stress, as well as insomnia and to inspect the changes in these prevalence over time by analyzing the existing evidence during this COVID-19 pandemic.

METHODS

A systematic search was performed on March 30, 2021, in PubMed, MEDLINE, Google Scholar databases, and Web of Science. To assess the heterogeneity, Q-test,I 2 statistics, and Meta regression and to search for the publication bias, Eggers's test and funnel plot were used. The random-effect model and subgroup analysis were performed due to the significant heterogeneity.

RESULTS

Among eighty-three eligible studies in the final synthesis, 69 studies (n = 144649) assessed the depression prevalence of 37.12% (95% CI: 31.80-42.43), 75 studies (n = 147435) reported the anxiety prevalence of 41.42% (95% CI: 36.17-46.54), 41 studies (n = 82783) assessed the stress prevalence of 44.86% (95% CI: 36.98-52.74), 21 studies (n = 33370) enunciated the insomnia prevalence of 43.76% (95% CI: 35.83-51.68). The severity of the mental health problems among health professionals increased over the time during January 2020 to September 2020.

LIMITATIONS

A significant level of heterogeneity was found among psychological measurement tools and across studies.

CONCLUSIONS

Therefore, it is an emergency to develop psychological interventions that can protect the mental health of vulnerable groups like health professionals.

A practical nutritional guide for the management of sleep disturbances in menopause

Sleep disturbances (SD) represent one of the main symptoms of menopause and they are caused by several factors. Hormonal changes such as the reduction of oestrogen levels and the consequent vasomotor symptoms (VMS) along with psychiatric disorders such as depression and anxiety could contribute to the onset of SD. Furthermore, obesity per sè or through the obstructive sleep apnoea (OSA) could blunt sleep. Moreover, in menopause is usual a reduction in melatonin, that could contribute to SD. Nutritional strategies are paramount because they could contribute to manage menopause-related SD, in particular tackling obesity and overweight. Furthermore, some foods, such as soy, fish, whole grains, vegetables and fruit could decrease symptoms like depression and VMS, correlated with SD in postmenopausal women. Therefore, the aim of this review is to provide an overview of the current evidence on SD in menopause and to provide nutritional strategies for managing SD in this context.

Insights Gained in the Aftermath of the COVID-19 Pandemic: A Follow-Up Survey of a Recreational Training Program, Focusing on Sense of Coherence and Sleep Quality

The original aim of this study was a follow-up assessment of a recreational program running for six months (September 2019-February 2020) within controlled conditions. Following the arrival of the COVID-19 pandemic, the survey acquired a new goal: how do the subjects of the follow-up sampling experience this severe stress situation, and in this experience, what role does physical activity and a salutogenetic sense of coherence play. Austrian women (N = 53) took part in the training program, whose physical condition was assessed before the start of the program, then reassessed after three months and after six months; the organizers also had them fill out the sense of coherence questionnaire (SOC) as well as the Regensburger insomnia scale. After the lifting of the lockdown introduced due to the pandemic, participants completed an online survey relating to their changed life conditions, physical activities, sense of coherence and sleep quality. Results: After the first three months of the training, no significant changes were detected. After six months, the participants SOC and sleep quality improved (Friedman test: p = 0.005 and p < 0.001). During the lockdown, sleep quality generally deteriorated (W-rank test: p = 0.001), while SOC did not change. The women in possession of a relatively stronger SOC continued the training (OR = 3.6, CI 95% = 1.2-12.2), and their sleep quality deteriorated to a lesser degree. (OR = 1.7, CI 95% = 1.1-2.8). Conclusion: The data reinforce the interdependency between physical exercise (PE) and SOC; furthermore, the personal training that the authors formulated for middle-aged women proved to be successful in strengthening their sense of coherence, and it also reduced the deterioration in sleep quality due to stress.

Wakefulness impairs selective consolidation of relevant trauma-associated memories resulting in more frequent intrusions

Recent studies show that sleep reduces intrusive memories after analog trauma. This effect is assumed to be caused by sleep's impact on memory consolidation. However, the underlying processes of this phenomenon have not been uncovered. Thus, the current study investigates the hypothesis that sleep reduces intrusive memories by supporting the selective consolidation of relevant memories. Seventy-five participants were exposed to traumatic picture stories before nocturnal sleep or wakefulness during daytime. Memory for relevant and irrelevant trauma-associated stimuli was assessed prior to and after the retention period. Consistent with the hypothesis, results demonstrate reduced memory loss for relevant as opposed to irrelevant trauma-associated stimuli after sleep but not after wakefulness. Moreover, an incremental retention benefit for relevant trauma-associated stimuli was negatively correlated with the number of intrusive trauma memories after wakefulness. These results suggest that lack of sleep impairs selective gating of relevant trauma-associated memories, thereby enhancing intrusion development after trauma.

Sleep apnea syndrome comorbid with and without restless legs syndrome: differences in insomnia specific symptoms

OBJECTIVE

Sleep Apnea Syndrome (SAS) is frequently comorbid with Restless Legs Syndrome (RLS). Both disorders are associated with disturbed sleep. However, data about insomnia specific symptoms in patients suffering from both sleep disorders (SAS-RLS) are rare.

METHODS

In a restrospective design, we investigated 202 patients suffering from SAS and SAS-RLS. All patients underwent polysomnography, performed a vigilance test (Quatember-Maly), and completed the Regensburg Insomnia Scale (RIS), Epworth Sleepiness Scale (ESS), Beck Depression Inventory-II (BDI-II), and a Morning Questionnaire (FZN). Differences in insomnia specific symptoms between SAS and SAS-RLS were calculated using ANOVA. In a secondary analysis, the differences in daytime sleepiness and depression were analyzed.

RESULTS

Of 202 patients, 42 (21%) had SAS-RLS. The proportion of women (60%) with SASRLS was higher than for men (40%) while men had had a higher proportion (71%) of SAS alone compared to women (29%), p < 0.0005. The RIS score was higher in SAS-RLS than in SAS. No differences were found in PSG data, ESS, BDI-II, or vigilance tests.

CONCLUSIONS

Patients with both disorders SAS and RLS show a higher degree of insomnia-specific symptoms than for SAS alone and may profit from additional insomnia specific treatment.

Cognitive behavioral therapy for insomnia in restless legs syndrome patients

OBJECTIVES

The purpose of this study was to investigate the effects of cognitive behavioral therapy for insomnia (CBTI) in patients with Restless Legs Syndrome (RLS).

METHODS

This is a randomized controlled study. The patients were sequentially selected and randomly assigned to either a CBTI group or a non-CBTI group. A total of 25 RLS patients with comorbid insomnia were recruited from a tertiary university hospital sleep center. Twelve were assigned to the CBTI group, and 13 were assigned to the non-CBTI group. The CBTI group received 4 sessions of behavioral therapy, while the non-CBTI group received one informative session on sleep hygiene. All patients completed sleep and psychiatric-related questionnaires. In addition, each individual completed a one-week sleep log for collecting subjective sleep data and actigraphy for objective sleep data.

RESULTS

After conducting the CBTI, there were significant improvements in severity of insomnia symptoms, subjective sleep efficiency, total sleep time, latency to sleep onset, wake after sleep onset, objective latency to sleep onset, and anxiety in the CBTI group as compared to the non-CBTI group. The effect of CBTI on sleep-related data was maintained for up to three months.

CONCLUSIONS

CBTI was effective in RLS patients by improving sleep quality and anxiety symptoms. CBTI may be considered in clinical practice for RLS patients with comorbid insomnia.

Psychophysiological insomnia and respiratory tract infections: results of an infection-diary-based cohort study

STUDY OBJECTIVES

The immune theory of sleep suggests an important role of sleep for a functioning immune system. Insomnia has been associated with heightened risk for infections. The aim of the study was to test whether psychophysiological insomnia (PI) is associated with subsequent respiratory tract infections (RTIs) in the context of an infection-diary-based cohort study.

METHODS

We recruited 674 adults from a cross-sectional survey on airway infections into the airway infection susceptibility (AWIS) cohort and invited them to self-report in diaries incident RTIs experienced during 7097 months (mean of 11.9 months of completed infection diaries per individual). The Regensburg Insomnia Scale (RIS) was assessed at baseline to measure PI. As outcome, we considered an infection diary score summing up prospectively reported RTIs.

RESULTS

The RIS score correlated significantly with the infection diary score summarizing reported RTIs (correlation coefficient = 0.265, p < 0.001). Adjustments by putative confounders did only marginally affect this relationship. No significant differences in the relationship between RIS score and diary score were found for subgroups including those by gender, body mass index, perceived stress, and comorbidity. People affected by a combination of high PI and obesity were eight times more likely to belong to the group reporting the highest 10% of RTIs compared to the nonobese group with low RIS score (p < 0.001). A high RIS score in men was associated with a higher neutrophil-to-lymphocyte ratio, an indicator of inflammation.

CONCLUSIONS

Our data support the relevance of adequate sleep for an immune system ready to fight pathogens and prevent airway infections.

Sleeping Patterns in Patients with Opioid Use Disorder: Effects of Opioid Maintenance Treatment and Detoxification

The aim of the study was to explore whether abstinent patients on recent opioid detoxification or on opioid maintenance treatment suffer from sleeping problems. 199 patients on opioid maintenance treatment (methadone, diacetylmorphine and buprenorphine) or recent opioid detoxification were included in this exploratory cross-sectional study. We used the Pittsburgh Sleep Quality Index (PSQI) and the Regensburger Insomnia Scale (RIS) in order to assess potential sleeping problems. There was a significant effect of the condition "opioid maintenance" or "recent opioid detoxification" on the total score of PSQI and RIS. All opioid maintenance drugs used by the study population were associated with more sleeping problems compared to the detoxification group when calculated with RIS values. Recently abstinent patients (opioid detoxification) displayed significantly fewer sleep disturbances than opioid-maintained patients. Since sleeping problems can seriously impair treatment success and quality of life, screening for sleep disturbances and their subsequent treatment is of pronounced relevance.

Development of the Lebanese insomnia scale (LIS-18): a new scale to assess insomnia in adult patients

OBJECTIVE

To define the development and validation of the Lebanese Insomnia Scale (LIS-18) to be used for the evaluation of insomnia in Lebanese adult patients.

METHODS

A first cross-sectional study, conducted between August 2017 and April 2018, enrolled 789 participants (sample 1). A second sample was recruited in May 2018 to confirm the results obtained from the first sample.

RESULTS

Five factors derived from the LIS-18 scale items with an Eigenvalue over 1, explaining a total of 59.64% of the variance (Cronbach's alpha = 0.821). The first ROC curve, comparing participants with diagnosed insomnia to healthy individuals, showed that the optimal score was seen at a cutoff of 58.00, with a good sensitivity and specificity at this cutoff (93.3 and 88.4%, respectively). A second ROC curve, comparing participants taking drug medication for insomnia vs. those not taking drug, showed that the optimal score was seen at a cutoff of 52.50, with a good sensitivity and specificity at this cutoff (89.5 and 80.0%, respectively). A third ROC curve, comparing participants diagnosed by a physician or taking drug medication for insomnia and healthy control without insomnia drug, showed that the optimal score was seen at 51.50, with good sensitivity and specificity at this cutoff as well (90.0 and 78.10%, respectively). The positive predicted value (PPV) of the LIS-18 score in sample 2 was 93.3%, whereas the negative predicted value (NPV) was 88.4%.

CONCLUSION

The results demonstrate that the LIS-18 can be used in clinical practice and research to measure insomnia.

Changes in Subjective-Objective Sleep Discrepancy Following Inpatient Cognitive Behavior Therapy for Insomnia

Discrepancy between objective and subjective sleep parameters is a frequent symptom in persons suffering from insomnia. Since it has an impairing effect on daytime well-being and neglects possible positive objective improvements, it would be useful if it was treated. Apart from hypnotics, cognitive behavior therapy (CBT-I) is the therapy of choice for chronic forms of insomnia. However, there is limited information about whether CBT-I can also improve subjective-objective sleep discrepancy. We investigated a large sample of patients showing chronic forms of insomnia regarding their subjective-objective sleep discrepancy pre and post CBT-I. Objective sleep data were obtained from 3 nights (2 baseline nights and 1 night after therapy) using polysomnography in our sleep laboratory. All 92 patients participated in a 14-day inpatient program with CBT-I including psychoeducation about subjective-objective sleep discrepancy. Repeated measures analyses showed an improvement in subjective-objective sleep discrepancy parameters after CBT-I. Those parameters were also correlated with perceived quality of sleep. We conclude that CBT-I is a useful tool to improve subjective-objective sleep discrepancy in patients showing chronic forms of insomnia.

Impact of Sleep Disorders and Other Factors on the Quality of Life in General Population: A Cross-Sectional Study

The study objective was to assess if insomnia, along with other factors, can impact the physical and mental quality of life (QOL) of the Lebanese general population. This cross-sectional study, conducted between November 2017 and March 2018, enrolled 756 community-dwelling participants. A first linear regression, using the SF-12 PCS score as the dependent variable, showed that having a family history of insomnia problems (β = 1.107, p = 0.026) was significantly associated with higher physical QOL (higher SF-12 PCS score), whereas increased stress (β = 0.048, p = 0.015) was significantly associated with lower physical QOL. A second linear regression, using the SF-12 MCS score as dependent variable, showed that having increased age (β = -0.079, p < 0.001) was significantly associated with lower mental QOL. Despite its cross-sectional design and the modest sample size, this study adds to the evidence that insomnia, along with other factors (including sociodemographic and psychological factors), can have a detrimental impact on both physical and mental QOL of participants.

Cognitive behavioral treatment for insomnia is equally effective in insomnia patients with objective short and normal sleep duration

BACKGROUND

It has been suggested that insomnia patients with short sleep duration and insomnia patients with normal sleep duration may respond differently to cognitive behavioral treatment for insomnia (CBT-I). To evaluate this hypothesis, we retrospectively examined a large sample of patients with chronic insomnia regarding their outcome post-treatment and six months after participating in a two-week standardized inpatient CBT-I program.

OBJECTIVES

Seventy-two women and 20 men with chronic insomnia received standardized inpatient CBT-I and were examined with three nights of polysomnography (two baseline nights and one post-treatment night directly following the two-week treatment). Follow-up measurements of subjective insomnia symptoms were conducted after six months. The CBT-I outcome was compared between insomnia patients with polysomnographically determined short (< 6 h) and normal (≥ 6 h) sleep duration.

RESULTS

Concerning subjective outcomes, CBT-I was equally effective in insomnia patients with objective short and normal sleep duration. Secondary analyses of polysomnographic data collected at post-treatment revealed that insomnia patients with short sleep duration showed a better treatment response in comparison to those with normal sleep duration.

CONCLUSIONS

These results suggest that the distinction in insomnia between objective short and normal sleep duration may be of limited value for treatment decisions regarding CBT-I. However, as the overall picture of the literature on this issue is not conclusive, we conclude that further prospective research is necessary to investigate the clinical validity of phenotyping insomnia patients by objective sleep data.