Development of a Measure of Sleep, Circadian Rhythms, and Mood: The SCRAM Questionnaire

Daily Associations Between Sleep Parameters and Depressive Symptoms in Individuals with Insomnia: Investigating Emotional Reactivity and Regulation as Mediators

OBJECTIVES

Previous research suggests that insomnia and depressive symptoms might be causally related. Emotional reactivity and regulation have been proposed to explain the potential causal relationship between insomnia and depression. However, longitudinal evaluations of their mediating effects are limited. Hence, the current study aimed to examine the mediating effects of emotional reactivity and regulation on the longitudinal associations between daily sleep parameters and depressive symptoms over 14 days in individuals with insomnia.

METHODS

Participants were sixty adults aged 18-65 who had clinically significant insomnia. They filled out a survey each morning and evening and wore actigraphy watches for 14 consecutive days. The five sleep parameters were measured by sleep diary in the morning survey (subjective total sleep time, subjective sleep efficiency, and sleep quality) and actigraphy watches (objective total sleep time and objective sleep efficiency). Emotional reactivity and emotion regulation strategy use during the day were assessed in the evening survey using the International Positive and Negative Affect Schedule Short Form, Emotion Regulation Questionnaire, and Cognitive Emotion Regulation Questionnaire. Depressive symptoms of the day were evaluated in the evening survey with the Center for Epidemiologic Studies Depression Scale.

RESULTS

Results showed that sleep quality and depressive symptoms, as well as actigraphy-measured sleep efficiency and depressive symptoms, predicted each other in individuals with insomnia, mediated by negative reactivity but not emotion regulation.

CONCLUSIONS

The present findings support the mediating role of negative emotional reactivity in the bidirectional, daily relationship between sleep parameters and depression in individuals with insomnia.

Development of a revised version of the SCRAM questionnaire to evaluate sleep, circadian rhythms, and mood characteristics

Sleep quality, chronotype, and mood may be closely interconnected processes. Typically, such constructs are measured independently, leaving out important information regarding their intrinsic relationships. The Sleep, Circadian Rhythms, and Mood (SCRAM) questionnaire is a promising tool for measuring sleep, chronotype, understood as diurnal preference, and depressive symptomatology, and the interrelationships between them. Anxiety has also been linked to sleep quality, chronotype, and depression, but there is currently no scale that measures these constructs together. This study aims to validate a revised version of the SCRAM questionnaire (rSCRAM), incorporating items to measure anxious mood. 486 Italian participants were involved in two studies. In Study 1, principal component analysis (PCA) identified representative anxiety elements from validated questionnaires. In Study 2, after adding the anxiety elements, exploratory factor analysis (EFA) and confirmatory factor analysis (CFA) established a 4-factor, 16-item model. The rSCRAM demonstrated excellent psychometric properties: high internal consistency (α = 0.72-0.90) and a strong test-retest reliability of the scales over 2 weeks (r = 0.73-0.82), a high correlation for convergent validity, and low correlations for divergent validity. The rSCRAM questionnaire measures the constructs for which it was created and revised. Including the anxiety scale enhances its utility in assessing mental health constructs within a single instrument.

Beat the Clock: Assessment of Night Eating Syndrome and Circadian Rhythm in a Sample of Greek Adults

The night eating syndrome (NES) is characterized by excessive food intake during the evening and night hours, with 25% of the daily intake being consumed post-dinner, paired with ep-isodes of nocturnal food intake, at a frequency of more than twice weekly. The NES has been associated with a misaligned circadian rhythm related to a delay in overall food intake, increased energy and fat consumption. The present cross-sectional study aimed to assess NES in a Greek population and evaluate possible links between NES and chronotype. NES was assessed using the Night Eating Questionnaire (NEQ), and circadian rhythm, sleep and mood were evaluated with the Sleep, Circadian Rhythms, and Mood (SCRAM) questionnaire. A total of 533 adults participated in the study. A relatively high prevalence of NES was revealed, with more than 8.1% (NEQ ≥ 30) of the participants reporting experiencing NES symptoms, depending on the NEQ threshold used. Most participants had the intermediate chronotype. NEQ score was positively associated with the morning chronotype, and SCRAM was negatively related to "Good Sleep". Each point increment in the depression score was associated with 6% higher odds of NES. The early identification of NES gains importance in clinical practice, in a collective effort aiming to reduce NES symptomatology and its detrimental health effects.

Social Rhythm Disruption is Associated with Greater Depressive Symptoms in People with Mood Disorders: Findings from a Multinational Online Survey During COVID-19

OBJECTIVES

Societal restrictions imposed to prevent transmission of COVID-19 may challenge circadian-driven lifestyle behaviours, particularly amongst those vulnerable to mood disorders. The overarching aim of the present study was to investigate the hypothesis that, in the routine-disrupted environment of the COVID-19, amongst a sample of people living with mood disorders, greater social rhythm disruption would be associated with more severe mood symptoms.

METHODS

We conducted a two-wave, multinational survey of 997 participants (MAge=39.75±13.39,Female=81.6%) who self-reported a mood disorder diagnosis (i.e., major depressive disorder or bipolar disorder). Respondents completed questionnaires assessing demographics, social rhythmicity (The Brief Social Rhythm Scale), depression symptoms (Patient Health Questionnaire-9), sleep quality and diurnal preference (The Sleep, Circadian Rhythms and Mood questionnaire) and stressful life events during the COVID-19 pandemic (The Social Readjustment Rating Scale).

RESULTS

The majority of participants indicated COVID-19-related social disruption had affected the regularity of their daily routines to at least some extent (n = 788, 79.1%). As hypothesised, lower social rhythmicity was associated with greater depressive symptoms when tested cross-sectionally (standardised β = -.25, t = -7.94, P = 0.000) and when tested using a 2-level hierarchical linear model across two time points (b = -0.14, t = -3.46, df = 264, P ≤ 0.001).

CONCLUSIONS

These results are consistent with the social zeitgeber hypothesis proposing that mood disorders are sensitive to life events that disrupt social rhythms.

Patient-reported sleep outcomes in randomized-controlled trials in persons with substance use disorders: A systematic review

BACKGROUND

Sleep disturbances and disorders are a common and sometimes recalcitrant problem in persons recovering from substance use disorders (SUDs). As such, several randomized-controlled trials (RCTs) have been conducted to address sleep disturbances in a variety of SUD subpopulations and clinical scenarios. The goal of this systematic review was to collate patient-reported sleep outcomes used in past SUD-related RCTs to provide guidance for future sleep research in persons with SUDs.

METHODS

This systematic review was registered in the International Prospective Register of Systematic Reviews (PROSPERO) on May 7th, 2020 (CRD42020182004). Studies were included if they were peer-reviewed manuscripts describing RCTs in an SUD population.

RESULTS

The initial search yielded 13,403 candidate articles, and 76 met a priori criteria and were included in this review. Thirty-five (46.1%) assessed sleep as a primary outcome (i.e., sleep improvement was the primary goal of the research) and 41 (53.9%) assessed sleep as a secondary outcome (i.e., sleep improvement was an important outcome, but not the primary outcome). The most commonly used measures included the Pittsburgh Sleep Quality Index, the Insomnia Severity Index, and sleep diaries. However, multiple additional sleep assessments were also used, including visual analogue and Likert scales.

CONCLUSIONS

The field of addiction medicine would benefit from a streamlined approach in assessing patient-reported sleep in RCTs, including commonly used and validated assessments of sleep quality, inserting daily or repeated measures into RCTs, and including questionnaires that assess clinically relevant insomnia or other sleep disorders.

The contribution of sleep to anorexia nervosa severity

PURPOSE

Anorexia nervosa (AN) is associated with poor sleep and altered circadian rhythms. Evidence is unclear as to whether these features relate to ongoing psychiatric symptoms of AN, or are merely concomitant with low weight. In this study, we sought to evaluate subjective sleep quality and sleep-wake preferences in a sample of individuals with lifetime AN. Furthermore, we aimed to examine whether sleep quality would significantly predict AN symptom severity, after accounting for demographic features and negative emotions (depression, anxiety and stress).

METHODS

Adults with a lifetime diagnosis of AN (n = 96) or no lifetime psychiatric diagnoses (NC; n = 246) completed an online survey assessing demographics, sleep quality, circadian sleep-wake preferences, eating disorder symptoms, and negative emotions.

RESULTS

AN participants reported significantly poorer sleep quality overall, including increased sleep disturbances, use of sleep medications, and daytime dysfunction, as compared to NC participants. Groups did not differ significantly in circadian sleep-wake preferences. Regression analysis showed that among AN participants, sleep quality and negative emotions significantly predicted AN symptom severity, while sex and body mass index (BMI) did not.

CONCLUSION

The findings demonstrate that poor sleep quality was associated with more severe symptoms of AN, even when accounting for negative emotions and BMI. Future research should investigate causal interactions between sleep quality and AN symptom severity longitudinally and across different recovery stages.

LEVEL OF EVIDENCE

Level III-Cohort and case-control analytic studies.

Translation and validation of the SCRAM questionnaire in a German adolescent inpatient sample

Sleep, depressive symptoms and circadian preference are highly interconnected processes. Evidence suggests that, especially in adolescence, all processes should be considered in the assessment and treatment of patients with clinically relevant psychopathology. The SCRAM (Sleep, Circadian Rhythms, and Mood) questionnaire was developed and validated in a student sample as a promising tool to conjointly measure and separate sleep, circadian preference and depression symptomatology. The present study aims to validate a German version of the SCRAM questionnaire in an adolescent psychiatric inpatient sample. A two-step analytic strategy consisting of an exploratory factor analysis EFA followed by confirmatory factor analyses (CFA) was conducted. The EFA was run in the first half of the sample (n = 422, M = 14.92, SD = 1.67). To validate the factor structure of the EFA and the original study, two CFA`s were performed in the second half of the adolescent sample (n = 438, M = 15.07, SD = 1.68). The EFA analysis revealed a 4-factor model with 12 items. Two Sleep items and one Morningness item had cross-factor loadings. The fit indices in the CFA were good using the factor model of the original study, whereas the 4-factor model of the EFA did not converge. The German SCRAM factor model seems structurally sound in an adolescent inpatient sample, but questions remain regarding the role of diagnosis, gender, external correlates, and examining the change scores of the SCRAM scores with treatment. Before this application, further research is needed to replicate the factor structure, investigate test-retest reliability, predictive and discriminant validity and test in more generalizable samples.

Web-based intervention to improve quality of life in late stage bipolar disorder (ORBIT): randomised controlled trial protocol

BACKGROUND

The primary objective of this randomised controlled trial (RCT) is to establish the effectiveness of a novel online quality of life (QoL) intervention tailored for people with late stage (≥ 10 episodes) bipolar disorder (BD) compared with psychoeducation. Relative to early stage individuals, this late stage group may not benefit as much from existing psychosocial treatments. The intervention is a guided self-help, mindfulness based intervention (MBI) developed in consultation with consumers, designed specifically for web-based delivery, with email coaching support.

METHODS/DESIGN

This international RCT will involve a comparison of the effectiveness and cost-effectiveness of two 5-week adjunctive online self-management interventions: Mindfulness for Bipolar 2.0 and an active control (Psychoeducation for Bipolar). A total of 300 participants will be recruited primarily via social media channels. Main inclusion criteria are: a diagnosis of BD (confirmed via a phone-administered structured diagnostic interview), no current mood episode, history of 10 or more mood episodes, no current psychotic features or active suicidality, under the care of a medical practitioner. Block randomisation will be used for allocation to the interventions, and participants will retain access to the program for 6 months. Evaluations will be conducted at pre- and post- treatment, and at 3- and 6- months follow-up. The primary outcome measure will be the Brief Quality of Life in Bipolar Disorder Scale (Brief QoL.BD), collected immediately post-intervention at 5 weeks (T1). Secondary measures include BD-related symptoms (mania, depression, anxiety, stress), time to first relapse, functioning, sleep quality, social rhythm stability and resource use. Measurements will be collected online and via telephone assessments at baseline (T0), 5 weeks (T1), three months (T2) and six months (T3). Candidate moderators (diagnosis, anxiety or substance comorbidities, demographics and current treatments) will be investigated as will putative therapeutic mechanisms including mindfulness, emotion regulation and self-compassion. A cost-effectiveness analysis will be conducted. Acceptability and any unwanted events (including adverse treatment reactions) will be documented and explored.

DISCUSSION

This definitive trial will test the effectiveness and cost-effectiveness of a novel QoL focused, mindfulness based, online guided self-help intervention for late stage BD, and investigate its putative mechanisms of therapeutic action.

TRIAL REGISTRATION

ClinicalTrials.gov : NCT03197974 . Registered 23 June 2017.