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Reffi AN, Kalmbach DA, Cheng P, Drake CL. The sleep response to stress: how sleep reactivity can help us prevent insomnia and promote resilience to trauma. J Sleep Res 2023; 32:e13892. [PMID: 37020247 DOI: 10.1111/jsr.13892] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Accepted: 03/08/2023] [Indexed: 04/07/2023]
Abstract
Sleep reactivity is a predisposition to sleep disturbance during environmental perturbations, pharmacological challenges, or stressful life events. Consequently, individuals with highly reactive sleep systems are prone to insomnia disorder after a stressor, engendering risk of psychopathology and potentially impeding recovery from traumatic stress. Thus, there is tremendous value in ameliorating sleep reactivity to foster a sleep system that is robust to stress exposure, ultimately preventing insomnia and its downstream consequences. We reviewed prospective evidence for sleep reactivity as a predisposition to insomnia since our last review on the topic in 2017. We also reviewed studies investigating pre-trauma sleep reactivity as a predictor of adverse post-traumatic sequelae, and clinical trials that reported the effect of behavioural treatments for insomnia on mitigating sleep reactivity. Most studies measured sleep reactivity via self-report using the Ford Insomnia Response to Stress Test (FIRST), demonstrating high scores on this scale reliably indicate a sleep system with a lower capacity to tolerate stress. Nascent evidence suggests elevated sleep reactivity prior to trauma increases the risk of negative posttraumatic outcomes, namely acute stress disorder, depression, and post-traumatic stress disorder. Lastly, sleep reactivity appears most responsive to behavioural insomnia interventions when delivered early during the acute phase of insomnia. Overall, the literature strongly supports sleep reactivity as a premorbid vulnerability to incident acute insomnia disorder when faced with an array of biopsychosocial stressors. The FIRST identifies individuals at risk of insomnia a priori, thereby guiding early interventions toward this vulnerable population to prevent insomnia and promote resilience to adversity.
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Affiliation(s)
- Anthony N Reffi
- Thomas Roth Sleep Disorders and Research Center, Henry Ford Health, Detroit, Michigan, USA
| | - David A Kalmbach
- Thomas Roth Sleep Disorders and Research Center, Henry Ford Health, Detroit, Michigan, USA
| | - Philip Cheng
- Thomas Roth Sleep Disorders and Research Center, Henry Ford Health, Detroit, Michigan, USA
| | - Christopher L Drake
- Thomas Roth Sleep Disorders and Research Center, Henry Ford Health, Detroit, Michigan, USA
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Morin CM, Bei B, Bjorvatn B, Poyares D, Spiegelhalder K, Wing YK. World sleep society international sleep medicine guidelines position statement endorsement of "behavioral and psychological treatments for chronic insomnia disorder in adults: An American Academy of sleep medicine clinical practice guidelines". Sleep Med 2023; 109:164-169. [PMID: 37454606 DOI: 10.1016/j.sleep.2023.07.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Accepted: 07/01/2023] [Indexed: 07/18/2023]
Abstract
This paper summarizes the position statement of the World Sleep Society (WSS) International Guidelines Committee regarding the Clinical Practice Guidelines on the Behavioral and Psychological Treatments for Chronic Insomnia Disorder in Adults prepared by a task force of the American Academy of Sleep Medicine (AASM). The practice guidelines were reviewed for their relevance and applicability to the practice of sleep medicine around the world. The WSS Work Group endorsed the AASM strong recommendation for Multicomponent Cognitive Behavioral Therapy as the treatment of choice for Insomnia Disorder and conditional endorsement for its single-therapy components (sleep restriction, stimulus control, relaxation); use of sleep hygiene education as single therapy was not endorsed due to lack of evidence for its efficacy. The strong recommendation for multicomponent CBT-I applied to patients with chronic insomnia disorder with or without comorbid psychiatric and medical conditions. Main caveats with regard to CBT-I remains the lack of adequately trained therapists and variability in terms of training available in different parts of the world. Unanswered questions about the applicability, availability, accessibility and potential sociodemographic (age, sex, ethnicity, regions) moderators of treatment outcomes were discussed. Despite growing evidence documenting the benefits of digital CBT-I, individual, in-person CBT-I delivered by a trained professional (mental health) provider is regarded as the optimal method to deliver CBT-I.
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Affiliation(s)
- Charles M Morin
- School of Psychology, CERVO/BRAIN Research Center, Université Laval, Quebec City, Quebec, Canada.
| | - Bei Bei
- Turner Institute for Brain and Mental Health, School of Psychological Sciences, Faculty of Medicine, Nursing and Health Sciences, Monash University, Victoria, Australia
| | - Bjørn Bjorvatn
- Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway and Norwegian Competence Center for Sleep Disorders, Haukeland University Hospital, Bergen, Norway
| | - Dalva Poyares
- Neurology and Sleep Medicine, Psychobiology Department, Sleep Division, Universidade Federal de Sao Paulo, Brazil
| | - Kai Spiegelhalder
- Department of Psychiatry and Psychotherapy, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Yun Kwok Wing
- Li Chiu Kong Family Sleep Assessment Unit, Department of Psychiatry, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong SAR, China
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Yang CM, Lu YL, Lee HC, Li S, Suh S, Okajima I, Huang YC. Can adding personalized rule-based feedback improve the therapeutic effect of self-help digital cognitive behavioral therapy for insomnia in young adults? Sleep Med 2023; 107:36-45. [PMID: 37105069 DOI: 10.1016/j.sleep.2023.04.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2023] [Revised: 04/01/2023] [Accepted: 04/13/2023] [Indexed: 04/29/2023]
Abstract
INTRODUCTION Cognitive-behavioral therapy for insomnia (CBT-I) is recommended as the first-line treatment for insomnia, but low accessibility and relatively high cost limits the dissemination of the treatment. Several forms of digital CBT-I have been developed to increase the accessibility and shown to be effective; however, the treatment effect may be restricted by the lack of interaction within the treatment. The current study examines whether the therapeutic effects of self-help digital CBT-I could be enhanced by adding simple rule-based personalized feedback. METHOD Ninety-two young adults with self-reported insomnia were randomly assigned to three groups: a self-help group (SH, n = 31), who received an eight-session email-delivered CBT-I program; a feedback group (FB, n = 31), who went through the same CBT-I program with personalized feedback; and a waitlist group (WL, n = 30). The Insomnia Severity Index (ISI) was used as the primary outcome measure, and the 16-item version of the Dysfunctional Beliefs and Attitudes about Sleep Scale (DBAS-16), Sleep Hygiene Practice Scale (SHPS), and sleep diary were used as the secondary outcome measures. Treatment satisfaction and adherence were also compared between the treatment groups. RESULTS Both the SH and FB groups showed significantly more improvements in insomnia severity, sleep-related beliefs, and sleep hygiene behaviors than the WL group. Sleep onset latency and sleep efficiency in the sleep diary were also significantly improved after treatment. None of these effects significantly differed between the two treatment groups. Nonetheless, participants in the FB group reported higher treatment satisfaction than those in the SH group. CONCLUSION This study supports the effectiveness of email-delivered self-help CBT-I for young adults with insomnia. Furthermore, while adding simple personalized feedback may not have an additional effect on sleep per se, it can enhance treatment satisfaction. This simple intervention shows promise in addressing sleep disturbance in young adults.
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Affiliation(s)
- Chien-Ming Yang
- Department of Psychology, National Chengchi University, 64, Sec. 2, Zhinan Rd., 116, Taiwan; The Research Center for Mind, Brain, & Learning, National Chengchi University, 64, Sec. 2, Zhinan Rd., 116, Taiwan.
| | - Ya-Li Lu
- Department of Psychology, National Chengchi University, 64, Sec. 2, Zhinan Rd., 116, Taiwan.
| | - Hsin-Chien Lee
- Department of Psychiatry, School of Medicine, College of Medicine, Taipei Medical University, 250 Wu-Hsing Street, Taipei City, 110, Taiwan.
| | - Shirley Li
- Sleep Research Clinic and Laboratory, Department of Psychology, The University of Hong Kong, Pokfulam, Hong Kong Special Administrative Region of China; The State Key Laboratory of Brain and Cognitive Sciences, The University of Hong Kong, Pokfulam, Hong Kong Special Administrative Region of China.
| | - Sooyeon Suh
- Department of Psychology, Sungshin Women's University, #911 Sungshin Bldg., 2 Bomun-ro 34da-gil Seongbuk-gu, Seoul, 136-742, South Korea.
| | - Isa Okajima
- Department of Psychological Counseling, Tokyo Kasei University, 1-18-1 Kaga, Itabashi-ku, Tokyo, 173-8602, Japan.
| | - Ya-Chuan Huang
- Department of Psychology, National Chengchi University, 64, Sec. 2, Zhinan Rd., 116, Taiwan.
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Vollert B, Müller L, Jacobi C, Trockel M, Beintner I. Effectiveness of an App-Based Short Intervention to Improve Sleep: Randomized Controlled Trial. JMIR Ment Health 2023; 10:e39052. [PMID: 36943337 PMCID: PMC10131838 DOI: 10.2196/39052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2022] [Revised: 09/15/2022] [Accepted: 09/30/2022] [Indexed: 11/13/2022] Open
Abstract
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.
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Affiliation(s)
- Bianka Vollert
- Department of Clinical Psychology and Psychotherapy, Faculty of Psychology, Technische Universität Dresden, Dresden, Germany
| | - Luise Müller
- Department of Clinical Psychology and Psychotherapy, Faculty of Psychology, Technische Universität Dresden, Dresden, Germany
| | - Corinna Jacobi
- Department of Clinical Psychology and Psychotherapy, Faculty of Psychology, Technische Universität Dresden, Dresden, Germany
| | - Mickey Trockel
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, CA, United States
| | - Ina Beintner
- Department of Clinical Psychology and Psychotherapy, Faculty of Psychology, Technische Universität Dresden, Dresden, Germany
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Predictors of dropout in university students participating in an 8-week e-mail-based cognitive-behavioral therapy for insomnia intervention. Sleep Breath 2023; 27:345-353. [PMID: 35412222 DOI: 10.1007/s11325-022-02609-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2021] [Revised: 02/07/2022] [Accepted: 03/22/2022] [Indexed: 10/18/2022]
Abstract
PURPOSE We conducted an exploratory study to identify risk factors of dropout in an 8-week e-mail-based cognitive-behavioral therapy for insomnia (REFRESH) to improve sleep among university students with insomnia symptoms. METHODS University and graduate students in Hong Kong and Korea who scored higher than 10 on the Insomnia Severity Index participated in REFRESH. RESULTS Of 158 participants from Hong Kong (n = 43) and Korea (n = 115), 90 (57%) did not complete all 7 sessions, while 52 of 90 (57.8%) dropped out prior to the fourth session. ROC analysis was conducted on the entire sample of 158 participants with intervention completion vs. dropout (non-completion) as the outcome variable. Predictors of dropout were wake time after sleep onset (WASO) < 7.1 min on the weekly sleep diary and expectations for sleep (a subscale of dysfunctional beliefs and attitudes about sleep; DBAS) < 18 at baseline. CONCLUSIONS These findings indicate that shorter WASO and less expectations for sleep at baseline were associated with risk of dropout from e-mail delivered self-help CBT-I-based intervention. Our results highlight the importance of identifying and tailoring treatment formats to students based on their presenting sleep characteristics.
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Ubara A, Tanizawa N, Harata M, Suh S, Yang CM, Li X, Okajima I. How Does E-mail-Delivered Cognitive Behavioral Therapy Work for Young Adults (18-28 Years) with Insomnia? Mediators of Changes in Insomnia, Depression, Anxiety, and Stress. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph19084423. [PMID: 35457291 PMCID: PMC9029643 DOI: 10.3390/ijerph19084423] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Revised: 03/31/2022] [Accepted: 03/31/2022] [Indexed: 11/16/2022]
Abstract
This study examined whether cognitive behavioral therapy (CBT) for insomnia (CBT-I) improved insomnia severity, by changing sleep-related mediating factors. It also examined whether an improvement in insomnia led to enhanced mental health. This study was a secondary analysis of a randomized controlled trial of e-mail-delivered CBT-I for young adults with insomnia. The participants were randomized to either CBT-I or self-monitoring. The mental health-related measures were depression, anxiety, and stress. The sleep-related mediating factors were sleep hygiene practices, dysfunctional beliefs, sleep reactivity, and pre-sleep arousal. A total of 41 participants, who completed all the sessions (71% females; mean age 19.71 ± 1.98 years), were included in the analysis. The hierarchical multiple regression analysis showed that 53% of the variance in the improvements in insomnia severity was explained by the treatment group (β = −0.53; ΔR2 = 0.25; p < 0.01) and the changes in sleep reactivity (β = 0.39; ΔR2 = 0.28; p < 0.05). Moreover, the mediation analysis showed that the reductions in depression and stress were explained by the changes in insomnia severity; however, anxiety symptoms were not reduced. CBT-I for young adults suggested that sleep reactivity is a significant mediator that reduces insomnia severity, and that the alleviation and prevention of depression and stress would occur with the improvement in insomnia.
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Affiliation(s)
- Ayaka Ubara
- Graduate School of Psychology, Doshisha University, Kyoto 610-0321, Japan;
- JSPS Research Fellowship, Chiyoda-ku, Tokyo 102-0083, Japan
- Department of Psychiatry, Shiga University of Medical Science, Otsu 520-2192, Japan
| | - Noriko Tanizawa
- Department of Innovation Laboratories, NEC Solution Innovators, Ltd., Tokyo 136-8627, Japan;
| | - Megumi Harata
- Public Children Support Center, Adachi-ku, Tokyo 121-0816, Japan;
| | - Sooyeon Suh
- Department of Psychology, Sungshin Women’s University, Seoul 02844, Korea;
| | - Chien-Ming Yang
- Department of Psychology, National Chengchi University, Taipei 11605, Taiwan;
- The Research Center for Mind, Brain & Learning, National Chengchi University, Taipei 11605, Taiwan
| | - Xin Li
- Department of Psychology, The University of Hong Kong, Hong Kong, China;
- The State Key Laboratory of Brain and Cognitive Sciences, The University of Hong Kong, Hong Kong, China
| | - Isa Okajima
- Department of Psychological Counseling, Tokyo Kasei University, Tokyo 173-8602, Japan
- Faculty of Human Sciences, Waseda University, Saitama 359-1192, Japan
- Correspondence: ; Tel.: +81-3-3961-5276
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Okajima I, Honda Y, Semba O, Kiyota Y, Tani Y. Effects of COVID-19-Related Anxiety and Sleep Problems on Loneliness and Feelings of School Refusal in Adolescents. Front Psychiatry 2022; 13:918417. [PMID: 35774091 PMCID: PMC9237466 DOI: 10.3389/fpsyt.2022.918417] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Accepted: 05/16/2022] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND COVID-19-related anxiety, sleep problems, and loneliness may be risk factors for school refusal in children and adolescents. However, few studies have examined the mechanisms by which these risk factors cause school refusal. This study examined the process by which COVID-19-related anxiety, sleep problems, and loneliness cause school refusal, using structural equation modeling. METHODS In this cross-sectional questionnaire-based study, 256 (109 male, 147 female, mean age: 15.37 ± 0.48 years) senior high school students were asked to complete the Stress and Anxiety associated with Viral Epidemics-6 questionnaire to assess COVID-19-related anxiety, the Athens Insomnia Scale (AIS), Sleep Debt Index (SDI), and chronotype (MSFsc) to assess sleep problems, the Three-Item Loneliness Scale (TILS) to assess loneliness, and Feelings of School-Avoidance Scale (FSAS) to assess school refusal. RESULTS Structural equation modeling showed that sleep problems affected loneliness (β = 0.52) and feelings of school refusal (β = 0.37), and that loneliness affected feelings of school refusal (β = 0.47). There was no significant pathway of COVID-19-related anxiety on sleep problems, loneliness, or feelings of school refusal. The indirect effect of sleep problems on feelings of school refusal through loneliness was significant. The results of hierarchical multiple regression analysis showed that AIS (β = 0.30) and SDI (β = 0.13) scores were associated with TILS, and AIS (β = 0.26) and MSFsc (β = -0.14) scores were associated with FSAS scores. CONCLUSION The findings of this study showed that sleep problems affected feelings of school refusal via both direct and indirect pathways through the exacerbation of loneliness. To prevent school refusal in adolescents, addressing the indirect pathway via loneliness could be effective in improving insomnia and sleep debt, while addressing the direct pathway could be effective in improving insomnia and chronotype.
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Affiliation(s)
- Isa Okajima
- Behavioral Sleep Medicine and Sciences Laboratory, Department of Psychological Counseling, Faculty of Humanities, Tokyo Kasei University, Tokyo, Japan
| | - Yukako Honda
- Graduate School of Human Life Sciences, Tokyo Kasei University, Tokyo, Japan
| | | | | | - Yasuo Tani
- Inochi and Future Strategy Headquarters Office, Policy Bureau, Kanagawa Prefectural Government, Kanagawa, Japan
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