Psychometric Evaluation of the Ford Insomnia Response to Stress Test (FIRST) in Early Pregnancy

Mood Disorders After COVID-19

Introduction. The COVID-19 pandemic has led to a high prevalence of post-COVID-19 syndrome (PCS), with mood disorders being the most common manifestations. Objective: To study the prevalence of PCS-associated mood disorders and their features. Materials and methods. We examined patients after COVID-19 (n = 91; age: 24-84 years; median time to recovery: 7 months) using the following tools: the BDI and HADS (screening for anxiety and depression); the Starkstein Apathy Scale; FIS and FSS (fatigue assessment); the MoCA, MMSE, and FAB (cognitive assessment); the FIRST, ESS, PSQI, and ISI (sleep disorders evaluation); the EQ5D (quality of life measurement). We designed a special questionnaire to collect data related to a history of COVID-19 and patients' condition after discharge. In addition, we analyzed electronic medical records and discharge summaries and performed neurological examination. Results. Of all the examined patients, 65 (71.4%) participants had signs and symptoms of PCS. Mood disorders were observed in 33 (50.8%) cases, with apathy (78.7%), anxiety (66.7%), and fatigue (60.6%) being the most common. Depressive disorders were found in 12 (36.3%) patients. Cognitive functions were impaired in 7 (21.2%) patients; sleep disorders were observed in 16 (48.5%) cases. We found a positive correlation between depressive disorders and fatigue based on the BDI, FIS, and FSS scores (rS = 0.711; rS = 0.453), depressive disorders and anxiety (rS = 0.366), fatigue and apathy (rS = 0.350). Anxiety increased the risk of sleep disorders (rS = 0.683). Quality of life has been shown to decrease in patients with mood disorders due to the negative effect of long-term fatigue and depressive disorders. Conclusions. There is a close connection between different types of mood disorders that develop after COVID-19 and exacerbate symptoms of each other. Early diagnosis and treatment of these disorders can improve patients' quality of life and preserve their ability to work.

Adaptation and Validation of the Turkish Version of the Ford Insomnia Response to Stress Test in University Students

Objective

We adapted the Ford Insomnia Response to Stress Test to Turkish (FIRST-T) and validated it.

Methods

We randomly divided 774 Turkish university students into two equal groups for exploratory (EFA) and confirmatory factor analysis (CFA). McDonald's omega and Cronbach's alpha values were utilized for reliability analyses. Item response theory (IRT) approach also used for psychometric properties on the full sample. For discriminant validity, study sample were classified into high and low sleep reactivity groups, and their sociodemographic and sleep data were compared.

Results

EFA results suggested a one-factor structure of the FIRST-T, which was confirmed by CFA results. The FIRST-T had solid internal reliability. Item analysis results showed that all the items could distinguish between low and high scorers. This scale showed the same construct (clinical insomnia vs good sleepers) across the sexes in multi-group CFA and differential item functioning results. In the high FIRST-T score group, sleep quality, severity of insomnia, and anxiety scores were higher. In this group, more participants had clinical insomnia according to the Insomnia Severity Index (ISI) and were poor sleepers according to the Pittsburg Sleep Quality Index (PSQI) (p < 0.01).

Conclusion

The FIRST-T has robust psychometric properties that assesses sleep reactivity among university students.

Cognitive Function Decline in the Third Trimester of Pregnancy Is Associated with Sleep Fragmentation

During late pregnancy, sleep deterioration is regularly observed. In concert with these observations, in previous studies by other researchers, a slight objective cognitive decline in pregnant women has been found. Sleep is essential for memory consolidation. The hypothesis of the study was that cognitive impairment could be related to sleep deterioration during pregnancy. The study included 19 pregnant women in their third trimester of pregnancy (28−40 weeks, median 33 weeks (IQR 32−37)) recruited at the Department of Gynecology and Obstetrics, Medical University of Warsaw, and 20 non-pregnant women as controls. The assessment was performed using the vocabulary subtest from the Wechsler Adult Intelligence Scale (WAIS), D2 Test of Attention, OSPAN task (Operational Span Task) to assess cognitive performance, actigraphy to examine sleep parameters, and a set of self-report instruments: Athens Insomnia Scale (AIS), Beck Depression Inventory (BDI), Ford Insomnia Response to Stress (FIRST), Regenstein Hyperarousal Scale (HS), and Epworth Sleepiness Scale (ESS). Although there were no differences between the groups in WAIS (p = 0.18), pregnant women had worse scores in working memory capacity (overall number of remembered letters: p = 0.012, WM span index: p = 0.004) and a significantly lower score in attention (p = 0.03). Pregnant women also had lower sleep efficiency (p = 0.001), more awakenings from sleep (p = 0.001), longer average awakenings (p < 0.0001), longer wake after sleep onset (WASO, p < 0.0001), and longer total time in bed (p < 0.0001). In psychological assessment, pregnant women had only a higher FIRST score (p = 0.02). Using mediation analysis, we found that frequent awakening might be the major factor contributing to deterioration in working memory performance, explaining almost 40% of the total effect. In conclusion, sleep fragmentation in the third trimester of pregnancy may impair working memory consolidation. Pregnant women often complain about poor daily performance as well as non-restorative sleep. In this study, we showed that there is a relationship between lower sleep quality in pregnancy and worse cognitive functioning. We can expect a cognitive decline in women with sleep disturbances in pregnancy. Therefore, we should pay more attention to the treatment of sleep disorders in pregnancy.

Insomnia evaluation and treatment during peripartum: a joint position paper from the European Insomnia Network task force "Sleep and Women," the Italian Marcè Society and international experts task force for perinatal mental health

Insomnia symptoms are frequent during peripartum and are considered risk factors for peripartum psychopathology. Assessing and treating insomnia and related conditions of sleep loss during peripartum should be a priority in the clinical practice. The aim of this paper was to conduct a systematic review on insomnia evaluation and treatment during peripartum which may be useful for clinicians. The literature review was carried out between January 2000 and May 2021 on the evaluation and treatment of insomnia during the peripartum period. The PubMed, PsycINFO, and Embase electronic databases were searched for literature published according to the PRISMA guidance with several combinations of search terms "insomnia" and "perinatal period" or "pregnancy" or "post partum" or "lactation" or "breastfeeding" and "evaluation" and "treatment." Based on this search, 136 articles about insomnia evaluation and 335 articles on insomnia treatment were found and we conducted at the end a narrative review. According to the inclusion/exclusion criteria, 41 articles were selected for the evaluation part and 22 on the treatment part, including the most recent meta-analyses and systematic reviews. Evaluation of insomnia during peripartum, as for insomnia patients, may be conducted at least throughout a clinical interview, but specific rating scales are available and may be useful for assessment. Cognitive behavioral therapy for insomnia (CBT-I), as for insomnia patients, should be the preferred treatment choice during peripartum, and it may be useful to also improve mood, anxiety symptoms, and fatigue. Pharmacological treatment may be considered when women who present with severe forms of insomnia symptoms do not respond to nonpharmacologic therapy.

Association of stress-related sleep disturbance with psychiatric symptoms among pregnant women

BACKGROUND

Physiological changes during pregnancy are often accompanied by reduced sleep quality, sleep disruptions, and insomnia. Studies conducted among men and non-pregnant women have documented psychiatric disorders as common comorbidities of insomnia and other sleep disorders. However, no previous study has examined the association between stress-related sleep disturbances and psychiatric disorders among pregnant women.

METHODS

This cross-sectional study included a total of 2051 pregnant women in Peru. The Spanish-language version of the Ford Insomnia Response to Stress Test (FIRST-S) was used to assess sleep disruptions due to stressful situations. Symptoms of antepartum depression, generalized anxiety disorder, and posttraumatic stress disorder (PTSD) were examined using the Patient Health Questionnaire-9, Generalized Anxiety Disorder Scale-7 and PTSD Checklist - Civilian Version, respectively. High risk for psychosis was assessed using the Prodromal Questionnaire. Multivariable logistic regression procedures were used to estimate adjusted odds ratios (ORs) and 95% confidence intervals (CI).

RESULTS

Stress-related sleep disturbance was reported by 33.2% of women. Of all women, 24.9% had antepartum depression, 32.2% had generalized anxiety disorder, 30.9% had PTSD, and 27.6% were assessed as having a high risk of psychosis. After adjusting for confounders, women with stress-related sleep disturbances were more likely to experience antepartum depression (OR = 2.74; 95%CI: 2.22-3.38), generalized anxiety disorder (OR = 2.48; 95%CI: 2.04-3.02), PTSD (OR = 2.36; 95%CI: 1.93-2.88), and high risk for psychosis (OR = 2.07; 95%CI: 1.69-2.54) as compared to women without stress-related sleep disturbances.

CONCLUSIONS

Stress-related sleep disturbances during pregnancy are associated with increased odds of psychiatric disorders. Inquiring about stress related sleep disturbances during antenatal care may be beneficial for identifying and caring for women at high risk of psychiatric disorders.

Stress-related sleep reactivity is associated with insomnia, psychopathology and suicidality in pregnant women: preliminary results

INTRODUCTION

Depression and anxiety symptoms are commonly experienced by women during pregnancy and may have negative consequences on mothers and newborns. Deterioration of sleep quality throughout pregnancy increases insomnia, which may lead to adverse outcomes including increased psychopathology in the perinatal period. Thus, identifying women at high risk of developing insomnia may have important clinical implications on maternal-fetal outcomes. Stress-related sleep reactivity is a well-established risk factor for future insomnia, depression, and anxiety in general adult samples. However, little is known of sleep reactivity and its relations to sleep and mood pathology in pregnancy. Therefore, we explored sleep reactivity in pregnant women and its relations to prenatal symptoms of insomnia, depression, anxiety, and suicidality.

METHOD

Sixty-two pregnant women (mean age 33.6 ± 3 years, 20.6 ± 0.6 weeks of pregnancy) were evaluated during their routine visit at the Gynecological Unit of the University of Pisa, Italy, using the Insomnia Severity Index (ISI) for insomnia symptoms, the Ford Insomnia Response to Stress Test for sleep reactivity (FIRST), Edinburgh Postnatal Depression Scale (EPDS) for depressive symptoms, and the Zung Self Rating Anxiety Scale (SAS) for anxiety symptoms. Item #10 of the EPDS was used to assess for suicidality. Differences in means between women with high vs low stress-related sleep reactivity were calculated using t-test or Mann-Whitney U/Wilcoxon test. Linear/multiple regression analyses have been performed to study associations between variables.

RESULTS

Pregnant women with high stress-related sleep reactivity, relative to those with low reactivity, reported greater symptoms of insomnia (t = 6.5, 0.004) as well as higher rates of depression (62.0% vs 6.1%, p < 0.001), anxiety (55.1% vs 15.1%, p = 0.030), and suicidality (17.2% vs 3.0%, p = 0.025). Multivariate models revealed sleep reactivity to correlate independently with symptoms of insomnia, depression, and anxiety, when controlling for comorbid symptoms.

CONCLUSIONS

In mid-pregnancy, women with high sleep reactivity report elevated symptoms of insomnia, depression, and anxiety, and are more likely to endorse suicidal ideation. As a prognostic marker of future insomnia and psychiatric illness, early detection of high prenatal sleep reactivity holds potential to prevent the development of sleep and mood pathology during pregnancy, thereby potentially improving maternal and child outcomes.

The impact of stress on sleep: Pathogenic sleep reactivity as a vulnerability to insomnia and circadian disorders

Sleep reactivity is the trait-like degree to which stress exposure disrupts sleep, resulting in difficulty falling and staying asleep. Individuals with highly reactive sleep systems experience drastic deterioration of sleep when stressed, whereas those with low sleep reactivity proceed largely unperturbed during stress. Research shows that genetics, familial history of insomnia, female gender and environmental stress influence how the sleep system responds to stress. Further work has identified neurobiological underpinnings for sleep reactivity involving disrupted cortical networks and dysregulation in the autonomic nervous system and hypothalamic-pituitary-adrenal axis. Sleep reactivity is most pathologically and clinically pertinent when in excess, such that high sleep reactivity predicts risk for future insomnia disorder, with early evidence suggesting high sleep reactivity corresponds to severe insomnia phenotypes (sleep onset insomnia and short sleep insomnia). High sleep reactivity is also linked to risk of shift-work disorder, depression and anxiety. Importantly, stress-related worry and rumination may exploit sensitive sleep systems, thereby augmenting the pathogenicity of sleep reactivity. With the development of cost-effective assessment of sleep reactivity, we can now identify individuals at risk of future insomnia, shift-work disorder and mental illness, thus identifying a target population for preventive intervention. Given that insomniacs with high sleep reactivity tend to present with severe insomnia phenotypes, patient sleep reactivity may inform triaging to different levels of treatment. Future research on sleep reactivity is needed to clarify its neurobiology, characterize its long-term prospective associations with insomnia and shift-work disorder phenotypes, and establish its prognostic value for mental illness and other non-sleep disorders.

Hyperarousal and sleep reactivity in insomnia: current insights

Hyperarousal is a key component in all modern etiological models of insomnia disorder. Overall patterns in the literature suggest that over-active neurobiological and psychological systems contribute to difficulty sleeping. Even so, mixed results regarding the specific mechanisms linking hyperarousal to sleep disturbance limit current etiological conceptualizations. Similar basal arousal profiles between individuals with high vs low risk for insomnia in the absence of stress exposure suggest that dysregulated stress "response" rather than general hyperarousal may be a more pertinent marker of risk. In this report, we discuss evidence for hyperarousal in insomnia and explore the role of sleep reactivity. A trait characteristic, sleep reactivity is the degree to which stress disrupts sleep, manifesting as difficulty falling and staying asleep. Premorbid sleep reactivity has been shown to identify individuals at risk for future insomnia disorder, such as highly reactive sleepers (whose sleep systems are sensitive to stress) who are at elevated disease risk. Research points to genetics, family history of insomnia, gender, and environmental stress as factors that influence sleep reactivity. Importantly, stress-related cognitive-emotional reactivity (e.g., rumination, worry) may exploit the vulnerability of a highly reactive sleep system. We propose that sleep reactivity and cognitive-emotional reactivity may share a bidirectional relationship, conferring an insalubrious environment for sleep in response to stress. Future research on sleep reactivity is needed to identify its neurobiology, characterize its relationship with cognitive-emotional reactivity, and explore the potential clinical utility of sleep reactivity in treatment planning.